Stress Management as a Clinical Approach to the Complementary Treatment of Fibromyalgia

Abstract

Fibromyalgia is a chronic syndrome that can have a devastating effect on the lives of those who suffer from it. These types of patients experience high levels of pain, as well as deficits in terms of positive affect and social relationships, which are not explicitly addressed in pharmacological treatments. Objectives: To know how pharmacological interventions combined with various stress management techniques reduce pain perception in adult patients clinically diagnosed with fibromyalgia. Data sources, study eligibility criteria: The search for the articles was carried out from January 2010 to July 2021, in six databases (Web Of Science (WOS), Scopus, Cochrane, Psycinfo, Psicodoc, Psychology and Behavioral Sciences Collection and Pubpsych) based on the clinical question, using the keywords derived from the DeCS and MeSH thesauri, combined with the Boolean operators “AND”, “NOT” and “OR”. The search was limited to publications from the last 11 years, in English or Spanish, based on randomized controlled studies (RCTs), and covering patients with a clinical and medical diagnosis of fibromyalgia, between 18 and 65 years of age, and of both genders. Results: Thirteen RCTs were included with a total sample of 2218 participants, where the mean methodological quality obtained from the studies reviewed using the PEDro scale was 7.07. The combined data showed a marked improvement in the quality of life of the patient (p < 0.001). Regarding other units measured during the review, a significant reduction could be observed in perceived pain (p < 0.001), stress (p < 0.001), anxiety (p < 0.001) and depression (p < 0.001). Conclusions and implications of key findings: Multidisciplinary treatment leads to notable improvements compared to conservative or pharmacological treatment, improving quality of life, social support, mental self-control and satisfaction. Cognitive-behavioral therapy favored therapeutic adherence, achieving in turn a decrease in anxiety, depression and vital exhaustion.

1. Introduction

Fibromyalgia is a clinical disorder of unknown origin, which is characterized by generalized chronic pain lasting more than 3 months, accompanied by fatigue, insomnia, cognitive complaints, alterations in mood and even neurocognitive or autoimmune deficiencies [1,2]. These symptoms are the most characteristic of this pathology, but patients frequently also report another series of less well-defined symptoms (headache, dizziness, intolerance to cold/heat and low-grade fever) presenting different levels of severity, worsening or exacerbation [1,3,4,5].

Fibromyalgia prevalence is higher in women than in men, in a ratio of 8.5 to 1, occurring in 2.10% of the general population, 2.31% of the European population and 2.40% of the Spanish population. This pathology leads to medical diagnosis and various alterations with regard to mental health, since fibromyalgia is associated with high levels of anxiety, depression and somatic complaints. These effects on emotional level can trigger a psychiatric disorder, making patients more sensitive to stimuli and activating mechanisms related to psychological stress. Psychological stress is one of the main factors intrinsically related to the hypothalamic-pituitary-adrenal (HHA) axis, a neuroendocrine mechanism responsible for transmitting stress and relaxation signals from their inception at the brain level through neuronal tissue to the target organs, resulting in the pathology in question. This type of psychological stress can be observed through reactions of depression and anxiety, although it is true that it does not affect all patients in the same way, nor is there a single psychological profile of reaction to cognitive/psychological factors that affects a significant proportion of people affected by fibromyalgia. Coping skills, adaptive behavior, social support and the implementation of activities/techniques (Tai Chi, cognitive behavioral therapy, mindfulness and/or multidisciplinary treatment) play an essential role in improving their quality of life [2,6,7].

The feelings of sadness, fatigue, insomnia and lack of interest noted among fibromyalgia patients are accompanied by hypervigilance in the face of pain signals and, therefore, catastrophizing in the face of illness and pain. Multiple studies suggest that somatic symptoms are related to measures of emotional stress, and somatization (physical expression of a psychological problem) is another of the characteristic features of fibromyalgia, where in most cases, the problems underlying psychological anxiety could be considered to be depression and stress (

Table 1. Databases consulted.

Somatic Symptoms in Fibromyalgia and Emotional and Cognitive Alterations.
Somatic symptoms	Chronic headaches, sleep disorders, dizziness, cognitive disorders, memory disorders, anxiety and depression, pain, fatigue, fasciculation (involuntary contraction and relaxation of muscle fibers), urination disorders, dysmenorrhea, vision problems, sexual dysfunction, nausea, morning stiffness, weight gain, cold symptoms, varied chemical sensitivity.
Affective symptoms	Dysphoria, anhedonia, anxiety, distress, irritability, and apathy.
Cognitive symptoms	Bradipsychia, presence of negative thoughts (hopelessness, catastrophic pain, low self-esteem, uselessness, hopelessness, ideas of death and suicide).
Behavioral symptoms	Frequent and unmotivated crying, decreased performance in daily activities, tendency to isolation and suicide attempts.

) [7].

This pathology causes a notorious economic impact of about EUR 10,000 per patient. Added to this figure is the loss of income, since due to the multiple somatic and mental ailments they suffer from, patients are forced to leave their work, leading to a series of indirect costs. These results show how fibromyalgia is one of the pathologies that causes the highest total costs in our country, compared with chronic low back pain or Alzheimer’s disease, which are pathologies that likewise consume a great deal of resources. With regard to rheumatic diseases, fibromyalgia generates the same costs as rheumatoid arthritis, far exceeding the costs caused by osteoarthritis, despite the fact that the latter has a high prevalence in the Spanish population [2,6].

Despite being a significant social health problem, there are very few treatments with evidence of functionality, giving rise to the dissatisfaction of patients with the public health system, where 42.9% say they are not satisfied with the care provided by health professionals [2,6].

Based on what has been argued, this study is necessary in order to assess the effectiveness of strategies focused on reducing the stress that the pathology entails, and on management and control techniques to reduce anxiety, depression, inability to cope and perceived pain [6].

The general objective of this work is to know how pharmacological interventions combined with various stress management techniques reduce the perception of pain in adult patients clinically diagnosed with fibromyalgia.

2. Materials and Methods

The preparation of this work was carried out through a systematic bibliographic review of the articles found by searching the following databases: Web Of Science (WOS), Scopus, Cochrane, Psycinfo, Psicodoc, Psychology and Behavioral Sciences Collection and Pubpsych. This systematic literature review was conducted in accordance with the PRISMA statement. To find the best possible scientific evidence, a series of inclusion and exclusion criteria were applied.

The keywords for this review were: fibromyalgia; stress; anxiety; coping; randomized; random allocation. These have been validated by DeCS and MeSH. Once selected, the corresponding Boolean operators were used: AND/OR, as well as the necessary parentheses and quotation marks. The criteria that have been taken into account for the selection of the relevant studies are the following. Inclusion criteria: the period from January 2010 to July 2021; randomized controlled studies (RCTs); studies aimed at the target population, namely, people between 18 and 65 years old, of both sexes; studies whose sample has a clinical and medical diagnosis of fibromyalgia; studies with scientific evidence and published in corroborated databases; Spanish or English language. The exclusion criteria were: articles prior to 2010; language other than English or Spanish; studies in which the population was under 18 or over 65; studies that do not provide scientific evidence justified by the level of indexing of articles in journals according to the latest criteria; pregnant women, given the possibility of childbirth and consequently the abandonment of treatment; psychiatric pathologies.

For the methodological evaluation of the individual studies and the detection of possible biases, the evaluation was carried out using the “PEDro Evaluation Scale”. This scale consists of 11 items, providing one point for each item that is met. Articles that obtain a score of 9–10 points have an excellent quality, those between 6–8 points have a good quality, those that obtain 4–5 points have an intermediate quality, and, finally, those articles that obtain less than 4 points have a poor methodological quality [8].

The Scottish Intercollegiate Guidelines Network (SIGN) classification was used in the data analysis and assessment of the levels of evidence, which focuses on the quantitative analysis of systematic reviews and on the reduction in systematic error. Although it takes into account the quality of the methodology, it does not assess the scientific or technological reality of the recommendations [9].

3. Results

The review question was constructed following the PICO format (population/patient, intervention, comparator and outcome): “Adult patients with a clinical diagnosis of Fibromyalgia (P), Pharmacological treatment plus stress management and control techniques (I), Pharmacotherapy (C), Pharmacological interventions combined with various stress control techniques decrease pain perception (O)” (Figure 1).

Below is a table that shows the search strategy used to select the 13 selected articles (

Table 2. Databases consulted.

Item Criteria	Psicodoc	Cochrane	Psycinfo	MedPsych/Pubmed	Scopus	WOS	Total
Identified	2	41	25	9	36	41	112
Duplicates	2	14	8	8	15	12	59
Title	2	4	3	4	7	4	24
Abstract	1	2	1	2	6	4	16
Text complete	0	2	1	1	6	4	14
Valid	0	2	0	1	6	4	13

). The total number of valid articles is summarized in the Appendix A.

Thirteen RCTs were included with a total sample of 2218 participants, where the mean methodological quality obtained from the studies reviewed using the PEDro scale was 7.07.

Characteristics of included studies: five clinical trials used cognitive behavioral therapy as a modality of intervention [10,11,12,13,14]. Two carried out a multidisciplinary treatment, which contained psychological, pharmacological, physiotherapeutic and psychosocial therapy in cases of socioeconomic adversity, where none of these were unique or exclusive, nor could they replace the others. Another three studies focused on fighting ailments through Tai Chi and mindfulness [15,16,17,18,19]. Some of the articles carried out more specific therapies, such as the Mitchell method relaxation technique or exposure treatment focused on emotions [20,21].

Methodological quality of the studies: the presence of interviewer or observer bias was relatively frequent, since some of the selected studies were not blinded, or they were partially blinded due to the complexity that full blinding would entail. In some trials, the sample presented was quite limited, which may influence their results, making it inconclusive.

Effect of interventions: five studies incorporated cognitive behavioral therapy (CBT) into the intervention. The combined data show how this type of treatment resulted in a marked improvement in patient quality of life (p < 0.001) [10]. Above all, there was a significant improvement in terms of depression (p < 0.001–p = 0.0003), anxiety (p < 0.044–p = 0.0416), vital exhaustion, sleep, strategies of coping, adherence to treatment and, therefore, greater pain control and reduction in severity (p = < 0.007) [10,11,12,13,14].

Regarding sleep, cognitive behavioral therapy did not bring a full recovery, but the clinical benefits it obtained are of great relevance, since it improved sleep quality and self-efficacy when dealing with pain [12].

CBT provided in person vs. online was also compared. Through these studies it was possible to observe how the participants of the first group presented optimal results earlier. In contrast, the online group obtained greater self-efficacy and also presented a sustained improvement at 6 and 12 months of follow-up. This was due to the ability that these individuals developed to perform this type of technique at home without the need for a professional [12,13].

Interventions that use Tai Chi and/or mindfulness: two studies published by Wang demonstrate how carrying out this type of intervention in individuals suffering from fibromyalgia was able to reduce its impact (p < 0.001). The interventions reduced perceived pain (p < 0.001), stress (p < 0.001), anxiety (p < 0.001) and depression (p < 0.001), in addition to improving coping skills (p < 0.001) and quality of life of the patient (p < 0.001). Wang also compared this method with aerobic exercise, administered with the same intensity and duration; the individuals belonging to the experimental group reported a greater benefit (p = 0.03), significantly improving their self-efficacy (p < 0.005) [16,17].

Another study published by Davis MC in 2013 demonstrates how mindfulness is not capable of significantly reducing pain. However, it improved the effectiveness of coping with pain (p < 0.0001), the ability of patients to participate in various social activities despite their symptoms (p < 0.0008) and their greater efficiency when facing stressful situations (p < 0.0007), as well as decreasing the feeling of loneliness perceived by the patient (p < 0.0003) [15].

Interventions using multidisciplinary treatments: patients who received this type of therapy showed notable improvements in terms of quality of life (p = 0.04), social support (p = 0.02), mental self-control (p = 0.05) and satisfaction (p = 0.001). Moreover, these techniques managed to evoke in the patient a decrease in anxiety levels (p < 0.05), depression (p < 0.01), pain (p = 0.03) and somatization (p < 0.01) and, consequently, led to less use of health services (p < 0.05) [17,19].

Interventions that use an alternative treatment: the study carried out by Boersaman K in 2019 on exposure therapy focused on emotion and showed optimal results, despite not obtaining improvement in anxiety levels or pain intensity, in so far as it was able to significantly reduce catastrophic pain (p = 0.39) and its interference in daily life (p = 0.63) [21].

The relaxation technique based on the Mitchell method was effective in reducing pain (42.8%), sleep problems and fatigue (37%). These types of interventions are effective when used as adjuvant treatment, being usually recommended due to the absence of adverse effects in those people who have been diagnosed with fibromyalgia [20].

4. Discussion

The purpose of this review is to assess the effectiveness of strategies for managing and reducing stress, anxiety and depression associated with fibromyalgia, improving coping capacity and lowering the perception of pain. The observed effectiveness may be due to the fact that the use of these techniques or treatments allows patients to obtain knowledge and skills when facing and managing pain, thus reducing the perception that the user has about it.

The data provided are sufficiently solid to verify the effectiveness of these actions, although it is true that the results of this review should be interpreted with caution due to the heterogeneity of the studies in terms of methodological quality, sample size and follow-up periods [10,11,12,13,14].

Several studies have shown that performing CBT while maintaining pharmacological treatment significantly reduces anxiety and depression and, therefore, confers greater control over pain. The pain suffered by the patient is the same, but after performing this type of intervention, the patient is able to manage the pain, making it more bearable, thus mitigating the impact it generates on activities of daily living [8,9,10,11]. This is why those individuals who have participated in clinical trials that provided CBT online present a longer-lasting improvement over time, since they are able to continue performing the techniques taught during the research [12,13].

Other research has shown how the implementation of interventions based on mindfulness (Tai Chi and/or mindfulness) is able to help the user, reducing anxiety, stress, insomnia, etc. [15,16,17]. One of the trials compared this type of technique with aerobic exercise. Both presented improvements, with the difference that those who carried out mindfulness experienced greater benefits, in addition to greater self-efficacy [16,17].

With regard to multidisciplinary treatment, it is demonstrated that physical exercise, directed by a physiotherapist, in addition to adequate psychological therapy provided by a professional specialist in this field, is capable of improving the quality of life of patients who present with this type of pain. These combined treatments yield better results than if they exclusively carried out conservative or pharmacological treatment, showing that this type of intervention represents an important supplement with regard to the treatment of musculoskeletal pain [18,19].

Interventions that used an alternative treatment were effective when used as adjuvant treatment, being usually recommended due to the absence of adverse effects in those people who have been diagnosed with fibromyalgia, since they are capable of significantly reducing catastrophic pain (tendency to focus excessively on the painful sensation, exaggerating the damage and feeling unable to control it) and the interference it causes in the patient’s daily life. This is due to learning techniques focused on the emotions of the individual, who thus gains a greater management of their person [20,21].

Regarding the limitations of the study, although the results obtained are conclusive in terms of the objectives of the study, larger samples could yield more conclusive results. The heterogeneity between the studies means that the results found should be considered with caution. Given the scarcity of clinical trials that address stress management in fibromyalgia, it is difficult to address and see how these therapies affect patients holistically, since each study focuses on specific somatic or psychiatric disorders. This in itself justifies the implementation of future research.

5. Conclusions

Multidisciplinary treatment of fibromyalgia has obtained notable improvements compared to conservative or pharmacological treatment. This treatment improves quality of life, social support, mental self-control and satisfaction, while reducing levels of anxiety, depression, pain, and somatization and, consequently, use of health services. Cognitive-behavioral therapy favors therapeutic adherence, achieving in turn a decrease in anxiety, depression and vital exhaustion. It also manages to improve the quality of sleep and coping strategies, and therefore gives the patient greater control over the pain they perceive, thus mitigating the impact generated by carrying out any type of daily life activity. Patients who participated in online therapies obtained better results during the 6- and 12-month follow-up compared to those who received the same treatment in person. Mindfulness (Tai Chi and/or mindfulness) helps reduce insomnia, feelings of loneliness, stress, anxiety, depression, etc., improving, in turn, self-efficacy and the ability to cope with stressful situations. In general, alternative treatments obtained positive results when used as adjunctive treatment, reducing the catastrophic vision of pain and pain and its interference in the daily life of the patient.