Friday, May 3, 2013

Fibromyalgia and Fear avoidance

Recently Jo Nijs and colleagues published a review on the role of fear avoidance. This review is in concordance to therapeutic principles that we established in our centre by the end of the 1990ies. I think that I have had the opportunity to make lots of first hand experience with fibromyalgia patients to comment on this topic.

But let us start with looking at the review of Jo Nijs and colleagues: “Fear of movement and avoidance behaviour toward physical activity in chronic-fatigue syndrome and fibromyalgia: state of the art and implications for clinical practice”. “The review revealed that fear of movement and avoidance behaviour toward physical activity […] is related to various clinical characteristics of CFS and FM, including symptom severity and self-reported quality of life and disability. It appears to be crucial for treatment (success) to identify CFS and FM patients displaying fear of movement and avoidance behaviour toward physical activity. Individually tailored cognitive behavioural therapy plus exercise training, […], appears to be the most promising strategy for treating fear of movement and avoidance behaviour toward physical activity in patients with CFS and FM.” (Clinical Rheumatology, May 2013)

We combined cognitive behavioral therapy and exercise training. We trained the trainers to be observant for fear avoidance of depressive avoiders as well for over pacing of happy sustainers. This was done in weekly meetings and more often, if patients’ lack of progress made it necessary. Sometimes patients at one time reacted like a happy sustainer and at another time like a depressive avoider, which didn’t make the task easier.
The crucial point for multimodal therapy is maintaining the same therapeutic theory throughout the whole therapeutic team, physical therapists, psychologist, nurses, and physicians.
For patients it’s important to learn, that a planned rest is according to treatment, but a rest because of pain might be just a symptom of fear avoidance. Patients learn better to assess exertion using the Borg scale.

I’ve written more on multimodal therapy and fibromyalgia in 2010:  


  1. meine eigene Erfahrung, bin seit über 30 Jahren erkrankt, ist, auf keinen Fall Krafttraining denn jede reißende Bewegung löst neue Schmerzen aus die dann lange danach noch anhalten.
    Ein Ausdauer-Bewegungstraining das keinen Muskelkater verursacht ist dagegen sehr wohltuend.
    Tai-Chi z.B. hilft mir sehr.
    Was auch enorm wichtig ist das ist Sonnenlicht, Bewegung in frischer Luft, das lindert merklich die Schmerzzustände.
    Ruhe oder Bettliegen ist pures Gift bei Fibromyalgie. Allerdings Mediation und Entspannungstraining wiederum wirkt sehr gut.
    Doxepin in niedriger Dosis habe ich versucht, half 3 Wochen danach war die Wirkung vorbei.
    Schmerzmittel wirken nicht.

    1. Vielen Dank für Ihren Kommentar!
      Auch wenn Ihre Erfahrung gegenteilig ist, Krafttraining kann man schon nutzbringend einsetzen, aber es darf eber nicht überlasten, das heißt nur mit wenig Gewicht arbeiten.
      Ihre Erfahrung mit Doxepin spiegelt auch die Ergebnisse von Studien wider. Kurzfristig ist eine Besserung in Studien nachweisbar, aber dies rechtfertigt meines Erachtens den Einsatz nicht, da Antidepressiva sehr häufig Nebenwirkungen verursachen.
      Schmerzmittel wirken beim chronifizierten Schmerz nicht, könnten aber wieder bei akuten Schmerzen wirksam sein.

      Thank you very much for your comment!
      Even if your experience is contrary to the text, you can use muscle training beneficially, but it must be without overexertion, one has to work only with small weights.
      Your experience with Doxepin is consisent with study results. On a short term basis, studies show improvements, but I believe, this does not justify the use of antidepressants, because these drugs often cause side effects. Painkillers do not work effectively in chronified pain, but could be effective in acute pain.