Heightened protective decision-making related to physical, but not cognitive, effort in individuals with fibromyalgia, 2025, Herman et al

[Andy]

Highlights

• Individuals with fibromyalgia require higher incentives for physical effort tasks.
• No differences in cognitive effort task between fibromyalgia and control groups.
• Fibromyalgia participants display increased willingness to wait for rewards.
• This suggests higher protective decision-making for physical effort in fibromyalgia.
• Insights may inform tailored intervention strategies for fibromyalgia patients.

Abstract
Fibromyalgia is a chronic condition involving widespread pain, fatigue, and cognitive dysfunction. Evidence-based interventions for fibromyalgia, such as education and exercise, often require prolonged, cognitive and/or physical effort, involving immediate costs (effort) for delayed benefits (improved pain/function). Initiation of, and adherence to, these interventions is often difficult, which may reflect pain-related alterations in an individual’s attitudes towards effortful and delayed rewards.

Here we explored whether individuals with fibromyalgia differed from age- and sex-matched pain-free controls in such attitudes. In cross-sectional Study 1, individuals with fibromyalgia (N=19) and controls (N=19) completed tasks offering real rewards for performing actual physical or cognitive effort or enduring real delays.

Despite individualizing task difficulty to each participant’s unique capacity, those with fibromyalgia required higher incentives to engage in the physical effort task (treadmill walking), especially at higher effort intensities (OR=1.077, 95%CI [1.003, 1.156]), but showed no differences in the cognitive effort task, indicating no general motivation deficit but rather a shift in attitudes toward physical exertion.

Additionally, participants with fibromyalgia showed a greater willingness to wait for rewards (OR=0.726, 95%CI [0.533, 0.990]), particularly at lower reward levels, suggesting an increased motivation driven by rewards. Study 2, conducted online (N=43 fibromyalgia, N=139 controls), replicated the findings regarding physical effort (t=3.36, 95%CI [0.08, 0.29]), reinforcing that fibromyalgia does not involve a broad motivational deficits. Instead, we found specific changes in physical effort discounting and indications of heightened sensitivity to rewards in delay discounting. These insights may help inform tailored intervention strategies for individuals with fibromyalgia.

Perspective
This article identifies altered attitudes toward physical effort and delayed rewards in individuals with fibromyalgia. These findings suggest that difficulties with treatment adherence may stem from over-protective physical effort-related decision-making rather than low motivation, offering a potential target for personalized education and intervention strategies in clinical care.

Open access

 

[Hoopoe]

It sounds like they are in the process of discovering fatigue.

Fatigue makes a person more selective in their decision whether to do something or not.

 

[Trish]

So are they talking about 'effort preference'?

 

[Kitty]

I think they're talking about people being reluctant to drink seven vodka shots on a school night because some bugger's curious about the effect on them, when they already know what the effect will be and they've never liked vodka much anyway.

 

[Peter T]

I am not yet motivated enough to read the article, but from the abstract it would seem the researchers are prejudging what is and what is not a reasonable response to the condition.

Clinicians get to go home after intervention but the patients have to live with its longer term consequences.

Also given we do not have equivalence scales of effort for cognitive and physical activity can we be sure that the relationships between subjects and controls in relation to the two types of activity are not due to a ceiling effect?

 

[Utsikt]

Evidence-based interventions for fibromyalgia, such as education and exercise, often require prolonged, cognitive and/or physical effort, involving immediate costs (effort) for delayed benefits (improved pain/function). Initiation of, and adherence to, these interventions is often difficult, which may reflect pain-related alterations in an individual’s attitudes towards effortful and delayed rewards.

«Evidence-based». Sure..

Additionally, participants with fibromyalgia showed a greater willingness to wait for rewards (OR=0.726, 95%CI [0.533, 0.990]), particularly at lower reward levels, suggesting an increased motivation driven by rewards.

I don’t understand their interpretation here. How does increased patience = increased reward-driven motivation? If you were more driven by rewards, you’d expect them to be relatively more willing to wait for higher rewards. They found the opposite trend.

Perspective
This article identifies altered attitudes toward physical effort and delayed rewards in individuals with fibromyalgia. These findings suggest that difficulties with treatment adherence may stem from over-protective physical effort-related decision-making rather than low motivation, offering a potential target for personalized education and intervention strategies in clinical care.

Where did they get the «over-protective» from?

Participants were informed that at the end of the study (following data collection), the raffle would be organized for a chance of winning an additional prize and that more raffle tickets gave higher chances of winning the prize (beyond the $40 voucher that every participant received for participating in the study). The value of the prize was not specified as an identical monetary prize may hold different value for each individual and thus a specific prize amount may induce divergent motivating properties. In reality, no raffle was conducted and every person received an additional $10 voucher at the end of data collection.

I don’t understand how this is ethical. They outright lied to the participants about the rewards. If you get $40 guaranteed and get told there is an additional raffle, you’d expect a prize far higher than $40.

I would be very interested in seeing a trial like this done with healthy controls and two sections in random order: one where they complete it without any interventions and one where pain is inflicted during the entire trial, but scaling with the effort chosen. Lets see how that affects motivation to wait or do hard tasks. I bet they’ll find that they do worse than pwFM.

 

[Sean]

These findings suggest that difficulties with treatment adherence may stem from over-protective physical effort-related decision-making...

Not from highly inappropriate 'treatment'? Didn't consider that rather obvious and critical possibility?

The only 'over-protective' behaviour here is the authors' towards their preferred hypothesis.

 

[shak8]

Uh-hem.

If I don't have the protective mechanism software running in my head all the time, I am likely to, for instance, vacuum the whole apartment and have my usual sites of upper back pain rise from 5/10 to 7/10 for TWO WEEKS which brings a cascade of other anti-pain measures I have to employ which don't always work or leave me with drug effect sedation and that useless feeling which is deleterious to my sense of self.

Ditto for lifting more than 2 lbs, repetitive forearm use, leg muscle use---a long list. Added are sensory and social over-stimulation by normal stimuli previously tolerated, fatigue inducing pain, fatigue, fatigue, IBS. Did I leave anything out?

In my case, FM pain began in tiny areas. Thirty years later, the extension of the pain generating regions has increased in area by roughly 700%,

To the average human who has not experienced FM, ME/CFS or LC or Lyme, it sound fantasist, or a psychological problem. But if the researchers would gather patients' descriptions of how they manage the activities that they manage to do, perhaps they might brush up against reality, become enlightened.

Walking sounds nice, doesn't it, but the thigh muscles' "feel" must be assessed for heaviness sensation (sign of muscle strain), and my general fatigue level, as well. Assess early in the walk, and during the walk so that I make myself sit down, lie down as needed to safely (concept of safety means the delayed symptoms are prevented or attenuated) accomplish the 20 minutes spent walking.

I have learned that if I don't monitor and assess how I am feeling (as opposed to what my pre-illness self would do or would want to do) I will have increased pain and fatigue---what I term PEM crossed with DOMS.

And increased symptoms always means decreased function.

 

[rvallee]

Always the same dynamics as the conspiracy fantasy communities: when you don't understand how things work, everything looks like a conspiracy. In health care, it slightly shifts to: when you don't understand a condition, it always looks psychosomatic. They can use whatever words they want to coat it up, this is just Dr Magoo pulling a Glonzo issue.

What's a Glonzo issue, you may not care to ask? Because it's inherently political, I will slightly adapt it for psychosomatic ideology:

An ideological concern held by a significant portion of low-information experts in a given profession that either completely misidentifies the cause of a real problem or is based on fears that have no basis in reality. Named after a joke on Bluesky about 25% of people believing a creature called "Glonzo" chewing through power lines causes high electricity prices.

Chronic illness is real, but half the profession thinks it's caused by TikTok. It's a total Glonzo issue.

Basically, they recognize the problem is real when it happens, even though they generally reject the very premise that it can exist, but attribute it to some other random thing. Whether it's deconditioning, fear, lack of motivation, effort preference, unhelpful illness beliefs, hopelessness driven by certainty of doom, or whatever they think they are arguing here, all of those are the exact same as attributing all of it to some creature called Glonzo doing all those things.

 

[Holinger]

Sounds like it is going down the path of Lorimer Mosley’s ‘protectormeter’ theory. Two of the authors are at his unit in South Australia university.

 

[Joan Crawford]

Highlights

• Individuals with fibromyalgia require higher incentives for physical effort tasks.
• No differences in cognitive effort task between fibromyalgia and control groups.
• Fibromyalgia participants display increased willingness to wait for rewards.
• This suggests higher protective decision-making for physical effort in fibromyalgia.
• Insights may inform tailored intervention strategies for fibromyalgia patients.

Abstract
Fibromyalgia is a chronic condition involving widespread pain, fatigue, and cognitive dysfunction. Evidence-based interventions for fibromyalgia, such as education and exercise, often require prolonged, cognitive and/or physical effort, involving immediate costs (effort) for delayed benefits (improved pain/function). Initiation of, and adherence to, these interventions is often difficult, which may reflect pain-related alterations in an individual’s attitudes towards effortful and delayed rewards.

Here we explored whether individuals with fibromyalgia differed from age- and sex-matched pain-free controls in such attitudes. In cross-sectional Study 1, individuals with fibromyalgia (N=19) and controls (N=19) completed tasks offering real rewards for performing actual physical or cognitive effort or enduring real delays.

Despite individualizing task difficulty to each participant’s unique capacity, those with fibromyalgia required higher incentives to engage in the physical effort task (treadmill walking), especially at higher effort intensities (OR=1.077, 95%CI [1.003, 1.156]), but showed no differences in the cognitive effort task, indicating no general motivation deficit but rather a shift in attitudes toward physical exertion.

Additionally, participants with fibromyalgia showed a greater willingness to wait for rewards (OR=0.726, 95%CI [0.533, 0.990]), particularly at lower reward levels, suggesting an increased motivation driven by rewards. Study 2, conducted online (N=43 fibromyalgia, N=139 controls), replicated the findings regarding physical effort (t=3.36, 95%CI [0.08, 0.29]), reinforcing that fibromyalgia does not involve a broad motivational deficits. Instead, we found specific changes in physical effort discounting and indications of heightened sensitivity to rewards in delay discounting. These insights may help inform tailored intervention strategies for individuals with fibromyalgia.

Perspective
This article identifies altered attitudes toward physical effort and delayed rewards in individuals with fibromyalgia. These findings suggest that difficulties with treatment adherence may stem from over-protective physical effort-related decision-making rather than low motivation, offering a potential target for personalized education and intervention strategies in clinical care.

Open access

"Despite individualizing task difficulty to each participant’s unique capacity, those with fibromyalgia required higher incentives to engage in the physical effort task (treadmill walking), especially at higher effort intensities (OR=1.077, 95%CI [1.003, 1.156]), but showed no differences in the cognitive effort task, indicating no general motivation deficit but rather a shift in attitudes toward physical exertion."

More physical effort = more pain (and other symptom feedback). Pts learn. Not hard to understand. All you have to do is ask the fibro patients.

 

[Sean]

@Joan Crawford

Are you seeing any progress in your profession on attitudes towards patients?

 

[Joan Crawford]

@Joan Crawford

Are you seeing any progress in your profession on attitudes towards patients?

Hi @Sean

There are a few odd balls with odd ideas. In relation to chronic pain and Fibromyalgia it's been about pain management for a long time, eg pacing etc in the absence of effective medications or treatments.

The usual suspects tried to influence IAPT re chronic pain and fatigue which didn't get far and has no real traction amongst anyone serious.

There are rumblings about psychological trauma and chronic pain/FMS that appears and re-appears from time to time. That'll hang about as patients with significant trauma and, for example, ptsd will often reduce or discontinue opiod medications with successful trauma focused therapy. Doesn't make a difference to their pain/Fibro.

After failing with ME, FMS, MUS , the usual suspects have moved to FND, NEAD etc. Failing their too. The CODES trial, was not helpful, but it won't stop a small group of academics keeping grinding away. This is far from the reality of attitudes of professionals I meet working with patients, at least in NW UK. May be different in areas of UK where psychosocial influence is greater. I suspect not though tbh. No fun flogging unhelpful nonsense.

 

[Sean]

@Joan Crawford

Good to hear. Thanks to you and your colleagues for continuing to plug away at this.

 

[Hoopoe]

To the average human who has not experienced FM, ME/CFS or LC or Lyme, it sound fantasist, or a psychological problem.

This is really the whole problem with the prejudice, isn't it? They cannot even imagine what patients are experiencing.

They don't believe patients because what they are describing is too strange and far from their own experience. They need to believe in "distorted perception", "hysteria", "psychological problem", "malingering" to make sense of what patients are describing and what they are seeing.