title: Cognitive-behavioral mechanisms in a pain-avoidance and a pain-persistence treatment for high-risk fibromyalgia patients.
abstract: OBJECTIVE
  The heterogeneity of cognitive-behavioral patterns in patients with fibromyalgia (FM) has been proposed to underlie the variability in treatment outcomes. It has previously been shown that pain-avoidance and pain-persistence treatments tailored to the patient's pattern are effective in improving physical and psychological functioning and overall impact in high-risk patients with heightened psychological distress. In the present study, the cognitive-behavioral effects of these treatments were evaluated to provide insight into the main proposed mechanisms, specifically pain-avoidance behaviors and activity pacing in the pain-avoidance and pain-persistence treatments, respectively.
  
  
  METHODS
  High-risk FM patients were classified into 2 groups, pain avoidance and pain persistence, and randomized in groups to the relevant treatment or waiting-list control condition. The pain-avoidance and pain-persistence treatments both comprised 16 twice-weekly sessions of cognitive-behavioral therapy and exercise training. Cognitive--behavioral factors assessed at pre- and posttreatment and 6 months of followup were evaluated using linear mixed models.
  
  
  RESULTS
  A significant treatment effect was found for pain-avoidance behavior in the pain-avoidance treatment and for activity pacing in the pain-persistence treatment, showing improvements in the treatment condition relative to the controls. Furthermore, the effect on functioning was mediated by changes in pain-avoidance behavior in the pain-avoidance treatment and by changes in activity pacing in the pain-persistence treatment. Both treatments also showed significant improvements in other relevant cognitive-behavioral factors.
  
  
  CONCLUSIONS
  Both the pain-avoidance and pain-persistence treatments are effective in improving cognitive-behavioral factors in high-risk FM patients. Pain-avoidance behavior and activity pacing might be important mediating mechanisms for beneficial outcomes in pain-avoidance and pain-persistence treatments, respectively.
authors.affiliation: Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands. s.vankoulil@mps.umcn.nl
authors.forename: S
authors.initials: S
authors.lastname: van Koulil
authors.forename: F W
authors.initials: FW
authors.lastname: Kraaimaat
authors.forename: W
authors.initials: W
authors.lastname: van Lankveld
authors.forename: T
authors.initials: T
authors.lastname: van Helmond
authors.forename: A
authors.initials: A
authors.lastname: Vedder
authors.forename: H
authors.initials: H
authors.lastname: van Hoorn
authors.forename: A R T
authors.initials: AR
authors.lastname: Donders
authors.forename: K
authors.initials: K
authors.lastname: Thieme
authors.forename: H
authors.initials: H
authors.lastname: Cats
authors.forename: P L C M
authors.initials: PL
authors.lastname: van Riel
authors.forename: A W M
authors.initials: AW
authors.lastname: Evers
mesh_terms: D000328:Adult; D001362:Avoidance Learning / Q000502:physiology*; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D005260:Female; D005356:Fibromyalgia / Q000523:psychology / Q000628:therapy*; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000523:psychology; D059408:Pain Management; D010147:Pain Measurement / Q000379:methods; D016896:Treatment Outcome