Chronic pelvic pain; more than just the bladder.

PURPOSE OF REVIEW: Chronic pelvic pain is much of a burden to those who suffer from it. Additionally, in many patients medical doctors, such as urologists are unable to identify a cause or clear pathology that can explain the pain. Still numerous patients and doctors keep on searching for a cause, focussing particularly on the pelvic organs. Lots of diagnostics and treatment methods are used but often without success. In recent years, we have gained increased insight into the mechanisms of pain and adapted the terminology accordingly. RECENT FINDINGS: Two aspects of chronic pelvic pain have gained more attention. First, the myofascial aspects, especially the role of the pelvic floor muscles in maintaining the pain and as a therapeutic option. Second, the role of the brain and the psychological aspects intertwine with the pain and its consequences also open up for alternative management options. In terminology chronic pain is now included in the ICD-11, a historical change. Introducing chronic primary pain (no cause found) helps us to look away from the organ and deal with the patient as a whole human being. SUMMARY: The findings reported here are helpful for your daily practice. Looking from a broad perspective gives the patient the feeling of being seen and heard. Working together in a multidisciplinary team makes your work easier and gives more satisfaction. VIDEO ABSTRACT: http://links.lww.com/COU/A44.

Effect moderators in Internet-based exposure therapy for fibromyalgia: The role of pain intensity.

BACKGROUND: A recent randomized controlled trial (N = 140) was indicative of large and sustained average improvements of Internet-based exposure for fibromyalgia, as compared to a waitlist. However, little is known about who benefits the most from this treatment. OBJECTIVES: To test for potential moderating effects of age, educational attainment, the duration of fibromyalgia, baseline overall fibromyalgia severity, pain intensity, fibromyalgia-related avoidance behaviour and symptom preoccupation on the waitlist-controlled effect of 10 weeks of Internet-based exposure for fibromyalgia. METHODS: Secondary analysis of a randomized controlled trial (ClinicalTrials.gov NCT02638636). We used linear mixed effects models to determine whether the waitlist-controlled effect of exposure therapy on overall fibromyalgia severity (Fibromyalgia Impact Questionnaire) differed as a function of the potential moderators. RESULTS: Only pain intensity (0-10) was found to be a significant moderator, where a higher baseline pain intensity predicted a more limited waitlist-controlled effect of Internet-based exposure (B = 3.48, 95% CI: 0.84-6.13). Standardized point estimates of effects were small for the sociodemographic variables, and in the moderate range for some clinical variables that did not reach statistical significance such as behavioural avoidance and time with the fibromyalgia diagnosis. CONCLUSIONS: Results suggest that Internet-based exposure treatment was more useful for participants with lower baseline levels of pain, and less so for participants with higher baseline levels of pain. The treatment had relatively similar effects across the other tested moderators. SIGNIFICANCE: This study evaluated potential effect moderators in exposure-based treatment for fibromyalgia. Results indicated that a higher level of pain intensity at baseline was predictive of a less favourable outcome. It may be extra important to monitor progression for these patients and to provide additional therapeutic support when needed.

Approach as a key for success: Reduced avoidance behaviour mediates the effect of exposure therapy for fibromyalgia.

Fibromyalgia (FM) is a prevalent chronic pain disorder associated with large suffering and substantial societal costs. Pain-related avoidance behaviour and hypervigilance to bodily symptoms are common in FM and contribute in maintaining and exacerbating the disorder. Exposure therapy targeting avoidance behaviours and hypervigilance has shown promise in the treatment of FM. The present study investigated mediators of treatment outcome in exposure therapy for FM. We used data from a randomised trial, where 140 participants were allocated to 10-week internet-delivered exposure therapy or to a waiting-list control condition. The main outcome variable (FM symptoms) and the hypothesized mediators (FM-related avoidance behaviour, mindful non-reactivity and FM-related worry) were measured weekly throughout treatment. Mediation analyses were conducted using linear mixed effects models with bootstrap replication and time-lagged analysis. Results indicated that all three process variables were significant mediators of FM severity. However, in the time-lagged analyses, only FM-related avoidance behaviour displayed a unidirectional relationship over time with FM symptoms, suggesting a causal effect. Thus, results illustrate that changes in avoidance behaviour mediate the outcome of exposure on FM symptoms, which implies that avoidance behaviour is an important treatment target in exposure therapy.

Cost-Effectiveness and Cost-Utility of Internet-Delivered Exposure Therapy for Fibromyalgia: Results From a Randomized, Controlled Trial.

Fibromyalgia (FM) is a prevalent and debilitating chronic pain disorder associated with a substantial economic burden. Although there are several studies investigating the effectiveness of psychological treatments such as cognitive-behavioral therapy for FM, studies on cost-effectiveness are scarce. The aim of the present study was to investigate the cost-effectiveness of Internet-delivered exposure therapy (iExp) for FM. We used health economic data from a recently conducted randomized, controlled trial, where 140 participants were randomized to either iExp or a waitlist control (WLC) condition. Economic data were collected at pre-treatment, post-treatment, and at the 1-year follow-up. Treatment effectiveness in relation to costs were analyzed using both a societal perspective (including all direct and indirect costs) and a health care unit perspective (including only the direct treatment costs). Bootstrapped net benefit regression analyses were also conducted, comparing the difference in costs and effects between iExp and WLC, within different willingness-to-pay scenarios. Results showed that the incremental cost-effectiveness ratio was -$15,295, indicating that iExp was highly cost-effective as each successfully treated case (treatment responder) was associated with a substantial net reduction in costs. The robustness of the results was tested in 2 different sensitivity analyses, where iExp remained cost-effective, even in a willingness-to-pay-scenario of $0. We conclude that iExp is a cost-effective treatment that generates large societal cost savings. PERSPECTIVE: Health-economic evaluations of psychological interventions for FM are scarce. This study is a cost-effectiveness analysis of Internet-delivered exposure therapy for patients with FM. Results showed that iExp was highly cost-effective compared with no treatment, where each successfully treated case generated a substantial societal cost saving.

Internet-Delivered Exposure Therapy for Fibromyalgia: A Randomized Controlled Trial.

BACKGROUND: Fibromyalgia (FM) is a common and disabling chronic pain disorder, for which existing pharmacological and psychological treatments have yet yielded insufficient effects. Previous literature has shown that exposure therapy may be an effective treatment for chronic pain. This study constitutes the first randomized controlled trial evaluating exposure therapy for FM. METHODS: A total of 140 participants with diagnosed FM were randomized to a 10-week Internet-delivered exposure treatment (iExp; n=70) or a waitlist control condition (WLC; n=70). Primary outcome measure were FM symptoms and impact, and secondary outcome measures were fatigue, disability, quality of life, pain-related distress and avoidance behaviors, insomnia, depression, and anxiety. RESULTS: Data retention was high (100% data completion at posttreatment for primary outcome, 96% at 6-month follow-up and 94% at 12-month follow-up). Results showed that participants in the iExp group made large and superior improvements compared with WLC on FM symptoms and impact (B, -1.93; z, -10.14; P<0.001, between-group Cohen d=0.90), as well as all secondary outcomes (between-group Cohen d ranging from 0.44 to 1.38) with sustained results. CONCLUSIONS: We conclude that iExp seems to be an efficacious treatment for FM compared with no treatment, and the results also highlight the potential increase of accessibility by using the Internet format to deliver psychological treatments for these patients. Future trials with active control conditions are warranted.

Reducing the threat value of chronic pain: A preliminary replicated single-case study of interoceptive exposure versus distraction in six individuals with chronic back pain.

This paper describes a preliminary experimental evaluation of a technique intended to help people suffering from chronic back pain and low pain acceptance to alter the aversiveness or threat value of their persisting pain. Using a multiple baseline cross-over design six individuals with chronic back pain were taught to use a form of interoceptive exposure as well as a relaxation/distraction breathing-based technique in the presence of their pain. Half the participants used one method for three weeks, and then crossed over to the other method for a further three weeks. The other half did the reverse. Assessments were conducted at pre/post treatment and at a three month follow-up. Daily monitoring of pain-related distress was also completed. The results indicated moderately high improvements in pain acceptance across most participants and corresponding declines in pain-related distress. No clear differences occurred between conditions, but the changes on disability and catastrophising scales for most cases were consistent with those reported after more substantial interventions. The study raises some important clinical and methodological issues that could inform future research in this area.