A Qualitative Examination of a New Combined Cognitive-Behavioral and Neuromuscular Training Intervention for Juvenile Fibromyalgia
Open accessAbstract
OBJECTIVES: Adolescents with juvenile fibromyalgia (JFM) are typically sedentary despite recommendations for physical exercise, a key component of pain management. Interventions such as cognitive-behavior therapy (CBT) are beneficial but do not improve exercise participation. The objective of this study was to obtain preliminary information about the feasibility, safety, and acceptability of a new intervention--Fibromyalgia Integrative Training for Teens (FIT Teens), which combines CBT with specialized neuromuscular exercise training modified from evidence-based injury prevention protocols. MATERIALS AND METHODS: Participants were 17 adolescent females (aged 12 to 18 y) with JFM. Of these, 11 completed the 8-week (16 sessions) FIT Teens program in a small-group format with 3 to 4 patients per group. Patients provided detailed qualitative feedback via individual semistructured interviews after treatment. Interview content was coded using thematic analysis. Interventionist feedback about treatment implementation was also obtained. RESULTS: The intervention was found to be feasible, well tolerated, and safe for JFM patients. Barriers to enrollment (50% of those approached) included difficulties with transportation or time conflicts. Treatment completers enjoyed the group format and reported increased self-efficacy, strength, and motivation to exercise. Participants also reported decreased pain and increased energy levels. Feedback from participants and interventionists was incorporated into a final treatment manual to be used in a future trial. DISCUSSION: Results of this study provided initial support for the new FIT Teens program. An integrative strategy of combining pain coping skills via CBT enhanced with tailored exercise specifically designed to improve confidence in movement and improving activity participation holds promise in the management of JFM.
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High BMI and inactivity may exacerbate motor deficits and perpetuate the cycle of disability.
“High BMI and inactivity may exacerbate motor deficits and perpetuate the cycle of disability.2,17”
From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [17]
The Introduction (page not provided) links activity avoidance and poor body mechanics in adolescents with juvenile fibromyalgia to a possible downward spiral of pain and disability. It does not say that high BMI contributes to this cycle or that inactivity exacerbates motor deficits. (LLM, conf=0.86)
Experimental — accuracy not yet measuredFM patients may also experience real pain flare-ups post-exercise, linked to metabolic dysfunction and impaired endogenous pain inhibition.
“FM patients may also experience real pain flare-ups post-exercise, linked to metabolic dysfunction and impaired endogenous pain inhibition.17”
From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [17]
The Introduction (page unavailable) says fibromyalgia patients may be prone to increased pain with exercise and reports impaired endogenous pain inhibition in adults. It does not link post-exercise pain flares to metabolic dysfunction. The Results (page unavailable) distinguish post-exercise soreness from participants’ usual pain flares, which they described as unrelated to the exercises. (LLM, conf=0.86)
Experimental — accuracy not yet measuredKinesiophobia was reported in patients with FM due to the association between pain, fatigue and movement, and was associated with reduced levels of physical activity, increased disability, and perpetuation of pain.
“Kinesiophobia was reported in patients with FM due to the association between pain, fatigue and movement, and was associated with reduced levels of physical activity, increased disability, and perpetuation of pain.17,29,30”
From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [17]
The Introduction (page unavailable) reports marked fear of movement in adolescents with juvenile fibromyalgia and describes pain-related activity avoidance as a possible contributor to reduced exercise and a downward spiral of pain and disability. It does not establish fatigue as a cause of fear of movement, and its account of the pain–disability spiral is qualified rather than a demonstrated association for fibromyalgia patients generally. (LLM, conf=0.86)
Experimental — accuracy not yet measuredLow levels of physical activity were correlated with poor motor control, lower movement velocity, and a higher body mass index (BMI), which are typical in FM populations.
“Low levels of physical activity were correlated with poor motor control, lower movement velocity, and a higher body mass index (BMI), which are typical in FM populations.”
From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [17]
The Introduction says that most patients with fibromyalgia, including adolescents with JFM, are sedentary and that adolescents with JFM show altered biomechanics and movement deficits. It does not report a correlation between activity level and motor control, movement velocity, or BMI; the searches for movement velocity and BMI found no supporting passage. (LLM, conf=0.84)
Experimental — accuracy not yet measuredCognitive behavioural therapy (CBT) for FM is effective in reducing symptoms of depression, functional disability, and catastrophizing and increasing pain-coping efficacy, but does not result in greater engagement in more vigorous activity or exercise when applied in isolation.
“Cognitive behavioural therapy (CBT) for FM is effective in reducing symptoms of depression, functional disability, and catastrophizing and increasing pain-coping efficacy,9,17 but does not result in greater engagement in more vigorous activity or exercise when applied in isolation.17”
From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [17]
Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measured
Aerobic or resistance training programs may be challenging for patients with FM due to poor movement confidence and competence and increased baseline lactate concentrations.
“Aerobic or resistance training programs may be challenging for patients with FM due to poor movement confidence and competence17 and increased baseline lactate concentrations.15”
From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [17]
The Introduction says traditional aerobic or resistance training may be difficult to sustain for adolescents with juvenile fibromyalgia because of poor movement confidence and a lack of fundamental movement competence. The citing sentence extends that explanation to patients with fibromyalgia generally. Increased baseline lactate has a separate citation and is not attributed to this source. (LLM, conf=0.84)
Experimental — accuracy not yet measuredCBT combined with adapted physical activity appears more effective than either intervention alone.
“CBT combined with adapted physical activity appears more effective than either intervention alone.9,17”
From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [17]
The Discussion (page not specified) describes the combined CBT and tailored-exercise program as promising. It also says that comparisons with exercise-only and CBT-only programs are future work needed to determine whether the combined program produces superior outcomes; this study does not establish that it is more effective than either alone. (LLM, conf=0.88)
Experimental — accuracy not yet measuredMore than 80% of people with fibromyalgia experience poor sleep quality with severe fatigue.
“More than 80% of people with FM experience poor sleep quality with severe fatigue impacting depression,3 pain perception, physical functioning10 and exercise adherence.2,17,21”
From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [17]
The Participants section lists fatigue and sleep disturbance as associated symptoms of juvenile fibromyalgia, and the Introduction says exercise adherence in fibromyalgia is generally poor. Neither section reports that more than 80% of people with fibromyalgia have poor sleep quality and severe fatigue; the paper also does not establish that those symptoms impair exercise adherence. Page numbers are unavailable in our copy. (LLM, conf=0.83)
Experimental — accuracy not yet measuredBalance confidence, decreased muscle strength and altered biomechanics can negatively affect patients' quality of life by increasing the risk of falling, fall-related injuries and fear of falling.
“Balance confidence, decreased muscle strength and altered biomechanics can negatively affect patients’ quality of life by increasing the risk of falling, fall-related injuries and fear of falling,9,17,19,30”
From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [17]
The Introduction (page not provided) reports decreased strength, altered biomechanics, fear of movement, and movement patterns resembling those associated with injury risk in adolescents with juvenile fibromyalgia. It does not establish increased risk of falls or fall-related injuries, fear of falling specifically, or the claimed pathway to reduced quality of life; its reference to poor movement confidence is not specifically balance confidence. (LLM, conf=0.87)
Experimental — accuracy not yet measuredSevere fatigue impacts depression, pain perception, physical functioning, and exercise adherence in fibromyalgia.
“More than 80% of people with FM experience poor sleep quality with severe fatigue impacting depression,3 pain perception, physical functioning10 and exercise adherence.2,17,21”
From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [17]
The Results (Domain 1: Feasibility; page unavailable) report that adolescents with juvenile fibromyalgia identified fatigue as a barrier to maintaining their exercise regimen. This supports the exercise-adherence portion of the sentence, but the paper does not establish that severe fatigue associated with poor sleep has this effect across people with fibromyalgia generally. (LLM, conf=0.85)
Experimental — accuracy not yet measuredAn integrative strategy combining pain-coping skills with tailored, enjoyable exercise that includes sensory and motor challenges holds promise in managing fibromyalgia.
“An integrative strategy combining pain-coping skills, enhanced with tailored, enjoyable exercise that includes sensory and motor challenges specifically designed to improve confidence in movement and enhance activity participation, holds promise in managing FM.2,17,30”
From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [17]
The Abstract Discussion says that combining CBT pain-coping skills with tailored exercise designed to improve movement confidence and activity participation holds promise for juvenile fibromyalgia. The Results report that participants liked some exercises, and the Introduction describes the neuromuscular training, but the paper does not describe the exercises as including sensory challenges. Its conclusion is also specific to adolescents with juvenile fibromyalgia, rather than fibromyalgia generally. (LLM, conf=0.85)
Experimental — accuracy not yet measuredKinesiophobia and pain catastrophizing are strongly associated with decreased physical performance, reduced postural control, and muscle weakness in fibromyalgia.
“Kinesiophobia and pain catastrophizing are prevalent in FM and are strongly associated with decreased physical performance, reduced postural control, and muscle weakness,9,17,29”
From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [17]
The Introduction (page unavailable) reports that adolescents with juvenile fibromyalgia showed fear of movement alongside reduced strength, impaired functional performance, and altered biomechanics compared with healthy peers. It does not establish a strong association between those findings, nor does it report the claimed link involving pain catastrophizing or specifically reduced postural control. The evidence is also limited to adolescents rather than fibromyalgia patients generally. (LLM, conf=0.86)
Experimental — accuracy not yet measuredKinesiophobia and pain catastrophizing are prevalent in fibromyalgia.
“Kinesiophobia and pain catastrophizing are prevalent in FM and are strongly associated with decreased physical performance, reduced postural control, and muscle weakness,9,17,29”
From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [17]
The Introduction reports marked fear of movement in adolescents with juvenile fibromyalgia compared with healthy peers, supporting the kinesiophobia part in that population. It does not report that pain catastrophizing is prevalent, and its evidence about fear of movement does not establish prevalence across fibromyalgia generally. (LLM, conf=0.83)
Experimental — accuracy not yet measuredRegular moderate to vigorous physical activity and weight-bearing exercises are recommended for pain management in patients with FM, but adherence to these recommendations is often poor.
“Regular moderate to vigorous physical activity and weight-bearing exercises are recommended for pain management in patients with FM,5,21 but adherence to these recommendations is often poor.9,17,30”
From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [17]
Patients with fibromyalgia demonstrate dysfunctional pain inhibition, whereby they do not show endogenous hypoalgesia following exercise.
“Patients with FM demonstrate dysfunctional pain inhibition, whereby they do not show endogenous hypoalgesia following exercise17 and may experience discrepancy between their perceived capability and actual ability to engage in exercise.3”
From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [17]
Finding the most appropriate type of exercise that is both tolerable and sustainable for fibromyalgia patients has been challenging.
“Tailored exercise programs are needed for FM patients,3,17 but thus far, finding the most appropriate type of exercise that is both tolerable and sustainable for these patients has been challenging.17”
From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [17]
Tailoring a flexible program with modifications in consultation with the patient, emphasizing graded exercise and positive coping strategies, may be effective in ensuring that initial muscle soreness does not hinder compliance.
“Tailoring a flexible program which allows for modifications in consultation with the patient, with an emphasis on graded exercise and positive coping strategies, may be effective in ensuring that initial muscle soreness does not hinder compliance.17”
From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [17]
The literature is mixed in implicating obesity concerning motor control and postural stability.
“However, the literature is mixed in implicating obesity concerning motor control and postural stability.2,17,30”
From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [17]
The Introduction discusses altered biomechanics in adolescents with juvenile fibromyalgia, not obesity. Searches for obesity, motor control, postural stability, weight, and BMI found no passage in our copy addressing whether the evidence about obesity and those outcomes is mixed. (LLM, conf=0.77)
Experimental — accuracy not yet measured
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- Authors
- Kashikar-Zuck, S., Tran, S. T., Barnett, K., Bromberg, M. H., Strotman, D., Sil, S., Thomas, S. M., Joffe, N., Ting, T. V., Williams, S. E., & Myer, G. D.
- Affiliations
- Seattle Children's Research Institute (US)
- Emory University (US)
- Cincinnati Children's Hospital Medical Center (US)
- Corresponding author
- Tran, Susan T.
- Barnett, Kimberly
- Strotman, Daniel
- Joffe, Naomi
- Williams, Sara E.
- Myer, Gregory D.
- ORCID
- Venue
- The Clinical Journal of Pain
- Published
- 2016-01
- Volume
- 32
- Issue
- 1
- Pages
- 70-81
- ISSN
- 0749-8047 (ISSN-L)
- PMC
- PMC4549228
- OpenAlex
- W1987291338
- Cited by
- 55
- References
- 8
- Citations by year
- 2026: 3 · 2025: 5 · 2024: 1 · 2023: 4 · 2022: 4 · 2021: 10 · 2020: 5 · 2019: 6 · 2018: 5 · 2017: 5 · 2016: 5 · 2015: 1
- FWCI
- 4.33
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Clinical Journal of Pain (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health (UL1TR001425)
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (R21AR063412, K24AR056687)
- National Center for Advancing Translational Sciences
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Fibromyalgia and Chronic Fatigue Syndrome Research
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Pediatric Pain Management Techniques
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Keywords
- juvenile fibromyalgia, cognitive behavioral therapy, adolescents, exercise adherence, pain coping, self-efficacy, feasibility and acceptability, group intervention, treatment manual development
- MeSH terms
- Adaptation, Psychological, Adolescent, Child, Disability Evaluation, Exercise Therapy, Feasibility Studies, Feedback, Female, Fibromyalgia, Humans, Motivation, Pilot Projects, Exercise, Cognitive Behavioral Therapy, Treatment Outcome, Self Efficacy, Muscle Strength
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