OBJECTIVES:Healthcare use in fibromyalgia (FM) is relatively high. Besides disease-related variables, cognitive-behavioural factors have been concurrently associated with healthcare use. It is unknown whether cognitive-behavioural and social factors also predict future healthcare use. The aim of this study was to identify cognitive-behavioural and social factors predicting recurrent secondary healthcare use in FM.METHODS:Using self-reported questionnaires, healthcare use, cognitive-behavioural, social, sociodemographic and disease-related variables including comorbidities were collected in 199 patients with FM, in a prospective longitudinal cohort spanning 18 months. Patients were recruited after receiving their diagnosis and protocolled treatment advice by a rheumatologist. Univariate and multivariate logistic regression models examined whether and which variables were predictors for recurrent secondary healthcare use. Internal validation was performed to correct for over-fit of the final multivariate model.RESULTS:Recurrent secondary healthcare use was lower than initial secondary healthcare use. Univariate analysis showed that having at least one comorbidity, depressive feelings, severe consequences of FM, low personal control and a high severity of fibromyalgia predicted recurrent secondary healthcare use. In the multivariate model, having at least one comorbidity was the only remaining predictor for recurrent secondary healthcare use.CONCLUSIONS:Our results suggest that the existence of comorbidities as communicated by the patient is the strongest warning signal for recurrent secondary healthcare use in FM. There seems no value in using cognitive-behavioural and social factors for early identification of patients with FM at risk for recurrent secondary healthcare use.

OBJECTIVES:To determine if experienced health care providers (HCPs) can recognise patients with fibromyalgia (FM) based on a limited set of personality items, exploring the existence of a FM personality.METHODS:From the 240-item NEO-PI-R personality questionnaire, 8 HCPs from two different countries each selected 20 items they considered most discriminative of FM personality. Then, evaluating the scores on these items of 129 female patients with FM and 127 female controls, each HCP rated the probability of FM for each individual on a 0-10 scale. Personality characteristics (domains and facets) of selected items were determined. Scores of patients with FM and controls on the eight 20-item sets, and HCPs' estimates of each individual's probability of FM were analysed for their discriminative value.RESULTS:The eight 20-item sets discriminated for FM, with areas under the receiver operating characteristic curve ranging from 0.71-0.81. The estimated probabilities for FM showed, in general, percentages of correct classifications above 50%, with rising correct percentages for higher estimated probabilities. The most often chosen and discriminatory items were predominantly of the domain neuroticism (all with higher scores in FM), followed by some items of the facet trust (lower scores in FM).CONCLUSIONS:HCPs can, based on a limited set of items from a personality questionnaire, distinguish patients with FM from controls with a statistically significant probability. The HCPs' expectation that personality in FM patients is associated with higher levels for aspects of neuroticism (proneness to psychological distress) and lower scores for aspects of trust, proved to be correct.

OBJECTIVES:The disease impact and economic burden of fibromyalgia (FM) are high for patients and society at large. Knowing potential determinants of economic costs may help in reducing this burden. Cognitive appraisals (perceptions) of the illness could affect costs. The present study estimated costs of illness in FM and examined the association between these costs and illness perceptions.METHODS:Questionnaire data of FM severity (FIQ), illness perceptions (IPQ-R-FM), productivity losses (SF-HLQ) and health care use were collected in a cohort of patients with FM. Costs were calculated and dichotomised (median split). Univariate and hierarchic logistic regression models examined the unique association of each illness perception with 1) health care costs and 2) costs of productivity losses. Covariates were FM severity, comorbidity and other illness perceptions.RESULTS:280 patients participated: 95% female, mean age 42 (SD=12) years. Annualised costs of FM per patient were €2944 for health care, and €5731 for productivity losses. In multivariate analyses, a higher disease impact (FIQ) and two of seven illness perceptions (IPQ-R-FM) were associated with high health care costs: 1) high scores on 'cyclical timeline' reflecting a fluctuating, unpredictable course and 2) low scores on 'emotional representations', thus not perceiving a connection between fibromyalgia and emotions. None of the variables was associated with productivity losses.CONCLUSIONS:Our study indicates that perceiving a fluctuating course and low emotional representation, which perhaps reflects somatic fixation, are associated with health care costs in FM. Future studies should examine whether targeting these illness perceptions results in reduction of costs.

Background Patients with Fibromyalgia (FM) experience a high disease burden, leading to substantial economic costs (1). These costs may be due to the chronic nature of FM, dissatisfaction with the diagnosis, lack of a uniform and effective treatment, and perhaps also beliefs of individuals. Investigating potential determinants of costs is pivotal for reducing the economic burden of FM. Several clinical and demographic factors are associated with costs in FM, but the influence of illness perceptions on costs is unknown. Illness perceptions refer to beliefs about timeline and course, consequences, control, illness coherence and emotional representation of a disease (2). As illness perceptions can be targeted in treatment, investigating whether illness perceptions may influence costs in FM is warranted. Objectives To examine the relationship between illness perceptions and costs in patients with FM, taking clinical factors into account. Methods Baseline data from a cohort of patients with FM were used. Clinical data, severity of FM (FIQ), and illness perceptions (IPQ-R-FM) were gathered. Cost data were based on self-reported questionnaires assessing health care use (e.g. consultation, medication use), work absenteeism and presenteeism, and productivity losses (SF-HLQ). Cost data were dichotomized by median split (high versus low costs). Descriptive statistics were computed. Two hierarchic logistic regression models were used to examine the unique association of illness perceptions with 1) health care costs and 2) costs of work absenteeism, presenteeism and productivity losses. Severity of FM and comorbidities were potential covariates for costs. In both hierarchic models step 1 included the potential covariates and step 2 included the seven illness perception dimensions. Results 280 patients participated in this study. Mean age of the study sample was 42 years (SD=11.8), the majority was female (95%), mean severity of FM was 58.6 (SD=14.9), and 78% had ≥1 comorbidities. A high score on severity of FM (P=.04), a high score on IPQ-dimension consequences (P=.03) and a low score on IPQ-dimension emotional representation (P<.01) were associated with high health care costs. Comorbidities was not associated with health care costs (P=.12). This model explained 7% of the variance. None of the variables were significantly associated with costs of work absenteeism, presenteeism and productivity losses. Conclusions Most illness perceptions are not related to costs in FM. Only patients perceiving more negative consequences of FM on daily life and perceiving less distress of FM have higher health care costs, when correcting for the severity of FM. Our results do not indicate that targeting illness perceptions will result in a reduction of costs. References Boonen A, et al. Large differences in cost of illness and wellbeing between patients with fibromyalgia, chronic low back pain, or ankylosing spondylitis. Ann Rheum Dis 2005; 64(3):396-402. Leventhal H, et al. Illness representations and coping with health threats. Lawrence Erlbaum Associates; 1984. Disclosure of Interest None declared

Fibromyalgie is een veelvoorkomend pijnsyndroom, waarvan de oorzaak grotendeels onbekend is. Een standaardbehandeling van fibromyalgie is er niet. De behandeling wordt afgestemd op de ernst van de klachten, de wijze waarop deze door de patiënt begrepen en gehanteerd worden en de mate waarin deze interfereren met het dagelijks leven. Patiënten met fibromyalgie worden bij voorkeur in de eerste lijn behandeld. Pijnmedicatie is niet werkzaam.

Objective. The heterogeneity of cognitive-behavioral patterns in patients with fibromyalgia (FM) has been proposed to underlie the variability in treatment outcomes. It has previously been shown that pain-avoidance and pain-persistence treatments tailored to the patient's pattern are effective in improving physical and psychological functioning and overall impact in high-risk patients with heigthened psychological distress. In the present study, the cognitive-behavioral effects of these treatments were evaluated to provide insight into the main proposed mechanisms, specifically pain-avoidance behaviors and activity pacing in the pain-avoidance and pain-persistence treatments, respectively.Methods. High-risk FM patients were classified into 2 groups, pain avoidance and pain persistence, and randomized in groups to the relevant treatment or waiting-list control condition. The pain-avoidance and pain-persistence treatments both comprised 16 twice-weekly sessions of cognitive-behavioral therapy and exercise training. Cognitive-behavioral factors assessed at pre- and posttreatment and 6 months of followup were evaluated using linear mixed models.Results. A significant treatment effect was found for pain-avoidance behavior in the pain-avoidance treatment and for activity pacing in the pain-persistence treatment, showing improvements in the treatment condition relative to the controls. Furthermore, the effect on functioning was mediated by changes in pain-avoidance behavior in the pain-avoidance treatment and by changes in activity pacing in the pain-persistence treatment. Both treatments also showed significant improvements in other relevant cognitive-behavioral factors.Conclusion. Both the pain-avoidance and pain-persistence treatments are effective in improving cognitive-behavioral factors in high-risk FM patients. Pain-avoidance behavior and activity pacing might be important mediating mechanisms for beneficial outcomes in pain-avoidance and pain-persistence treatments, respectively.

Objectives Patients with fibromyalgia have diminished levels of physical fitness, which may lead to functional disability and exacerbating complaints. Multidisciplinary treatment comprising cognitive–behavioural therapy (CBT) and exercise training has been shown to be effective in improving physical fitness. However, due to the high drop-out rates and large variability in patients' functioning, it was proposed that a tailored treatment approach might yield more promising treatment outcomes. Methods High-risk fibromyalgia patients were randomly assigned to a waiting list control group (WLC) or a treatment condition (TC), with the treatment consisting of 16 twice-weekly sessions of CBT and exercise training tailored to the patient's cognitive–behavioural pattern. Physical fitness was assessed with two physical tests before and 3 months after treatment and at corresponding intervals in the WLC. Treatment effects were evaluated using linear mixed models. Results The level of physical fitness had improved significantly in the TC compared with the WLC. Attrition rates were low, effect sizes large and reliable change indices indicated a clinically relevant improvement among the TC. Conclusions A tailored multidisciplinary treatment approach for fibromyalgia consisting of CBT and exercise training is well tolerated, yields clinically relevant changes, and appears a promising approach to improve patients' physical fitness. ClinicalTrials.gov ID NCT00268606

OBJECTIVE:To illustrate a multidisciplinary group treatment for patients with fibromyalgia (FM) tailored to the patient's cognitive-behavioral pattern. METHOD:In a case-study design the tailored treatment approaches of two FM patients were described. One patient characterized by avoidance behavior (pain-avoidance pattern) participated in a group treatment aimed at changing pain-avoidance mechanisms and one patient characterized by continuing with activities in spite of pain (pain-persistence pattern) participated in a group treatment aimed at changing pain-persistence mechanisms. Assessments were made at baseline, post-treatment and at 6-months follow-up. RESULTS:Comparison of the pretest, post-test and follow-up scores on pain, functional disability, fatigue and psychological distress showed clinically significant improvements for both patients. CONCLUSION:The heterogeneity of patients regarding pain-related cognitive-behavioral mechanisms has been proposed to underlie varying treatment outcomes in FM patients. These results demonstrate that a group treatment tailored to pain-avoidance and pain-persistence patterns is feasible and can result in clinically significant changes for FM patients. PRACTICE IMPLICATIONS:FM offers a great challenge for clinicians due to the lack of effective treatment options. These case studies suggests that tailored CBT and exercise training directed at specific patient patterns can contribute to the improvement of the care of FM patients.

Background : The heterogeneity of patients regarding pain-related cognitive-behavioral mechanisms, such as pain-avoidance and pain-persistence patterns, has been proposed to underlie varying treatment outcomes in patients with fibromyalgia ( FM ). Purpose : To investigate the validity of a screening instrument to discriminate between pain-persistence and pain-avoidance patterns in FM. Method : In a three-part study, a self-reported screening instrument that assesses pain-avoidance behavior was used to distinguish patients with pain-persistence and pain-avoidance patterns. The resultant groups were compared with regard to several pain-related cognitive-behavioral factors, performance on a physical fitness test, and with regard to the judgments of trained therapists based on a semi-structured interview. Results : The validity of the screening instrument to distinguish between pain-avoidance and pain-persistence patterns was supported by other validated self-report questionnaires for pain-related cognitive-behavioral factors, physical exercise tests, as well as by a high correspondence with blinded therapist judgment after intake assessments. Conclusion : These findings suggest that a short self-report screening instrument can be used to distinguish between pain-avoidance and pain-persistence patterns within the heterogeneous population of FM patients, which offers promising possibilities to improve treatment efficacy by tailoring treatment to specific patient patterns.

Samenvatting Fibromyalgie is een chronisch pijnsyndroom waarvan de etiologie onbekend is. Het belangrijkste criterium is de aanwezigheid van wijdverspreide pijn die langer dan drie maanden bestaat, samen met een pijngevoeligheid ter hoogte van minstens elf van achttien tender points. Dit zijn nauwkeurig omschreven punten op het lichaam die bij uitoefening van een bepaalde druk pijnlijk zijn. Behalve pijn rapporteren patiënten vaak symptomen als vermoeidheid, slaapproblemen, ochtendstijfheid, darmklachten, angst en depressieve gevoelens (Wolfe e.a., 1990). De prevalentie van fibromyalgie wordt in westerse landen geschat op 2 procent van de algemene bevolking en het syndroom komt vaker voor bij vrouwen dan bij mannen (Wolfe e.a., 1995).

This review provides an overview of the effects of non-pharmacological treatments for patients with fibromyalgia (FM), including cognitive-behavioural therapy, exercise training programmes, or a combination of the two. After summarising and discussing preliminary evidence of the rationale of non-pharmacological treatment in patients with FM, we reviewed randomised, controlled trials for possible predictors of the success of treatment such as patient and treatment characteristics. In spite of support for their suitability in FM, the effects of non-pharmacological interventions are limited and positive outcomes largely disappear in the long term. However, within the various populations with FM, treatment outcomes showed considerable individual variations. In particular, specific subgroups of patients characterised by relatively high levels of psychological distress seem to benefit most from non-pharmacological interventions. Preliminary evidence of retrospective treatment analyses suggests that the efficacy may be enhanced by offering tailored treatment approaches at an early stage to patients who are at risk of developing chronic physical and psychological impairments.

This review provides an overview of the effects of non-pharmacologica I treatments for patients with fibromyalgia (FM), including cognitive behavioral therapy, exercise training programmes, or a combination of the two. After summarizing and discussing preliminary evidence of the rationale of non-pharmacological treatment in patients with FM, we reviewed randomized, controlled trials for possible predictors of the success of treatment such as patient and treatment characteristics. In spite of support for their suitability in FM, the effects of nonpharmacological interventions are limited and positive outcomes largely disappear in the long-term. However, within the various populations with FM, treatment outcomes showed considerable individual variations. In particular, specific subgroups of patients characterised by relatively high levels of psychological distress seem to benefit most from non-pharmacological interventions. Preliminary evidence of retrospective treatment analyses suggests that the efficacy may be enhanced by offering tailored treatment approaches at an early stage to patients who are at risk of developing chronic physical and psychological impairments.