Tips From Sports Medicine May Boost Teen Fibromyalgia Treatment

Nancy A Melville

March 13, 2018

ANAHEIM, California — An innovative multidisciplinary approach to treating fibromyalgia in teens, which borrows neuromuscular training tips from the field of sports medicine, reduces disability and boosts confidence, new research suggests.

The Fibromyalgia Integrative Training for Teens (FIT Teens) program combines the conventional components of psychotherapy with exercises and state-of-the-art tracking methods commonly used in injury prevention. This includes biomechanical assessment, three-dimensional (3D) motion capture, and virtual reality.

A pilot phase 2 randomized controlled trial showed that participants in the FIT Teens group had greater reductions in functional disability at 8 weeks and at 3-month follow-up than those who received cognitive-behavioral therapy (CBT) alone.

Although a multicenter trial with more than 400 participants launched last year and will continue through 2022, early feedback is also encouraging for the FIT Teens program, report the investigators, led by Susmita Kashikar-Zuck, PhD, Cincinnati Children's Hospital, Ohio.

The findings were presented here at the American Pain Society (APS) 2018 meeting.

"Among the most interesting comments we've received was 'I trust my body more,'" Kashikar-Zuck told meeting attendees. "It is incredible to hear that because a lot of times these patients will tell you they feel they've lost their trust in their body."

A New Intervention

FIT Teens was developed partly out of frustration with lackluster results from a previous trial that used only CBT to treat patients with fibromyalgia, Kashikar-Zuck reported.

"We found some improvements in functional disability with CBT. But we also found that patients in the study, despite recommendations to exercise, were still extremely sedentary," she said.

Patients with fibromyalgia often have a high fear of movement, associating physical activity with pain. That avoidance of activity can consequently translate to a loss of movement competence, as observed in a recent study. That study showed that adolescents with fibromyalgia have lower strength and altered functional movements compared with healthy teens.

Inspired by advances in the sports medicine field in helping athletes work on balance, strength, and confidence in physical movement after injury, the current researchers sought to design a new program. They wanted a multidisciplinary effort that incorporated some behavioral and sports medicine components, as well as evidence-based practices from rheumatology and pain medicine.

"Our goal was to seamlessly integrate CBT with neuromuscular exercise training, with a focus on improving movement competence while minimizing muscle soreness post-exercise," Kashikar-Zuck said.

In the group-based intervention, designed to provide engagement and peer support, participants take part in 1.5-hour small-group treatment sessions twice a week for 8 weeks.

The sessions are led by psychiatrists, physical therapists, and exercise physiologists and use manualized protocols. Parents are included in 6 of the 16 sessions.

The teens are able to choose moderate to vigorous physical activities and are instructed on how to gradually incorporate these activities into the program.

Coping skills taught in the program include cognitive and behavioral distraction, activity pacing, stress management, and muscle relaxation. Neuromuscular training includes core strength, coordination, posture control, fundamental movement, stress recovery, and functional skills.

Fast, Durable

In the pilot study, 40 participants were randomly assigned to the FIT Teens program (n = 20) or CBT alone (n = 20) for 8 weeks. The assigned intervention was completed by 17 and 19 group members, respectively.

The FIT Teens group had significantly greater reductions in functional disability scores at the end of the intervention (26.34 at baseline vs 18.71 at 8 weeks) compared with the CBT group (24.21 vs 23.95, respectively). They also had greater disability score reductions than the CBT group at the 3-month follow-up (19.76 vs 22.68, respectively; P = .01 for all three time points).

Kashikar-Zuck noted that the improvements over 8 weeks in the FIT Teens group were similar to those seen in the earlier CBT-only study after as much as 6 months. "This shows significantly faster improvements with the FIT Teens program," she said.

The duration of the effects was also encouraging, Kashikar-Zuck told Medscape Medical News.

"What was most encouraging was that pain reduction was maintained even 3 months after the treatment had ended. In our current trial, we will be following them for 1 year," she said.

Participants also reported significant improvements in sleep, feeling happier and more active, having less tightness and less pain, and appreciating the camaraderie of being with others who are going through the same challenges.

Well-Tolerated

For the ongoing multicenter trial, 420 teens with fibromyalgia aged 12 to 17 were randomly assigned to one of three groups for 8 weeks: FIT Teens, group aerobic exercise, or CBT only — with a "booster session" at 1.5 months after treatment. Follow-up at 3 months is the primary endpoint.

Additional booster sessions will also be offered at 4.5 months, 7.5 months, and 10.5 months after treatment, with additional follow-up assessments at 6, 9, and 12 months.

Kashikar-Zuck said that so far, patients have responded well and have tolerated the exercise regimens generally well.

"We have had very little dropout in the program [10% or less] in our early research," she reported.

The only adverse effects reported have been some temporary soreness upon learning new exercises, "and this is to be expected," said Kashikar-Zuck. "The soreness resolves on its own within a couple of days at most."

Participants also seem to respond particularly well to the engagement aspect of the program, as evidenced by the popularity of booster sessions and peer support, she added.

"Participants have expressed a strong interest in having periodic booster sessions where they can meet again with the trainers and group members to refresh their CBT and neuromuscular exercise training and get group support to main their skills."

Measures to track progress include exercise-based 3D motion capture systems and other methods for looking at the kinetics of how bodies move and how the brain can be trained using exercise-based techniques.

"We want to find out if it is possible to rewire the brain to decrease the experience of centralized pain, pain unpleasantness, and, consequently, pain-related disability," Kashikar-Zuck concluded.

Exercise Important, Challenging

Commenting on the findings for Medscape Medical News, Richard Harris, PhD, associate professor in the Chronic Pain and Fatigue Research Center at the University of Michigan, Ann Arbor, noted that exercise routines, though important, can be a challenge for patients with fibromyalgia.

"Exercise has some barriers, for example fatigued populations, of which fibromyalgia is one, often have difficulties initiating and maintaining any exercise intervention. Many patients simply don't have the energy to exercise. However, this is not specific to teens. This is true for adults as well," he said.

Harris added that the FIT Teens method appears to offer an important strategy to help such patients.

"The FIT Teens approach that uses neuromuscular information is innovative as it incorporates a personalized assessment of neuromuscular function. This could lead to improved care," he said.

Whether the program could be translated to adults remains to be seen, said Vitaly Napadow, PhD, an associate professor at the Martinos Center for Biomedical Imaging at Massachusetts General Hospital and Harvard Medical School, in Boston, Massachusetts, who also commented on the study.

"The findings in teens for a synergy in efficacy in combining CBT with exercise are very interesting, but may not extrapolate to adults," Napadow told Medscape Medical News.

"Fibromyalgia in teens may in fact differ in mechanism and presentation to that in adults, and we need to directly evaluate if this combined approach can also work synergistically in adults."

Other recent studies have in fact suggested that exercise in related conditions, such as chronic fatigue syndrome (CFS), could make symptoms worse, he said.

"This was particularly the case for anaerobic exercise. While fibromyalgia is not CFS, there is some overlap, and many patients may in fact be diagnosed with both disorders. Thus, recommendations for greater exercise in fibromyalgia should be carefully considered based on individual patient presentation."

Nevertheless, the innovative approach of learning from sports medicine and injury prevention in improving confidence in the body is intriguing, Napadow added.

"This has not been a current focus in fibromyalgia care, and opens up a new direction of research in diagnosis and therapy for patients," Napadow said.

"Additionally, the proliferation of technology inherent with these therapies is an excellent way to get patients, particularly teens, motivated to try a new therapeutic approach, which ultimately provides the important element of hope that can be missing for these chronic pain patients."

The trial is supported by the National Institutes of Health (National Institute of Arthritis and Musculoskeletal and Skin Diseases).Harris and Napadow have disclosed no relevant financial relationships.

American Pain Society (APS) 2018. Presented March 5, 2018.

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