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Operant behavioral treatment of fibromyalgiaA controlled study.

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Arthritis & Rheumatism (Arthritis Care & Research)
Vol. 49, No. 3, June 15, 2003, pp 314 –320
DOI 10.1002/art.11124
© 2003, American College of Rheumatology
ORIGINAL ARTICLE
Operant Behavioral Treatment of Fibromyalgia:
A Controlled Study
KATI THIEME, ERIKA GROMNICA-IHLE,
AND
HERTA FLOR
Objective. To evaluate the efficacy of operant pain treatment for fibromyalgia syndrome (FMS) in an inpatient setting.
Methods. Sixty-one patients who fulfilled the American College of Rheumatology criteria for FMS were randomly
assigned to the operant pain treatment group (OTG; n ⴝ 40) or a standardized medical program with an emphasis on
physical therapy (PTG; n ⴝ 21). Pain assessments were performed before, immediately after, 6 months after, and 15
months after treatment.
Results. The OTG patients reported a significant and stable reduction in pain intensity, interference, solicitous behavior
of the spouse, medication, pain behaviors, number of doctor visits, and days at a hospital as well as an increase in
sleeping time. Sixty-five percent of the OTG compared with none of the patients in the PTG showed clinically significant
improvement.
Conclusion. These results suggest that operant pain treatment provided in an inpatient setting is an effective treatment
for FMS, whereas a purely somatically oriented program may lead to a deterioration of the pain problem.
KEY WORDS. Fibromyalgia; Pain; Behavior therapy; Operant treatment.
INTRODUCTION
According to the 1990 classification criteria of the American College of Rheumatology (ACR), fibromyalgia syndrome (FMS) is defined as widespread pain in combination with tenderness at 11 or more of 18 specific tender
point sites (1). The most frequent additional symptoms are
chronic exhaustion, reduced ability to cope with stress,
sleep disorders combined with a pathologically altered
sleep pattern (2,3), and concentration problems. More than
40% of FMS patients also have thyroid problems and
primary Sjögren’s syndrome (4). FMS is accompanied by
many vegetative and functional disorders, such as irritable
bowel syndrome, classic migraine, or tachycardia.
Pharmacologic treatments of FMS include nonsteroidal
antiinflammatory drugs (NSAIDs), muscle relaxants, tricyclic antidepressants, and serotonin antagonists, which
have direct or indirect consequences on the hypothalamic–pituitary–adrenal (HPA) axis. The therapeutic goal is to
Kati Thieme, PhD, Erika Gromnica-Ihle, MD, Herta Flor,
PhD: University of Heidelberg, Mannheim, Germany.
Address correspondence to Kati Thieme, PhD, Department of Psychosomatic and Psychotherapeutic Medicine,
University of Heidelberg, Central Institute of Mental Health,
J 5, D-68159 Mannheim, Germany. E-mail: thieme@zimannheim.de.
Submitted for publication January 5, 2002; accepted in
revised form June 13, 2002.
314
regulate the HPA axis and thus reduce such symptoms of
FMS as pain, weakness, sleep disorders, and psychological
stress reactivity (5). A metaanalysis of 9 studies on the
efficacy of tricyclic antidepressant medication (6) showed
that antidepressives have the most significant effect on
quality of sleep. Stiffness and sensitivity to pressure had
the lowest effect size. Thirty percent of the patients were
responders (⬎50% improvement of symptoms). Serotonin
antagonists showed a responder rate of 30 –50% (7,8),
NSAIDs had a rate of 37% (9). The majority of the pharmacologic treatment studies indicate short-term effects
(4 –9 weeks). There is a need for more placebo-controlled
double-blind studies with longer outcome assessments (6).
Nonpharmacologic interventions, such as cognitive-behavioral treatment programs, showed significant changes
in pain-related convictions of control and self instructions,
reductions in pain intensity and interference, as well as
improvements in emotional variables (10 –13). A study on
the efficacy of an interdisciplinary outpatient cognitivebehavioral treatment revealed significant improvements in
pain severity, interference, life control, affective distress,
depression, perceived physical disability, as well as a reduction of solicitous spouse behaviors (13). A clinically
significant reduction in pain severity, measured with the
reliability of change index, was found in 42% of the sample and was maintained over a period of 6 months (13).
A metaanalysis (14) of 49 FMS treatment outcome studies compared the efficacy of pharmacologic and nonpharmacologic treatments (cognitive-behavioral treatment and
Operant Behavioral Treatment of Fibromyalgia
physical therapy) with respect to physical status, FMS
symptoms, psychological status, and functional ability.
Antidepressive medication showed significant improvements in physical status and subjective FMS symptoms.
Cognitive-behavioral pain treatment yielded significant
improvements in all 4 criteria as compared with physical
therapy. Cognitive-behavioral treatment was more effective with respect to improvement of subjective FMS symptoms and daily functioning than pharmacologic treatment.
This metaanalysis suggests that optimal treatment for FMS
includes cognitive-behavioral methods.
Although operant behavioral treatment has been widely
applied to a variety of chronic pain syndromes (15,16), it
has so far not been systematically tested with FMS patients. Operant treatment involves interventions such an
increase of activity levels at home and at work, inclusion
of significant others to reduce reinforcement of pain behaviors, and the management of pain-related medication
(17). Because chronic pain is invariably accompanied by
learning-related changes that lead to the development of
pain behaviors, and because FMS patients have been
shown to display pain behaviors and high levels of interference related to their pain, an operant treatment approach might also be effective with this group (15,16). For
example, Turk et al (18) identified a dysfunctional subgroup of patients with high levels of pain and pain-related
interference as well as high solicitous spouse behaviors
who might especially profit from operant procedures.
The goal of the present study was the evaluation of an
inpatient program of operant pain treatment for patients
with FMS. The operant pain treatment was compared with
a standard inpatient medical treatment program that had
physical therapy components. The effects were tested before treatment, immediately after treatment, and at 6- and
15-month followups. In addition, the psychosocial subgroups that were described by Turk et al (18) were determined and it was tested to what extent the dysfunctional
subgroup profited especially from operant pain treatment.
315
Table 1. Demographic and clinical data of the patients*
Age, years
M
SD
Range
Duration of the pain, years
M
SD
Range
Pain zones, n
M
SD
Range
Pain intensity, pain diary
M
SD
Range
Marital status, n (%)
Single
With significant other
With significant other
and children
Education, n (%)
ⱕ10 years
11–13 years
University degree
Occupational status, n (%)
Working
Unemployed
Workers’ compensation
Duration of occupational
activity, years
M
SD
Range
Operant
pain
treatment
group
n ⴝ 40
Physical
therapy
group
n ⴝ 21
46.61
8.67
16–64
48.51
7.51
17–62
17.05
7.12
0.6–33
15.57
6.32
0.6–36
6.31
2.4
4–9
6.62
1.9
5–9
4.72
0.98
3–9
4.69
0.87
3–8
6 (15.00)
14 (35.00)
20 (50.00)
2 (9.53)
13 (61.90)
6 (28.57)
18 (45.00)
12 (30.00)
10 (25.00)
11 (52.38)
5 (23.81)
5 (23.81)
11 (27.50)
20 (50.00)
9 (22.50)
6 (28.57)
10 (47.62)
5 (23.81)
26.00
7.72
0–32
25.40
8.82
0–34
* M ⫽ mean; SD ⫽ standard deviation.
PATIENTS AND METHODS
Patients. Sixty-one female FMS patients were recruited
from the regular patients of a hospital for rheumatic disorders at Berlin-Buch. Inpatient treatments for rheumatic
disorder in special hospitals for rheumatic disorders are
common in Germany and the sample can be viewed as
representative of the German FMS population. The patients signed informed consent and were randomly assigned to either an operant treatment group (OTG) or a
standard medical treatment group with physical therapy
(PTG). The 2 treatments were not provided at the same
time and provision of the treatment was counterbalanced
for time of year. The study was approved by the ethics
committee of Humboldt University.
All patients had an FMS diagnosis based on the ACR
criteria (1). Exclusion criteria for the study were inflammatory cause of the pain; neurologic complications; duration of pain less than 4 months; pregnancy; another severe
disease such as a tumor, liver, or renal disease; major
psychiatric disorders; problems with the German language.
The groups were not significantly different with respect
to age, duration of pain, pain intensity, or the number of
distinct pain areas as indicated in the pain assessment
interview (see Table 1). About half of the patients were
unemployed, 20% received workers’ compensation. Initially, 63 patients had begun the inpatient treatment. Two
patients of the OTG dropped out after 4 days of treatment.
The reasons for drop out were a severe depressive episode
in 1 patient and a bipolar disorder diagnosis in the second
patient. Thus, 61 patients completed the entire treatment.
Methods. Medical somatic assessment. The somatic assessment included a standardized internal medicine and
rheumatologic program, including assessment of blood
values, a neurologic diagnosis, evaluation of tender points,
and imaging methods such as radiographs or magnetic
resonance imaging.
316
Verbal-subjective pain assessment. The Multidimensional Pain Inventory (MPI) (15,19,20) was used to determine pain intensity, interference of the pain, life control,
affective distress, social support, and self efficacy. In addition, significant other responses (i.e., solicitous, punishing, and distracting behaviors) and the general activity
level of the patients were assessed. The patients also completed a pain diary where pain intensity was recorded
hourly on visual analog scales.
Behavioral pain assessment. The intake of medication,
amount of daily activities, and sleep behavior were assessed in the pain diary. At the followup, assessments
were from the patients’ medical records at the rheumatology outpatient clinic the patients attended every 6 weeks.
Activity levels were recorded using the respective scales of
the MPI and pain behaviors were assessed with the Tübingen Pain Behavior Scale (TBS) (21), which was completed by only 41 significant others. The low number of
TBS values was due to the fact that 5 patients did not have
spouses and 15 of the spouses refused to complete the
scale. The number of doctor visits and the number of days
at a hospital in the 12 months before and after treatment
was taken from the medical records.
Treatment. A standardized operant pain treatment program was employed based on the manual devised by Flor
and Birbaumer (15,22). It comprised time contingent intake and reduction of medication; increase of bodily activity; reduction of interference of the pain in the family, at
work, in leisure time, and in social activities; reduction of
pain behaviors in dealing with the medical system; and
training in assertive pain incompatible behavior.
The patients engaged in role play to reduce pain behaviors and to increase healthy behaviors. The entire group
used a reinforcer plan that consisted of the delivery of a
red card when pain behaviors were shown and a green
card when healthy behaviors were displayed. The patients
also trained increases in activity levels assisted by a physical therapist.
The reduction of medication was instituted immediately
following the assessment phase and was based on a physician-coordinated individual time contingent interval
plan. The patients received homework that included increase of activities and reduction of pain behaviors when
dealing with members of the inpatient clinic; this homework was extended to the family during family visits on
the weekends. The operant pain program was conducted
in groups of 5 to 7 patients. The treatment team consisted
of a psychologist, a rheumatologist, a physical therapist,
and a member of the nursing personnel.
The standardized physical therapy treatment included 7
different types of mainly passive physical therapy exercises (e.g., muscle relaxation with thermotherapy, mud
bath, concentrated relaxation and light movement therapy
in warm water) as usually applied to this group of patients
in this type of clinic setting in Germany. In addition, the
patients received antidepressants. The treatment was conducted in open groups and the team consisted of the rheumatologist, a physical therapist, and the nursing personnel. The OTG and the PTG teams were composed of
different personnel to prevent experimenter bias.
Both treatments began with a patient education module
Thieme et al
(4 hours) provided by a rheumatologist in which the patients and significant others were informed about the
symptoms, possible etiology, and possible somatic treatment strategies of FMS. Both treatments were employed
daily over the course of 5 weeks and comprised 71 hours of
treatment plus 4 hours of patient education.
Statistical analysis. We employed repeated measures
analyses of variance with the treatment groups as between
factors and the assessment times as within factors. This
was followed by Bonferroni corrected t-tests. The effect
sizes for both treatment groups were computed based on
the formula PTG (MeanT2– 4) – OTG (MeanT2– 4)/OTG
(standard deviationT1) (23). The reliable change (RC) index
(24) was computed as RC ⫽ X2 – X1/S1 公1 – Rxx, where
X1 ⫽ T1 value, X2 ⫽ T4 value, S1 ⫽ standard deviation,
and Rxx ⫽ test-retest reliability. The RC index is an empirical
measure for the responder rate of the respective treatment. To
assess predictors of outcome of the various treatments, the
initial values of the responders and nonresponders were
compared. To assess subgroups of FMS and to compare them
within the course of treatment, a cluster analysis was performed that included both treatment groups.
RESULTS
Pain intensity and interference. A significant interaction for group ⫻ time was found for pain intensity
(F[3,177] ⫽ 33.82, P ⬍ 0.001) as well as interference
(F[3,177] ⫽ 35.84, P ⬍ 0.001). A significant improvement
occurred only in the OTG (intensity: F[1,59] ⫽ 33.74, P ⬍
0.001; interference: F[1,59] ⫽ 53.28, P ⬍ 0.001), with the
OTG showing significantly reduced pain intensity (t[59] ⫽
– 6.83, P ⬍ 0.001) and interference (t[59] ⫽ –7.87, P ⬍
0.001) compared with the PTG at all 3 posttreatment assessment times. By contrast, the PTG showed a significant
increase in pain intensity and interference immediately
posttreatment (pain intensity: t[20] ⫽ – 8.92, P ⬍ 0.001;
interference: t[20] ⫽ –7.41, P ⬍ 0.001) as well as at the
6-month (pain intensity: t[20] ⫽ –5.99, P ⬍ 0.001; interference: t[20] ⫽ –5.34, P ⬍ 0.001) and 15-month followups
(pain intensity: t[20] ⫽ –5.69, P ⬍ 0.001; interference: t[20]
⫽ – 6.98, P ⬍ 0.001). Pain intensity (1.68 –2.14) and interference (1.97–2.5) showed the highest effect sizes (see
Table 2) of the operant treatment. In general, the effect
sizes of the OTG increased over time.
Emotional and cognitive variables. Affective distress
(F[3,177] ⫽ 22.65, P ⬍ 0.001), life control (F[3,177] ⫽
15.02, P ⬍ 0.001), and self efficacy (F[3,177] ⫽ 18.72, P ⬍
0.001) all showed a significant interaction of group ⫻ time.
Affective distress, life control, and self efficacy changed
significantly over time only in the OTG (T2: F[1,59] ⫽
28.61, P ⬍ 0.001; T3: F[1,59] ⫽ 15.49, P ⬍ 0.001; T4:
F[1,59] ⫽ 14.69, P ⬍ 0.001), with the OTG displaying
significantly lower affective distress (t[59] ⫽ – 6.19, P ⬍
0.001), higher life control (t[59] ⫽ 7.09, P ⬍ 0.001), and
higher self efficacy (t[59] ⫽ 10.72, P ⬍ 0.001) than the PTG.
By contrast, the PTG showed a significant increase of affective distress immediately after treatment as well as at
the 6- and 15-month followups (t[20] ⫽ –3.62, P ⬍ 0.002),
Operant Behavioral Treatment of Fibromyalgia
317
Table 2. Means, standard deviations, and effect sizes of the dependent variables in the operant and physical therapy groups*
Dependent
variables
MPI scales
Pain intensity
Interference
Life control
Affective distress
Social support
Self efficacy†
Punishing responses
Solicitous responses
Distracting responses
Household activities
Activities outside the house
Leisure activities
Total activity scale
Diary/medical record data
Number of doctor visits
Number of days at the hospital
Sleep behavior, hours
Medication
Tübingen Pain Behavior Scale
T1
T2
T3
T4
Groups
M (SD)
M (SD)
M (SD)
M (SD)
OTG
PTG
OTG
PTG
OTG
PTG
OTG
PTG
OTG
PTG
OTG
PTG
OTG
PTG
OTG
PTG
OTG
PTG
OTG
PTG
OTG
PTG
OTG
PTG
OTG
PTG
4.43 (0.98)
4.34 (1.11)
4.35 (1.01)
4.43 (0.91)
3.11 (1.27)
3.09 (1.19)
3.69 (1.33)
3.72 (1.57)
3.82 (1.88)
3.79 (1.56)
3.05 (1.53)
2.66 (1.46)
1.37 (1.61)
1.31 (1.46)
3.30 (1.9)
3.29 (1.3)
3.34 (1.85)
3.36 (1.17)
3.98 (1.21)
4.52 (1.30)
1.12 (1.22)
1.77 (1.35)
2.50 (0.91)
2.44 (0.87)
2.53 (0.78)
2.89 (0.91)
3.82 (0.96)
5.47 (1.06)
3.29 (1.02)
5.28 (0.86)
3.73 (0.76)
2.43 (0.94)
2.54 (1.03)
4.46 (1.48)
3.49 (1.59)
3.40 (1.95)
3.67 (0.73)
1.76 (1.14)
1.27 (1.61)
1.17 (1.43)
2.78 (1.53)
3.48 (1.41)
3.41 (1.29)
3.39 (1.07)
3.93 (1.06)
4.50 (1.30)
1.18 (1.01)
1.77 (1.35)
2.81 (0.89)
2.47 (0.86)
2.65 (0.65)
2.90 (0.92)
3.66 (1.22)
4.85 (0.86)
2.96 (1.18)
4.83 (0.72)
3.85 (0.91)
2.64 (0.77)
2.38 (1.29)
4.47 (1.65)
3.48 (1.55)
3.39 (1.93)
3.75 (1.27)
1.90 (1.09)
1.12 (1.54)
1.22 (1.53)
2.75 (1.33)
3.68 (1.50)
3.29 (1.34)
3.55 (0.98)
4.05 (1.14)
4.52 (1.30)
1.28 (1.26)
1.77 (1.35)
2.74 (0.97)
2.47 (0.86)
2.68 (0.81)
2.90 (0.93)
3.18 (1.27)
5.28 (0.83)
2.79 (1.37)
5.33 (0.81)
3.95 (0.95)
2.18 (0.85)
2.46 (1.28)
4.78 (1.60)
3.33 (1.31)
3.99 (1.76)
4.07 (0.92)
1.41 (0.93)
0.86 (1.18)
1.22 (1.64)
2.67 (1.36)
3.98 (1.69)
3.48 (1.14)
3.76 (1.07)
3.92 (0.97)
4.52 (1.30)
1.25 (1.04)
1.77 (1.35)
2.76 (0.97)
2.47 (0.86)
2.63 (0.70)
2.90 (0.93)
OTG
PTG
OTG
PTG
OTG
PTG
OTG
PTG
OTG
PTG
31.61 (19.88)
28.60 (18.40)
13.24 (22.96)
10.35 (14.76)
5.77 (2.63)
5.81 (2.27)
1.85 (2.03)
1.71 (2.17)
13.95 (2.58)
13.74 (2.63)
—
—
—
—
6.95 (1.43)
6.43 (1.25)
0.90 (1.08)
1.24 (1.38)
12.33 (2.45)
16.85 (2.47)
7.40 (1.10)
5.57 (1.83)
0.80 (0.96)
2.04 (1.80)
11.52 (1.91)
15.35 (2.30)
14.70 (9.90)
37.8 (22.03)
2.61 (6.34)
18.65 (17.82)
7.55 (1.19)
5.28 (1.59)
0.70 (1.04)
2.52 (2.23)
9.95 (2.22)
14.23 (2.12)
ES
1–2
ES
1–3
ES
1–4
1.68
1.21
2.14
1.97
1.88
2.50
1.02
0.95
1.39
1.44
1.57
1.74
0.05
0.05
0.35
1.25
1.21
1.89
0.06
0.06
0.22
0.37
0.49
0.69
0.01
0.14
0.15
0.47
0.38
0.49
0.48
0.40
0.43
0.37
0.29
0.32
0.32
0.28
0.35
1.16
0.70
0.20
0.16
0.70
0.61
0.86
0.90
1.75
1.48
1.66
* T1 ⫽ pretreatment; T2 ⫽ posttreatment; T3 ⫽ 6-month followup; T4 ⫽ 15-month followup; ES ⫽ effect size; M ⫽ mean; SD ⫽ standard deviation;
MPI ⫽ Multidimensional Pain Inventory; OTG ⫽ operant therapy group; PTG ⫽ physical therapy group. Effect sizes ⱖ0.7 are marked in bold indicating
a high treatment effect.
† Item added to German version.
a significant reduction of life control (t[20] ⫽ 4.17, P ⬍
0.001), and a decrease of self efficacy (t[20] ⫽ 4.99, P ⬍
0.001). The OTG had high effect sizes for affective distress
(1.44 –1.74), life control (1.02–1.39), and self efficacy
(1.25–1.89) (Table 2). Again, the effect sizes increased over
time.
Pain behaviors. Number of doctor visits (F[1,51] ⫽
41.037, P ⬍ 0.001), number of days at a hospital (F[1,51] ⫽
10.75, P ⫽ 0.002), medication intake (F[3,177] ⫽ 10.69,
P ⬍ 0.001), pain behavior as assessed by the TBS (F[3,120]
⫽ 28.27, P ⬍ 0.001), and sleeping behavior (F[3,177] ⫽
9.61, P ⬍ 0.01) showed a significant interaction of group ⫻
time. Only the OTG reduced its medication intake (F[1,59]
⫽ 16.22, P ⬍ 0.001) and pain behaviors (F[1,40] ⫽ 28.27,
P ⬍ 0.001) and improved its sleep behavior (F[1,59] ⫽
9.61, P ⬍ 0.001) over time. In addition, the OTG reduced
the number of doctor visits by 53.5% (t[39] ⫽ 5.62, P ⬍
0.001) and the number of days at a hospital by 80.3% (t[39]
⫽ 2.84, P ⫽ 0.008) compared with pretreatment. This
amounts to a reduction of $3,933 per patient per year in
hospitalization costs and a reduction of $1,840 per patient
per year regarding costs of primary care. By contrast, the
PTG’s number of doctor visits increased by 32.2% (P ⬍
0.001) and the number of days at a hospital by 80.2% (P ⫽
0.034). The PTG showed a significant increase of $1,905.50
per patient per year in hospitalization costs and $442 per
patient per year regarding costs of primary care. The operant pain treatment had high effect sizes (see Table 2).
The OTG showed significantly reduced pain behaviors
(t[59] ⫽ –5.68, P ⬍ 0.001), improved sleep behavior (t[59]
⫽ 6.26, P ⬍ 0.001), and significantly lower medication use
318
Thieme et al
(t[59] ⫽ – 4.37, P ⬍ 0.001) than the PTG at all posttreatment assessment times. Their medication intake related to
antidepressant drugs (F[3,177] ⫽ 11.68, P ⬍ 0.001),
NSAIDs (F[3,177] ⫽ 14.67, P ⬍ 0.001), and opioids
(F[3,177] ⫽ 21.22, P ⬍ 0.001) was also reduced. In contrast, the PTG showed a significant deterioration of all
variables immediately after physical therapy as well as at
the 6- and 15-month followup times (see Table 2). The
operant treatment had high effect sizes (see Table 2) especially at the 15-month followup.
The activity variables of the MPI, including overall activity, leisure time activities, household activities, and
activities outside the house, did not show any significant
change.
Significant other behaviors. A significant interaction of
group ⫻ time was found only for solicitous behaviors
(F[3,177] ⫽ 7.65, P ⬍ 0.001). Only the OTG experienced a
significant reduction of solicitous significant other behaviors (F[1,59] ⫽ 7.19, P ⬍ 0.001) at all treatment points
(t[39] ⬎ –3.29, P ⬍ 0.001) compared with the PTG. The
effect sizes were smaller (Table 2).
Clinical significance of the changes. The RC index of
the MPI interference scale showed a responder rate of 65%
in the OTG as compared with 0% responders in the PTG
(F[1,58] ⫽ 69.08, P ⬍ 0.001). The responders showed high
pain intensity (F[1,38] ⫽ 5.25, P ⫽ 0.028) and interference
(F[1,38] ⫽ 21.87, P ⬍ 0.001) before treatment as compared
with the nonresponders.
Changes in patient subgroups in the course of treatment. The cluster analysis that was based on the MPI
variables revealed 3 patient subgroups that were identical
to those described by Turk et al (18) and can be characterized as dysfunctional (DYS), interpersonally distressed
(IP), and adaptive copers (AC). As previously reported, the
DYS patients showed the highest pain intensity with
strong interference and high solicitous spouse behaviors.
The AC patients had the lowest values in all variables. The
IP patients displayed high pain intensity and strong interference values that were somewhat lower than in the DYS
group and showed, in addition, strong affective distress
and high punishment from the spouse. The pretreatment
group assignment of the OTG patients was 50.25% in the
DYS, 17.5% in the AC, and 30% in the IP group (Figure 1).
Fifteen months after the operant treatment, 27.5% of the
patients were still in the DYS and 7.5% in the IP group,
whereas 65% were characterized as adaptive copers.
By contrast, the PTG (see Figure 1) had initially 28.57%
of the patients in the DYS or the AC group and 42.86% in
the IP group. Fifteen months after treatment, the AC group
was reduced by 23.81% to 4.76% and the IP group was
increased by 19.05% to 62.0%. No changes were apparent
in the DYS group. Although the cluster assignment of the
OTG and PTG was not significantly different at pretreatment (␹2(2) ⫽ 3.24, not significant), the cluster distribution
of the OTG and PTG groups was significantly different at
all 3 posttreatment assessment times (post: ␹2(2) ⫽ 26.99,
P ⬍ 0.001; 6 months: ␹2(2) ⫽ 29.22, P ⬍ 0.001; 15 months:
␹2(2) ⫽ 32.99, P ⬍ 0.001).
Figure 1. Distribution of the psychosocial subgroups: dysfunctional (DYS), interpersonally distressed (IP), and adaptive coper
(AC) before treatment (T1), immediately after treatment (T2), 6
months after treatment (T3), and 15 months after treatment (T4) in
the operant treatment group (OTG) and physical therapy group
(PTG). The P values refer to the change in the clusters at the
posttreatment assessments compared with pretreatment: *P ⬍
0.05; ***P ⬍ 0.001.
DISCUSSION
The goal of this treatment outcome study was the evaluation of the efficacy of operant pain treatment for fibromyalgia compared with traditional somatic treatment. This
study showed a clear superiority of the operant intervention. The most significant changes were found with respect
to pain intensity, interference, affective distress, self efficacy, spouse responses to pain, medication intake, and
pain behaviors. Healthy behaviors were successively increased, pain behaviors were decreased, patients learned
to be more assertive, and the significant others learned to
reduce their pain-increasing solicitous behaviors. Thus,
pain-related interference as well as pain intensity were
significantly reduced despite concurrently reduced medication intake. A similar effect was found in the number of
physician visits and inpatient treatments in the year after
the intervention. The clinically most relevant result was a
Operant Behavioral Treatment of Fibromyalgia
high responder rate of 65% in the OTG with respect to
pain-related interference as compared with no responders
in the PTG.
The PTG deteriorated in almost all variables, a result
that has previously been reported by Flor and colleagues
(10,22,25) in similar studies with chronic back pain patients. In those studies as well as in the present study, a
traditional inpatient treatment that is usually prescribed
for patients with FMS or chronic back pain in Germany
was used as the control treatment. It must be assumed that
the physical therapy and medication regimen as currently
applied in German inpatient hospitals increase pain and
pain behaviors, probably due to the mostly passive type of
treatment that may have pain-reinforcing properties. Interestingly, the deterioration of the PTG was not limited to
the pretreatment–posttreatment comparison, but persisted
up to the 15-month followup. The long-lasting deterioration of the PTG was unexpected and needs to be explained.
It is possible that the specific type of physical therapy
employed was not beneficial because FMS patients show
hypo- rather than hyperfunctionality of the sympathetic
and muscular system (26 –28) and would require increased
activity rather than relaxing treatments.
The question arises to what extent the positive effects of
the operative pain treatment might be explained by the
deterioration of the PTG. A closer look at the data of the
statistical analysis reveals that there were significant pretreatment to posttreatment and pretreatment to followup
improvements in most variables in the OTG and a high
responder rate of 65%, whereas there were no significant
improvements in the PTG. Thus, there were genuine clinical improvements in the OTG.
The cluster analysis that was performed in this study
showed a significant change in the distribution of the
patients in the empirically derived subgroups of the multiaxial pain classification system as described by Turk and
colleagues (18). The patients in the dysfunctional group
were especially profiting from operant pain treatment and
a large number of patients in the OTG changed from the
DYS and IP to the AC groups. Higher values in pain and
interference also led to more reduction in pain-related
interference (13). It is possible that the patients who did
not profit from the operant group treatment might have
more benefits from a cognitive-behavioral intervention. In
the Turk et al (18) study, patients with a high level of
interference, high solicitous behavior of the spouse, high
affective distress, and little life control profited less from
cognitive-behavioral treatment. This result is opposite to
the outcome of this operant treatment study where the
more affected patients improved more, suggesting that different patients might do well with OTG and cognitivebehavioral treatments.
Both treatment studies suggest that it is necessary to
develop and evaluate subgroup-specific treatment approaches. A direct comparison of operant and more cognitive-behaviorally oriented pain treatment and their respective criteria for indication would be desirable.
This study has several limitations. First, a no treatment
control could not be used due to the necessity to provide
inpatient treatment. However, all of the patients had longstanding FMS and it is unlikely that they would have
319
shown spontaneous improvement during their hospitalization. In addition, an inpatient setting for the treatment
of FMS seems to be the exception rather than the rule in
most countries and the results of this study cannot necessarily be generalized to outpatient treatments. Although
outpatient operant programs have yielded excellent results
with chronic pain other than fibromyalgia (15,22,25), it
must be noted that the inpatient setting permits more
stringent behavioral control and is more intense than the
traditional outpatient groups.
Taken together, the results of this study suggest that
operant behavioral treatment might be an efficacious treatment approach for FMS, although criteria for indication
still need to be further specified.
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