CONTROVERSIES IN FIBROMYALGIA

AND RELATED CONDITIONS 0889-857>(/96 $0.00 + .20

MULTIDISCIPLINARY GROUP
PROGRAMS TO TREAT
FIBROMYALGIA PATIENTS
Robert M. Bennett, MD, FRCP, FACP

The 1990 American College of Rheumatology criteria defined fi-

bromyalgia in terms of widespread body pain and multiple tender
points.58It is readily apparent, however, that the fibromyalgia syndrome
is more than a musculoskeletal pain p r ~ b l e mVirtually
.~ all fibromyalgia
patients have dysfunctional sleep. Fatigue often is cited as being more
debilitating than chronic pain. In addition, there is a concentration of
symptom complexes and distinctive syndromes within the fibromyalgia
population. Such problems include irritable bowel syndrome, irritable
bladder, sicca syndrome, migraine headaches, lifetime history of depres-
sion, restless leg syndrome, cold intolerance, Raynaud's phenomena,
cognitive dysfunction, premenstrual syndrome, fluid retention, and diz-
ziness. It is quite evident that there can be no one single physiologic
aberration to account for this wide array of symptoms. In this sense,
fibromyalgia is not a distinctive pathophysiologic entity. It is a readily
recognized syndrome, however, that can be distinguished from other
causes of musculoskeletal pain. It is the clinical complexity and lack
of a well defined pathogenesis that make the effective treatment of
fibromyalgia patients so difficult and frustrating. It is time-consuming
to analyze fully the symptom complex that is unique to each patient, let
alone a host of interconnected paramedical issues. Strategies for manag-
ing fibromyalgia patients must also take into account the reality that
this condition is chronic and expectations for improvement are more

From the Department of Medicine, Division of Arthritis and Rheumatic Diseases, Oregon
Health Sciences University, Portland, Oregon

RHEUMATIC DISEASE CLINICS OF NORTH AMERICA

- -
VOLUME 22 NUMBER 2 MAY 1996 351
352 BENNETT

palliative than curative. In the United States, we are experiencing health

care reforms that place an emphasis on cost effectiveness that curbs an
individual physician's ability to take on the management of complex
chronic problems like fibromyalgia. Against this backdrop, several
groups in the United States and Europe have set up experimental treat-
ment programs based on two concepts: (1) fibromyalgia patients are
seen in groups, and (2) a team of dedicated and experienced health
professionals are involved in their comprehensive care.

UNDERSTAND THE PROBLEM

Because fibromyalgia is a complex multifactorial disorder, the de-

sign of a rational treatment program demands that its eclectic nature be
addressed. There is increasing evidence that the defining feature of the
fibromyalgia syndrome is a persistent up-regulation in the spinal and
supraspinal pain pathways. This leads to sensations that are not nor-
mally painful being perceived as pain. For instance, muscle tension does
not normally activate muscle nociceptors, but most fibromyalgia patients
perceive stress-induced muscle tension to be painful. This central pain
sensitization is often referred to as neuuoplasticity, a term that implies
both functional and structural reorganization of synaptic connections.21,
23

The adult brain has much more plasticity in its circuitry than previously
thought. Experimentally induced pain causes three plasticity changes:
1. Sensitization of the dorsal horn cells so that they are activated
by lesser stimuli.
2. Enlargement of the original receptive field.
3. The development of new receptive fields in both muscle and skin
that are distant from the site of original injury.
Interestingly, dorsal horn neurons do not receive input exclusively
from skeletal muscle. They have two receptive fields: (1) deep muscle
and ( 2 ) a cutaneous field, which usually is distal to the muscle. Thus,
input from both the cutaneous and muscle receptive fields converges on
the same neuron; this is the basis for the cutaneous representation of
deep muscular pain.38There is evidence that the persistent release of
neurotransmitters (e.g., substance P) from the dorsal root ganglia and
subsequent "spillover" leads to an unmasking of adjacent dorsal horn
connections, with resulting synaptic changes (neuroplasticity) in the
spinal cord.21This probably accounts for the spread of pain beyond the
original site of an injury. Furthermore, antidromic release of substance
P results in tissue sen~itization.'~
Muscle pain seems especially potent in
causing neuroplastic changes in the spinal Thus, chronic muscle
pain can lead to the development of new receptive fields. In the fully
 MULTIDISCIPLINARY GROUP PROGRAMS TO TREAT FIBROMYALGIA PATIENTS 353

Uncomplicated
local pain

Central
changes

Figure 1. Primary and secondary factors

driving symptomatology in fibromyalgia.
\ Complicated
widespread pain
-
developed state this becomes the total body pain syndrome of fibromy-
algia. It should be noted that pain is not only a sensory experience but
also an emotional experience. In this way, events during childhood, such
as sexual abuse, family sick role environment, and a host of other
developmental variables can modify an individual’s interpretation of
pain. It is ultimately the context in which pain is interpreted that be-
comes the major determinant of the amount of distress and suffering it
causes. Once pain becomes persistent and pervasive the generation of
new symptoms is partly dependent on the patient’s coping mechanisms.
For instance, chronic pain usually has profound effects on both voca-
tional and avocational activities and thus causes varying degrees of
psychological distress. Chronic stress, in turn, may lead to dysfunctional
sleep, dysphoria, neuroendocrine dysfunction, and inactivity. Thus nega-
tive feedback loops become established that drive symptom generation
(Fig. 1). Factors that are relevant to the generation of fibromyalgia
symptomatology can be divided into those that are biologic and those
that are nonbiologic:
Biologic
Myofascial pain
Central pain sensitization
Dysfunctional sleep
Muscle deconditioning
Psychological issues
Neuroendocrine dysfunction
Chronic stress effects
Associated symptoms
Nonbiologic
Occupational demands
Environmental stresses
354 BENNETT

Interpersonal problems
Social changes or role expectations
Family problems
Economic stresses
Disability issues
Medicolegal issues

THEORETICAL BASIS FOR MULTIDISCIPLINARY

GROUP THERAPY

Given the complexity of the fibromyalgia syndrome, it seems intu-

itively unlikely that a multidisciplinary group approach can substitute
fully for a careful individualized analysis of relevant etiologic issues and
one-on-one interaction with a knowledgeable physician. The multidisci-
plinary group treatment of fibromyalgia is potentially useful in three
areas: (1) to provide patients with basic background information regard-
ing fibromyalgia, (2) to make them aware of the various treatment
options, and (3) to sow the seeds of self-efficacy theory. Thus, the
ultimate goal of multidisciplinary group treatment programs should be
to complement and maximize subsequent physician-patient interactions.
In the Portland Program, two of the greatest changes were a reduc-
tion of catastrophizing and an increased aerobic fitness? This suggests
that overall improvements are owing to improved self-efficacy. There is
a large literature describing a positive relationship between enhanced
self-efficacy and beneficial health behaviors and health status.', 6, 12, 29, 43,
47* 49* 50, 53* 54 It is important that health care professionals involved in
fibromyalgia treatment programs understand some of the theory behind
enhanced self-effi~acy.~~, ", 24, 27, 42, 52, 54, 59 The basic tenet is that the stress

Primary symptom
(Chronic pain)
J.
Psychological distress

J.
Physiological arousal

Secondary symptoms
(Despondency, dysfunctional sleep,
dysphoria, deconditioning etc.)
Figure 2. Cognitive-behavioral feedback loop of secondary symptom generation in fibro-
myalgia.
 MULTIDISCIPLINARY GROUP PROGRAMS TO TREAT FIBROMYALGIA PATIENTS 355

of chronic pain leads to physiologic arousal that, in turn, generates

secondary symptoms (Fig. 2 ) . The aim of cognitive behavioral therapy
is to down-regulate this positive feedback loop. A simple definition of
self-efficacy is the enhanced sense of control that derives from a per-
ceived ability to manage symptoms. Interestingly, it is the perception
and not the actual capability that determines enhanced self-efficacy and
resulting positive behaviors. Bandura2has described four techniques for
altering patients’ beliefs about self capabilities that can enhance self-
efficacy:
1. Social persuasion: Health-care professional and peer pressure
that persuades people that they have the capability to be more
functional.
2. Mastery experiences: Actually performing a previously off-lim-
its activity.
3. Modeling: Observing someone who is similarly afflicted being
successful in performing the desired activity.
4. Physiologic feedback: This is basically ”listening to one’s body”
by monitoring pain, fatigue, anxiety levels, and so forth, as a
way of optimizing the timing of the new activities.
Although self-efficacy enhancement is an exercise in positive thinking,
it is the element of ”mastery learning” that is the most powerful
technique-nothing succeeds like success. In other words, success in
performing a function that was previously off-limits promotes confi-
dence in repeating that activity and moving on to new activities. Group
therapy in fibromyalgia treatment programs is ideally suited to self-
efficacy enhancement; over a period of months, a camaraderie builds up
with resulting peer pressure to succeed in new behaviors. The positive
feedback that occurs in a group setting when one or two patients
experience such successes can be infectious-the success of a few encour-
aging others. Repetition and mastery of new behaviors using the feed-
back from small successes, as well as observing successes in one’s peers,
seem to be critical features in promoting self-efficacy.

COGNITIVE-BEHAVIORAL TREATMENT OF
FIBROMYALGIA

Over the last few years there has been an increasing number of
reports of cognitive-behavioral therapy to treat fibromyalgia patients.*
Some preliminary results have been en~ouraging’~, 2h, 31, 34, 40 as regards
major outcome measures, such as pain. One follow-up report of a study

*References 15, 17, 22, 26, 30, 31, 34, 36, 37, 39, 40, 55, 57
356 BENNETT

that initially demonstrated significant improvements in major outcomes

subsequently was negative apart from a persistence of improved coping
strategies for control over pain and less pain behavior.57The results of
the Portland Program are shown in Table 1. There was a significant
improvement in all major outcome measures that continued at 2 years
after finishing the program (Fig. 3). A comparison of the Portland Pro-
gram and the Gothenberg, Sweden, Program was reported by Burck-
hardt,16 - who was a team member in both programs. Whereas the
Portland Program resulted in a significant improvement in all major
outcome measures, the Gothenberg Program was only successful in
improving the quality of life and self-efficacy. The major differences
between the two programs were: (1) duration (Portland = 6 months,
Gothenberg = 6 weeks); (2) multidisciplinary team approach (Portland
used two psychologists, one exercise physiologist, two rheumatologists,
and a headache specialist; Gothenberg used one physical therapist); (3)
sleep management/therapy (Portland = yes, Gothenberg = no); and

Table 1. OVERALL RESULTS OF PORTLAND PROGRAM COMPARING INITIAL AND

END OF PROGRAM SCORES (N = 104)
initial End
Outcome Measure (Mean & SD) (Mean f SD) P value

Total FIQ score 50.39 f 12.84 37.7 f 15.8 <0.00001*

FIQ sub-scales:
Physical function 3.79 k 2.39 3.2 f 2.339 0.0069
Days felt bad 6.79 f 3.1 5.13 5 2.9 <0.0001*
Days missed work 0.95 f 1.9 1.21 f 2.7 0.5368
Difficulty with job 5.91 f 2.7 4.76 k 2.8 0.0038
VAS pain 6.8 f 2.1 5.12 f 2.7 0.0002'
VAS fatigue 7.90 f 2.1 6.1 +- 2.6 <0.0001*
VAS AM tiredness 7.84 f 2.1 5.79 f 2.9 <0.0001*
VAS stiffness 6.74 f 2.4 5.30 f 2.7 ~0.0001*
VAS depression 5.76 f 2.9 4.01 f 3 ~0.0001
VAS anxiety 4.69 f 3.1 3.06 f 2.7 <0.0001*
Number of tender points 15.9 f 2.4 9.06 f 3.9 <0.0001*
Total myalgic score 36.49 f 10.1 15.78 k 8.7 <0.0001*
Quality of life index 71.64 f 15.2 77.28 k 12.3 <0.0001*
Walking (yards in 6 min) 530 f 87 589 k 93 <0.0001*
VAS fatigue on walking 6.91 f 1.7 5.25 5 1.5 <0.0001*
Training index 14.43 f 35.2 50.1 f 44.6 <0.0001*
Flexibility (inches) 13.80 -t 4.5 15.85 f 3.7 <0.0001*
Beck depression inventory 16.32 f 8.7 10.81 +- 7.9 <0.0001*
Beck anxiety inventory 15.72 f 10.2 11.01 f 8.8 <0.0001
Fibromyalgia attitudes index 45.76 k7.7 53.29 f 7.9 <0.0001
CSQ sub-scales:
Catastrophizing index 11.7 4 9.3 5.8 f 6.4 0.0001 *
Ability to decrease pain 13.8 f 7.4 18.9 5 7.2 <0.0001*
Ability to control pain 16.4 *
8.1 20.8 f 8.1 0.0004'

FIQ = Fibromyalgia Impact Questionnaire; VAS = Visual Analogue Scale; CSQ = Coping Strate-
gies Questionnaire.
* = Statistically significant after a Bonteroni correction.
 MULTIDISCIPLINARY GROUP PROGRAMS TO TREAT FIBROMYALGIA PATIENTS 357

52 - 84

50 - H FIQresults
HQOLresults - 82
48 -
- 80
v)
46 -
9
/ u)
2 -44 fl -78 $
8 0
v)

a 42 -
v)
-76 6
U

A - 74
(3

- 72
34 I I I I I - 70

Figure 3. Long-term follow-up. Thirty patients who finished the Portland program 2 years
ago have been followed up with the FIQ and QOL questionnaires at 6-month intervals for
2 years. Improvement is sustained and even increases during the follow-up period, when
the patients are not being seen on a regular basis.

(4) aerobic conditioning (Portland = major focus, Gothenberg = lesser

focus). The interpretation of these differing results was as follows: al-
though coping skills can be improved in a short unidisciplinary pro-
gram, a more comprehensive multidisciplinary program can improve
major outcomes, such as pain and number of tender points. Which
components of a multidisciplinary program are the essential ingredients,
however, has not been analyzed.

TREATMENT TEAM MAKE UP

The optimal make up of the health professional team involved in a

multidisciplinary program is a matter of experiment and conjecture.
Currently, most directors of such programs are rheumatologists or reha-
bilitation experts. There is no intuitive reason, however, why other
informed and dedicated health professionals should not assume this
role. In some programs in which cognitive behavioral changes are the
358 BENNETT

major focus for change, the only professionals involved are a rheumatol-
ogist and psychologists or psychiatrists. Because most fibromyalgia pa-
tients have difficulties dealing with stress, pacing issues, interpersonal
problems, and are at increased risk for developing depression and anxi-
ety disorders, the psychologist or psychiatrist is an essential member of
most teams. Exercise is a critical ingredient in treating fibromyalgia
patients and is also a key component of successful cognitive behavioral
therapy. Thus, an exercise physiologist or physical therapist with exper-
tise in prescribing stretching, aerobic conditioning, and
strength training
is a useful addition to most programs. Other health professionals who
could be part of the team or program consultants are: social workers,
occupational therapists, sleep specialists, headache specialists, massage
therapists, acupuncturists, and endocrinologists.

PROGRAM LOGISTICS

The optimum length of a multidisciplinary program is not known.

Nielson et aI4O in London, Ontario, have used an intensive 3-week in-
patient program, whereas the Portland Program has an outpatient pro-
gram that lasts for 6 months with weekly meeting^.^ The rationale for
the latter approach is that knowledge acquired slowly on a repetitive
basis is retained more often. Furthermore, this permits patients to affect
change through peer pressure and allows the development of camarade-
rie. Because one major function of group therapy is to change patient’s
attitudes and behaviors, a slower-paced approach seems more likely to
permit the development of new patterns of thought and action.

PROGRAM CONTENT

The multidisciplinary group therapy programs that are being devel-

oped to treat fibromyalgia patients are, in a large part, based on the
cognitive behavioral therapy approaches that have been used to treat
patients with rheumatoid arthritis and osteoarthritis.12,32, 41, 43, 47, 49, 53 This
body of research has provided evidence that patients with chronic rheu-
matic disorders can learn to control their everyday lives more effectively
and increase their level of endurance and strength without experiencing
major exacerbations of disease. Based on these ideas, the major elements
of any fibromyalgia program include education about fibromyalgia (e.g.,
diagnosis, prognosis, prevalence, muscle function, stress effects, sleep
physiology, and so forth), physical conditioning, and cognitive behav-
ioral techniques. Other aspects that are specially pertinent to fibromyal-
gia are principles of sleep hygiene, strategies for pacing activities, and
 MULTIDISCIPLINARY GROUP PROGRAMS TO TREAT FIBROMYALGIA PATIENTS 359

information about comorbid conditions (e.g., spastic colon, irritable blad-

der, and so forth). Sharpe46from Oxford, United Kingdom, has reported
on a controlled trial of cognitive behavioral therapy in patients with
chronic fatigue syndrome. This was intensive individualized therapy
that challenged the patients’ attributions to organic disease as well as
behavioial modification. The components of this program (modified for
fibromyalgia patients) are as follows:
1. Engagement
Establishing a collaborative approach
Negotiating an individual program
2. Behavioral change
Overcoming avoidance
Increasing activity
Reduction in catastrophizing
3. Cognitive change
Illness
Reducing concern about symptoms
Standards
Reappraisal of excessive standards
Re-evaluation of self-critical attitudes
4. Problem solving
Socioeconomic difficulties
Occupational issues
Implications of improved function
If multidisciplinary group therapy programs are to act as an effective
bridge between health care providers and patients, it is essential that
both parties have realistic expectations of what can be achieved in the
group setting. Issues that are and are not amenable to group therapy in-
clude:
Issues appropriately covered in group therapy
Increased knowledge base
Problem-solving techniques
Basic sleep hygiene
Principles of exercise therapy
Stress reduction techniques
Role of pharmacologic agents
Role of nonpharmacologic therapies
Effective doctor and patient communication
Issues that are not amenable to group therapy
”Hands-on” myofascial pain therapy
Prescription of medications
360 BENNETT

Individual psychotherapy
Disability issues
Medicolegal issues
Individual stress reduction

INDIVIDUALIZED EVALUATION

Ideally, all patients entering a multidisciplinary group program

should have had a carefully and expertly structured evaluation by a
physician who is an expert in the field of fibromyalgia. The purposes of
such an evaluation are to pinpoint those factors that are playing an
important role in symptom generation. For instance, it appears im-
portant to identify patients with major depression or anxiety disorders
and provide appropriate medical treatment. Some patients have contrib-
utory factors, such as alcohol abuse, hypothyroidism, or use medications
that may affect muscle function (e.g., beta blockers and HMGOA inhibi-
tors). Other patients may have primary sleep disorders, such as periodic
limb movement disorder (nocturnal myoclonus), sleep apnea, rapid eye
movement sleep behavioral disorder, or narcolepsy-all of which require
specific and often expert therapy. It also is important to have some
information about a patient’s current exercise regimen, past level of
physical fitness, and experiences with exercise. Seldom is all of this
information available from the primary care provider. Thus, question-
naires need to be used or developed as appropriate screening tools. For
instance, in the Portland Program we have used the Beck Depression
Inventory and Beck Anxiety Inventory as primary screens of significant
psychiatric comorbidity. We have developed a simple sleep question-
naire that provides clues as to primary sleep disorders. Similarly, a
simple exercise questionnaire was developed to help the exercise thera-
pist in developing specific strategies. It is also relevant to know what
the patient’s expectations are for improvement. For instance, patients
who will accept nothing less than a complete cure of all symptoms may
well require more intensive individual cognitive behavioral therapy.

OUTCOME EVALUATION

The buzzword for contemporary health care is cost effectiveness.

Unfortunately, cost effectiveness cannot always be equated with clinical
effectiveness. If multidisciplinary group programs are to survive, how-
ever, it is essential that they are documented to be effective in the areas
of improving patients’ function, maintaining employability, reducing
 MULTIDISCIPLINARY GROUP PROGRAMS TO TREAT FIBROMYALGIA PATIENTS 361

expensive investigations, and minimizing unnecessary doctor visits. In

the program at Oregon Health Sciences University we initially used a
broad range of outcome measures. With the benefit of hindsight, how-
ever, four questionnaires-( l) the FIQ,16 (2) Quality of Life Question-
naire,18 (3) CSQI"5and (4) the aerobic training index8-were shown to be
quite sensitive to ~ h a n g e The
. ~ results of the Portland Program using
these instruments are shown in Table 1 and Figure 3.

PROGRAM ITEMS

Not all aspects of the fibromyalgia syndrome are amenable to multi-

disciplinary group therapy. Patients still need to interact one on one
with an experienced clinician. There are four features of the fibromyalgia
syndrome that need to be addressed on an individual basis: (1)manage-
ment of myofascial pain, (2) improved sleep, (3) exercise and (4)psycho-
logical issues. The educational component of a multidisciplinary group
therapy can provide valuable information in these areas that ensures
more effective doctor-patient communication.

Myofascial Pain

The usual pain medications, such as nonsteroidal anti-inflammatory

agents and even narcotics, are not very effective in managing myofascial
pain.48Corticosteroids have also been shown to be ineffective.20Myofas-
cia1 pain occurs when a muscle group is stressed outside its normal
range or function or actually is injured. If the resulting pain persists,
there is a progressive loss of normal activities, decreased endurance,
loss of flexibility, and eventually muscle de~onditioning.~~Effective myo-
fascia1 therapy aims to abort a recursive cycle of muscle pain and
dysfunction leading to deconditioning. Thus, it is important to eliminate
aggravating and perpetuating factors that occur as part of the patient's
usual activities. In an acute flare of myofascial pain, rest, analgesics,
icing, and stretching are the major modalities. Chronic myofascial pain,
the situation in most fibromyalgia patients, needs to be treated by gentle
muscle rehabilitation. In the chronic stage, disuse usually has led to
weakness and shortening of the muscle. Hence the long-term goal of
physical therapy must be stretching, progressive strengthening, and
endurance training. The use of myofascial trigger-point injections is a
well-established technique in the treatment of myofascial pain syn-
dromes (see the article by Joanne Borg-Stein and Joel Stein). There
have been few studies of their use in fibromyalgia patients, although
anecdotally many practitioners report beneficial results. In general, the
362 BENNETT

injections are given with 1%procaine or lidocaine and the addition of

corticosteroids is not indicated in most situation^.^^ These should be
considered as adjunctive to the overall myofascial treatment program.
Unless the patient is an active participant in stretching and muscle
reconditioning, trigger-point injection therapy will fail.

Exercise

Patients need to understand that muscle is a living tissue. If it is

not used, its function progressively declines and it becomes shorter and
stiffer; these viscoelastic effects are worsened by cold. Fibromyalgia
patients cannot afford not to exercise; however, musculoskeletal pain and
severe fatigue are powerful circumstances for perpetuating inactivity. By
providing positive feedback, group therapy can stimulate patients to
persevere with their exercise program. All fibromyalgia patients need to
have a home program of muscle stretching, gentle strengthening, and
aerobic conditioning. There are several points that can be made about
exercise in fibromyalgia patients:
1. Exercise is health training, not sports training. Many patients,
particularly those who were formerly into routine exercise, at-
tempt to exercise at their old levels with inevitable failures owing
to increased pain. Patients who were athletic often view with
disdain the level of exercise recommended for fibromyalgia pa-
tients. This is an area that is amenable to education through
group therapy.
2. Exercise should be nonimpact loading. Suitable aerobic exercise
includes regular walking, use of a stationary exercycle, or Nordic
Track (initially not using the arm component). Patients who are
very deconditioned or incapacitated should be started with water
therapy using a buoyancy belt (Aqua-Jogger).Other low impact
forms of exercise include yoga and T’ai Chi.
3. Aerobic exercise should be done 3 to 4 times a week at about 70%
of maximum pulse rate for 20 to 30 minutes. Many fibromyalgia
patients are unable to meet this goal initially but this should be
the stated aim of the program to achieve this level of exercise
over a period of 6 to 12 months.
Regular exercise needs to become part of the patient’s usual lifestyk. It
should not be considered merely a 6-month program that they can then
forget. Fibromyalgia patients have to be seen regularly and encouraged
to continue with their exercise program. The use of an exercise log that
is inspected every few months provides a positive reinforcement to be
persistent. Exercise is an important ”mastery experience” on the route
 MULTIDISCIPLINARY GROUP PROGRAMS TO TREAT FIBROMYALGIA PATIENTS 363

to self-efficacy enhancement. Furthermore, progressive incremental im-

provements in exercise capacity and stretching provide a positive physi-
ologic feedback. In the Portland Program, a measure of aerobic condi-
tioning called the Training Index increased over 200% at 6 months (see
Table l).9

Sleep

Nearly all patients with fibromyalgia describe being light sleepers

with frequent awakenings. They typically wake up in the morning
feeling tired, so-called nonrestorative sleep. Some fibromyalgia patients
have a primary sleep disorder. By far the most common is periodic
limb movement disorder or nocturnal myoclonus. These patients can be
readily recognized by the daytime symptoms of restless leg syndrome.
This has two symptom components: (1)dysesthesia (numbness, tingling,
insect crawling, and so forth) and (2) the need to constantly move the
legs for reasons that the patients find difficult to describe. It is important
to make this diagnosis, because both the daytime symptoms of restless
legs and the nocturnal myoclonus are substantially helped by either
carbidopa/levodopa (Sinemet) (10/100) or clonazepam (0.5 mg) taken
at supper-time. Some fibromyalgia patients, in particular males, may
have a sleep apnea Apart from causing repeated sleep
disruption and daytime sleepiness, it may also lead to other problems,
such as hypertension and cardiac arrhythmias. Treatment is with contin-
uous positive airway pressure or surgical procedures on the oropharynx.
Other causes contributing to sleep disruptions in fibromyalgia patients
are bruxism, psychophysiologic insomnia, rhinitis, and acid reflux. Occa-
sional patients have been described with narcolepsy and rapid eye
movement behavioral sleep disturbance. No obvious cause is found for
sleep disruption in most patients, and treatment relies on stressing the
basics of sleep hygiene and the use of low-dose tricyclic antidepressant
medications.l0C19, 25, 35 In part, these work because of the prominent
antihistamine-induced drowsiness and they also increase serotonin lev-
els in the brain; this is an important neurotransmitter in both sleep and
in descending pain inhibitory pathways. There is a considerable varia-
tion in the side-effect profiles of the different tricyclics, mainly de-
pending on their antagonism of histamine and acetylcholine. In practice,
it is often worth giving a patient a 5-day trial of several different
preparations with somewhat different side effects; for instance one might
try amitriptyline, 10 mg/d, nortriptyline, 10 mg/d, and trazadone, 25
mg/d. In addition, the muscle relaxant cyclobenzaprine (Flexeril, 10
mg/d), which has a tricyclic structure, is a proved benefit to some
fibromyalgia patients.lO,l 9
364 BENNETT

Psyche
Most fibromyalgia patients experience psychological distress as a
consequence of chronic pain and its effects on the quality of life; how-
ever, 70% of fibromyalgia patients have no specific psychiatric diagnosis.
Nevertheless, it is important to pick up the psychological problems in
the other 30%. Most commonly they are: dysthymia, depression, anxiety
disorders, and maladaptive pain behavior. Except in the mildest cases,
it is best to coordinate a treatment program with a psychologist or
psychiatrist. Patients with significant depression are initially treated with
antidepressant doses of tricyclic antidepressants. If a good response is
not obtained within 3 months, try switching to one of the selective
serotonin reuptake inhibitors. When used alone, these drugs have been
found to be ineffective in the treatment of FM. When they are used to
treat depression in fibromyalgia patients, one needs to bear in mind
that they may cause increased anxiety and insomnia; this requires the
continuation of a tricyclic antidepressant at night, usually in an interme-
diate dose range. Patients with a history of childhood abuse or other
severe psychological trauma usually need counseling and psychother-
apy. Anxiety disorder in fibromyalgia patients may be part of the depres-
sion complex or a problem of its own. In such cases, graded use of
aprazolam (0.25 to 5 mg/day) often in combination with counseling and
psychotherapy should be considered.
There is a subset of fibromyalgia patients who have become inactive
and deconditioned in an effort to avoid pain. They often become con-
vinced that they can do nothing, including active participation in their
own rehabilitation and continued employability. The general term given
to this vicious cycle is maladaptive pain behavior. This is a really difficult
group of patients to treat. There is often an unrecognized psychiatric
component, including a personality disorder. The combination of fibro-
myalgia symptoms and psychopathology often makes it impossible for
these patients to be competitively employed. This combination needs to
be recognized at an early stage, and appropriate recommendations made
to their employers and disability agencies. There are no objective param-
eters to measure functional disability in fibromyalgia. The question of
disability continues to be one of contention and controvery (see the
article by Frederick Wolfe). An excellent analysis of the contribution of
chronic pain to disability may be found in the latest AMA guides to the
evaluation of permanent impairment.28
-
SUMMARY

There are three realities that need to be understood by both clini-

cians and patients: (1)fibromyalgia is a complex chronic pain condition
 MULTIDISCIPLINARY GROUP PROGRAMS TO TREAT FIBROMYALGIA PATIENTS 365

and current treatment is palliative rather than curative; (2) the major
aim of treatment is to improve function, not abolish pain; and (3) a cycle
of chronic pain, stress, and psychological arousal often generates a set
of secondary symptoms. These secondary symptoms provide a positive
feedback loop that is amenable to modification by cognitive-behavioral
techniques. Multidisciplinary group treatment programs are especially
suited to such techniques; their aim should be to maximize subsequent
clinician-patient interactions. Thus, a current concept of optimal manage-
ment is a blend of multidisciplinary group therapy and individualized
clinician-based treatment.

References

1. Bakal DA, Dernjen S, Kaganov JA: Cognitive behavioural treatment of chronic head-
ache. Headache 21:81-86, 1981
2. Bandura A: Self-efficacy mechanism in physiological activation and health-promoting
behavior. In Madden JIV, Matthysse S, Barchas J (eds): Adaption, Learning and Affect.
New York, Raven Press, 1986
3. Bandura A: Social Foundations of Thought and Action: A Social Cognitive Theory.
Englewood Cliffs, New Jersey, Prentice Hall, 1986
4. Bandura A, O’Leary A, Taylor CB, et al: Perceived self-efficacy and pain control:
Opioid and nonopioid mechanisms. J Pers SOCPsychol 53:563-571, 1987
5. Bandura A, Wood R Effect of perceived controllability and performance standards on
self-regulation of complex decision making. J Pers SOCPsychol 562305-814, 1989
6. Beck AT, Rush AJ, Shaw BF, Emery G: Cognitive Therapy of Depression. New York,
Guilford Press, 1979
7. Bennett RM: Confounding features of the fibromyalgia syndrome: A current perspec-
tive of differential diagnosis. J Rheumatol 19:58-61, 1989
8. Bennett RM: A multidisciplinary approach to treating fibromyalgia. In Vaeroy H,
Merskey H (eds): Progress in Fibromyalgia and Myofascial Pain. Amsterdam, Elsevier,
1993, pp 393410
9. Bennett RM, Burckhardt CS, Clark SR, et al: Multidimensional treatment of fibromyal-
gia: Description and results of a six month out-patient program. J Rheumatol 23:521-
528, 1996
10. Bennett RM, Gatter RA, Campbell SM, et al: A comparison of cyclobenzaprine and
placebo in the management of fibrositis. A double-blind controlled study. Arthritis
Rheum 31:1535-1542, 1988
11. Bradley LA: Behavioral interventions for managing chronic pain. Bull Rheum Dis
4312-5, 1994
12. Bradley LA, Young LD, Anderson KO, et al: Effects of psychological therapy on pain
behavior of rheumatoid arthritis patients. Treatment outcome and six-month followup.
Arthritis Rheum 30:1105-1114, 1987
13. Brimijoin S, Lundberg JM, Brodin E, et al: Axonal transport of substance P in the
vagus and sciatic nerves of the guinea pig. Brain Res 191:443457, 1980
14. Buckelew SP, Murray SE, Hewett JE, et al: Self-efficacy, pain, and physical activity
among fibromyalgia subjects. Arthritis Care and Research 8:43-50, 1995
15. Burckhardt CS, Bjelle A: Education programmes for fibromyalgia patients: Description
and evaluation. Baillieres Clin Rheumatol 8:935-955, 1994
16. Burckhardt CS, Clark SR, Bennett RM: The fibromyalgia impact questionnaire: Devel-
opment and validation. J Rheumatol 18:728-733, 1991
17. Burckhardt CS, Mannerkorpi K, Hedenberg L, et al: A randomized, controlled clinical
trial of education and physical training for women with fibromyalgia. J Rheumatol
21:714-720, 1994
366 BENNETT

18. Burckhardt CS, Woods SL, Schultz AA, et al: Quality of life of adults with chronic
illness: A psychometric study. Res Nurs Health 12:347-354, 1989
19. Carette S, Bell MJ, Reynolds WJ, et al: Comparison of Amitriptyline, Cyclobenzaprine,
and placebo in the treatment of fibromyalgia. Arthritis Rheum 373240, 1994
20. Clark S, Tindall E, Bennett RM: A double blind crossover trial of prednisone versus
placebo in the treatment of fibrositis. J Rheumatol 12:980-983, 1985
21. Coderre TJ, Katz J, Vaccarino AL, et al: Contribution of central neuroplasticity to
pathological pain: Review of clinical and experimental evidence. Pain 52:259-285, 1993
22. de Voogd JN, Knipping AA, de Blecourt ACE, et al: Treatment of fibromyalgia
syndrome with psycho-motor therapy and marital counseling. Scand J Rheumatol
Suppl 94:42, 1992
23. Dubner R, Ruda MA: Activity-dependent neuronal plasticity following tissue injury
and inflammation. Trends Neurosci 15:96-103, 1992
24. Fordyce WE: Behavioral Methods for Chronic Pain and Illness. St. Louis, Mosby, 1976
25. Goldenberg DL A review of the role of tricyclic medications in the treatment of
fibromyalgia syndrome. J Rheumatol Suppl 19:137-139, 1989
26. Goldenberg DL, Kaplan KH, et al: A controlled study of a stress-reduction, cognitive-
behavioral treatment program in fibromyalgia. Journal of Musculoskeletal Pain 2:53-
66, 1994
27. Gonzalez VM, Goeppinger J, Lorig K: Four psychosocial theories and their application
to patient education and clinical practice. Arthritis Care and Research 3:132-143, 1990
28. Drege TC, Houston TP (eds): Guides to the Evaluation of Permanent Impairment.
American Medical Association, 1993
29. Holman H, Mazonson P, Lorig K: Health education for self-management has significant
early and sustained benefits in chronic arthritis. Trans Assoc Am Physicians 102:204-
208, 1989
30. Kleinen J, Gerards FM, Kok G: Self management and the treatment of fibromyalgia: A
randomized controlled trial. Arthritis Care Research 5:S18, 1992
31. Kogstad 0, Heintringer F, Jonsson YM: Patients with fibromyalgia in pain schools.
Scand J Rheumatol 94(suppl):48,1992
32. Lorig K, Lubeck D, Kraines RG, et al: Outcomes of self-help education for patients
with arthritis. Arthritis Rheum 28:680-685, 1985
33. May KP, West SG, Baker MR, et al: Sleep apnea in male patients with the fibromyalgia
syndrome. Am J Med 94:505-508, 1993
34. McCain GA, Bell DA, Mai FM, et al: A controlled study of the effects of a supervised
cardiovascular fitness training program on the manifestations of primary fibromyalgia.
Arthritis Rheum 31:1135-1141, 1988
35. Melzack R, Wall P D Pain mechanisms: A new theory. Science 150:971-979, 1965
36. Mengshoel AM, Forseth KO, Haugen M, et al: Multidisciplinary approach to fibromy-
algia. A pilot study. Clin Rheumatol 14:165-170, 1995
37. Mengshoel AM, Komnaes HB, Forre 0: The effects of 20 weeks of physical fitness
training in female patients with fibromyalgia. Clin Exp Rheumatol 10:349, 1992
38. Mense S Nociception from skeletal muscle in relation to clinical muscle pain. Pain
54~241-289, 1993
39. Nichols DS, Glenn TM: Effects of aerobic exercise on pain perception, affect, and level
of disability in individuals with fibromyalgia. Phys Ther 74:327-332, 1994
40. Nielson WR, Walker C, McCain GA: Cognitive behavioral treatment of fibromyalgia
syndrome: Preliminary findings. J Rheumatol 19:98-103, 1992
41. O’Leary A, Shoor S, Lorig K, et al: A cognitive-behavioral treatment for rheumatoid
arthritis. Health Psychol 7527-544, 1988
42. Ozer EM, Bandura A: Mechanisms governing empowerment effects: A self-efficacy
analysis. J Pers SOCPsychol 58:472486, 1990
43. Parker JC, Frank RG, Beck NC: Pain management in rheumatoid arthritis patients: A
cognitive-behavioural approach. Arthritis Rheum 31:593-601, 1988
44. Rosen NB: Physical medicine and rehabilitation approaches to the management of
myofascial pain and fibromyalgia syndromes. Baillieres Clin Rheumatol 82381-916,
1994
 MULTIDISCIPLINARY GROUP PROGRAMS TO TREAT FIBROMYALGIA PATIENTS 367

45. Rosenthiel AK, Keefe FJ: The use of coping strategies in chronic low back pain patients:
Relationship to patient characteristics and current adjustment. Pain 1733-44, 1983
46. Sharpe MC: CIBA Foundation Symposium 173. Toronto, John Wiley and Sons, 1993
47. Sharpe MC: Cognitive behavior therapy and treatment of chronic fatigue syndrome.
Journal of Musculoskeletal Pain 3:141-147, 1995
48. Simms RW: Controlled trials of therapy in fibromyalgia syndrome. Baillieres Clin
Rheumatol 8:917-934, 1994
49. Stenn PG, Mothersell KJ, Brooke RI: Biofeedback and a cognitive-behavioural approach
to treatment of myofascial pain dysfunction syndrome. Behav Ther 10:29-36, 1979
50. Tan SY: Cognitive and cognitive-behavioral methods for pain control: A selective
review. Pain 12:201-228, 1982
51. Travel1 JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual.
Baltimore, Williams & Wilkins, 1983
52. Turk DC, Meichenbaum D, Genest M: Pain and Behavioral Medicine: A Cognitive-
Behavioral Perspective. New York, Guilford, 1983
53. Turner J A Comparison of group progressive relaxation training and cognitive-behav-
ioural therapy for chronic low back pain. J Consult Clin Psychol 50:757-765, 1982
54. Turner JA, Chapman CR: Psychological interventions for chronic pain: A critical
review. 11. Operant conditioning, hypnosis, and cognitive behavioral therapy. Pain
12:2346, 1982
55. Walco GA, Ilowite NT: Cognitive-behavioral intervention for juvenile primary fibro-
myalgia syndrome. J Rheumatol 19:1617-1619, 1992
56. Wall PD, Woolf CJ: Muscle but not cutaneous C-afferent input produces prolonged
increases in the excitability of the flexion reflex in the rat. J Physiol 356:443-458, 1984
57. White KE, Nielson WA: Cognitive behavioral treatment of fibromyalgia syndrome:
Follow up assessment. J Rheumatol 22:717-721, 1995
58. Wolfe F, Smythe HA, Yunus MB, et a1 The American College of Rheumatology
1990 criteria for the classification of fibromyalgia: Report of the Multicenter Criteria
Committee. Arthritis Rheum 33:160-172, 1990
59. Wood R, Bandura A: Impact of conceptions of ability on self-regulatory mechanisms
and complex decision making. J Pers SOCPsychol 56:407415, 1989

Address reprint requests to

Robert M. Bennett, MD
Department of Medicine (L329A)
Oregon Health Sciences University
Portland, OR 97201