In a recent randomized clinical trial of patients with fibromyalgia, cognitive-behavioral therapy (CBT)—which uses structured techniques to alter distorted thoughts and negative moods—was superior to a matched education treatment in reducing the interfering effects of pain and other aspects of fibromyalgia on daily living.
Within the group that received CBT in the trial, which is published in Arthritis & Rheumatology, improvements were at least partly attributable to reductions in what’s known as catastrophizing, a state comprised of cognitive and emotional processes such as helplessness, rumination, and magnification of pain complaints.
Neuroimaging tests indicated that CBT exerts these effects by altering the connectivity of specific regions of the brain. Therefore, changes in the brain circuitry underlying pain catastrophizing may underpin CBT’s benefits for patients with fibromyalgia, a condition characterized by function-impairing symptoms such as widespread pain, fatigue, cognitive difficulties, and psychosocial distress.
“These findings contribute to a growing literature highlighting the benefits of non-pharmacologic treatments—including CBT—for chronic pain conditions such as fibromyalgia,” said corresponding author Jeungchan Lee, PhD, of Spaulding Rehabilitation Hospital and Harvard Medical School. “Identifying the multiple biopsychosocial mechanisms by which these treatments help to alleviate pain may help to facilitate the practice of precision pain medicine and improve treatment outcomes for the many patients suffering from chronic pain.”
A randomized, controlled trial led by Mass General Brigham researchers demonstrates that cognitive behavioral therapy can significantly reduce the impact of fibromyalgia pain
Patients living with fibromyalgia (FM) – a disease that predominantly affects women and is characterized by chronic pain, fatigue and brain fog – often find limited treatment options and a scarcity of explanations for their symptoms. Research led by Mass General Brigham investigators has found that cognitive behavioral therapy (CBT) can significantly reduce the burden of FM by, in part, reducing pain-catastrophizing, a negative cognitive and emotional response that can intensify pain through feelings of helplessness, rumination and intrusive thoughts. This finding is backed by neuroimaging data, evidencing reduced connectivity between regions of the brain associated with self-awareness, pain and emotional processing. Results are published on September 20in Arthritis & Rheumatology.
“In this study, we looked at the interplay between psychological processes and the brain’s connectivity patterns in response to pain,” said co-senior author Robert Edwards, PhD, a clinical psychologist in the Department of Anesthesiology, Perioperative & Pain Medicine at Brigham and Women’s Hospital, a founding member of the Mass General Brigham healthcare system. “We wanted to explore how CBT, a talk therapy aimed at combatting maladaptive thoughts, can enhance individuals’ daily functioning and alter the brain’s processing of pain-related information.”
Edwards explains that CBT can reduce negative cognitive and emotional responses to pain. He says that while these responses are normal, they can amplify the disabling effects of chronic pain, and make conditions like FM more burdensome.
The research team for the study included researchers from three Mass General Brigham members: Spaulding Rehabilitation Hospital, Brigham and Women’s Hospital and Massachusetts General Hospital. Mass General Brigham brings together 16 member institutions, including academic medical centers, top-tier specialty hospitals, community hospitals and more. Research that spans more than one of these entities is more than the sum of its parts, helping to provide insights and unique perspectives from multiple settings and areas of expertise.
Researchers recruited 98 women, randomly assigning 64 to a treatment group receiving CBT and 34 to a control group that received education about FM and chronic pain but was not taught specific CBT techniques. All participants were between 18 and 75 years old and had a confirmed FM diagnosis for at least six months. To collect baseline data, all participants completed several validated pain and quality of life questionnaires.
Each group participated in eight intervention sessions, consisting of 60–75-minute visits with a licensed mental health provider. Participants were primarily assessed for their levels of pain interference, or a measure of how much their pain disrupted their daily activities, pain catastrophizing, pain severity and the overall impact FM had on patients’ quality of life.
Results demonstrated that those who underwent CBT experienced significantly greater reductions in pain interference. CBT participants also exhibited significantly less pain catastrophizing and reported that their FM symptoms had significantly less impact on their daily lives.
The team saw evidence that after undergoing CBT, patients experienced changes in the activities of all three networks that suggested a diminished focus on pain.
“Prior to participants undergoing CBT, we saw that certain parts of the brain linked to self-awareness and sensation were very connected, suggesting patients were pertinently aware of the pain sensation they were experiencing and internalized these symptoms,” said co-first author Jeungchan Lee, PhD, an instructor in the Department of Physical Medicine and Rehabilitation based at Spaulding Rehabilitation Hospital and the Athinoula A. Martinos Center for Biomedical Imaging at Massachusetts General Hospital. “After CBT, these connections were significantly less strong, suggesting that patients were better at separating themselves from their pain after therapy.”
This study was limited to women, partly because of its high prevalence, and partly to eliminate confounding gender differences in brain activity. In the future, the researchers hope to collect data from men and non-binary patients with FM. Additionally, CBT includes several therapeutic components, and these results cannot be generalized to assess the impact across all forms of CBT on reducing FM chronic pain.
Both Lee and Edwards agree that these findings ultimately suggest that complex chronic pain conditions like fibromyalgia should be addressed with a multitude of pharmacological and cognitive therapies.
“I hope that these findings motivate healthcare providers to consider CBT as an effective treatment option to reduce the impact of pain patients experience,” explained Edwards. “Chronic pain conditions like fibromyalgia involve long-standing patterns of changes in the central nervous system, and CBT is one among many treatment options, such as medication and physical therapy, that we know can be beneficial for those living with FM.”
Patient standing at 0 minutes CREDIT University of Leeds
An unusual case of a Long Covid patient’s legs turning blue after 10 minutes of standing highlights the need for greater awareness of this symptom among people with the condition, according to new research published in the Lancet.
The paper, authored by Dr Manoj Sivan at the University of Leeds, focuses on the case of one 33-year man who developed with acrocyanosis – venous pooling of blood in the legs.
A minute after standing, the patient’s legs began to redden and became increasingly blue over time, with veins becoming more prominent. After 10 minutes the colour was much more pronounced, with the patient describing a heavy, itchy sensation in his legs. His original colour returned two minutes after he returned to a non-standing position.
The patient said he had started to experience the discolouration since his COVID-19 infection. He was diagnosed with postural orthostatic tachycardia syndrome (POTS), a condition that causes an abnormal increase in heart rate on standing.
Dr Sivan, Associate Clinical Professor and Honorary Consultant in Rehabilitation Medicine in the University of Leeds’ School of Medicine, said: “This was a striking case of acrocyanosis in a patient who had not experienced it before his COVID-19 infection.
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Patient standing at 2 minutes
“Patients experiencing this may not be aware that it can be a symptom of Long Covid and dysautonomia and may feel concerned about what they are seeing. Similarly, clinicians may not be aware of the link between acrocyanosis and Long Covid.
“We need to ensure that there is more awareness of dysautonomia in Long Covid so that clinicians have the tools they need to manage patients appropriately.”
Long Covid affects multiple systems in the body and has an array of symptoms, affecting patients’ ability to perform daily activities. The condition also affects the autonomic nervous system, which is responsible for regulating blood pressure and heart rate.
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Patient standing at 10 minutes
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Acrocyanosis has previously been observed in children with dysfunction of the autonomic nervous system (dysautonomia), a common symptom of post-viral syndromes.
Dysautonomia is also seen in a number of other long-term conditions such as Fibromyalgia and Myalgic Encephalomyelitis, also known as Chronic Fatigue Syndrome or ME.
Dr Sivan said: “We need more awareness about dysautonomia in long term conditions; more effective assessment and management approaches, and further research into the syndrome. This will enable both patients and clinicians to better manage these conditions.”
…From accidents, infections, and especially suicide, pooled data analysis suggests; regular physical and mental health monitoring warranted to minimise these risks
Please wear a purple tie to help promote fibromyalgia awareness
Fibromyalgia, a condition that causes persistent widespread pain and fatigue, may be linked to a heightened risk of death as a result of vulnerability to accidents, infections, and especially suicide, suggests a pooled data analysis of the available evidence, published in the open access journal RMD Open.
The findings prompt the researchers to call for regular monitoring of patients’ physical and mental health to minimise these risks.
It’s not clear what causes fibromyalgia, but its prevalence is increasing, say the researchers. And there’s growing recognition that the condition often coexists with other health problems, including rheumatic, gut, neurological, and mental health disorders.
Given the extent of the pain they experience and the likelihood of other painful and debilitating conditions in these patients, it is thought that they are probably at heightened risk of dying before their time.
To strengthen this hypothesis, the researchers reviewed the findings of 8 relevant studies, published between 1999 and 2020, out of an initial haul of 33. They pooled the results from 6 of them, involving a total of 188,751 adults, all of whom had other coexisting conditions.
The analysis showed that fibromyalgia was associated with a 27% heightened risk of death from all causes over time, although this wasn’t true for those diagnosed by the 1990 criteria.
But the diagnostic criteria for fibromyalgia have evolved since 1990 in tandem with increasing understanding of the array of clinical symptoms associated with the condition. And they were consequently revised in 2010, 2011, and 2016, point out the researchers.
Specifically, the analysis showed that the risk of death from cancer was 12% lower than it was for the general population of the same age, and only marginally higher (5%) for accidents.
But it was 44% higher for infections, including pneumonia and septicaemia, and more than 3 times as high for suicide.
Whether this heightened risk is due to the fibromyalgia itself or the concomitant conditions isn’t clear, note the researchers, as their research wasn’t designed to evaluate this. But this is an important issue, they emphasise, which further research needs to address.
And they caution that their findings should be interpreted in the light of differing designs and the small number of participants in the studies included in their analysis.
“Due to significant heterogeneity across the studies, which were also small in number, no clear conclusions can be drawn from the available data,” they write. “However, it is possible that for the subgroup of patients diagnosed by the 1990 criteria there is no increased risk for mortality, and for those diagnosed by later versions the risk is increased,” they add.
And there are plausible explanations for their findings, they suggest. “The finding of increased mortality associated with accidents can stem from fatigue, unrefreshing sleep, and the concentration difficulties that accompany fibromyalgia, and are a component of its diagnostic criteria since 2010.
“More and more evidence supports immune system involvement and inflammation in fibromyalgia pathophysiology, which can explain the finding of increased mortality from infections. Physical comorbidity may be an additional explanation.”
And the reduced risk of a cancer death may be due to these patients’ extensive use of health services, they suggest.
The risks identified in their analysis “could represent a serious public health problem, given the high prevalence of the condition,” which clinicians don’t always take seriously, they note.
“Studies have shown that medical staff are reluctant to accept fibromyalgia as a medical condition, and they face emotional and psychological difficulties interacting with these patients and coping with their disorder,” they write.
“Fibromyalgia is often called an ‘imaginary condition,’ with ongoing debates on the legitimacy and clinical usefulness of this diagnosis. Our review provides further proof that fibromyalgia patients should be taken seriously, with particular focus on screening for suicidal ideation, prevention of accidents, and prevention and treatment of infections,” they conclude.
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Fibromyalgia is common, affecting around 2% of people in the general population.1,2 The 2017 EULAR recommendations state that tramadol – a weak opioid – may be considered for pain management in fibromyalgia, but advise against use of strong opioids due to lack of evidence of efficacy, and the high risk of side effects and addiction.3 However, with limited therapeutic options available to tackle this condition, opioids are frequently used in clinical practice.
The impact of the opioid epidemic in North America has caused concern around the world. Long-term opioid use is associated with potential harm and adverse outcomes. In their abstract presented at the 2023 annual congress, in a session on Pain in RMDs, Ramirez Medina and colleagues argue that understanding the factors associated with long-term opioid use in such patients is the first step in helping to develop targeted interventions for de-prescribing.
The team conducted a retrospective cohort study using data from the Clinical Practice Research Datalink (CPRD) – a UK database of electronic health records from primary care. Overall, 28,554 fibromyalgia patients without prior cancer who were new opioid users between 2006 and 2021 were included. Long-term opioid use was defined as having at least three opioid prescriptions within a 90-day period, or at least one prescription lasting 90 days or more in the first year of follow-up.
Findings show that 26% of new opioid users became long-term users in the first year. Several factors were associated with higher risk of long-term opioid use. These included mean daily morphine milligram equivalents (MME) at initiation, history of suicide and self-harm, substance use disorder, deprivation, and obesity. Modelling showed that, of these, the three most important variables were mean MME/day at initiation, history of suicide and self-harm, and deprivation.
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