Recent research suggests that cognitive behavioral therapy can improve the lives of children and adolescents suffering from fibromyalgia. The condition affects between two and seven percent of school-aged children, primarily adolescent girls. It causes widespread pain, fatigue, disrupted sleep and mood disturbances.
Patients have “substantial physical, school, social and emotional impairments,” says Dr. Susmita Kashikar-Zuck of Cincinnati Children’s Hospital Medical Center in Ohio. As there is no solid evidence for the effectiveness of current treatments, Dr Kashikar-Zuck and her colleagues carried out a randomized trial of cognitive behavioral therapy (CBT).
They recruited 114 adolescents between the ages of 11 and 18 years who suffered from juvenile fibromyalgia. Usual medical care was given for eight weeks. While some patients then saw a psychologist for eight weekly CBT sessions plus two booster sessions over six months, others simply received education on disease management.
CBT was found to be “significantly superior” to disease education at reducing functional disability, showing a 37 percent improvement vs. 12 percent.
Depression scores dropped in both groups, with the average score for both groups falling into the range of normal/healthy. The researchers say, “This implies that attention and support from health care providers via intensive weekly individual sessions can in and of themselves reduce emotional distress.”
They add, “These nonspecific positive effects were also observed in both groups on more global measures of patient-reported health-related quality of life. However, CBT clearly had the additional benefit of significantly improving daily functioning over and above the positive effects on overall well-being.”
Nevertheless, pain was not reduced significantly (i.e. by 30 percent or more) in either group. The effects on sleep quality also were very small, and the sensitivity of so-called “tender points” was mostly unchanged. But the authors say it is encouraging that a marked improvement in the patients’ ability to carry out previously avoided activities such as going to school, doing chores, going out with friends, and the like was achieved without increasing pain or interfering with sleep.
Almost 90 percent of the participants completed the treatment plans and followups. Much of the high retention could probably be attributed to the strong relationship that participants and parents developed with the therapists, say the researchers, because anecdotal reports were positive and treatment credibility ratings at the end of the study were high.
Details were published in the journal Arthritis & Rheumatism. The authors conclude, “In this controlled trial, cognitive behavioral therapy was found to be a safe and effective treatment for reducing functional disability and depressive symptoms in adolescents with juvenile fibromyalgia.” They add that, when added to usual medical care, CBT was “clearly the superior choice for the treatment of juvenile fibromyalgia.”
Dr. Kashikar-Zuck said, “When added to standard medical care, cognitive behavioral therapy helps to improve daily functioning and overall well-being for adolescents with fibromyalgia. All the research we’re doing shows this is something that can and should be managed early, and when left untreated can essentially lead to long-term problems.”
Interestingly, the relatively strong improvements found in this study contrast with quite small improvements in studies of adult fibromyalgia. One reason for this, the experts suggest, might be that adults with fibromyalgia have likely had the symptoms and their related dysfunctions for many more years.
Furthermore, involving the patients’ parents may have “increased support in the family environment to enhance or maintain treatment effects,” the experts write. They suggest that early identification and effective treatment of symptoms that are first noticed in adolescence “might mitigate long-term problems with disability.”
They call for further followup studies to examine longer-term effects of CBT. They also propose that future research tests whether CBT can be used to increase the patient’s ability to exercise more vigorously, and whether this combination of CBT plus exercise leads to improved functioning or reduced pain. The addition of specifically-targeted sleep training within CBT might be useful, they add.
Internet-based CBT may be another possibility for the treatment of pain in children. It has been shown to be safe, and to impart self-management skills which are sustained for at least six months after the end of treatment. This approach could be modified for use in young fibromyalgia patients, say the experts.
Kashikar-Zuck, S. et al. A Randomized Clinical Trial of Cognitive Behavioral Therapy for the Treatment of Juvenile Fibromyalgia. Arthritis & Rheumatism. Published online November 22, 2011