Background & Aims

European guidelines for the treatment of chronic widespread pain (CWP) recommend individual physical exercise and cognitive behavioural therapy (CBT) (1). Physical activity has been shown to contribute to positive effects on both stress-related illnesses and chronic pain (2, 3). According to the World Health Organization (WHO), all adults should undertake 150–300 minutes of moderate intensity or 75–150 minutes of vigorous intensity physical activity per week, in combination with regular strengthening exercises, for optimal health outcomes (4). Internet-based CBT (I-CBT) has been developed for both chronic pain (5) and stress-related illness (6), showing positive effects. The close relationship between stress and pain has led to the aims of this study, which were to investigate the effect on pain of a stress-reducing treatment that combines I-CBT and physiotherapy in persons with CWP, and to examine factors associated with improvement.

Methods

129 persons with CWP (92% women, mean age 51 years) participated in a randomized controlled trial in Sweden. Both groups received three visits (at baseline, 4 weeks, and 12 weeks) with a physiotherapist in primary health care, during which a person-centered health plan was formulated and followed up. The health plan was individualized and aimed at achieving the WHO recommendations of weekly aerobic and strengthening exercises. At visit 3, the physiotherapist assessed whether the WHO recommendations were achieved, and the participants evaluated whether their health plan goals were met. The intervention group also received an 8 week I-CBT program aimed at reducing and coping with stress, the program started 8 weeks after baseline. The participants completed health questionnaires at baseline and 6 months follow-up. Between-group analyses were made with the Mann-Whitney U test. Associations were analysed with linear regression on both groups together, adjusted for group of randomization.

Results

No differences were found between groups at the 6-month follow-up in the primary outcome pain intensity. The intervention group was more likely to reach their main goals from their health plans after 12 weeks than the control group (p=0.018).
Eighty-eight participants (68%) successfully completed all three visits with a physiotherapist. During the 12-week visit, 44 participants (50%) achieved the recommended level of physical activity according to the WHO.
Regarding participants’ personal goals within their health plans, 19 participants (22%) had not reached their personal goals at all, while 44 participants (50%) had partially achieved their main goals, and 25 (28%) had completely reached them.
Achieving the WHO recommendations at the 12-week visit was significantly associated with the extent the participants reached their main goals with their health plans at the same visit, and also with higher self-rated improvement at the 6-month follow-up.

Conclusions

The intervention group, receiving both I-CBT and a person-centered health plan of physical activity, reached their individual goals to a higher extent than the control group after 12 weeks, although the I-CBT program for stress was not completed until after 16 weeks at the earliest. This indicates that the I-CBT program might contribute valuable tools and strategies for patients already in the beginning of the treatment period.
Fifty percent of the participants succeeded in achieving the WHO recommendations for aerobic and strengthening exercise, and 78% reached their individual goals partly or completely. It appears that a majority of persons with CWP could benefit from a person-centered health plan to reach a health-enhancing level of physiotherapy. The results are preliminary.

References

1. Carville SF, Arendt-Nielsen S, Bliddal H, Blotman F, Branco JC, Buskila D, et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis. 2008;67(4):536-41.

2. Löfgren M, Mannerkorpi K, Bergman S, Knardahl S. Fysisk aktivitet vid långvariga utbredda smärttillstånd. Fyss 20172016.

3. Jonsdottir I, Andersson AL. Stress och fysisk aktivitet. FYSS 2017: Läkartidningen Förlag AB; 2016.

4. Bull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP, Cardon G, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med. 2020;54(24):1451-62.

5. Buhrman M, Nilsson-Ihrfeldt E, Jannert M, Strom L, Andersson G. Guided internet-based cognitive behavioural treatment for chronic back pain reduces pain catastrophizing: a randomized controlled trial. J Rehabil Med. 2011;43(6):500-5.

6. Lindsater E, Axelsson E, Salomonsson S, Santoft F, Ejeby K, Ljotsson B, et al. Internet-Based Cognitive Behavioral Therapy for Chronic Stress: A Randomized Controlled Trial. Psychother Psychosom. 2018;87(5):296-305.

Presenting Author

Anna Bergenheim

Poster Authors

Anna Bergenheim

PhD

Region Västra Götaland

Lead Author

E-mail

Chan-Mei Ho-Henriksson

PhD

Institute of Neuroscience and Physiology, University of Gothenburg, Sweden

Lead Author

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Anna Grimby

School of Public Health and Community Medicine, Department of Med., Gothenburg Univ

Lead Author

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Maria EH Larsson

Institute of Neuroscience and Physiology, University of Gothenburg, Sweden

Lead Author

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Anna Larsson

Research, Education, Development and Innovation Primary HealthCare, Region Västra Götaland, Sweden

Lead Author

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Marie Persson

Ulricehamn

Lead Author

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Sandra Weineland

Associate prof

Department of Psychology, University of Gothenburg, Sweden

Lead Author

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Lena Nordeman

Research Education Development and Innovation in primary care, Region Vastra Gotaland

Lead Author

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Topics

  • Specific Pain Conditions/Pain in Specific Populations: Nociplastic and chronic widespread pain