Transcript Cognitive behavioural therapy and aerobic exercise in muscular

Overcoming Fatigue
Cognitive behavioural therapy (CBT) and exercise for
neuromuscular conditions
Mark Hamilton
Research Fellow in Clinical Genetics
University of Glasgow / Queen Elizabeth University Hospital
Overview
• Defining fatigue
• Theory of CBT
• Exercise therapy and CBT
• Evidence for use in muscle disease
Fatigue
“Extreme tiredness resulting from
mental or physical exertion or
illness”
• Duchenne
41%1
FSHD
61%2
Myotonic dystrophy 90%3
1Pangalila
et al.2015; 2Voet et al. 2014; 3Heatwole et al. 2012
Fatigue
• Acute vs. chronic
• Central vs. peripheral
General population
Duchenne MD
Chronic Fatigue
Fatigue, pain and anxiety/depression
in DMD
Pangalila et al.2015
Cognitive Behavioural Therapy
• “talking” therapy
• Structured sessions
– Typically short-term over several sessions
– Examining aspects of thinking and behaviour
– Identify areas of change
– Goal-setting
“No point in going”
“I won’t enjoy it”
“I won’t be able to do it”
“It’ll just make me feel worse”
Muscle ache,
Fatigue,
Sleepiness
Isolated,
Low in mood,
Hopeless
Don’t get out of bed
Cancel plans
Avoid exertion
Thought Challenging
“Negative automatic thoughts”
1. Catch the thought
2. Look for evidence
3. Find an alternative, evidence-based thought
Thought Challenging
Activity Planning
• List activities
– Routine
– Necessary
– Pleasurable
• Specific exercise or activity programme
• Accountability
Activity Planning
Goals in CBT for muscle disease likely
involve increased exercise
• Goal-setting in CBT is likely to
include increased activity
levels
• Goal-setting and “coaching”
relationship also an
important component of
physiotherapy
So does it work?
• Well recognised
benefits in
– Depression, anxiety, OCD
• But also:
– chronic fatigue syndrome
(40% vs. 26%)1
– multiple sclerosis
(sustained effect)2
– post-chemotherapy
(54% vs. 4%)3
1Price
2008; 2Van Kessel 2008; 3Gielissen 2006
Aerobic exercise and CBT in
Facioscapulohumeral MD
• 77 individuals with severe fatigue
– 1. Aerobic exercise
– 2. CBT
– 3. Usual care
• Followed up for 6 months
Results
• Fatigue scores
– AET: ~24%
– CBT: ~30%
• 76% of CBT group and 50% of AET group no longer severely fatigued
• Improvements in
– sleep disturbance
– physical activity
– Social participation
• Sustained (more than 70% kept up new habits)
Myotonic dystrophy type 1
• Commonest form of
muscular dystrophy
among adults
• Multi-system disorder
• Central effects heighten
fatigue, apathy and low
mood symptoms
The OPTIMISTIC Trial
“We hypothesise that a DM1-specific CBT intervention, aimed at the fatiguemaintaining beliefs and behaviours will lead to a significant reduction of fatigue
and improved quality of life”
•
250 patients people with myotonic dystrophy type 1
– Newcastle, Munich, Paris, Nijmegen
•
10 to 14 sessions over 10 months (some can be Skype), focusing on:
–
–
–
–
–
•
Improving sleep patterns
Starting new activities
Increasing physical activity
Thinking about ways to change how symptoms affect you
Improving relationships with others
Followed up for 6 months after that
Progress …
• Recruitment now closed
• Final follow-up due March
• Results expected later in 2016
• Anecdotally, patients have enjoyed taking part
What do I tell patients now?
• If mood problems are predominant
– Talk to your GP about referral for CBT
• Otherwise
– Talk to patients about relationship between
activity levels, mood and physical symptoms
– Goal-setting with encouragement
– Encourage use of patient’s own support networks
to achieve goals and maintain new behaviours
Summary
• Physical symptoms, mood, motivation and social
participation are inter-dependent
• CBT may become more increasingly mainstream in
management of muscle disease
• Meantime
–
–
–
–
Help patients reflect on habits and ways of thinking
Challenge unhelpful ones
Goal-setting and “coaching” are key
If mood is a major concern, encourage discussion with GP
about CBT
Questions?