Going Mental With Fibromyalgia
Do you ever feel like a psychologist in the clinic? Pain affects so many aspects of life, and some days I am navigating emotions, thoughts, and behaviors much more than I am assessing joint mobility or muscular function.
Fibromyalgia is one condition that can be overwhelming at evaluation because the patient might say that “everything hurts” or that they would like to see why they hurt in their neck, back, shoulders, hips, and knees. If I were to systematically evaluate and treat each joint as if the pain is purely nociceptive, then I would be overwhelmed… and possibly misguided.For fibromyalgia, there is evidence that psychological treatments — and cognitive-behavioral therapy in particular — are more effective than active controls for pain, disability, and negative mood. But what is cognitive-behavioral therapy, and how does it work?
What is Cognitive Behavioral Therapy?
Cognitive-behavioral therapy is hard to define, but typically involves attempts to change thoughts, modify unhelpful behaviors, and/or introduce self-management strategies. There isn’t a universal definition, though typically it is a structured intervention used by mental health practitioners.
Cognitive-behavioral therapy often tries to encourage “skills” that help with managing pain or improving the quality of life despite pain. Some skills include progressive muscle relaxation, cognitive restructuring, mental imagery, goal-setting, and activity-rest cycling.
Activity-rest cycling is one skill that I find especially helpful for those with fibromyalgia. If the patient feels that they “overdo” something often, then perform a thought experiment about how taking some rest breaks might prevent a flare or allow the patient to do even more of the activity than just trying to power through.
As we discussed in the first newsletter about fibromyalgia, pain modulation doesn’t work the same way in fibromyalgia, might make intermittent rest much more valuable in painful moments.
Be Present, CBT-style
To make things complicated, there are many “third-wave” cognitive-behavioral strategies that incorporate other frameworks such as Acceptance and Commitment Therapy (ACT) or mindfulness-based strategies. I think ACT and mindfulness are valuable additions to psychological interventions because of their goal to bring more attention to the present moment and to emphasize that we should try to find aspects of our life that we can control without preoccupying ourselves with what we can’t control.
If you’re interested in exploring some of these strategies, then I would first encourage you to reach out to a psychologist friend or to find one for your referral network, and see if they can mentor you.
Next, check out Psychology Tools for many free handouts and resources that are useful for patients with these types of treatments. Using these strategies are at the heart of psychologically-informed physical therapy.
How CBT Changes Thoughts and the Brain
Many physios understandably think we should stick to exercise as our treatment. As we discussed last week, exercise is effective for fibromyalgia. So why notstick with exercise without struggling through psychobabble?
Here’s how I see it…
Exercise is often our product in order to allow patients to meet their ultimate goals. Psychological treatment is kind of a customer service line for when the product isn’t working. In many cases, exercise might seem too dangerous or painful for patients, or perhaps patients are struggling with stress or sleep or weight loss and these other factors are interfering with the thought of exercising. Psychological intervention can troubleshoot these problems by providing coping skills, modifying behaviors, and addressing unhelpful thoughts.
In fact, one RCT using fMRI suggests a possible mechanism for how CBT can lead to decreased pain. A group of patients with fibromyalgia who participated in CBT showed reduced resting-state connectivity between the S1 area and anterior/medial insula after treatment. Moreover, this reduction in connectivity correlated with reductions in pain catastrophizing, which was also significantly decreased in the CBT group compared to control. Therefore, this study suggests not only the role of catastrophizing in mediating the effects of CBT on pain but also the possible biomarkers of these effects.
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