Cognitive behavioural therapies for fibromyalgia.
By Kathrin Bernardy, et al.
BACKGROUND: Fibromyalgia (FM) is a clinically well-defined chronic condition of unknown aetiology characterized by chronic widespread pain that often co-exists with sleep disturbances, cognitive dysfunction and fatigue. Patients often report high disability levels and negative mood. Psychotherapies focus on reducing key symptoms, improving daily functioning, mood and sense of personal control over pain.
OBJECTIVES: To assess the benefits and harms of cognitive behavioural therapies (CBTs) for treating FM at end of treatment and at long-term (at least six months) follow-up.
SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 8), MEDLINE (1966 to 28 August 2013), PsycINFO (1966 to 28 August 2013) and SCOPUS (1980 to 28 August 2013). We searched http://www.clinicaltrials.gov (web site of the US National Institutes of Health) and the World Health Organization Clinical Trials Registry Platform (ICTRP) (http://www.who.int/ictrp/en/) for ongoing trials (last search 28 August,2013), and the reference lists of reviewed articles.
SELECTION CRITERIA: We selected randomised controlled trials of CBTs with children, adolescents and adults diagnosed with FM.
DATA COLLECTION AND ANALYSIS: The data of all included studies were extracted and the risks of bias of the studies were assessed independently by two review authors. Discrepancies were resolved by discussion.
MAIN RESULTS: Twenty-three studies with 24 study arms with CBTs were included. A total of 2031 patients were included; 1073 patients in CBT groups and 958 patients in control groups. Only two studies were without any risk of bias. The GRADE quality of evidence of the studies was low.
CBTs were superior to controls
in reducing pain at end of treatment by 0.5 points on a scale of 0 to 10 (standardised mean difference (SMD) – 0.29; 95% confidence interval (CI) -0.49 to -0.17) and by 0.6 points at long-term follow-up (median 6 months) (SMD -0.40; 95% CI -0.62 to -0.17);
in reducing negative mood at end of treatment by 0.7 points on a scale of 0 to 10 (SMD – 0.33; 95% CI -0.49 to -0.17) and by 1.3 points at long-term follow-up (median 6 months) (SMD -0.43; 95% CI -0.75 to -0.11);
and in reducing disability at end of treatment by 0.7 points on a scale of 0 to 10 (SMD – 0.30; 95% CI -0.51 to -0.08) and at long-term follow-up (median 6 months) by 1.2 points (SMD -0.52; 95% CI -0.86 to -0.18).
There was no statistically significant difference in dropout rates for any reasons between CBTs and controls (risk ratio (RR) 0.94; 95% CI 0.65 to 1.35).
AUTHORS' CONCLUSIONS: CBTs provided a small incremental benefit over control interventions in reducing pain, negative mood and disability at the end of treatment and at long-term follow-up. The dropout rates due to any reason did not differ between CBTs and controls.
Plain language summary
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Researchers in The Cochrane Collaboration conducted a review of research about the effects of cognitive-behavioural therapies (CBTs) on fibromyalgia (FM). After searching for all relevant studies, they found 23 studies with up to 2031 people. Their findings are summarised below.
After about 12 weeks, children, adolescents and adults with FMS, who used CBTs compared to controls, were likely to report that CBT
may reduce slightly pain, negative mood and disability at the end of the treatment;
may reduce slightly pain, negative mood and disability six months after the end of treatment.
There was no difference between CBTs and controls in the number of people who withdrew from treatment.
We do not have precise information about side effects and complications of CBTs. Rare complications may include worsening of co-existing mental disorders.
What is fibromyalgia and what are cognitive behavioural therapies?
People with FM suffer from chronic widespread pain, sleep problems and fatigue. There is no cure for FM at present, so treatments aim to relieve symptoms and to improve daily functioning.
Cognitive behavioural therapies (CBTs) are widely used psychological treatments for a wide range of health problems, including chronic pain. CBTs are effective in enhancing patients’ beliefs in their own abilities and developing ways to deal with health problems. The primary goals of CBTs are to change negative thoughts and feelings that individuals may have of their physical and mental problems and to change their behaviour accordingly. Patients learn skills (for example, relaxation, activity pacing) to help them to manage their pain better or develop different attitudes towards pain (for example, more acceptance), or both.
Best estimates of what happens to people with FMS when they use CBTs
Pain (higher scores mean worse or more severe pain):
People who used CBTs rated their pain to be 0.5 points lower at the end of treatment (6.3% absolute improvement) and to be 0.6 points lower six months after the end of treatment on a scale of 0 to 10 (4.2% absolute improvement).
People who used CBTs rates their pain to be 6.9 points on a scale of 0-10.
People who used a control treatment rated their pain to be 7.4 points on a scale of 0 to 10.
Negative mood (higher scores mean worse or more severe negative mood):
People who used CBTs rated their depressed mood to be 0.7 points lower at the end of treatment (10.2% absolute improvement) and to be 1.3 points lower six months after the end of treatment on a scale of 0 to 10 (2.7% absolute improvement).
People who used CBTs rated their negative mood to be 6.1 points on a scale of 0 to 10.
People who had a control treatment rated their negative mood to be 6.8 points on a scale of 0 to 10.
Disability (higher scores mean more disability):
People who used CBTs rated their disability to be 0.7 points lower at the end of treatment (7.2% absolute improvement) and to be 1.2 points lower six months after the end of treatment on a scale of 0 to 10 (11.7% absolute improvement).
People who used CBTs rated their disability to be 2.0 points on a scale of 0 to 10.
People who used a control treatment rated their disability to be 2.8 points on a scale of 0 to 10.
Withdrawing from treatment:
The number of people who withdrew from CBTs compared to control interventions due to any reason was equal.
15 people out of 100 who used CBTs withdrew from treatment due to any reason;
15 people out of 100 who used control interventions withdrew from treatment due to any reason.
Source: Cochrane Database of Systematic Reviews, September 10, 2013. By Kathrin Bernardy, Petra Klose, Angela J Busch, Ernest HS Choy and Winfried Häuser. Department of Pain Medicine, BG University Hospital Bergmannsheil GmbH, Ruhr University Bochum, Cample-de-la Bürk Platz 1, Bochum, Germany, 44789.