Reducing Patients’ Avoidance of Pain May Help Them in Exposure Therapy, Study Finds

Reducing Patients’ Avoidance of Pain May Help Them in Exposure Therapy, Study Finds
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Strategies to reduce avoidance behavior in people with fibromyalgia can help them achieve better results from exposure therapy, a study shows.

The study, “Approach as a key for success: Reduced avoidance behaviour mediates the effect of exposure therapy for fibromyalgia,” was published in the journal Behaviour Research and Therapy.

Fibromyalgia is a chronic pain disorder that can lead to functional impairment and high levels of distress, which in turn can severely affect patients’ overall health and quality of life.

To date, it remains unclear what causes or which mechanisms are involved in driving the constant pain sensation in fibromyalgia patients. This uncertainty has made it difficult for researchers to find effective strategies to tackle the symptoms associated with this chronic illness.

While medications are usually insufficient to manage fibromyalgia pain, cognitive behavior therapy (CBT) has shown some promise. The goal of CBT is to change negative thought patterns and teach patients how to cope with pain.

One CBT strategy is the fear-avoidance model that suggests that “pain-related fear elicits avoidance of physical activity and hypervigilance toward pain symptoms,” which in turn results in increased functional disability and more pain.

To help address this avoidance behavior in fibromyalgia patients, Swedish researchers developed a strategy. The protocol required systematic and repeated exposure to external and internal stimuli that could represent stressors for fibromyalgia symptoms. The exposure was combined with systematic attention training to prevent avoidance behaviors.

Results from a controlled clinical trial (NCT02638636) revealed that internet-delivered exposure therapy for fibromyalgia patients could effectively reduce the pain intensity and severity of symptoms compared with no treatment. Despite the positive outcome of this strategy, the researchers are unclear about the specific processes involved.

Therefore, the team conducted a new study to evaluate potential mechanisms that could change the outcome of this new exposure treatment for fibromyalgia. The researchers focused on assessing the impact of three parameters: fibromyalgia-related avoidance behavior and worry, and mindful non-reactivity.

They defined fibromyalgia-related avoidance behavior as avoiding activities associated with pain and distress; worry as “catastrophizing, worry and rumination about FM;” and mindful non-reactivity as “a core aspect of mindfulness and reflects the observation of thoughts, emotions and bodily sensations without trying to alter them.”

The researchers reviewed data collected during the controlled trial, which included 140 adults diagnosed with fibromyalgia who either received internet-delivered exposure therapy or had no such treatment for 11 weeks.

Those who underwent the therapy showed significant improvements, with a 1.90-point change per week on the Fibromyalgia Impact Questionnaire, compared with the other group.

Overall, treated patients showed reduced fibromyalgia-related avoidance behavior and worry, and increased mindful non-reactivity, all of which were associated with a reduction in fibromyalgia symptoms.

A more detailed analysis revealed that changes in fibromyalgia-related avoidance behavior could explain 48% of the positive outcome, while changes in mindful non-reactivity explained 17% of the outcome, and changes in fibromyalgia-related worry explained 42% of the outcome.

“We found that all three process variables … were significant mediators of fibromyalgia symptoms in internet-delivered exposure therapy and together explained 60% of the outcome,” the researchers reported.

As avoidance behavior has “a causal effect” on fibromyalgia symptoms, targeting it through exposure therapy may represent a beneficial strategy for patients with this pain disorder, they said.

“Successfully targeting the FM-specific pattern of avoidance behavior may have beneficial effects on symptom severity in exposure therapy for fibromyalgia,” they said.

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