FİBROMİYALJİ SENDROMUNDA BİLİŞSEL DAVRANIŞÇI TERAPİ VE TENS TEDAVİLERİNİN ETKİNLİĞİ

Öz

Günümüzde fibromiyalji sendromu (FMS) için farklı tedavi yöntemleri vardır, ancak standart bir tedavi yöntemi konusunda fikir birliği yoktur. Randomize kontrollü çalışmamızda, FMS’de TENS (Transcutaneous Electrical Nerve Stimulation), hasta eğitimi ve bilişsel davranışçı terapinin (BDT) etkinliği araştırıldı. Bu amaçla, American College of Rheumatology (ACR) 1990 tanı kriterlerine göre FMS tanısı konan, 18-60 yaş arası, 60 kadın hasta rastgele yöntemle 20’şer kişilik 3 gruba ayrıldı. 1. gruba (n=20) 10 seans plasebo TENS ve 5 seans hasta eğitimi (HE); 2. gruba (n=20) 10 seans TENS ve 5 seans HE; 3. gruba (n=20) 10 seans TENS ve 8 seans BDT uygulandı. Olgular tedavi öncesi ve sonrası, tedavi bitiminden 6 hafta sonra ağrı açısından, vizüel analog skala (VAS), algometrik ölçüm, ağrılı nokta sayısı, haftalık analjezik kullanım sayısı; uyku kalitesi açısından VAS ve sabah yorgunluğu (5’li Likert tipi skala); depresyon açısından Beck depresyon ölçeği; genel değerlendirme açısından hasta ve doktorun genel değerlendirmesi (5’li Likert tipi skala); fonksiyonel değerlendirme açısından FMS etki sorgulaması formu (FIQ); ve yaşam kalitesi açısından Short Form36 (SF-36) ile değerlendirildiler. Hastalar tedavi sonrasında kendilerine uygulanan tedaviyi 5’li Likert tipi skala ile değerlendirdiler. Günümüzde FMS tedavisinde çok değişik yöntemler kullanılmaktadır. Ancak FMS tedavisinde kabul edilmiş ortak bir tedavi yöntemi bulunmamaktadır. Bu çalışmamızda HE, BDT ve TENS tedavilerinin FMS üzerine olan etkileri incelendi. Bu çalışmada FMS’li hastalarda TENS’in ağrı üzerine etkili olduğunu ve grup halinde uygulanan BDT ve HE’nin ağrı, depresyon, hastalığın genel değerlendirmesi ve yaşam kalitesine olumlu etkileri olduğu, ayrıca BDT’nin depresyon, hastanın kendini genel değerlendirmesi ve uyku parametrelerinde HE’ye üstün olduğu saptandı. Ancak FMS’de fizik tedavi ajanları ve BDT’yi değerlendiren daha uzun takipli ve daha çok olgu içeren çalışmalara ihtiyaç vardır.

Anahtar Kelimeler

• Fibromiyalji sendromu,Bilişsel davranışçı terapi,TENS

EFFICACY OF COGNITIVE BEHAVIORAL THERAPY AND TENS THERAPY IN FIBROMYALGIA SYNDROME

Öz

At the present time, there are different typeS of treatment methods for fibromyalgia syndrome (FMS), but there is no consensus on a standart treatment method. In our randomized controlled study, we researched the efficacy of patient’s education, cognitive behavioral therapy (CBT) along with TENS in FMS. Sixty women aged between 18-60, who fullfilled the American College of Rheumatology criteria for FMS, were separated into three groups. The first group (n=20) received plasebo TENS as 10 sessions and education as 5 sessions; the second group (n=20) received TENS as 10 sessions and education as 5 sessions whereas the third group received TENS 10 sessions and CBT as 8 sessions. Our evaluation parameters were intensity of pain with algometer, number of the tender points, VAS index for pain, VAS index for quality of sleep and morning fatigue (5-point Likert-type scale), Beck depression inventory, fibromyalgia impact questionnaire, SF-36, patient and physican global assesments at the beginning, at the end of the theraphy, and 6 weeks after. Each patient evaluated the therapy with a Likert type scale at the end of therapy as well. It was found TENS is effective on pain in FMS. Patients education and CBT as group therapy format were also effective on pain, depression, global assesment of disease and quality of life in FMS. CBT was found more effective on depression, quality of sleep along with patient and physican global assesment parameters than education alone. It is obvious that studies with great number of patients and with longer follow up periods on the effectiveness of physical therapy agents and CBT both together, or in comparative design will answer further questions.

Anahtar Kelimeler

• Fibromyalgia syndrome,Cognitive behavioral therapy,TENS

Kaynakça

1. 1- Akkuş, S., Koşar, A., Beyazıt, O., “Fibromiyalji tanısı konan 220 vakanın klinik özellikleri”, Türkiye Fiziksel Tıp ve Rehabilitasyon Dergisi, 1(1), 41-46, 1998
2. 2- Arnold, L.M. & Clauw, D. J., “ Challenges of implementing fibromyalgia treatment guidelines in current clinical practice” , Postgraduate Medicine, (just-accepted), 129(7), 709-714, 2017
3. 3- Atlı, A.D., Öztek, F., Erdoğan, S., “Primer Fibromiyalji Sendromu’nda Nokturnal Growth Hormon Sekresyonu”, Fiziksel Tıp ve Rehabilitasyon Dergisi, 22(3), 106-110, 1997
4. 4- Bengtsson, A., Henriksson, K.G and Larsson, J., “Muscle biopsy in primary fibromyalgia: Lightmicroscopical and histochemical findings”, Scandinavian Journal Rheumatology, 15(1), 1-6, 1986
5. 5- Bennett, R.H., Burckhardt, C.S., Clark, S.R., O’Reilly, C. A., Wiens, A. N., & Campbell, S.M., “Group treatment of fibromyalgia: A 6 month outpatient program”, The Journal of Rheumatology, 23(3), 521-528, 1996
6. 6- Buckkelew, S.P., Conway, R., Parker, J., Deuser, W. E., Read, J., Witty, T. E. & McIntosh, M. J., “Biofeedback/ relaxtion training and exercise interventions for fibromialgia: A prospective trial”, Arthritis & Rheumatology, 11(3), 196-209, 1998
7. 7- Buckelew, S.P., Huyser, B., Hewett, J.E., Johnson, J. C., Conway, R., Parker, J. C. & Kay, D. R., “Selfefficacy predicting outcome among fibromialgia subjects”, Arthritis & Rheumatology, 9(2), 97- 104, 1996
8. 8- Burckhardt, C.S., Clark, S.R., Bennett, R.M., “The fibromyalgia impact questionnaire: development and validation”, J Rheumatol, 18(5), 728-733, 1991

9. 9- Burckhardt, C.S., Mannerkorpi, K., Hedenberg, L., Bjelle, A., “A randomized controlled clinical trial of education and physical training for women with fibromyalgia”, The Journal of Rheumatology, 21(4), 714-720, 1994
10. 10- Busch, A. J., Barber, K. A., Overend, T. J., Peloso, P.M.J. & Schachter, C.L., “Exercise for treating fibromyalgia syndrome”, The Cochrane Library, 2007, CD003786
11. 11- Çeliker, R., “Kronik ağrı sendromları”, 20. Ulusal Fiziksel Tıp ve Rehabilitasyon Kongresi. Konferans Metinleri, 6-7, 2005
12. 12- Deyo, R.A., Walsh, N.E., Martin, D.C., Schoenfeld, L.S., & Ramamurthy, S., “A controlled trial of transcuteneous electrical nevre stimülation (TENS) and exercise for chronic low back pain”, New England Journal of Medicine, 322(23), 1627-1634, 1990
13. 13- Dunkl, P.R., Taylor, A.G., McConnell, G.G., Alfano, A.P., Conaway, M.R., “Responsiveness of fibromyalgia clinical trial outcome measures”, The Journal of rheumatology, 27(11), 2683-2691, 2000
14. 14- Fisher, A., : Pressure algometry in differential diagnosis of muscle pain; Myofascial Pain and Fibromyalgia, Mosby-Year Book, Inc, 121-139, 1994
15. 15- Güven, Z., Özaras, N., Babacan, A.G., Kayhan, Ö., “Değişik TENS Modalitelerinin Fibromiyalji Sendromuna Etkileri”, Fizik Tedavi ve Rehabilitasyon Dergisi, 16(1), 32-37, 1992
16. 16- Henriksson, K.G., Bengtsson, A., “Fibromyalgia–a clinical entity?”, Canadian journal of physiology and pharmacology, 69(5), 672-677, 1991
17. 17- Kılıç, A.M., “Fibromiyalji Sendromlu Hastalarda TENS ve Egzersiz Tedavilerinin Etkinliğinin Karşılaştırılması” Yüksek Lisans Tezi, 1999
18. 18- King, S.J., Wessel, J., Bhambhani, Y., Sholter, D., & Maksymowych, W., “The Effects of Exercise and Education, İndividually or Combined, in Women with Fibromyalgia”, The Journal of rheumatology, 29(12), 2620- 2627, 2002
19. 19- Korszun, A., Lundden, L.S., Papadopoulos, E., Brucksch, C., Masterson, L., Engelberg, N.C., & Crofford, L. “Melatonin levels in women with fibromyalgia and chronic fatigue syndrome.”, The Journal of rheumatology, 26(12), 2675-2680, 1999
20. 20- Moldofsky, H., Lue, F.A., Roth-Schechter, B., & Reynolds, W. J. “The effect of Zolpidem in patients with fibromyalgia; a dose ranging, double blind, placebo controlled, modified crossover study” , The Journal of Rheumatology, 23(3), 529-533, 1996
21. 21- Mountz, J.M., Bradley, L.A., Alercon, G.S., “Abnormal functional activity of the central nervous system in fibromialgia syndrome”, The American journal of the medical sciences, 315(6), 385- 396, 1998
22. 22- Nicassio, P.M., Radojerevic, V., Weismen, M.H., Schuman, C., Jung, K., Schoenfiel, S.M., Knoll, T., “Cognitive and Behavioral, Interventions for Fibromyalgia”, J. Rheumatol, 24(10), 200-207, 1997
23. 23- Nicassio, P.M., Radojevic, V., Weisman, M.H., Schuman, C., Kim, J., Schoenfeld-Smith, K. & Krall, T, “A comparison of behavioral and educational interventions with fibromialgia”, The Journal of Rheumatology, 24(10), 2000-2007, 1997.
24. 24- Nusreti, H., Safati, B., Güneri, S., Durmaz, B., Akşit, R. “Primer Fibromiyalji Tedavisinde Akupunktur ve TENS’ in Yeri”, Ege Fiz Tıp Reh Der, 1(3), 175-178, 1995
25. 25- Pellegrino, M.J., “A typical chest pain as initial presentation of primary fibromyalgia”, Archieves of Physical Medicine Rehabilitation, 71(7), 526-528, 1990
26. 26- Pellegrino, M.J., Waylanis, G.W., & Sommer, A., “Familial occurence of primary fibromyalgia”, Archives of physical medicine and rehabilitation, 70(1), 61-63, 1989
27. 27- Vlaeyen, J.W.S., Teken-Gruben, N.J.G., Goosens, M.E.J.B., “Cognitive- educational treatment of fibromyalgia: A randomized clinical trial. I. Clinical effects”, The Journal of Rheumatology, 23, 1237-1245, 1991
28. 28- Weigent, D.A., Bradley, L.A., Blalock J.E. & Alarcon, G.S., “Current concepts in the pathophysiology of abnormal pain perception in fibromyalgia”, The American journal of the medical sciences, 315(6), 405-412, 1998
29. 29- White, K.P., Speechley, M., Harth, M., “Fibromyalgia in Rheumatology Practice; A survey of Canadian Rheumatologists”, The Journal of Rheumatology, 22(4), 722-726, 1995
30. 30- Wolfe, F., Clauw, D. J., Fitzcharles, M. A., Goldenberg, D. L., Katz, R. S., Mease, P. & Yunus, M. B., “The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity”, Arthritis care & research , 62(5), 600-610, 2010
31. 31- Wolfe, F., Ross, K., Anderson, J., Russell, I.J. “Aspects of fibromyalgia in the general population sex, pain threshold and fibromyalgia symptoms”, The Journal of rheumatology, 22(1), 151-156, 1995
32. 32- Yunus, M.B., Masi, A.T., “Fibromyalgia, Restless Legs Syndrome, Periodic Limb, Movement Disorder and Psychogenic Pain; In arthritis and allied Condition, 12th edition, Lea & Febigeredited by D.J. McCartyand , W.J. Kopman, 1992, 1383
33. 33- Yunus, M.B., “Research in Fibromyalgia and Myofascial Pain Syndromes: Current Status, Problems and Future Directions”, Journal of Musculoskeletal Pain 1(1), 23-42, 1993