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Fear of movement and avoidance behaviour toward physical activity in CFS and fibromyalgia-Nijs et al

Dolphin

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Clin Rheumatol. 2013 Aug;32(8):1121-9. doi: 10.1007/s10067-013-2277-4. Epub 2013 May 3.

Fear of movement and avoidance behaviour toward physical activity in chronic-fatigue syndrome and fibromyalgia: state of the art and implications for clinical practice.

Nijs J, Roussel N, Van Oosterwijck J, De Kooning M, Ickmans K, Struyf F, Meeus M, Lundberg M.

Source

Pain in Motion research group, Department of Human Physiology and Rehabilitation Sciences, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Building L-Mfys, Pleinlaan 2, 1050 Brussels, Belgium. Jo.Nijs@vub.ac.be

Abstract

Severe exacerbation of symptoms following physical activity is characteristic for chronic-fatigue syndrome (CFS) and fibromyalgia (FM).

These exacerbations make it understandable for people with CFS and FM to develop fear of performing body movement or physical activity and consequently avoidance behaviour toward physical activity.

The aims of this article were to review what measures are available for measuring fear of movement and avoidance behaviour, the prevalence fear of movement and avoidance behaviour toward physical activity and the therapeutic options with fear of movement and avoidance behaviour toward physical activity in patients with CFS and FM.

The review revealed that fear of movement and avoidance behaviour toward physical activity is highly prevalent in both the CFS and FM population, and it 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, depending on the patient's classification as avoiding or persisting, appears to be the most promising strategy for treating fear of movement and avoidance behaviour toward physical activity in patients with CFS and FM.

There is also this thread:
Dr. Enlander tackles a poor paper "Fear of movement and avoidance behaviour..."
http://forums.phoenixrising.me/inde...ar-of-movement-and-avoidance-behaviour.23495/
But, of the 142 comments, very few were directly on the paper itself so I thought I'd start a specific thread on it. There is an interesting discussion in that thread about "Fear of movement" and "avoidance behaviour".
 
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Dolphin

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Here, the authors justify putting the two together:
Chronic-fatigue syndrome (CFS) and fibromyalgia (FM) are severely disabling and largely overlapping [1, 2] disorders, both characterised by chronic fatigue, chronic widespread pain, concentration difficulties and physical inactivity [3, 4]. Both disorders are associated with high direct and indirect medical costs [5, 6]. CFS and FM share many clinical features, and the diagnostic criteria are partly overlapping as well [1, 2]. Both disorders are characterised by the same underlying mechanism: signs and symptoms result from the hyperexcitability of the central nervous system (or central sensitisation) [7–9].
I'm not convinced of the supreme importance of central sensitisation in ME/CFS in particular. But the authors thankfully do keep the two separate a lot of the time.
 

Dolphin

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17,567
I found a lot of this paper annoying but thought this was interesting:
Fear of performing physical activity or body movement has been described with a variety of conceptual definitions among which pain-related fear, fear-avoidance beliefs, fear of movement and kinesiophobia are the most commonly used [24]. Kinesiophobia is defined as ‘an excessive, irrational and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or reinjury’ [25]. Following its definition, kinesiophobia is one end of the spectrum of fear of movement, and kinesiophobia does not comply with the requirements of a phobia, as stipulated by the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders [26]. Therefore, the term kinesioiphobia will not be used here.

26. American Psychiatric Association. (1997) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). p. 1085

Anyone know why this is the case?
 

Dolphin

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The review seemed quite good in mentioning (questionnaire) evidence that contradicted the viewpoint that thinks fear avoidance is very important.

It also seemed quite good in highlighting weakness in the literature.

However, it didn't discuss biological findings that I can recall.
 

Dolphin

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17,567
It highlights that there can be different types of behaviour, which is good (CBT crowd often don't mention this), although I'm not convinced that either should be seen as necessarily pathological behaviour:

[..]

Fibromyalgia

Turk et al. studied a large group of FM patients (n=233), and found that nearly 39 % (n=90) displayed high levels of fear of movement [34]. In another study, fear of movement and avoidance behaviour toward physical activity was identified in 145 (40 %) out of 359 FM patients [32].

The above study findings suggest that not all patients with FM have fear-avoidance beliefs. In fact, many patients with FM display persistence behaviour (214 of 359 FM patients) [32], which often results from self-discrepancies. Patients with persistence behaviour try to ignore pain sensations and the (physical) boundaries of their body, suppress pain-related thoughts and persist in daily activities (including physical activities), resulting in over activity. Compared with fear-avoidant FM patients, persisting FM patients experience less pain and fatigue, functional disability, negative mood, worrying about, hypervigilance, helplessness, and perform better on physical fitness tests (e.g. they walk longer during a shuttle walking test) [32, 40].

Summary

The scientific literature suggests that approximately 40 % of patients with FM display high levels of fear of movement and avoidance behaviour toward physical activity, but the CFS literature - although consistently indicating that fear of movement is prevalent in the CFS population - is less clear in reporting prevalence data.
 

Dolphin

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I'm uneasy with the sort of language used (and the view underlying it):
Importantly, data from one CFS study indicate that fear of movement is of relevance for threatening physical activities like stair climbing but not for physical activity in general [38]. Fear of movement was not associated with daily physical activity in patients with CFS [38]. This is important for treatments aiming at increasing daily physical activity level in patients with CFS (as typically done in graded activity programs). Diminishing fear of movement appears only relevant for targeting physical activities that are perceived as threatening and not for increasing work-related or social (physical) activities. This suggests that clinicians should first identify physical activities that are perceived as threatening, and then restructure the patients’ beliefs in relation to this threatening task specifically.
 

Dolphin

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17,567
The authors do mention a weakness in the evidence for CBT:

Cognitive behaviour therapy is an effective treatment for patients with CFS [10, 11], but it does not result in a decrease in avoidance behaviour toward physical activity [48]. Moreover, the decrease in the focus on fatigue rather than changes in avoidance toward physical activity mediates the effects of cognitive behaviour therapy in CFS [48].

48. Wiborg JF, Knoop H, Prins JB, Bleijenberg G (2011) Does a decrease in avoidance behavior and focusing on fatigue mediate the effect of cognitive behavior therapy for chronic fatigue syndrome? J Psychosom Res 70(4):306–310

However, they contrast that with the following study which I don't think really invalidates the finding in Wiborg et al:
Partly contrasting these findings are the results from a randomised controlled clinical trial showing that illness beliefs about avoidance of physical activity in CFS patients improved in response to cognitive behaviour therapy but not following relaxation therapy [31]. In addition, the same study showed that good outcome following cognitive behaviour therapy in CFS is associated with changes in avoidance behaviour and related beliefs, rather than causal attributions [31].

31. Deale A, Chalder T, Wessely S (1998) Illness beliefs and treatment outcome in chronic fatigue syndrome. J Psychosom Res 45:77–83
The authors don't made clear that the Deale et al. study didn't measure actual behaviour, just responses (which may not represent actual behaviour) to:
I should avoid exercise when tired
Doing less helps fatigue
The participants may simply know/have been taught what are the "right" answers to give.

--------
I have some other observations but don't feel inclined at present to put in more time on this paper.
 
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Anyone know why this is the case?
The mere existence of kinesiophobia seems like a bit of an alternative or quacky belief. There's also an acknowledged rationality to the belief that movement is harmful, in the form of ongoing pain, whereas other phobias are based on distant past experiences or nothing at all.

A phobia should also involve a strong anxiety or other emotional response, which isn't the case for most ME patients. I think most of us have a very calm response to the thought or experience of over-exertion, even it is very oppositional to what certain experts believe. At least, my own response to a persistent suggestion to exercise might be surly, defiant, and extremely stubborn, but I wouldn't get upset or fearful.

There's also the problem that people who avoid movement probably pretty much universally want to move - so long as it is without pain or disability resulting. I doubt that is true for people who have a phobia of spiders, or dogs, or heights.

So I think kinesiophobia suffers from similar problems as pysochosomatic theories. They are simply the beliefs of certain therapists who cannot prove that they actually exist. And in the case of kinesiophobia, there are real phobias which it can easily be compared to, which suggests that it has very little in common with those phobias.
 

user9876

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A phobia should also involve a strong anxiety or other emotional response, which isn't the case for most ME patients.

Isn't that something that could be measured. For example measure the physiological signs associated with fear with people with various phobias when confronted with whatever was causing the fear and compare this to this with fear of movement.

Any experiments would need to separate out movement from fear or anger of doctors causing a relapse through forced exercise programs.
 

Ecoclimber

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Rebuttal to Ickmans et al. Association between cognitive performance, physical fitness, and physical activity level in women with chronic fatigue syndrome. J Rehabil Res Dev. 2013;50(6):795–810.

As argued before, cognitive deficits in ME/CFS can plausibly be explained by neurological abnormalities, e.g., hypoperfusion of and hypometabolism in specific brain regions, impaired cerebral oxygenation during exercise and orthostatic stress, SPECT-scan abnormalities in the cerebral cortex, and a reduction in white and gray matter. A correlation between neurological abnormalities and neurocognitive functioning has been observed repeatedly.

As substantiated by Meeus et al. , elevated oxidative and nitrosative stress, frequently observed in ME/CFS, can account for mitochondrial dysfunction, a decrease of the aerobic exercise capacity, and increased pain sensitivity.
 

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Dolphin

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Rebuttal to Ickmans et al. Association between cognitive performance, physical fitness, and physical activity level in women with chronic fatigue syndrome. J Rehabil Res Dev. 2013;50(6):795–810.

As argued before, cognitive deficits in ME/CFS can plausibly be explained by neurological abnormalities, e.g., hypoperfusion of and hypometabolism in specific brain regions, impaired cerebral oxygenation during exercise and orthostatic stress, SPECT-scan abnormalities in the cerebral cortex, and a reduction in white and gray matter. A correlation between neurological abnormalities and neurocognitive functioning has been observed repeatedly.

As substantiated by Meeus et al. , elevated oxidative and nitrosative stress, frequently observed in ME/CFS, can account for mitochondrial dysfunction, a decrease of the aerobic exercise capacity, and increased pain sensitivity.
Thanks for posting that. However, the letter is replying to a different paper.