Cognitive Behavior Therapy, Exercise Improves Chronic Widespread Pain

A recent study reported in the Archives of Internal Medicine [2012;172(1):48-57] has demonstrated that telephone-delivered cognitive behavior therapy (TCBT) and exercise, alone or in combination, provided statistically significant and sustained gains in patient global assessment compared with usual care. The study included primary care patients with chronic widespread pain (CWP), a prominent feature of fibromyalgia. Patients were identified through a mailed screening questionnaire. Eligible participants reported CWP, classified according to the definition used in the American College of Rheumatology criteria for fibromyalgia, for which they had received care through their primary care physician in the past year. Patients were excluded from the trial if they had a severe comorbid psychiatric disorder, contraindications for exercise, or a condition for which the interventions were not indicated, such as CWP associated with metastatic cancer. Patients were randomized to the TCBT intervention, an exercise regimen, a combined intervention of TCBT and exercise, or usual care. A total of 442 patients were included in the study, and received the randomized intervention over a period of 6 months. The primary outcome was change in patient global assessment as measured on a 7-point scale. Assessments were conducted at baseline, 6 months, and 9 months after randomization. The TCBT intervention consisted of an initial assessment of 45 to 60 minutes, followed by 7 weekly sessions (30-45 minutes each), 1 session at 3 months after randomization, and 1 session 6 months after randomization. All sessions were conducted by telephone. The exercise intervention was consistent with the American College of Sports Medicine guidelines for improving cardiorespiratory fitness. The combined intervention included both of these treatments, and the usual care group was treated for CWP at the discretion of their local primary care physician without additional intervention. Positive outcome rates (responses of “much better” or “very much better”) at 6 and 9 months after randomization were 8.1% and 8.3%, respectively, in the usual care group. These rates contrasted with positive outcome rates of 29.9% and 32.6% in the TCBT group, 34.8% and 24.2% in the exercise group, and 37.2% and 37.1% in the combination group. The TCBT, exercise, and combined interventions were all associated with nonsignificant increases in quality-adjusted life-years. The authors concluded that both the TCBT and exercise interventions, either alone or in combination, have the potential to provide substantial, significant, and clinically meaningful improvements in self-rated global health in patients with CWP. They noted that the effective treatment of fibromyalgia, which is characterized by CWP, is challenging, and that multidisciplinary physical and psychological approaches are recommended, despite a lack of evidence from previous studies demonstrating consistent benefits. The primary study limitation noted by the authors was the fact that patients were identified through a mailed questionnaire, and not during a primary care consultation. As such, patients seeking care for CWP could have been misidentified. Usual care was not characterized and could have consisted of a variety of interventions, the authors added. The sample size was also small and could limit the strength of the study findings. Finally, the authors noted that social desirability bias could have resulted in patients reporting higher levels of disability and lower levels of psychological symptoms, although previous studies had demonstrated a lack of effect with this phenomenon. Overall, the authors concluded that at least short-term improvements with CBT and exercise are possible in a substantial proportion of patients with CWP.