Staff Perspective: Fighting Fibromyalgia with Military-Connected Patients
Fibromyalgia (FM) is a chronic pain condition characterized by diffuse and persistent non-inflammatory musculoskeletal pain. It is estimated that the prevalence of FM in the general population ranges from 2-4%, with it being more frequently diagnosed in women compared to men (Galvez-Sánchez & Reyes del Paso, 2020). The American College of Rheumatology revised the diagnostic criteria in 2016 to include:
- Presence of generalized pain (pain reported in at least four of five regions)
- Symptoms have been present at a similar level for at least three months
- Scores on the Widespread Pain Index (WPI) and Symptom Severity (SS) Scale have to be either 1) WPI 7 and SS 5 or 2) WPI = 4-6 and SS 9
- Diagnosis of FM is valid irrespective of other diagnoses and does not exclude the presence of other clinically important illnesses.
Research using the Defense Medical Surveillance System (DMSS) to review medical encounters for active duty Service members found a prevalence rate 0.15% in the calendar year of 2018 (Hulse et al., 2020). The authors noted that despite the relatively low prevalence rate, this population had a high number of healthcare encounters, averaging 57 appointments per year. This pattern of healthcare service utilization is 3 to 4 times higher than other active-duty Service members (Hulse et al., 2020). This can be problematic in terms of military readiness because the Armed Forces has strict retention criteria. For example, if patients with FM “requiring regular use of controlled medications, schedule II-IV, or requiring frequent follow-up or duty restrictions” they are not qualified for retention (Department of Defense Instruction 6490.07 and Department of Defense Instruction 1332.45). Therefore, military Service members need treatments that help them manage their chronic pain conditions and maintain their military readiness.
Research has also found that patients who have chronic pain conditions are more likely to have comorbid psychiatric conditions, particularly PTSD. Lacefield et al. (2020) conducted a study examining an integrated intervention for women veterans who had both FM and PTSD. For the purposes of their study, the authors looked at combining a cognitive behavioral treatment (CBT) protocol for chronic pain and cognitive processing therapy (CPT) for PTSD. CBT for chronic pain is a 12-session treatment protocol that can be done individually or in a group format. The treatment includes psychoeducation about pain and its impact, identifying and modifying beliefs related to pain and impairment, and includes exposure-based exercises. CPT is also a 12-session treatment protocol that can be done on an individual basis or in a group format as well. CPT provides psychoeducation about the symptoms of PTSD and focuses on identifying and modifying problematic cognitions known as stuck points using various writing exercises. The authors combined these two treatments based on the rationale that 1) a small number of studies have shown positive results of combining PTSD treatment with treatment of chronic pain for FM; 2) given the symptom overlap, rates of comorbidity, and bi-directional increased risk for each disorder it makes sense to incorporate psychoeducation about both conditions and how skills learned in treatment can be applied to both, and 3) by combining treatments into a single episode of care it may help reduce overall healthcare utilization while increasing access to effective treatment.
Lacefield et al. (2020) conducted twice weekly 90 minute sessions over the course of six weeks for six female veterans receiving care in the VA system to test the feasibility of delivering an integrated treatment for PTSD and FM. Only one of the six did not complete all 12 sessions and dropped out of the study due to transportation issues. Results from the study found that patients had clinically significant improvement on measures of PTSD, FM, and depression (i.e., PCL-5, Fibromyalgia Impact Questionnaire-Revised, and PHQ9). Patient scores on the PCL-5 scores decreased on average by 14.6 points (i.e., average PCL-5 baseline was 75.4, posttreatment average scores were 60.8), decreased on the FIQR (Fibromyalgia Impact Questionnaire-Revised) by 19.1 points (i.e., average FIQR baseline was 88.0, posttreatment average scores were 68.9) and decreased on the PHQ9 by 11 points (i.e., average PHQ9 baseline was 23.2, posttreatment average score was 12.2).
The authors noted that although the patients reported a high degree of satisfaction with the treatment and experienced symptom reduction, posttreatment scores for PTSD, FM, and depression were still above the clinical cut-off range. Additionally, it can be difficult for mental health providers to offer twice weekly appointments for 90 minutes to patients. Given the few number of studies examining the integration of PTSD treatment and treatment of chronic pain conditions like FM and the small sample size of Lacefield et al. (2020) study, it is important for additional studies to examine how we as clinicians can integrate evidence-based treatments to provide high-quality and comprehensive care to our Service members and veterans.
Editor's note: For more resources and information on the topic, check out this month's Chronic Pain spotlight page here.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Tim Rogers, Ph.D., is a Senior Military Internship Behavioral Health Psychologist and serves as the Associate Program Director for the Air Force Clinical Psychology Internship Program at Joint Base San Antonio-Lackland Texas.
References:
Galvez-Sánchez, C. M., & Reyes Del Paso, G. A. (2020). Diagnostic Criteria for
Fibromyalgia: Critical Review and Future Perspectives. Journal of Clinical Medicine, 9(4), 1219-1235. https://doi.org/10.3390/jcm9041219
Hulse, S. T., Stahlmen, S. L., Fedgo A., Serafica, T. S., & Clausen, S. (2020).
Fibromyalgia: Prevalence and burden of disease among active component service. Medical Surveillance Monthly Report. https://health.mil/News/Articles/2020/11/01/Fibromyalgia-MSMR-2020
Lacefield, K., Samph, S. P., Orbon, S., & Otis, J. (2020). Integrated intervention for comorbid posttraumatic stress disorder and fibromyalgia: A pilot study of women veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 12(7), pg 725-729. http://dx.doi.org/10.1037/tra0000635
Fibromyalgia (FM) is a chronic pain condition characterized by diffuse and persistent non-inflammatory musculoskeletal pain. It is estimated that the prevalence of FM in the general population ranges from 2-4%, with it being more frequently diagnosed in women compared to men (Galvez-Sánchez & Reyes del Paso, 2020). The American College of Rheumatology revised the diagnostic criteria in 2016 to include:
- Presence of generalized pain (pain reported in at least four of five regions)
- Symptoms have been present at a similar level for at least three months
- Scores on the Widespread Pain Index (WPI) and Symptom Severity (SS) Scale have to be either 1) WPI 7 and SS 5 or 2) WPI = 4-6 and SS 9
- Diagnosis of FM is valid irrespective of other diagnoses and does not exclude the presence of other clinically important illnesses.
Research using the Defense Medical Surveillance System (DMSS) to review medical encounters for active duty Service members found a prevalence rate 0.15% in the calendar year of 2018 (Hulse et al., 2020). The authors noted that despite the relatively low prevalence rate, this population had a high number of healthcare encounters, averaging 57 appointments per year. This pattern of healthcare service utilization is 3 to 4 times higher than other active-duty Service members (Hulse et al., 2020). This can be problematic in terms of military readiness because the Armed Forces has strict retention criteria. For example, if patients with FM “requiring regular use of controlled medications, schedule II-IV, or requiring frequent follow-up or duty restrictions” they are not qualified for retention (Department of Defense Instruction 6490.07 and Department of Defense Instruction 1332.45). Therefore, military Service members need treatments that help them manage their chronic pain conditions and maintain their military readiness.
Research has also found that patients who have chronic pain conditions are more likely to have comorbid psychiatric conditions, particularly PTSD. Lacefield et al. (2020) conducted a study examining an integrated intervention for women veterans who had both FM and PTSD. For the purposes of their study, the authors looked at combining a cognitive behavioral treatment (CBT) protocol for chronic pain and cognitive processing therapy (CPT) for PTSD. CBT for chronic pain is a 12-session treatment protocol that can be done individually or in a group format. The treatment includes psychoeducation about pain and its impact, identifying and modifying beliefs related to pain and impairment, and includes exposure-based exercises. CPT is also a 12-session treatment protocol that can be done on an individual basis or in a group format as well. CPT provides psychoeducation about the symptoms of PTSD and focuses on identifying and modifying problematic cognitions known as stuck points using various writing exercises. The authors combined these two treatments based on the rationale that 1) a small number of studies have shown positive results of combining PTSD treatment with treatment of chronic pain for FM; 2) given the symptom overlap, rates of comorbidity, and bi-directional increased risk for each disorder it makes sense to incorporate psychoeducation about both conditions and how skills learned in treatment can be applied to both, and 3) by combining treatments into a single episode of care it may help reduce overall healthcare utilization while increasing access to effective treatment.
Lacefield et al. (2020) conducted twice weekly 90 minute sessions over the course of six weeks for six female veterans receiving care in the VA system to test the feasibility of delivering an integrated treatment for PTSD and FM. Only one of the six did not complete all 12 sessions and dropped out of the study due to transportation issues. Results from the study found that patients had clinically significant improvement on measures of PTSD, FM, and depression (i.e., PCL-5, Fibromyalgia Impact Questionnaire-Revised, and PHQ9). Patient scores on the PCL-5 scores decreased on average by 14.6 points (i.e., average PCL-5 baseline was 75.4, posttreatment average scores were 60.8), decreased on the FIQR (Fibromyalgia Impact Questionnaire-Revised) by 19.1 points (i.e., average FIQR baseline was 88.0, posttreatment average scores were 68.9) and decreased on the PHQ9 by 11 points (i.e., average PHQ9 baseline was 23.2, posttreatment average score was 12.2).
The authors noted that although the patients reported a high degree of satisfaction with the treatment and experienced symptom reduction, posttreatment scores for PTSD, FM, and depression were still above the clinical cut-off range. Additionally, it can be difficult for mental health providers to offer twice weekly appointments for 90 minutes to patients. Given the few number of studies examining the integration of PTSD treatment and treatment of chronic pain conditions like FM and the small sample size of Lacefield et al. (2020) study, it is important for additional studies to examine how we as clinicians can integrate evidence-based treatments to provide high-quality and comprehensive care to our Service members and veterans.
Editor's note: For more resources and information on the topic, check out this month's Chronic Pain spotlight page here.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Tim Rogers, Ph.D., is a Senior Military Internship Behavioral Health Psychologist and serves as the Associate Program Director for the Air Force Clinical Psychology Internship Program at Joint Base San Antonio-Lackland Texas.
References:
Galvez-Sánchez, C. M., & Reyes Del Paso, G. A. (2020). Diagnostic Criteria for
Fibromyalgia: Critical Review and Future Perspectives. Journal of Clinical Medicine, 9(4), 1219-1235. https://doi.org/10.3390/jcm9041219
Hulse, S. T., Stahlmen, S. L., Fedgo A., Serafica, T. S., & Clausen, S. (2020).
Fibromyalgia: Prevalence and burden of disease among active component service. Medical Surveillance Monthly Report. https://health.mil/News/Articles/2020/11/01/Fibromyalgia-MSMR-2020
Lacefield, K., Samph, S. P., Orbon, S., & Otis, J. (2020). Integrated intervention for comorbid posttraumatic stress disorder and fibromyalgia: A pilot study of women veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 12(7), pg 725-729. http://dx.doi.org/10.1037/tra0000635