Next Article in Journal
Analysis of Physical Demands in Four Tug of War World Indoor Championships (2010–2016)
Previous Article in Journal
An Update on the Implications of New Psychoactive Substances in Public Health
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
IJERPH
Volume 19
Issue 8
10.3390/ijerph19084870
ijerph-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles thumb_up
...
Endorse textsms
...
Comment
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Exploring the Relationship between Fibromyalgia-Related Fatigue, Physical Activity, and Quality of Life

by
Marcos C. Alvarez
1,
Maria Luiza L. Albuquerque
1,
Henrique P. Neiva
1,2,
Luis Cid
2,3,4,
Filipe Rodrigues
4,5,
Diogo S. Teixeira
6,7,
Rui Matos
4,5,
Raúl Antunes
4,5,8,
Verónica Morales-Sánchez
9 and
Diogo Monteiro
2,4,5,*
1
Department of Sport Sciences, University of Beira Interior, 6201-001 Covilhã, Portugal
2
Research Center in Sport, Health and Human Development (CIDESD), Trás os Montes and Alto Douro University, 5000-558 Vila Real, Portugal
3
Sport Sciences School of Rio Maior, Polytechnic of Santarém (ESDRM-IPSantarém), 2040-413 Rio Maior, Portugal
4
Life Quality Research Centre (CIEQV), 2400-901 Leiria, Portugal
5
ESECS—Polytechnic of Leiria, 2411-901 Leiria, Portugal
6
Faculty of Physical Education and Sport, Lusófona University (ULHT/FEFD), 1749-024 Lisbon, Portugal
7
Research Center in Sport, Physical Education, and Exercise and Health (CIDEFES), 1749-024 Lisbon, Portugal
8
Center for Innovative Care and Health Technology (ciTechCare), 2415-396 Leiria, Portugal
9
Department of Social Psychology, Social Work, Social Anthropology and East Asian Studies, Faculty of Psychology, Malaga University, 29003 Malaga, Spain
*
Author to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health 2022, 19(8), 4870; https://doi.org/10.3390/ijerph19084870
Submission received: 18 March 2022 / Revised: 14 April 2022 / Accepted: 15 April 2022 / Published: 17 April 2022
Versions Notes

Abstract

:
The symptoms of fibromyalgia are varied, including general muscle pain and pain at specific points (also called tender points), excessive fatigue, anxiety, depression, and some psychological problems that can have a negative impact on quality of life. Physical activity is a widely used option by health professionals to alleviate the effects of this syndrome. However, there is no clear information on the possible mediating role of physical activity in the relationship between fibromyalgia-related fatigue and quality of life. Therefore, this study aims to evaluate the relationship between fibromyalgia-related fatigue and quality of life, and to investigate the mediating role of physical activity in patients with this syndrome. Methods: In a cross-sectional study, 237 Portuguese women aged 28 to 75 years (M = 49.12; SD ± 8.87) and 117 Brazilian women aged 20 to 69 years (M = 46.72; SD ± 8.38) were recruited to participate in this study. These patients completed three valid and reliable questionnaires related to the assessment of fibromyalgia-related fatigue (MDF-Fibro-17), physical activity (IPAQ), and quality of life (SF-36). Results: Both samples had scores above the midpoint for all dimensions of fibromyalgia-related fatigue and scores below the midpoint for quality of life. Physical activity had no mediating effect in either sample, as the total indirect effect was not significant. Conclusions: Physical activity does not mediate the relationship between fatigue and quality of life. However, the results also show that the fatigue dimensions associated with fibromyalgia had a negative and significant association with physical and mental health indicators in both samples. Thus, patients with FM with higher scores on fatigue-related symptoms might suffer more from physical and mental health, both of which are related to quality of life.

1. Introduction

Fibromyalgia Syndrome (FM) is defined as a neurological, physical, and chronic condition that causes sensory changes and muscle pain [1]. However, its pathogenesis is still debated by experts. Hyperexcitability of the central nervous system and neurotransmitter imbalance is seen as the main causes [2,3]. FM affects between 2% and 6% of the world’s population, with middle-aged women (between 30 and 50 years old) seeming to be the most affected [4,5]. One of the main characteristics of FM is its symptomatologic diversity namely: generalized muscle pain in specific points (called tender points); excessive fatigue (which does not improve even with prolonged rest); reduced muscle strength [6,7]; some psychological adversities: sleep problems, anxiety, depression, low self-esteem, and lower levels of satisfaction with life [8,9]. The studies developed by Gracely et al. [10] and Jensen et al. [11] verified, through imaging exams, that FM patients have a different brain function compared to healthy individuals. These FM patients have a higher activation and mild brain distortion in areas of pain control [10,11,12]. Furthermore, the study conducted by Lutz et al. [13] demonstrated that patients with FM have less gray matter in brain areas that regulate pain signals.
Due to this complexity, many patients have difficulties in describing their complaints and symptoms and, sometimes, health professionals do not identify the patient’s chronic pain as fibromyalgia-related pain or still do not believe in this condition reported by patients [12]. By itself, the diagnosis is complex, due to a lack of consistent assessment tools and means to accurately diagnose FM [14]. To obtain this diagnosis, the patient must reach certain values in two questionnaires, one focused on the severity of symptoms, the Symptom Severity Scale (SSS), and another focused on measuring the levels of generalized muscle pain, the Expanded Pain Index (WPI) [13]. After combining the criteria obtained in these questionnaires and without symptomatic changes for at least three months, the patient is diagnosed with FM [15]. The studies developed by Clauw [9] and White et al. [16] found that establishing the diagnosis of fibromyalgia in the early stages can help health professionals to create effective interventions to reduce fibromyalgia-related symptoms, decrease health care costs. In addition, effective diagnosis can reduce tests to search for the causes of the pain reported by these patients.

1.1. Fatigue and Quality of Life

Fatigue is widely known and understood, as it is a natural response of the body to some type of physical and mental stress, but it can also be a sign of some possible physical and/or mental disorder [17,18]. In healthy individuals, fatigue is a physiological reaction to a prolonged activity, from which the body tends to recover easily with rest, and which usually does not end up interfering with daily activities. However, in individuals affected by some pathology (e.g., FM, anemia, hypothyroidism, chronic obstructive pulmonary disease) or with physical limitations, fatigue symptoms are more pronounced when compared to healthy individuals [17]. Specifically, patients with FM report that their fatigue is characterized by excessive physical, mental, and cognitive tiredness and that it is usually not alleviated after hours of sleep or rest, which may end up hindering the performance of work or daily tasks, and thus may contribute to the adoption of sedentary behavior [17,19,20].
Several studies (e.g., Arnold et al. [19]; Hudson et al. [21]) have shown that fatigue is one of the main symptoms reported by patients with FM when asked about the determining factor impacting their overall health, quality of life, and overall perception of this syndrome. While fibromyalgia-related fatigue has a negative relationship with several health-related indicators such as quality of life, it is not always measured in clinical practice and scientific research [22,23].
Because of its complexity, FM leaves patients more vulnerable to stigmatization and psychological conditions (e.g., poor quality of life, higher levels of anxiety and depression, and low self-esteem) as evidenced by Garcia-Martinez et al. [24]. Patients with FM have significantly worse levels of quality of life when compared to healthy individuals [24]. These patients see their syndrome as a serious condition that entails major consequences for their daily lives, affecting their socialization, making it difficult for them to work and perform their daily tasks [25].

1.2. The Mediation Role of Physical Activity

There is still no cure or fully effective treatment for FM, and the most recommended intervention for this type of population is the implementation of approaches that can reduce fibromyalgia-related symptoms [8,26]. In this sense, physical activity has been pointed out by health professionals as a means to alleviate the effects of this syndrome [8,26]. Physical activity is recommended since it is considered a low-cost intervention, aimed at improving physical and psychological components, through the increase of some neurotransmitters (i.e., endorphins and serotonin) capable of producing a sense of self-efficacy and satisfaction, promoting thus a better quality of life [27,28].
Health professionals are advised to consider the physical limitations of each patient and measure the levels of physical fitness and fibromyalgia-related fatigue as a means to understand possible pain caused by the training program [28,29]. Therefore, research recommends a frequency of 2–3 times a week of low- to moderate-intensity physical activity for patients with FM [28,29]. Some studies have shown that aerobic and strength exercises have moderate effects on physical functioning, can reduce fibromyalgia-related pain (by increasing muscle strength) and increase flexibility, as well as improve quality of life [6,30].

1.3. Present Study

As previously described, FM is a chronic and complex biopsychosocial disorder that deteriorates and compromises the quality of life, and several studies [31,32,33] demonstrate that those patients may have these lower levels, which are influenced by several psychological aspects, such as depression and fatigue. Some studies [34,35] demonstrated that patients with FM tend to have worse health status and quality of life when compared to other patients with other chronic diseases (e.g., osteoarthritis, rheumatoid arthritis, lupus, hypertension, spondylarthritis, and Sjogren’s Syndrome). Studies [36,37] found that women with FM, when compared to healthy women, present significant differences in quality of life values, especially in the domains of functional capacity, vitality, emotional role, pain, and general health perception.
However, to the best of our knowledge, the association between fibromyalgia-related fatigue and quality of life is still under-researched. As demonstrated by Offenbaecher et al. [38], more than 50% of FM patients reported that their quality of life levels are not related to pain, but to other aspects of FM.
Daily physical activity is an important behavioral mechanism that can influence fatigue directly or indirectly, through changes in neuroendocrine activities (increased levels of serotonin and other neurotransmitters, regulation of the hypothalamic-pituitary-adrenal axis, and the autonomic nervous system) and, consequently, it can help improve quality of life levels due to its role in promoting well-being, increasing levels of general health status, and improving some psychological aspects in cases where there is social interaction during physical exercise [39,40]. However, when the literature on the mediating role of physical activity in this relationship between fatigue and quality of life was consulted, a scarcity of specific literature was observed. Therefore, this study aims to evaluate the relationship between fatigue and quality of life in patients, as well as investigate how physical activity can act as a mediator of this relationship.

2. Materials and Methods

2.1. Study Design and Participants

A cross-sectional study considering two independent samples was collected for the present study. Sample 1 consisted of a total of 237 Portuguese women aged between 28 and 75 (M = 49.12; SD ± 8.87) years was conducted. The Portuguese subjects were diagnosed with FM on average 8.62 ± 7.14 years ago. Sample 2 consisted of data from 117 Brazilian women aged between 20 and 69 years (M = 46.72; SD = ± 8.38). The Brazilian subjects were diagnosed with FM on average 8.91 ± 6.92 years ago. According to Fritz and Mackinnon [41], the present sample size is in line with simulations for mediation purposes with this number of variables, thus, ensuring proper statistical power.

2.2. Procedure: Data Collection

Prior to data collection, ethical approval was obtained from the Ethics and Scientific Committee of the University of Beira Interior (UBI), under reference number CE-UBI-Pj-2021-038. The present study was conducted in accordance with the Declaration of Helsinki [42] and its subsequent amendments.
Regarding data collection procedures, the National Association against Fibromyalgia and Chronic Fatigue Syndrome (MYOS) and the Brazilian Association of Fibromyalgia (ABRAFIBRO) were contacted, and the objectives were explained. After approval, FM specialists contacted potential participants to participate voluntarily in this study. Afterward, the authors contacted patients with FM and explained the purpose of this study, along with providing detailed information regarding data collection procedures. After contact and clarification of the study objectives, informed consent was obtained from each individual participant. All individuals voluntarily participated in this study, and the time to complete the questionnaire was approximately 25 min.

2.3. Instruments

2.3.1. Fibromyalgia-Related Fatigue

The Multidimensional Daily Diary of Fatigue-Fibromyalgia-17 MDF-Fibro-17 Portuguese and Brazilian versions [43] were used to measure the levels of different fatigue components in patients with FM. The 17 items assess different dimensions of fatigue: Global Fatigue Experience (4 items, for example, “How severe is your fatigue today?”); Physical Fatigue (3 items, for example, “How weak your muscles felt today?”); Cognitive Fatigue (4 items, e.g., “How hard was it to concentrate because you were tired today?”); Motivation (3 items, for example, “How much effort was it doing today?”), and Role Impact (3 items, for example, “Did you slow things down because you were tired today?”). Participants responded to each item using a 10-point scale ranging from 0 (“not at all”) to 10 (“extremely”). Higher scores indicated greater severity of fatigue. Previous studies have supported the validity and reliability of these questionnaires [43,44].

2.3.2. Physical Activity

The International Physical Activity Questionnaire short form (IPAQ) was used to assess the levels of physical activity [45]. The questionnaire comprises a total of seven questions, related to activities carried out in the last seven days before the application of the questionnaire [46].
The questions measure principles of physical activity, such as walking, moderate-intensity and vigorous-intensity activities, frequency, and duration [46,47]. The estimation of energy expenditure is processed according to the levels of physical activity [48]. Specifically, the data obtained are converted to MET min/week (i.e., metabolic equivalent task) by calculating the scored minutes per week in each activity category by the specific metabolic equivalent, according to previous research [46].

2.3.3. Quality of Life

The SF-36 survey [49] was used to measure the quality of life dimensions. This survey consists of 11 questions and 36 items that encompass 8 components (domains or dimensions) on the quality of life state, represented by: physical functioning (10 items, for example, “Does your health limit you to performing violent activities, such as running, lifting weights, participating in strenuous sports? If yes, how much?”); Difficulties in Role Performance Caused by Physical Problems (4 items, for example, “During the past 4 weeks have you, in your work or daily activities, had decreased time spent working or in other activities as a result of your physical health status?”); Pain (2 items, for example, “During the past 4 weeks, how much has pain interfered with your normal work? (both outside work and housework)”); General Health (5 items, for example, “In general, I would say your health is”); Vitality (4 items, for example, “During the last 4 weeks, have you felt full of vitality?”); Social Functioning (2 items, for example, “During the past four weeks, how much has your physical health or emotional problems limited your social activity? (such as visiting friends or close family)”); Difficulties in Role Performance Caused by Emotional Problems (3 items, for example, “During the past 4 weeks, have you had, with your work or daily activities, a decrease in time spent at work or in other activities due to any emotional problems? (such as feeling depressed or anxious)”); Mental Health (5 items, for example, “During the past 4 weeks, have you felt so depressed that nothing cheered you up?”) [50]. To verify the physical health status of the patient, a calculation is made of the following domains: Physical Functioning, Difficulties in Role Performance Caused by Physical Problems, Pain, and General Health. As for the psychological health status, the calculation is made from the domains: Vitality, Social Functioning, Difficulties in Role Performance Caused by Emotional Problems, and Mental Health. Values range from 0 to 100, where higher scores suggest better levels in each domain of the patient’s quality of life, and mental and physical health [51].

2.4. Statistical Analysis

Descriptive statistics (mean and standard deviation), as well as bivariate correlations, were calculated for all variables under analysis. The IBM SPSS Statistics version 22.0 (IBM Corp. Armonk, New York, NY, USA) was used for data analysis. Possible missing values and outliers were also searched in the data.
To test the proposed interactions, simple mediation (model 4) analysis according to Hayes’ [52] recommendations was conducted using SPSS PROCESS v.3.5 (IBM Corp. Armonk, New York, NY, USA). In total, twenty models were tested, considering five fatigue dimensions as independent variables and two dependent variables in two independent samples. Specifically, the levels of Global Fatigue Experience (GFE); Physical Fatigue (PF); Motivation (MOT), and Impact on Function (IF) were selected as independent variables in this model. The levels of physical activity (PA) were used as a mediator, and the levels of Physical Health (PH) and Mental Health (MH) were selected as dependent variables. This procedure allows the estimation of the direct and indirect effects in the proposed models while controlling for k mediators’ influence between variables [52]. A 5000 samples bootstrap was used according to several recommendations [52,53] and significant indirect effects were considered if the confidence interval did not include zero. For all tests, the level of significance was set at p < 0.05.

3. Results

3.1. Descriptive Statistics and Bivariate Correlations

Data inspection did not show missing values and outliers. Descriptive statistics showed that both samples had scores above the midpoint for the experience of Global Fatigue, Physical Fatigue, Cognitive Fatigue, Motivation, and Impact on Function. The observed values of fibromyalgia-related fatigue dimensions are similar in both samples as can be seen in Table 1. Furthermore, the Portuguese sample seems to be physically more active than the Brazilian patients (MET = 2573.54 vs. MET = 1734.15). In terms of quality of life (physical and mental health), both the Portuguese and Brazilian patients showed scores below average. Fibromyalgia-related fatigue dimensions displayed a negative and significant association with physical and mental health indicators.

3.2. The Mediation Role of Physical Activity in the Relationship between Fibromyalgia-Related Fatigue and Quality of Life

Fibromyalgia-related fatigue dimensions displayed a negative and significant association with physical and mental health indicators in both samples, since direct regression coefficients were negative and significant (p < 0.05). However, fibromyalgia-related fatigue dimensions did not display any significant association with levels of physical activity. The levels of physical activity did not display any significant association with physical and mental health in both samples. Overall, no mediation effect of physical activity was identified, since the total indirect effect was not significant in both samples (see Table 2).

4. Discussion

The present study aimed to evaluate the influence of fatigue on the quality of life of patients with FM, and to verify whether the level of physical activity can mediate the association between fatigue and quality of life. First, the results of this study showed that women with FM scored above the midpoint on all components of fatigue in both samples. This has been observed in previous studies that showed that patients with FM have higher levels of fatigue and its components, especially at the muscular, cognitive, and emotional levels [20,54,55]. The studies conducted by Humphrey [20] and Öncü [56] have shown that fatigue at FM affects patients not only at the physical level, but also at the cognitive and psychosocial levels. These patients reported reduced mental resilience and slow thinking, which directly affects their quality of life [56].
Other studies show that patients with FM tend to be more aware of fatigue and its components compared to other pathologies [38,57,58,59]. For example, the study by Humphrey et al. [20] showed that patients described their fatigue as excessive, affecting their motivation to perform desired activities and even interfering with their ability to concentrate, think clearly, and remember certain things or themselves. This was confirmed by the patients in the study by Offenbaecher et al. [38]. They reported that fatigue is an important symptom of the disease, and that it has several important consequences that affect their functioning and well-being [38].
In terms of quality of life (physical and mental health), the results of the present study indicated that, both in the Brazilian and Portuguese sample, the scores were below the midpoint. This finding is supported by the existing literature [24,51,59], which demonstrates that patients with FM have a low perception of their quality of life. Garcia-Martinez et al. [24] found in their study that patients with FM had significantly worse levels of quality of life when compared to healthy people, which is understandable given the number of symptoms that patients with FM face. In addition, a study conducted by Wolfe et al. [59] verified that patients with FM have lower levels of quality of life when compared to patients with other systemic disorders (namely chronic obstructive pulmonary disease and insulin-dependent diabetes mellitus). Concomitantly, the study carried out by da Costa et al. [51] verified that women with FM had a lower perception of their quality life values when compared to women with systemic lupus erythematosus.
The studies conducted by Tander et al. [60] and Walker et al. [61] compared patients with FM and rheumatoid arthritis and found that patients with FM had higher values in fatigue and social isolation, and lower values in sleep quality and all parameters of the SF-36 in terms of quality of life. The study by Borman et al. [62] also found that patients with FM had lower levels of quality of life when compared to patients with rheumatoid arthritis. Another important finding was that patients with FM had lower levels of perceived ability to cope with their disease when compared with patients with rheumatoid arthritis. The study by Burckhardt et al. [63] corroborates these findings, as their study compared the quality of life among patients with FM, rheumatoid arthritis, and osteoarthritis, and found that patients with FM had much lower values in all domains of quality of life.
Neumann et al. [64] carried out a study comparing the quality of life between patients with FM, patients with generalized chronic pain syndrome, and healthy people, and demonstrated that patients with FM had the lowest values of quality of life. Picavet et al. [65] compared 12 different pathologies of the musculoskeletal system (i.e., herniated disc, gout, repetitive strain injury, epicondylitis, knee osteoarthritis, hip osteoarthritis, osteoporosis, whiplash, rheumatoid arthritis, fibromyalgia, tendonitis, and capsulitis), and found that all patients had low scores of quality of life. However, patients with rheumatoid arthritis and FM had the lowest values compared to other pathologies under analysis [65].
Yilmaz et al. [66] carried out a comparative study among four diseases (i.e., knee osteoarthritis, shoulder impingement syndrome, fibromyalgia, and osteoporosis), and found that patients with FM had low values in all quality of life scores. The study by Ataoğlu et al. [67] compared the quality of life of patients with FM, knee osteoarthritis, and rheumatoid arthritis, and found that patients with FM had lower values in all quality of life parameters compared to other diseases [66].

4.1. The Mediation Role of Physical Activity

In our study, it was possible to verify that physical activity does not play a mediating role in the relationship between fibromyalgia-related fatigue and quality of life. The study developed by Doerr et al. [39] corroborates our findings, where no association was found between the mediating role of physical activity concerning fatigue and other symptoms associated with FM. However, Sawatzy et al. [27] verified in their study that physical activity partially mediates the relationship between chronic diseases and quality of life. Another study with contradictory findings compared to ours was by Molinari et al. [68] who found that physical activity acted as a possible mediator between FM symptoms and patients’ quality of life. These results demonstrated the need for further studies to verify if physical activity can act as a mediator between fibromyalgia-related fatigue and quality of life in patients with FM [68].
Indeed, physical activity is considered an effective tool of controlling the symptoms of FM. It could reduce fatigue, pain, depression, and anxiety, and could promote improvement in quality of life [6,69,70,71].
However, research still differs on what intensity of physical activity is best for FM patients. For instance, the studies conducted by Gavilán-Carrera et al. [72] and Buman et al. [73] have shown that patients with FM have better control of fibromyalgia-related symptoms when they engage in low-intensity physical activity. Further, the studies developed by Fanning et al. [74] and Kaleth et al. [75] demonstrated that patients with FM showed improvement in quality of life and relieved symptoms of the syndrome when they participate in a high-intensity physical activity program. However, Clauw [9] argued that moderate-intensity physical activity is the most effective treatment for the management of fibromyalgia-related symptoms. Therefore, Cunha Ribeiro et al. [76] suggested that exercise programs should be individualized. That is, the intensity should be considered based on the patient’s limitations, level of physical fitness, and fatigue. In this regard, Rooks [29] found that the health benefits of physical activity in patients with FM are increased and/or maintained compared to those patients who are physically inactive. Some studies [28,29] have shown that FM patients undergoing group exercises improved their physical, emotional, and social capacities. Therefore, it is reasonable to assume that the physical activity intensity could act as a possible mediator, however, the type of intensity of physical activity should be further investigated in the future.
Despite all the benefits of physical activity for this type of population, training programs must be supervised by a qualified professional [77]. For example, King et al. [78] and Ayan et al. [79] found that patients with FM who adhered to the supervised physical exercise protocol showed an improvement in their ability to manage the FM symptoms. In addition, Sevimli et al. [80] found that patients who exercise under supervision had a significant reduction in pain and FM impact when compared to other patients who performed physical activity without supervision. One of the factors that may explain the difference between our results and the existing literature [77], is that the patients had difficulties in remembering and performing exercise programs without supervision, thus generating a fear that these exercises performed incorrectly could increase pain levels. The study by Kayo et al. [81] found that after the end of the supervised exercise program, there was low adherence to physical activity by patients, leading to a detraining effect. Thus, it seems that, for physical activity to influence FM symptoms and other related health indicators (e.g., quality of life), exercise programs should be supervised. Hence, we suspect that in our study, physical activity did not mediate the relationship between FM fatigue and both mental and physical health since physical activity was subjectively measured and not determined as supervised exercise.
For instance, the study by Carus et al. [82] demonstrated that in 3 months of exercise, patients demonstrate great relief from pain, emotional problems, an improvement in quality of life, physical functional capacity, and balance. This same study found that 12 weeks after the end of the experimental intervention, there was a decrease in physical fitness, as well as in some components of quality of life. This can demonstrate that the monitoring of physical activity can help to improve the quality of life and attenuate the symptoms of patients with FM.
The study by Salvat et al. [83] showed that patients who underwent a multidisciplinary treatment, involving supervised physical activity, showed an improvement in their functional status, and an increase in the level of physical activity. However, the study by Ramsay et al. [77] compared a supervised and unsupervised aerobic exercise program and found that the group that underwent the supervised training program had an improvement in measures of psychological well-being when compared to the other group. Another interesting finding of the study by Ramsay et al. [77] was that exercise adherence by the unsupervised group was very low when compared to the supervised exercise group.
The study conducted by Burckhardt et al. [84] compared the effects of an education program (where patients were instructed and performed the activity independently) with exercise monitoring and found that both groups showed improvements in quality of life and self-efficacy. However, only in the group that performed supervised physical activity was there also improvement in pain, fatigue, and muscle stiffness. King et al. [78] also suggested that for this type of population, it may be better to emphasize the adoption of a physically active lifestyle, with appropriate professional supervision, rather than just promoting exercise per se.

4.2. Practical Implications and Limitations

In recent years, scientific publications on FM have increased considerably, which can be explained by a greater awareness and shared interest from various stakeholders, including patients with FM, specific organizations for these groups, researchers, and professionals in the field of health and physical activity. Although our results show that it does not have a connection between the quality of life and fatigue, some studies [28,29,82] show that physical activity is an important tool in reducing fatigue levels and improving quality of life levels in patients with FM.
However, the physical activity prescribed for this population should be supervised and performed in an observational manner. Thus, the professional can adjust and adapt the intensity and volume, so that the patient can better adapt to this type of activity and prevent poor performance, avoiding any worsening of FM symptoms resulting from incorrect or exaggerated physical activity.
Firstly, this study had a cross-sectional design. Therefore, longitudinal/experimental studies may be useful in measuring fatigue symptoms and quality of life in FM patients. Another limitation of this study was the specificity of the sample, where only Portuguese and Brazilian patients took part in the research, meaning that the data obtained cannot be generalized and compared to other countries and cultures. In addition, the physical activity was evaluated through a self-reported way (i.e., questionnaire). It means that no definition of intensity was considered, nor whether there was any type of professional supervising the activity. Therefore, future studies should try to address this limitation to confirm the importance of professional supervision in performing physical activities for these groups.
The age group presented between patients in both samples should be considered as another limitation, since some studies [85,86] suggest that patients with younger ages tend to have higher levels of fatigue and lower levels of quality of life when compared to older patients. As a suggestion for future research, studies could be carried out on how age can influence the quality of life, fatigue, and levels of physical activity in patients with FM.
Finally, one more limitation is the participation of male patients, since in the current study, only female participants were included. This decision was made considering the existing literature which demonstrates that FM has a greater impact in women compared with men, so we opted for a more conservative approach, solely with female patients with FM [87,88]. Nevertheless, future studies should try to collect some data on male FM patients to analyze these associations between gender and explore their impact across cultures.

5. Conclusions

Overall, the results suggest that physical activity does not mediate the association between quality of life and fatigue in patients with FM. However, the results also show that fatigue dimensions associated with fibromyalgia have negative and significant associations with physical and mental health indicators in both samples. Thus, FM patients with higher scores on fatigue-related symptoms might suffer more from physical and mental health, both of which are related to quality of life.

Author Contributions

Conceptualization, M.C.A., M.L.L.A., H.P.N., and D.M.; methodology, M.C.A., M.L.L.A., H.P.N., L.C., F.R., D.S.T., and D.M.; Data curation, M.C.A. and M.L.L.A., formal analysis, M.C.A., F.R., D.S.T., L.C., and D.M.; investigation, writing—original draft preparation, M.C.A., F.R., L.C., D.S.T., R.M., R.A., V.M.-S., and D.M.; writing— review and editing, M.C.A., H.P.N., M.L.L.A., R.M., R.A., V.M.-S., and L.C. All authors have read and agreed to the published version of the manuscript.

Funding

H.N., L.C., and D.M. were supported by national funds through the Portuguese Foundation for Science and Technology, I.P., under the project UID04045/2020; F.R., R.A. and R.M. were supported by the national funds through the Portuguese Foundation for Science and Technology, I.P., under the project UID/DTP/04748/2020.

Institutional Review Board Statement

All data collection procedures were in accordance with the ethical standards of the Institutional Research Committee, and with the 2013 Helsinki Declaration and its later amendments or comparable ethical standards. Approval for this study was granted by the Universidade da Beira Interior institution that is registered in the Portuguese National Science Foundation (FCT) under the reference CE-UBI-Pj-2021-038: ID939.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patient(s) to publish this paper.

Data Availability Statement

Due to issues of participant consent, data will not be shared publicly. Interested researchers may contact the corresponding author ([email protected]).

Acknowledgments

The authors would like to thank all the participants.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Henriksson, K.G. The Fibromyalgia Syndrome: Translating Science into Clinical Practice. J. Musculoskelet. Pain 2009, 17, 189–194. [Google Scholar] [CrossRef]
  2. Demirbag, B.C.; Bulut, A. Demographic characteristics, clinical findings and functional status in patients with fibromyalgia syndrome. Pak. Med. Assoc. 2018, 68, 1043–1047. [Google Scholar]
  3. Shipley, M. Chronic widespread pain and fibromyalgia syndrome. Medicine 2018, 46, 252–255. [Google Scholar] [CrossRef]
  4. Assumpção, A.; Matsutani, L.A.; Yuan, S.L.; Santo, A.S.; Sauer, J.; Mango, P.; Marques, A.P. Muscle stretching exercises and resistance training in fibromyalgia: Which is better? A three-arm randomized controlled trial. Eur. J. Phys. Rehabil. Med. 2018, 54, 663–670. [Google Scholar] [CrossRef] [PubMed]
  5. Saral, I.; Sindel, D.; Esmaeilzadeh, S.; Sertel-Berk, H.O.; Oral, A. The effects of long- and short-term interdisciplinary treatment approaches in women with fibromyalgia: A randomized controlled trial. Rheumatol. Int. 2016, 36, 1379–1389. [Google Scholar] [CrossRef] [PubMed]
  6. Busch, A.J.; Webber, S.C.; Brachaniec, M.; Bidonde, J.; Bello-Haas, V.D.; Danyliw, A.D.; Overend, T.J.; Richards, R.S.; Sawant, A.; Schachter, C.L. Exercise therapy for fibromyalgia. Curr. Pain Headache Rep. 2011, 15, 358–367. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  7. Chang, K.V.; Hung, C.H.; Sun, W.Z.; Wu, W.T.; Lai, C.L.; Han, D.S.; Chen, C.C. Evaluating soreness symptoms of fibromyalgia: Establishment and validation of the Revised Fibromyalgia Impact Questionnaire with Integration of Soreness Assessment. J. Formos. Med. Assoc. 2020, 119, 1211–1218. [Google Scholar] [CrossRef]
  8. Wolfe, F.; Clauw, D.J.; Fitzcharles, M.A.; Goldenberg, D.L.; Hauser, W.; Katz, R.S.; Mease, P.; Russell, A.S.; Russell, I.J.; Winfield, J.B. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: A modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J. Rheumatol. 2011, 38, 1113–1122. [Google Scholar] [CrossRef]
  9. Clauw, D.J. Fibromyalgia: A clinical review. JAMA 2014, 311, 1547–1555. [Google Scholar] [CrossRef]
  10. Gracely, R.H.; Petzke, F.; Wolf, J.M.; Clauw, D.J. Functional magnetic resonance imaging evidence of augmented pain processing in fibromyalgia. Arthritis Rheum. 2002, 46, 1333–1343. [Google Scholar] [CrossRef]
  11. Jensen, K.B.; Kosek, E.; Petzke, F.; Carville, S.; Fransson, P.; Marcus, H.; Williams, S.C.; Choy, E.; Giesecke, T.; Mainguy, Y.; et al. Evidence of dysfunctional pain inhibition in Fibromyalgia reflected in rACC during provoked pain. Pain 2009, 144, 95–100. [Google Scholar] [CrossRef] [PubMed]
  12. Qureshi, A.G.; Jha, S.K.; Iskander, J.; Avanthika, C.; Jhaveri, S.; Patel, V.H.; Potini, B.R.; Azam, A.T. Diagnostic Challenges and Management of Fibromyalgia. Cureus 2021, 13, e18692. [Google Scholar] [CrossRef] [PubMed]
  13. Lutz, J.; Jäger, L.; de Quervain, D.; Krauseneck, T.; Padberg, F.; Wichnalek, M.; Beyer, A.; Stahl, R.; Zirngibl, B.; Morhard, D.; et al. White and grey matter abnormalities in the brain of patients with fibromyalgia: A diffusion-tensor and volumetric imaging study. Arthritis Rheum. 2008, 58, 3960–3969. [Google Scholar] [CrossRef] [PubMed]
  14. Wolfe, F.; Clauw, D.J.; Fitzcharles, M.A.; Goldenberg, D.L.; Katz, R.S.; Mease, P.; Russell, A.S.; Russell, I.J.; Winfield, J.B.; Yunus, M.B. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res. 2010, 62, 600–610. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  15. Bernard, P.; Hains-Monfette, G.; Atoui, S.; Kingsbury, C. Differences in daily objective physical activity and sedentary time between women with self-reported fibromyalgia and controls: Results from the Canadian health measures survey. Clin. Rheumatol. 2018, 37, 2285–2290. [Google Scholar] [CrossRef] [Green Version]
  16. White, K.P.; Nielson, W.R.; Harth, M.; Ostbye, T.; Speechley, M. Does the label “fibromyalgia” alter health status, function, and health service utilization? A prospective, within-group comparison in a community cohort of adults with chronic widespread pain. Arthritis Rheum. 2002, 47, 260–265. [Google Scholar] [CrossRef]
  17. Finsterer, J.; Mahjoub, S.Z. Fatigue in healthy and diseased individuals. Am. J. Hosp. Palliat Care 2014, 31, 562–575. [Google Scholar] [CrossRef]
  18. Ulus, Y.; Akyol, Y.; Bilgici, A.; Kuru, O. The impact of the presence of fibromyalgia on fatigue in patients with psoriatic arthritis: Comparison with controls. Adv. Rheumatol. 2019, 60, 1. [Google Scholar] [CrossRef]
  19. Arnold, L.M.; Wang, F.A.; Ahl, J.; Gaynor, P.J.; Wohlreich, M.M. Improvement in multiple dimensions of fatigue in patients with fibromyalgia treated with duloxetine: Secondary analysis of a randomized, placebo-controlled trial. Arthritis Res. Ther. 2011, 13, 86. [Google Scholar] [CrossRef] [Green Version]
  20. Humphrey, L.; Arbuckle, R.; Mease, P.; Williams, D.A.; Samsoe, B.D.; Gilbert, C. Fatigue in fibromyalgia: A conceptual model informed by patient interviews. BMC Musculoskelet. Disord. 2010, 11, 216. [Google Scholar] [CrossRef] [Green Version]
  21. Hudson, J.I.; Arnold, L.M.; Bradley, L.A.; Choy, E.H.; Mease, P.J.; Wang, F.; Ahl, J.; Wohlreich, M.M. What makes patients with fibromyalgia feel better? Correlations between Patient Global Impression of Improvement and changes in clinical symptoms and function: A pooled analysis of 4 randomized placebo-controlled trials of duloxetine. J. Rheumatol. 2009, 36, 2517–2522. [Google Scholar] [CrossRef] [PubMed]
  22. Mease, P.J.; Clauw, D.J.; Gendreau, R.M.; Rao, S.G.; Kranzler, J.; Chen, W.; Palmer, R.H. The efficacy and safety of milnacipran for treatment of fibromyalgia. a randomized, double-blind, placebo-controlled trial. J. Rheumatol. 2009, 36, 398–409. [Google Scholar] [CrossRef] [PubMed]
  23. Morris, S.; Li, Y.; Smith, J.A.M.; Dube, S.; Burbridge, C.; Symonds, T. Multidimensional daily diary of fatigue-fibromyalgia-17 items (MDF-fibro-17). part 1: Development and content validity. BMC Musculoskelet. Disord. 2017, 18, 195. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  24. Garcia-Martinez, A.M.; De Paz, J.A.; Masquez, S. Effects of an exercise programme on self-esteem, self-concept and quality of life in women with fibromyalgia: A randomized controlled trial. Rheumatol. Int. 2012, 32, 1869–1876. [Google Scholar] [CrossRef]
  25. Verbunt, J.A.; Pernot, D.H.; Smeets, R.J. Disability and quality of life in patients with fibromyalgia. Health Qual. Life Outcomes 2008, 6, 8. [Google Scholar] [CrossRef] [Green Version]
  26. Carville, S.F.; Arendt-Nielsen, L.; Bliddal, H.; Blotman, F.; Branco, J.C.; Buskila, D.; Da Silva, J.A.; Danneskiold-Samsoe, B.; Dincer, F.; Henriksson, C.; et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann. Rheum. Dis. 2008, 67, 536–541. [Google Scholar] [CrossRef]
  27. Sawatzky, R.; Liu-Ambrose, T.; Miller, W.C.; Marra, C.A. Physical activity as a mediator of the impact of chronic conditions on quality of life in older adults. Health Qual. Life Outcomes 2007, 5, 68. [Google Scholar] [CrossRef] [Green Version]
  28. Larsson, A.; Feldthusen, C.; Mannerkorpi, K. Factors promoting physical activity in women with fibromyalgia: A qualitative interview study. BMJ Open 2020, 10, e031693. [Google Scholar] [CrossRef]
  29. Rooks, D.S. Talking to patients with fibromyalgia about physical activity and exercise. Curr. Opin. Rheumatol. 2008, 20, 208–212. [Google Scholar] [CrossRef]
  30. Soriano-Maldonado, A.; Ruiz, J.R.; Aparicio, V.A.; Estevez-Lopez, F.; Segura-Jimenez, V.; Alvarez-Gallardo, I.C.; Carbonell-Baeza, A.; Delgado-Fernandez, M.; Ortega, F.B. Association of Physical Fitness With Pain in Women With Fibromyalgia: The al-Andalus Project. Arthritis Care Res. 2015, 67, 1561–1570. [Google Scholar] [CrossRef] [Green Version]
  31. Lopez-Roig, S.; Pastor, M.A.; Penacoba, C.; Lledo, A.; Sanz, Y.; Velasco, L. Prevalence and predictors of unsupervised walking and physical activity in a community population of women with fibromyalgia. Rheumatol. Int. 2016, 36, 1127–1133. [Google Scholar] [CrossRef] [PubMed]
  32. Sechi, C.; Vismara, L.; Brennstuhl, M.J.; Tarquinio, C.; Lucarelli, L. Adult attachment styles, self-esteem, and quality of life in women with fibromyalgia. Health Psychol. Open 2020, 7, 2055102920947921. [Google Scholar] [CrossRef] [PubMed]
  33. Amir, M.; Neumann, L.; Bor, O.; Shir, Y.; Rubinow, A.; Buskila, D. Coping Styles, Anger, Social Support, and Suicide Risk of Women with Fibromyalgia Syndrome. J. Musculoskelet. Pain 2000, 8, 7–20. [Google Scholar] [CrossRef]
  34. Lee, J.W.; Lee, K.E.; Park, D.J.; Kim, S.H.; Nah, S.S.; Lee, J.H.; Kim, S.K.; Lee, Y.A.; Hong, S.J.; Kim, H.S.; et al. Determinants of quality of life in patients with fibromyalgia: A structural equation modeling approach. PLoS ONE 2017, 12, e0171186. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  35. Bucourt, E.; Martaille, V.; Goupille, P.; Joncker-Vannier, I.; Huttenberger, B.; Reveillere, C.; Mulleman, D.; Courtois, A.R. A Comparative Study of Fibromyalgia, Rheumatoid Arthritis, Spondyloarthritis, and Sjogren’s Syndrome; Impact of the Disease on Quality of Life, Psychological Adjustment, and Use of Coping Strategies. Pain Med. 2021, 22, 372–381. [Google Scholar] [CrossRef] [PubMed]
  36. Bernard, A.L.; Prince, A.; Edsall, P. Quality of life issues for fibromyalgia patients. Arthritis Rheum. 2000, 13, 42–50. [Google Scholar] [CrossRef]
  37. Lorente, G.D.; Stefani, L.F.B.D.; Martins, M.R.I. Kinesiophobia, adherence to treatment, pain and quality of life in fibromyalgia syndrome patients. Rev. Dor 2014, 15, 121–125. [Google Scholar] [CrossRef] [Green Version]
  38. Offenbaecher, M.; Kohls, N.; Ewert, T.; Sigl, C.; Hieblinger, R.; Toussaint, L.L.; Sirois, F.; Hirsch, J.; Vallejo, M.A.; Kramer, S.; et al. Pain is not the major determinant of quality of life in fibromyalgia: Results from a retrospective “real world” data analysis of fibromyalgia patients. Rheumatol. Int. 2021, 41, 1995–2006. [Google Scholar] [CrossRef]
  39. Doerr, J.M.; Fischer, S.; Nater, U.M.; Strahler, J. Influence of stress systems and physical activity on different dimensions of fatigue in female fibromyalgia patients. J. Psychosom. Res. 2017, 93, 55–61. [Google Scholar] [CrossRef] [Green Version]
  40. Junior, M.H.; Goldenfum, M.A.; Fávaro Siena, C.A. Fibromialgia: Aspectos clínicos e ocupacionais. Rev. Assoc. Médica Bras. 2012, 58, 358–365. [Google Scholar] [CrossRef] [Green Version]
  41. Fritz, M.S.; Mackinnon, D.P. Required Sample Size to Detect the Mediated Effect. Psychol. Sci. 2007, 18, 233–239. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  42. Association, W.M. World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Sub-jects. J. Am. Med. Assoc. 2013, 310, 2191–2194. [Google Scholar]
  43. Alvarez, M.C.; Albuquerque, M.L.L.; Neiva, H.P.; Cid, L.; Rodrigues, F.; Teixeira, D.S.; Monteiro, D. The Multidimensional Daily Diary of Fatigue-Fibromyalgia-17 Items (MDF-Fibro-17): Evidence from Validity, Reliability and Transcultural Invariance between Portugal and Brazil. J. Clin. Med. 2020, 9, 2330. [Google Scholar] [CrossRef] [PubMed]
  44. Li, Y.; Morris, S.; Cole, J.; Dube, S.; Smith, J.A.M.; Burbridge, C.; Symonds, T.; Hudgens, S.; Wang, W. Multidimensional daily diary of fatigue-fibromyalgia-17 items (MDF-fibro-17): Part 2 psychometric evaluation in fibromyalgia patients. BMC Musculoskelet. Disord. 2017, 18, 198. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  45. Craig, C.L.; Marshall, A.L.; Sjostrom, M.; Bauman, A.E.; Booth, M.L.; Ainsworth, B.E.; Pratt, M.; Ekelund, U.; Yngve, A.; Sallis, J.F.; et al. International physical activity questionnaire: 12-country reliability and validity. Med. Sci. Sports Exerc. 2003, 35, 1381–1395. [Google Scholar] [CrossRef] [Green Version]
  46. Benitez-Porres, J.; Delgado, M.; Ruiz, J.R. Comparison of physical activity estimates using International Physical Activity Questionnaire (IPAQ) and accelerometry in fibromyalgia patients: The Al-Andalus study. J. Sports Sci. 2013, 31, 1741–1752. [Google Scholar] [CrossRef]
  47. Santos, R.S. Avalição da Actividade Física, em Doentes com Diabetes Mellitus tipo 2, Seguidos na Consulta de Endrocrinologia do Centro Hospitalar do Porto—Hospital Geral Santo Antonio; University Do Porto: Porto, Portugal, 2009. [Google Scholar]
  48. I.P.A.Q. Guidelines for Data Processing and Analysis of the International Physical Activity Questionnaire (IPAQ)—Short and Long Forms; 2005. Available online: https://www.researchgate.net/file.PostFileLoader.html?id=5641f4c36143250eac8b45b7&assetKey=AS%3A294237418606593%401447163075131 (accessed on 18 February 2022).
  49. Ware, J.E.; Sherbourne, C.D. The MOS 36-Item Short-Form Health Survey (SF-36). Conceptual framework and item selection. Med. Care 1992, 30, 473–483. [Google Scholar] [CrossRef]
  50. Hoffman, D.L.; Dukes, E.M. The health status burden of people with fibromyalgia: A review of studies that assessed health status with the SF-36 or the SF-12. Int. J. Clin. Pract. 2008, 62, 115–126. [Google Scholar] [CrossRef] [Green Version]
  51. da Costa, D.; Dobkin, P.L.; Fitzcharles, M.A.; Fortin, P.R.; Beaulieu, A.; Zummer, M.; Senecall, J.L.; Goulet, J.R.; Rich, E.; Choquette, D.; et al. Determinants of health status in fibromyalgia: A comparative study with systemic lupus erythematosus. J. Rheumatol. 2000, 27, 365–372. [Google Scholar]
  52. Hayes, A.F. Introduction to Mediation, Moderation, and Conditional Process Analysis. A Regression-Based Approach, 2nd ed.; The Guilford Press: New York, NY, USA, 2018. [Google Scholar]
  53. Williams, J.; Mackinnon, D.P. Resampling and Distribution of the Product Methods for Testing Indirect Effects in Complex Models. Struct. Equl. Modeling 2008, 15, 23–51. [Google Scholar] [CrossRef] [Green Version]
  54. Zautra, A.J.; Fasman, R.; Parish, B.P.; David, M.C. Daily fatigue in women with osteoarthritis, rheumatoid arthritis, and fibromyalgia. Pain 2007, 128, 128–135. [Google Scholar] [CrossRef] [PubMed]
  55. Ofluoglu, D.; Berker, N.; Guven, Z.; Canbulat, N.; Yilmaz, I.T.; Kayhan, O. Quality of life in patients with fibromyalgia syndrome and rheumatoid arthritis. Clin. Rheumatol. 2005, 24, 490–492. [Google Scholar] [CrossRef] [PubMed]
  56. Oncu, J.; Basoglu, F.; Kuran, B. A comparison of impact of fatigue on cognitive, physical, and psychosocial status in patients with fibromyalgia and rheumatoid arthritis. Rheumatol. Int. 2013, 33, 3031–3037. [Google Scholar] [CrossRef] [PubMed]
  57. Park, D.C.; Glass, J.M.; Minear, M.; Crofford, L.J. Cognitive function in fibromyalgia patients. Arthritis Rheum. 2001, 44, 2125–2133. [Google Scholar] [CrossRef] [Green Version]
  58. Suhr, J.A. Neuropsychological impairment in fibromyalgia. J. Psychosom. Res. 2003, 55, 321–329. [Google Scholar] [CrossRef]
  59. Wolfe, F.; Hawley, D.J.; Goldenberg, D.L.; Russell, I.J.; Buskila, D.; Neumann, L. The assessment of functional impairment in fibromyalgia (FM): Rasch analyses of 5 functional scales and the development of the FM Health Assessment Questionnaire. J. Rheumatol. 2000, 27, 1989–1999. [Google Scholar]
  60. Tander, B.; Cengiz, K.; Alayli, G.; Ilhanli, I.; Canbaz, S.; Canturk, F. A comparative evaluation of health related quality of life and depression in patients with fibromyalgia syndrome and rheumatoid arthritis. Rheumatol. Int. 2008, 28, 859–865. [Google Scholar] [CrossRef]
  61. Walker, E.A.; Keegan, D.; Gardner, G.; Sullivan, M.; Katon, W.J.; Bernstein, D. Psychosocial Factors in Fibromyalgia Compared With Rheumatoid Arthritis. Psychosom. Med. 1997, 59, 565–571. [Google Scholar] [CrossRef]
  62. Borman, P.; Çeliker, R. A Comparative Analysis of Quality of Life in Rheumatoid Arthritis and Fibromyalgia. J. Musculoskelet. Pain 1999, 7, 5–14. [Google Scholar] [CrossRef]
  63. Burckhardt, C.S.; Clark, S.R.; Bennett, R.M. Fibromyalgia and quality of life: A comparative analysis. J. Rheumatol. 1993, 20, 475–479. [Google Scholar]
  64. Neumann, L.; Berzak, A.; Buskila, D. Measuring Health Status in Israeli Patients With Fibromyalgia Syndrome and Widespread Pain and Healthy Individuals: Utility of the Short Form 36-Item Health Survey (SF-36). Semin. Arthritis Rheum. 2000, 29, 400–408. [Google Scholar] [CrossRef] [PubMed]
  65. Picavet, H.S.; Hoeymans, N. Health related quality of life in multiple musculoskeletal diseases: SF-36 and EQ-5D in the DMC3 study. Ann. Rheum. Dis. 2004, 63, 723–729. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  66. Yilmaz, F.; Sahin, F.; Ergoz, E.; Deniz, E.; Ercalik, C.; Yucel, S.D.; Kuran, B. Quality of life assessments with SF 36 in different musculoskeletal diseases. Clin. Rheumatol. 2008, 27, 327–332. [Google Scholar] [CrossRef] [PubMed]
  67. Ataoğlu, S.; Ankaralı, H.; Ankaralı, S.; Ataoğlu, B.B.; Ölmez, S.B. Quality of life in fibromyalgia, osteoarthritis and rheumatoid arthritis patients: Comparison of different scales. Egypt. Rheumatol. 2018, 40, 203–208. [Google Scholar] [CrossRef]
  68. Molinari, G.; Miragall, M.; Enrique, Á.; Botella, C.; Baños, R.M.; Gracía-Palacios, A. How and for whom does a positive affect intervention work in fibromyalgia: An analysis of mediators and moderators. Eur. J. Pain 2020, 24, 248–262. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  69. Busch, A.J.; Overend, T.J.; Schachter, C.L. Fibromyalgia treatment: The role of exercise and physical activity. Int. J. Clin. Rheumatol. 2009, 4, 343–376. [Google Scholar] [CrossRef]
  70. Fontaine, K.R.; Conn, L.; Clauw, D.J. Effects of lifestyle physical activity in adults with fibromyalgia: Results at follow-up. J. Clin. Rheumatol. 2011, 17, 64–68. [Google Scholar] [CrossRef] [Green Version]
  71. Segura-Jimenez, V.; Borges-Cosic, M.; Soriano-Maldonado, A.; Estevez-Lopez, F.; Alvarez-Gallardo, I.C.; Herrador-Colmenero, M.; Delgado-Fernandez, M.; Ruiz, J.R. Association of sedentary time and physical activity with pain, fatigue, and impact of fibromyalgia: The al-Andalus study. Scand. J. Med. Sci. Sports 2017, 27, 83–92. [Google Scholar] [CrossRef]
  72. Gavilan-Carrera, B.; Segura-Jimenez, V.; Mekary, R.A.; Borges-Cosic, M.; Acosta-Manzano, P.; Estevez-Lopez, F.; Alvarez-Gallardo, I.C.; Geenen, R.; Delgado-Fernandez, M. Substituting Sedentary Time With Physical Activity in Fibromyalgia and the Association With Quality of Life and Impact of the Disease: The al-Andalus Project. Arthritis Care Res. 2019, 71, 281–289. [Google Scholar] [CrossRef] [Green Version]
  73. Buman, M.P.; Hekler, E.B.; Haskell, W.L.; Pruitt, L.; Conway, T.L.; Cain, K.L.; Sallis, J.F.; Saelens, B.E.; Frank, L.D.; King, A.C. Objective light-intensity physical activity associations with rated health in older adults. Am. J. Epidemiol. 2010, 172, 1155–1165. [Google Scholar] [CrossRef] [Green Version]
  74. Fanning, J.; Porter, G.; Awick, E.A.; Ehlers, D.K.; Roberts, S.A.; Cooke, G.; Burzynska, A.Z.; Voss, M.W.; Kramer, A.F.; McAuley, E. Replacing sedentary time with sleep, light, or moderate-to-vigorous physical activity: Effects on self-regulation and executive functioning. J. Behav. Med. 2017, 40, 332–342. [Google Scholar] [CrossRef] [PubMed]
  75. Kaleth, A.S.; Saha, C.K.; Jensen, M.P.; Slaven, J.E.; Ang, D.C. Effect of moderate to vigorous physical activity on long-term clinical outcomes and pain severity in fibromyalgia. Arthritis Care Res. 2013, 65, 1211–1218. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  76. da Cunha Ribeiro, R.P.; Franco, T.C.; Pinto, A.J.; Pontes Filho, M.A.G.; Domiciano, D.S.; de Sa Pinto, A.L.; Lima, F.R.; Roschel, H.; Gualano, B. Prescribed Versus Preferred Intensity Resistance Exercise in Fibromyalgia Pain. Front. Physiol. 2018, 9, 1097. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  77. Ramsay, C.; Moreland, J.; Ho, M.; Joyce, S.; Walker, S.; Pullar, T. An observer-blinded comparison of supervised and unsupervised aerobic exercise regimens in fibromyalgia. Rheumatology 2000, 39, 501–505. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  78. King, S.J.; Wessel, J.; Bhambhani, Y.; Sholter, D.; Maksymowych, W. The effects of exercise and education, individually or combined, in women with fibromyalgia. J. Rheumatol. 2002, 29, 2620–2627. [Google Scholar]
  79. Ayan, C.; Álvarez, M.J.; Alonso-Cortés, B.; Barrientos, M.J.; Valencia, M.; Martín, V. Health education home-based program in females with fibromyalgia: A pilot study. J. Back Musculoskelet. Rehabil. 2009, 22, 99–105. [Google Scholar] [CrossRef]
  80. Sevimli, D.; Kozanoglu, E.; Guzel, R.; Doganay, A. The effects of aquatic, isometric strength-stretching and aerobic exercise on physical and psychological parameters of female patients with fibromyalgia syndrome. J. Phys. Ther. Sci. 2015, 27, 1781–1786. [Google Scholar] [CrossRef] [Green Version]
  81. Kayo, A.H.; Peccin, M.S.; Sanches, C.M.; Trevisani, V.F. Effectiveness of physical activity in reducing pain in patients with fibromyalgia: A blinded randomized clinical trial. Rheumatol. Int. 2012, 32, 2285–2292. [Google Scholar] [CrossRef]
  82. Tomas-Carus, P.; Garrido, M.; Branco, J.C.; Castano, M.Y.; Gomez, M.A.; Biehl-Printes, C. Non-supervised breathing exercise regimen in women with fibromyalgia: A quasi-experimental exploratory study. Complement. Ther. Clin. Pract. 2019, 35, 170–176. [Google Scholar] [CrossRef]
  83. Salvat, I.; Zaldivar, P.; Monterde, S.; Montull, S.; Miralles, I.; Castel, A. Functional status, physical activity level, and exercise regularity in patients with fibromyalgia after Multidisciplinary treatment: Retrospective analysis of a randomized controlled trial. Rheumatol. Int. 2017, 37, 377–387. [Google Scholar] [CrossRef]
  84. Burckhardt, C.S.; Mannerkorpi, K.; Hedenberg, L.; Bjelle, A. A randomized, controlled clinical trial of education and physical training for women with fibromyalgia. J. Rheumatol. 1994, 21, 714–720. [Google Scholar] [PubMed]
  85. Keskindag, B. Exploring symptom expressions according to different age groups in fibromyalgia: A cross-sectional study. Health Psychol. Rep. 2018, 6, 243–251. [Google Scholar] [CrossRef] [Green Version]
  86. Jiao, J.; Vincent, A.; Cha, S.S.; Luedtke, C.A.; Oh, T.H. Relation of age with symptom severity and quality of life in patients with fibromyalgia. Mayo Clin. Proc. 2014, 89, 199–206. [Google Scholar] [CrossRef] [PubMed]
  87. Yunus, M.B. The role of gender in fibromyalgia syndrome. Curr. Rheumatol. Rep. 2001, 3, 128–134. [Google Scholar] [CrossRef] [PubMed]
  88. Yunus, M.B.; Inanici, F.; Aldag, J.C.; Mangold, R.F. Fibromyalgia in men: Comparison of clinical features with women. J. Rheumatol. 2000, 27, 485–490. [Google Scholar]
Table
Table 1. Descriptive statistics and bivariate correlations across study variables.
Table 1. Descriptive statistics and bivariate correlations across study variables.
Portuguese Sample
VariablesMSD12345678
1.GFE7.931.521-------
2.PF8.131.520.81 **1------
3.CF7.781.710.66 **0.67 **1-----
4.MOT8.131.540.75 **0.75 **0.77 **1----
5.IF8.201.520.73 **0.74 **0.76 **0.86 **1---
6.PA2573.54675.04−0.05−0.003−0.040.030.0201--
7.MH32.789.31−0.24 **−0.27 **−0.31 **−0.32 **−0.28 **0.031-
8.MH27.4115.48−0.15 **−0.14 *−0.30 **−0.33 **−0.29 **−0.010.50 **-
Brazilian sample
VariablesMSD12345678
1.GFE8.061.441-------
2.PF8.331.460.68 **1------
3.CF7.951.500.66 **0.51 **1-----
4.MOT8.491.480.60 **0.54 **0.76 **1----
5.IF8.421.590.65 **0.59 **0.70 **0.83 **1---
6.PA1734.15368.120.03−0.05−0.10−0.06−0.051--
7.MH33.818.85−0.16 **−0.12 *−0.17 *−0.17 *−0.14 *−0.13 *1-
8.MH26.9015.83−0.023 **−0.21 **−0.22 **−0.16 *−0.16 *−0.18 *0.23 **-
Notes: M = Mean; SD = Standard deviation; GFE = Global Fatigue Experience; PF = Physical Fatigue; CF = Cognitive Fatigue; MOT = Motivation; IF = Impact on Function; PH = Physical Health; MH = Mental Health; PA = Physical Activity; * p < 0.05; ** p < 0.01.
Table
Table 2. Mediation analysis between fibromyalgia-related fatigue, physical activity, and quality of life.
Table 2. Mediation analysis between fibromyalgia-related fatigue, physical activity, and quality of life.
Portuguese Sample
Path 1EffectPath 2EffectPath 3EffectTotal Indirect Effect
GFE→PH−0.17 (−0.251, −0.078)GFE→PA0.03 (−0.057, 0.120)PA→PH0.04 (−0.088, 0.161)0.01 (−0.04, 0.010)
GFE→MH−0.11 (−0.191, −0.015)GFE→PA0.03 (−0.057, 0.120)PA→MH−0.06 (−0.133, 0.120)−0.01 (−0.06, 0.04)
PF→PH−0.18 (−0.255, −0.093)PF→PA−0.01 (−0.086, 0.823)PA→PH0.02 (−0.098, 0.148)<0.01 (−0.07, 0.05)
PF→MH−0.09 (−0.174, −0.07)PF→PA−0.01 (−0.086, 0.823)PA→MH−0.01 (−0.140, 0.113)<0.01 (−0.05, 0.03)
CF→PH−0.18 (−0.253, −0.110)CF→PA−0.02 (−0.097, 0.052)PA→PH0.01 (−0.108, 0.135)−0.01 (−0.016, 0.028)
CF→MH−0.17 (−0.245, −0.102)CF→PA−0.02 (−0.097, 0.052)PA→MH−0.02 (−0.146, 0.098)0.01 (−0.017, 0.010)
MOT→PH−0.20 (−0.283, −0.126)MOT→PA0.02 (−0.062, 0.102)PA→PH0.04 (−0.086, 0.157)0.01 (−0.05, 0.010)
MOT→MH−0.22 (−0.704, −0.329)MOT→PA0.02 (−0.062, 0.102)PA→MH−0.03 (−0.123, 0.118)−0.01 (−0.06, 0.03)
IF→PH−0.18 (−0.263, −0.101)IF→PA0.01 (−0.070, 0.097)PA→PH0.03 (−0.091, 0.154)<0.01 (−0.04, 0.08)
IF→MH−0.19 (−0.270, −0.109)MOT→PA0.02 (−0.062, 0.102)PA→MH−0.07 (−0.129, 0.115)−0.01 (−0.05, 0.02)
Brazilian sample
Path 1EffectPath 2EffectPath 3EffectTotal indirect effect
GFE→PH−0.19 (−0.259, −0.103)GFE→PA0.02 (−0.088, 0.129)PA→PH0.03 (−0.128, 0.188)0.01 (−0.03, 0.011)
GFE→MH−0.16 (−0.266, −0.053)GFE→PA0.02 (−0.088, 0.129)PA→MH0.05 (−0.109, 0.198)0.01 (−0.04, 0.012)
PF→PH−0.17 (−0.245, −0.112)PF→PA−0.03 (−0.140, 0.075)PA→PH0.03 (−0.127, 0.189)−0.01 (−0.018, 0.03)
PF→MH−0.14 (−0.243, −0.030)PF→PA−0.03 (−0.140, 0.075)PA→MH0.03 (−0.127, 0.183)−0.01 (−0.022, 0.03)
CF→PH−0.15 (−0.241, −0.098)CF→PA−0.07 (−0.172, 0.036)PA→PH0.05 (−0.054, 0.156)−0.02 (−0.022, 0.07)
CF→MH−0.14 (−0.244, −0.037)CF→PA−0.07 (−0.172, 0.036)PA→MH0.02 (−0.139, 0.171)−0.01 (−0.022, 0.011)
MOT→PH−0.08 (−0.167, −0.05)MOT→PA0.06 (−0.127, 0.248)PA→PH0.04 (−0.122, 0.194)−0.01 (−0.014, 0.07)
MOT→MH−0.11 (−0.210, −0.013)MOT→PA0.06 (−0.127, 0.248)PA→MH0.03 (−0.128, 0.185)−0.01 (−0.057, 0.155)
IF→PH−0.12 (−0.201, −0.023)IF→PA−0.04 (−0.135, 0.063)PA→PH0.03 (−0.129, 0.188)−0.01 (−0.08, 0.07)
IF→MH−0.10 (−0.190, −0.09)IF→PA−0.04 (−0.135, 0.063)PA→MH0.03 (−0.127, 0.186)−0.01 (−0.010, 0.09)
Notes: Path 1 = Path between independent and dependent variables; Path 2 = Path between independent variable and mediator; Path 3 = Path between mediator and dependent variable; GFE = Global Fatigue Experience; PF = Physical Fatigue; CF = Cognitive Fatigue; MOT = Motivation; IF = Impact on Function; PH = Physical Health; MH = Mental Health; PA = Physical Activity. For exploratory purpose and since results were similar between samples, the authors examined the model with both samples (total sample). However, the results did not differ significantly from those reported in the manuscript. Thus, we maintained current results from each sample for clarity.
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Share and Cite

MDPI and ACS Style

Alvarez, M.C.; Albuquerque, M.L.L.; Neiva, H.P.; Cid, L.; Rodrigues, F.; Teixeira, D.S.; Matos, R.; Antunes, R.; Morales-Sánchez, V.; Monteiro, D. Exploring the Relationship between Fibromyalgia-Related Fatigue, Physical Activity, and Quality of Life. Int. J. Environ. Res. Public Health 2022, 19, 4870. https://doi.org/10.3390/ijerph19084870

AMA Style

Alvarez MC, Albuquerque MLL, Neiva HP, Cid L, Rodrigues F, Teixeira DS, Matos R, Antunes R, Morales-Sánchez V, Monteiro D. Exploring the Relationship between Fibromyalgia-Related Fatigue, Physical Activity, and Quality of Life. International Journal of Environmental Research and Public Health. 2022; 19(8):4870. https://doi.org/10.3390/ijerph19084870

Chicago/Turabian Style

Alvarez, Marcos C., Maria Luiza L. Albuquerque, Henrique P. Neiva, Luis Cid, Filipe Rodrigues, Diogo S. Teixeira, Rui Matos, Raúl Antunes, Verónica Morales-Sánchez, and Diogo Monteiro. 2022. "Exploring the Relationship between Fibromyalgia-Related Fatigue, Physical Activity, and Quality of Life" International Journal of Environmental Research and Public Health 19, no. 8: 4870. https://doi.org/10.3390/ijerph19084870

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop