Internet versus face-to-face group cognitive-behavioral therapy for fibromyalgia: A randomized control trial

Highlights

• Compared group delivered CBT vs. Internet delivered iCBT.

• In post-treatment, only the CBT group showed improvement in the primary outcome.

• At 12-month follow-up, the iCBT group was superior to CBT.

• Self-efficacy or catastrophizing, could be enhanced by iCBT.

Abstract

Background

The aim of this study was to explore the effectiveness of Internet-delivered cognitive-behavioral therapy (iCBT) in treating fibromyalgia (FM) compared with an identical protocol using conventional group face-to-face CBT.

Methods

Sixty participants were assigned to either (a) the waiting list group, (b) the CBT group, or (c) the iCBT group. The groups were assessed at baseline, after 10 weeks of treatment, and at 3-, 6-, and 12-month follow-ups. The primary outcome measured was the impact of FM on daily functioning, as measured by the Fibromyalgia Impact Questionnaire (FIQ). The secondary outcomes were psychological distress, depression, and cognitive variables, including self-efficacy, catastrophizing, and coping strategies.

Results

In post-treatment, only the CBT group showed improvement in the primary outcome. The CBT and iCBT groups both demonstrated improvement in psychological distress, depression, catastrophizing, and utilizing relaxation as a coping strategy. The iCBT group showed an improvement in self-efficacy that was not obtained in the CBT group. CBT and iCBT were dissimilar in efficacy at follow-up. The iCBT group members improved their post-treatment scores at their 6- and 12-month follow-ups. At the 12-month follow-up, the iCBT group showed improvement over their primary outcome and catastrophizing post-treatment scores. A similar effect of CBT was expected, but the positive results observed at the post-treatment assessment were not maintained at follow-up.

Conclusions

The results suggest that some factors, such as self-efficacy or catastrophizing, could be enhanced by iCBT. Specific characteristics of iCBT may potentiate the social support needed to improve treatment adherence.

Introduction

Fibromyalgia (FM) is a syndrome of unknown etiology that is characterized by widespread pain, fatigue, sleep disturbance, and decline in physical functioning (Wolfe et al. 1995). FM also has an important emotional impact, leading to mood disturbances, anxiety and stress reactions (Thieme and Turk, 2000). Patients must adapt to this chronic condition, which often exerts an overwhelming influence on their lives (Van Middendorp et al. 2008).

In the absence of an etiological treatment, an important goal is to reduce the impact of FM on patients' quality of life. Because of the limitations of pharmacological interventions, patients may require non-pharmacological interventions, including cognitive-behavioral therapy (CBT) and exercise (Goldenberg et al. 2004). CBT is useful in treating emotional disorders, such as depression and anxiety, and it is useful in facilitating coping and reactivating psychosocial activities (Craighead et al. 2007).

Several studies have demonstrated the efficacy of CBT in improving depression and anxiety (Castel et al., 2012, Vázquez-Rivera et al., 2009, Wells-Federman et al., 2003), coping strategies (Vázquez-Rivera et al., 2009, Thieme et al., 2006), pain (Wells-Federman et al., 2003, Lera et al., 2009), cognitive factors such as self-efficacy or catastrophizing (Castel et al., 2012, Thieme et al., 2006), and fatigue and physical health in FM patients (Lera et al., 2009, Williams et al., 2002). There is evidence to suggest that CBT is the best option for reducing the impact of these symptoms on FM patients (García et al. 2006). In terms of Cohen's categories, the effect size of the benefits of CBT are small for depression and high for self-efficacy of pain. There is no impact on pain or fatigue (Bernardy et al., 2010). When CBT is compared with pharmacological treatment such as minalcipran, the psychological treatment has a moderate to large effect in improving physical function (Ang et al., 2013).

The standard care for FM is pharmacological. In most clinical settings (primary care or rheumatology units), there are no psychologists to implement CBT intervention. A better combined treatment could be implemented by using the Internet to deliver CBT to any patient who needs it (Busch et al., 2008, Thieme and Gracely, 2009).

CBT has a psychoeducational style and is configured as a systematic protocol. This characteristic allows it to easily integrate into software programs run on Internet servers. Many controlled studies have shown the efficacy of CBT on the Internet (iCBT) (Cuijpers et al. 2008) for chronic pain (Bender et al., 2011, Palermo et al., 2009). One study (Williams et al. 2010) compared standard care (pharmacological treatment) with iCBT but not with face-to-face conventional CBT.

The present study compares the efficacy of a CBT program for FM delivered in a group face-to-face setting with iCBT using the same treatment protocol. We also used a waiting list (WL) control group to isolate the treatment effects. The study used an intent-to-treat (ITT) randomized design with 3 groups: (a) the WL group, (b) the CBT face-to-face group, and the (c) iCBT group. There were 5 data collection periods: baseline, post-treatment and 3-, 6- and, 12-month follow-ups.