Juvenile Fibromyalgia Pain Treatment Enhanced By Psychosocial Impact Therapies

Fear and Avoidance

Acute pain signals normally suggest injury or illness that requires rest and recovery before engaging in full physical activity. Because chronic pain syndromes such as RA and fibromyalgia involve misguided pain signals that are not triggered by normal injuries or illness, treatment approaches require patients to “push through” pain to maintain or increase physical activity levels.

Fear of pain and avoidance in adolescent activities results in sedentary behaviors and withdrawal from social interactions that have a significant negative impact on physical health, family life, and school performance.

Treatment of Juvenile Chronic Pain Syndromes

The study by Sil et al18 concluded that children with fibromyalgia from controlling environments were at a higher risk for poorer emotional function in subsequent years, and that interventions are needed to target both independent coping skills in patients and greater flexibility in their parents in order to effect the most significant improvements.

Work by Fisher and Palermo21 reached a similar conclusion, proposing a new model of chronic pain management in juveniles that focuses on shifting “goal pursuit” within the same contexts of patient and parental coping strategies. This model reflects the notion that “the child’s experience of pain is modified by child factors (eg, goal salience, motivation/energy, pain-related anxiety/fear, and self-efficacy) and parent factors (eg, parent expectations for pain, protectiveness behaviors, and parent anxiety), which lead to specific goal pursuit behaviors.” The model suggests adjustment of goals particularly in the direction of achieving higher levels of activity and function despite pain through direct confrontation of these behaviors.

Cognitive Behavioral Therapy – FIT for Teens Program

A new psychosocial approach to chronic pain management that has demonstrated efficacy in fibromyalgia is cognitive behavioral therapy (CBT), which involves retraining of patient perceptions of pain and focuses on engagement in moderate physical activity to reduce pain.22 In juvenile fibromyalgia, however, exercise retention rates have tended to be poor even after CBT.23 A group of investigators designed a program to combine CBT with special neuromuscular exercise, called the Fibromyalgia Integrative Training for Teens (FIT for Teens) program.

The study involved two 90-minute sessions per day for 8 weeks (16 total), with 45 minutes devoted to CBT techniques for pain management and 45 minutes given to physical resistance training in neuromuscular exercises designed to improve strength, fitness and body mechanics. Parents were asked to participate in 6 CBT sessions to enhance the independence of adolescent patients in taking responsibility for pain management.

The pilot study for FIT Teens demonstrated significant reductions in all psychosocial domains evaluated in 22 female participants (age 12 to 18), including functional disability (P <.05), depression (P <.001), fear of movement (P <.01), and pain catastrophizing (P <.001) with treatment.24 Additionally, the investigators found a substantial decrease in pre-contemplation (P <.01) associated with avoidance.

At the end of 8 weeks, the participants all achieved improvement in physical function in less time than previously recorded with CBT interventions without exercise. They also reported a reduction in general fear of pain and lessened avoidance was marked by an 80% retention to exercise after the trial ended.24

Summary & Clinical Applicability

Overall, psychosocial impact therapies such as CBT are effective in the treatment of chronic pain conditions, including fibromyalgia. In adolescents who tend to demonstrate higher degrees of catastrophizing and avoidance behaviors, however, the addition of a neuromuscular training component significantly enhances adherence and success of the program.

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