EDITORIAL For reprint orders, please contact: [email protected]
Treating juvenile fibromyalgia: cognitive–behavioral therapy, exercise and pharmacotherapy
Dan Buskila*1
Jacob N Ablin2
Fibromyalgia (FM) is an idiopathic chronic pain syndrome defined by widespread non articular musculoskeletal pain and diffuse tenderness. Juvenile FM (JF) has been less studied than FM in adults, although the clinical features of FM in children are similar [1]. JF is a frustrating condition, affecting children and adolescents at a crucial stage of their physical and emotional development [2]. Since JF is a complex syndrome associated with a wide range of symptoms, treatment should be tailored to the individual child, targeting their most distressing symptoms. A multidisciplinary approach to treatment should be implemented, incorporating edu cation, cognitive–behavioral therapy (CBT) and physical exercise, with a certain role for pharmacological treatment. Cognitive–behavioral therapy CBT is a psychotherapeutic approach that aims to influence maladaptive and dysfunc tional emotions, cognitions and behav iors through a goal-oriented systematic procedure. Several studies have addressed the effect of CBT on JF patients. In total, 67
“Controlled, well-designed studies are needed to assess the applicability of newer drugs, which are FDA approved in adult fibromyalgia, for the management of juvenile fibromyalgia, as well as novel therapeutic medications.” children suffering from JF and their par ents were recruited to participate in an 8-week intervention that included modules on pain management, psychoeducation, sleep hygiene and activities of daily liv ing. Children were taught techniques of cognitive restructuring, thought stopping, distraction, relaxation and sleep reward [3]. Following CBT, children reported signif icant reductions in pain, somatic symptoms, anxiety and fatigue, as well as improvement in sleep quality. Additionally, children reported improved functional ability and had fewer school absences [3]. Kashikar-Zuck et al. reported a multi site, single-blind randomized clinical trial, the objective of which was to test whether CBT was superior to FM education in reducing functional disability, pain and symptoms of depression in JF [4]. CBT was found to be a safe and effective treat ment for reducing functional disability and symptoms of depression in adolescents with JF [4]. CBT intervention was not associated with increased physical activity in adoles cents with JF [5]. The authors suggest that this indicates that combining CBT with
“A multidisciplinary approach to treatment should be implemented…”
Department of Medicine H, Soroka Medical Center & Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel 2 Institute of Rheumatology, Tel Aviv Sourasky Medical Center & Sackler Faculty of Tel Aviv University, Tel Aviv, Israel *Author for correspondence: Tel.: +972 507 883 360; [email protected] 1
10.2217/PMT.13.37 © 2013 Future Medicine Ltd
Pain Manage. (2013) 3(5), 323–324
part of
ISSN 1758-1869
323
Editorial Buskila & Ablin interventions to increase physical activity may enhance treatment effects [5]. A recent study examined changes in pain cop ing, catastrophizing and coping efficacy after CBT in 100 children and adolescents [6]. CBT led to significant improvements in pain coping catastrophizing and efficacy that were sustained over time in adolescents with JF. The authors con cluded that clinicians treating adolescents with JF should focus on teaching a variety of adaptive coping strategies to help patients simultaneously regain functioning and improve mood [6].
“Surprisingly, little evidence is available regarding the pharmacological treatment of juvenile fibromyalgia.”
Exercise Exercise interventions in adults who have FM have been successful in improving quality of life, physical fitness and reducing fatigue and pain. A randomized controlled trial of a 12-week exercise intervention in JF subjects demonstrated significant improvements in functional capacity, physical function, quality of life and fatigue in children treated with aerobic exercise of moder ate intensity [7]. Exercise has been shown to be effective in a variety of pediatric rheumatic conditions, including juvenile idiopathic arthritis, juve nile systemic lupus erythematosus and juvenile dermatomyositis, as well as JF. Pharmacologic treatment Surprisingly, little evidence is available regard ing the pharmacological treatment of JF. There have been no well-controlled systematic studies of drugs in JF. While three medications, includ ing two serotonin–norepinephrine reuptake inhibitors (duloxetine and milnacipran) and one a-2-d ligand (pregabalin), have been approved by the US FDA for the treatment of FM in adults [8], none of these medications have been tested
References
5
1
Buskila D. Pediatric fibromyalgia. Rheum. Dis. Clin. North. Am. 35, 253–261 (2009).
2
Buskila D, Ablin J. Pediatric fibromyalgia. Reumatismo 64, 230–237 (2012).
3
Degotardi PJ, Klass ES, Rosenberg BS et al. Development and evaluation of a cognitive behavioral intervention for juvenile fibromyalgia. J. Pediatr. Psychol. 31, 714–723 (2006).
4
Kashikar-Zuck S, Ting TV, Arnold LM et al. Cognitive behavioral therapy for the treatment of juvenile fibromyalgia. Arthritis Rheum. 64, 297–305 (2012).
324
6
7
in well-controlled trials in JF. Analgesics and NSAIDs are not very effective. Thus, for the time being, the management of JF must rely on the implementation of nonpharmacological interventions. JF causes considerable impairment in quality of life, disrupts social and educational achieve ments, and is a cause for frustration and concern for patients and their parents. Despite that, JF appears to carry a better prognosis when com pared with FM in adults. Buskila et al. assessed the outcome of JF in a 30-month follow-up study in children who suffered from JF. After 30 months, 73%, of the children who had JF were no longer fibromyalgic [9]. Siegel and col leagues found that the majority of JF patients improved over 2–3 years of follow-up [10]. JF and especially its pharmacological manage ment have been less studied than FM in adults. Thus, the management of JF is centered on the issues of education, CBT and physical exercise, with a relatively minor role for pharmacologi cal treatment, with muscle relaxants, analgesics and tricyclic agents. Controlled, well-designed studies are needed to assess the applicability of newer drugs, which are FDA approved in adult FM, for the management of JF, as well as novel therapeutic medications. Financial & competing interests disclosure The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.
Kashikar-Zuck. S, Flowers SR, Strotman D et al. Physical activity monitoring in adolescents with juvenile fibromyalgia: findings from a clinical trial of cognitive behavioral therapy. Arthritis Care Res. 65, 398–405 (2013). Kashikar-Zuck S, Sil S, Lynch-Jordan AM et al. Changes in pain coping, catastrophizing and coping efficacy after cognitive behavioral therapy in children and adolescents with juvenile fibromyalgia. J. Pain 14, 492–501 (2013). Stephens S, Feldman BM, Bradely N et al. Feasibility and effectiveness of an aerobic exercise program in children with
Pain Manage. (2013) 3(5)
fibromyalgia: results of a randomized controlled pilot trial. Arthritis Rheum. 59, 1399–1406 (2008). 8
Crofford LJ. Pain management in fibromyalgia. Curr. Opin. Rheumatol. 20, 246–250 (2008).
9
Buskila D, Neumann L, Hershman E et al. Fibromyalgia syndrome in children – an outcome study. J. Rheumstol. 22, 525–528 (1995).
10 Siegel DM, Janeway D, Braun J. Fibromyalgia
syndrome in children and adolescents: clinical features at presentation and status at follow-up. Pediatrics 101, 377–382 (1998).
future science group
Treating juvenile fibromyalgia: cognitive–behavioral therapy, exercise and pharmacotherapy
Dan Buskila*1
Jacob N Ablin2
Fibromyalgia (FM) is an idiopathic chronic pain syndrome defined by widespread non articular musculoskeletal pain and diffuse tenderness. Juvenile FM (JF) has been less studied than FM in adults, although the clinical features of FM in children are similar [1]. JF is a frustrating condition, affecting children and adolescents at a crucial stage of their physical and emotional development [2]. Since JF is a complex syndrome associated with a wide range of symptoms, treatment should be tailored to the individual child, targeting their most distressing symptoms. A multidisciplinary approach to treatment should be implemented, incorporating edu cation, cognitive–behavioral therapy (CBT) and physical exercise, with a certain role for pharmacological treatment. Cognitive–behavioral therapy CBT is a psychotherapeutic approach that aims to influence maladaptive and dysfunc tional emotions, cognitions and behav iors through a goal-oriented systematic procedure. Several studies have addressed the effect of CBT on JF patients. In total, 67
“Controlled, well-designed studies are needed to assess the applicability of newer drugs, which are FDA approved in adult fibromyalgia, for the management of juvenile fibromyalgia, as well as novel therapeutic medications.” children suffering from JF and their par ents were recruited to participate in an 8-week intervention that included modules on pain management, psychoeducation, sleep hygiene and activities of daily liv ing. Children were taught techniques of cognitive restructuring, thought stopping, distraction, relaxation and sleep reward [3]. Following CBT, children reported signif icant reductions in pain, somatic symptoms, anxiety and fatigue, as well as improvement in sleep quality. Additionally, children reported improved functional ability and had fewer school absences [3]. Kashikar-Zuck et al. reported a multi site, single-blind randomized clinical trial, the objective of which was to test whether CBT was superior to FM education in reducing functional disability, pain and symptoms of depression in JF [4]. CBT was found to be a safe and effective treat ment for reducing functional disability and symptoms of depression in adolescents with JF [4]. CBT intervention was not associated with increased physical activity in adoles cents with JF [5]. The authors suggest that this indicates that combining CBT with
“A multidisciplinary approach to treatment should be implemented…”
Department of Medicine H, Soroka Medical Center & Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel 2 Institute of Rheumatology, Tel Aviv Sourasky Medical Center & Sackler Faculty of Tel Aviv University, Tel Aviv, Israel *Author for correspondence: Tel.: +972 507 883 360; [email protected] 1
10.2217/PMT.13.37 © 2013 Future Medicine Ltd
Pain Manage. (2013) 3(5), 323–324
part of
ISSN 1758-1869
323
Editorial Buskila & Ablin interventions to increase physical activity may enhance treatment effects [5]. A recent study examined changes in pain cop ing, catastrophizing and coping efficacy after CBT in 100 children and adolescents [6]. CBT led to significant improvements in pain coping catastrophizing and efficacy that were sustained over time in adolescents with JF. The authors con cluded that clinicians treating adolescents with JF should focus on teaching a variety of adaptive coping strategies to help patients simultaneously regain functioning and improve mood [6].
“Surprisingly, little evidence is available regarding the pharmacological treatment of juvenile fibromyalgia.”
Exercise Exercise interventions in adults who have FM have been successful in improving quality of life, physical fitness and reducing fatigue and pain. A randomized controlled trial of a 12-week exercise intervention in JF subjects demonstrated significant improvements in functional capacity, physical function, quality of life and fatigue in children treated with aerobic exercise of moder ate intensity [7]. Exercise has been shown to be effective in a variety of pediatric rheumatic conditions, including juvenile idiopathic arthritis, juve nile systemic lupus erythematosus and juvenile dermatomyositis, as well as JF. Pharmacologic treatment Surprisingly, little evidence is available regard ing the pharmacological treatment of JF. There have been no well-controlled systematic studies of drugs in JF. While three medications, includ ing two serotonin–norepinephrine reuptake inhibitors (duloxetine and milnacipran) and one a-2-d ligand (pregabalin), have been approved by the US FDA for the treatment of FM in adults [8], none of these medications have been tested
References
5
1
Buskila D. Pediatric fibromyalgia. Rheum. Dis. Clin. North. Am. 35, 253–261 (2009).
2
Buskila D, Ablin J. Pediatric fibromyalgia. Reumatismo 64, 230–237 (2012).
3
Degotardi PJ, Klass ES, Rosenberg BS et al. Development and evaluation of a cognitive behavioral intervention for juvenile fibromyalgia. J. Pediatr. Psychol. 31, 714–723 (2006).
4
Kashikar-Zuck S, Ting TV, Arnold LM et al. Cognitive behavioral therapy for the treatment of juvenile fibromyalgia. Arthritis Rheum. 64, 297–305 (2012).
324
6
7
in well-controlled trials in JF. Analgesics and NSAIDs are not very effective. Thus, for the time being, the management of JF must rely on the implementation of nonpharmacological interventions. JF causes considerable impairment in quality of life, disrupts social and educational achieve ments, and is a cause for frustration and concern for patients and their parents. Despite that, JF appears to carry a better prognosis when com pared with FM in adults. Buskila et al. assessed the outcome of JF in a 30-month follow-up study in children who suffered from JF. After 30 months, 73%, of the children who had JF were no longer fibromyalgic [9]. Siegel and col leagues found that the majority of JF patients improved over 2–3 years of follow-up [10]. JF and especially its pharmacological manage ment have been less studied than FM in adults. Thus, the management of JF is centered on the issues of education, CBT and physical exercise, with a relatively minor role for pharmacologi cal treatment, with muscle relaxants, analgesics and tricyclic agents. Controlled, well-designed studies are needed to assess the applicability of newer drugs, which are FDA approved in adult FM, for the management of JF, as well as novel therapeutic medications. Financial & competing interests disclosure The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.
Kashikar-Zuck. S, Flowers SR, Strotman D et al. Physical activity monitoring in adolescents with juvenile fibromyalgia: findings from a clinical trial of cognitive behavioral therapy. Arthritis Care Res. 65, 398–405 (2013). Kashikar-Zuck S, Sil S, Lynch-Jordan AM et al. Changes in pain coping, catastrophizing and coping efficacy after cognitive behavioral therapy in children and adolescents with juvenile fibromyalgia. J. Pain 14, 492–501 (2013). Stephens S, Feldman BM, Bradely N et al. Feasibility and effectiveness of an aerobic exercise program in children with
Pain Manage. (2013) 3(5)
fibromyalgia: results of a randomized controlled pilot trial. Arthritis Rheum. 59, 1399–1406 (2008). 8
Crofford LJ. Pain management in fibromyalgia. Curr. Opin. Rheumatol. 20, 246–250 (2008).
9
Buskila D, Neumann L, Hershman E et al. Fibromyalgia syndrome in children – an outcome study. J. Rheumstol. 22, 525–528 (1995).
10 Siegel DM, Janeway D, Braun J. Fibromyalgia
syndrome in children and adolescents: clinical features at presentation and status at follow-up. Pediatrics 101, 377–382 (1998).
future science group
