A meta-analysis of fibromyalgia treatment interventions.

OBJECTIVE: To evaluate and compare the efficacy of pharmacological and nonpharmacological treatments of fibromyalgia syndrome (FMS). METHODS: This meta-analysis of 49 fibromyalgia treatment outcome studies assessed the efficacy of pharmacological and nonpharmacological treatment across four types of outcome measures-physical status, self-report of FMS symptoms, psychological status, and daily functioning. RESULTS: After controlling for study design, antidepressants resulted in improvements on physical status and self-report of FMS symptoms. All nonpharmacological treatments were associated with significant improvements in all four categories of outcome measures with the exception that physically-based treatment (primarily exercise) did not significantly improve daily functioning. When compared, nonpharmacological treatment appears to be more efficacious in improving self-report of FMS symptoms than pharmacological treatment alone. A similar trend was suggested for functional measures. CONCLUSION: The optimal intervention for FMS would include nonpharmacological treatments, specifically exercise and cognitive-behavioral therapy, in addition to appropriate medication management as needed for sleep and pain symptoms.

Protocol for verifying expertise in locating fibromyalgia tender points.

OBJECTIVE: To develop a protocol for determining when an individual is adequately trained to locate the tender points relative to fibromyalgia in an exam. METHODS: The error distance for each tender point was established by polling individuals with experience in conducting tender point exams. Bayesian statistical methods were employed to form a protocol for determining an individual's proficiency in locating the tender points. A predictive distribution was utilized to find the probability of remaining trained at locating tender points. Also, the probability of classifying at least 11 tender points as tender (mild) under different "locating" criteria and different number of points that are truly tender was computed. RESULTS: Critical values indicating the number of tender points needed in the qualification process for various standards of reliability--80%, 85%, and 90%--are presented. To be certified after 3 subjects have been examined in the 80%, 85%, and 90% criteria, one has to correctly identify 48, 50, and 52, respectively, out of the 54 possible tender points. CONCLUSION: We believe that at least 3 subjects should be examined before certification is granted using any of the 3 criteria--80%, 85%, and 90%. In our example, when using the 85% criterion, the qualification process required 7 subjects to certify an individual.

Biofeedback/relaxation training and exercise interventions for fibromyalgia: a prospective trial.

OBJECTIVE: To compare the effectiveness of biofeedback/relaxation, exercise, and a combined program for the treatment of fibromyalgia. METHODS: Subjects (n = 119) were randomly assigned to one of 4 groups: 1) biofeedback/relaxation training, 2) exercise training, 3) a combination treatment, or 4) an educational/attention control program. RESULTS: All 3 treatment groups produced improvements in self-efficacy for function relative to the control condition. In addition, all treatment groups were significantly different from the control group on tender point index scores, reflecting a modest deterioration by the attention control group rather than improvements by the treatment groups. The exercise and combination groups also resulted in modest improvements on a physical activity measure. The combination group best maintained benefits across the 2-year period. CONCLUSION: This study demonstrates that these 3 treatment interventions result in improved self-efficacy for physical function which was best maintained by the combination group.

The importance of enhancing self-efficacy in rheumatoid arthritis.

OBJECTIVE: To examine relationships among changes in self-efficacy and changes in other clinically relevant outcome measures. METHOD: Subjects (n = 44) were participants in a prospective, randomized stress-management study followed over 15 months. Outcome measures included self-efficacy, depression, pain, health status, and disease activity. RESULTS: Correlational analyses revealed significant associations between changes in self-efficacy (particularly total self-efficacy) and changes in selected measures of depression, pain, health status, and disease activity. The observed associations were not due to changes in medication regimen or to nonadherence to the stress-management program. CONCLUSIONS: Evidence is provided that induced changes in self-efficacy following a stress-management program were significantly related to other clinically important outcome measures.

Risk factors for depression in rheumatoid arthritis.

OBJECTIVE: To identify risk factors for the development of depression in persons with rheumatoid arthritis (RA). METHODS: Subjects were divided into depressed versus nondepressed groups on the basis of the Center for Epidemiologic Studies-Depression Scale; a range of psychological, pain-related, disease-related, and demographic variables were analyzed to predict depression. Both cross-sectional and longitudinal predictive models were examined. RESULTS: A series of analyses, including multiple logistic regression, found that the optimal predictors of depression in RA were average daily stressors, confidence in one's ability to cope, and degree of physical disability. The model was successfully cross-validated on separate data sets (i.e., same subjects at different time points). CONCLUSION: All of the identified risk factors for depression in RA are preventable to some extent and, therefore, should be addressed in comprehensive, rheumatology team care.

Self-efficacy predicting outcome among fibromyalgia subjects.

OBJECTIVES: This study examined whether pretreatment self-efficacy and pre- to post-treatment changes in self-efficacy predict post-treatment tender point index, disease severity, pain, and physical activity. METHODS: One hundred nine subjects with fibromyalgia were assessed before and after a 6-week training intervention. Measures included tender point index, physician ratings of disease severity, the visual analog scale for pain, the Physical Activities subscale of the Arthritis Impact Measurement Scales, and the Arthritis Self-Efficacy Scale. RESULTS: Pretreatment self-efficacy significantly predicted post-treatment physical activity, with higher self-efficacy associated with better physical activity outcome. Changes in self-efficacy significantly predicted post-treatment tender point index, disease severity, and pain; improvements in self-efficacy were associated with better outcomes on each measure. CONCLUSIONS: Higher levels of self-efficacy are associated with better outcome, and may mediate the effectiveness of rehabilitation-based treatment programs for fibromyalgia.

Effects of stress management on clinical outcomes in rheumatoid arthritis.

OBJECTIVE: To examine the effects of stress-management training on clinical outcomes in persons with rheumatoid arthritis (RA). METHODS: Patients with RA (n = 141) were randomly assigned to 1 of 3 groups: a stress management group, an attention control group, or a standard care control group. The stress management and the attention control groups received a 10-week intervention followed by an additional 15-month maintenance phase. RESULTS: The stress management group showed statistically significant improvements on measures of helplessness, self-efficacy, coping, pain, and health status. Selected beneficial effects were still detectable at the 15-month followup evaluation. CONCLUSION: The data indicated that stress management interventions are capable of producing important clinical benefits for persons with RA.

Selection of measures suitable for evaluating change in fibromyalgia clinical trials.

OBJECTIVE: To use growth curve model methods to investigate which of 46 variables associated with fibromyalgia (FM) clinical trials are potentially useful in measuring change. METHODS: For each of the 46 variables the reliability of change and corresponding standard error were estimated. Data were from a randomized clinical trial designed to compare the effectiveness of biofeedback/relaxation, exercise, and a combined program for the treatment of FM. There was also a control group. RESULTS: The reliabilities of change for the outcome variables Myalgic Score, Tenderpoint Count, and Tenderpoint Index, as well as the variable, number of words chosen from the McGill Pain Questionnaire were quite acceptable for both the 18 and 58 week time periods. There were 9 other variables that had reliabilities of change in the acceptable range. CONCLUSION: Thirteen of 46 variables considered had desirable reliabilities of change by the methods used. The 3 variables often used as measures of disease activity as well as one pain variable were among the 13. Data from this study produced no acceptable reliabilities of change for the 33 other variables. For these variables, further evaluation is required.

Self-efficacy, pain, and physical activity among fibromyalgia subjects.

PURPOSE: The purpose of this study was to examine the effects of self-efficacy on self-report pain and physical activities among subjects with fibromyalgia (FM). In addition, descriptive statistics of the Arthritis Impact Measurement Scale (AIMS), a measure developed for use with arthritis patients, were reported. METHODS: Seventy-nine subjects with FM, as classified by the American College of Rheumatology (ACR) criteria, completed the Visual Analogue Scale for Pain, the AIMS, and the Arthritis Self-Efficacy Scale. A myalgic score was obtained during a tender point evaluation. Hierarchical multiple regression analyses were used to assess the effect of self-efficacy on self-report pain and physical activities measures after controlling for demographic variables (age, education, and symptom duration), disease severity (myalgic scores), and psychological distress (negative affect from the AIMS). RESULTS: Higher self-efficacy was associated with less pain and less impairment on the physical activities measure after controlling for demographic and disease severity measures. CONCLUSIONS: This study underscores the unique importance of self-efficacy in understanding pain and physical activities impairment.

Weather, beliefs about weather, and disease severity among patients with fibromyalgia.

OBJECTIVE: This investigation 1) examined the relationships among actual weather, disease severity, and symptoms for individuals with fibromyalgia, 2) assessed subjects' beliefs about weather affecting their symptoms, and 3) examined differences between individuals with high and low "weather sensitivity." METHODS: Eighty-four individuals meeting Yunus' criteria for the diagnosis of fibromyalgia participated. Subjects completed the Weather and Pain Questionnaire (WPQ), the Arthritis Impact Measurement Scales (AIMS), the Symptom Checklist-90-Revised (SCL-90-R), and a Visual Analog Scale (VAS) assessing pain. A tender point index and a myalgic score were also obtained. RESULTS: Subjects reported that weather affected musculoskeletal symptoms predominantly. The strongest relationship was found between weather beliefs and self-reported pain scores. Subjects with high weather sensitivity tended to have more functional impairment and psychological distress.

Moderator-variable effect on the Brief Symptom Inventory test-item endorsements of spinal cord injury patients.

This study shows that results from the Brief Symptom Inventory (BSI), an instrument used in several US rehabilitation centers to assess psychological distress among patients, are significantly confounded by the somatic characteristics of physically disabled patients with a specific diagnosis: spinal cord injury. Our findings also illustrate the nature and the effect of this moderator variable of physical condition on BSI item endorsement and suggest a method for controlling the moderator's variable effect. The BSI item responses of 288 persons with spinal cord injury (SCI) were compared to a non-patient normative sample of 719 persons. Thirty-six items reliably differentiated the two groups (p < 0.001) and seven of these items were judged to be physical sequelae of SCI. Other highly endorsed items describe a frequent pattern of psychological response to SCI. This response pattern does not appear to reflect the latent variables which are claimed to underlie test items. Expected endorsement of these items by patients with SCI can lead to errors in test interpretation by rehabilitation professionals.

Spontaneous coping strategies to manage acute pain and anxiety during electrodiagnostic studies.

Electrodiagnostic studies produce both anxiety and pain, which can prevent adequate examination and limit the usefulness of test results. This study examined the spontaneous coping strategies used to manage the pain and anxiety experienced during electrodiagnostic testing. Fifty patients (26 women and 24 men) evaluated in our electrodiagnostic laboratory were administered visual analogue scale (VAS) pain and anxiety measures and the Spielberger State-Trait Anxiety Inventory (STAI) before the procedure. Immediately after the procedure, subjects reported pain, anxiety, and coping strategies used during electrodiagnostic testing using the VAS, the STAI, and a situation-specific version of the Coping Strategies Questionnaire (CSQ-S). The CSQ-S appears to be a valid and reliable measure of spontaneous coping strategies. Multiple-regression analyses revealed that frequent use of catastrophizing, diverting attention, and coping self-statement strategies was significantly and positively correlated with pain, whereas reinterpreting pain was significantly and negatively associated with pain. Judgments of control over pain were also significantly and negatively associated with anxiety experienced during electrodiagnostic studies. Physicians' ratings of pain and anxiety were highly correlated with patients' self-reports. This study suggests that ineffective coping strategies may enhance the pain and anxiety experienced during electromyography. Alternatively, teaching subjects active self-control skills and increasing patients' self-efficacy beliefs may help manage this situation-specific acute anxiety and, possibly, the associated pain.

Relationship of self-efficacy to pain behavior.

Our purpose was to examine the effects of self-efficacy on the pain behaviors exhibited by patients with rheumatoid arthritis (RA). Seventy-two patients with RA were assessed using a standardized videotaping procedure for rating specific pain behaviors such as limps, facial grimaces, and guarded movements. Patients also completed questionnaires measuring self-efficacy and depression. Hierarchical regression was used to assess the relationship between self-efficacy and pain behavior after the effects of demographic characteristics and disease activity were statistically controlled. Higher self-efficacy was found to be related to fewer pain behaviors. In contrast, depression was found to be unrelated to pain behavior. Our results indicate that the pain behaviors that patients with RA exhibit are related to their self-efficacy, not solely to their disease activity.

Behavioral treatment of dizziness secondary to benign positional vertigo following head trauma.

Benign positional vertigo (BPV) represents a challenge to rehabilitation due to the subjective nature of the complaint of dizziness, frequent failure of pharmacologic intervention, and complicating psychologic factors. Behavioral therapy was used to treat a 26-year-old woman who complained of debilitating dizzy spells after mild head injury sustained in a motor vehicle accident. During a three-week baseline period before treatment, the patient reported a weekly average of 48 dizzy spells, which prevented participation in independent activities and kept her homebound and psychologically distressed. Nine-week behavioral treatment included biofeedback-assisted relaxation training, psychologic counseling, gaze-fixation practice, desensitization exercise, and generalization training. This protocol has been used successfully to train aviators to combat vertigo and nausea in flight. Our regimen included hourly recording of physical activity, notation of frequency of dizzy spells, and use of behavioral methods during nine weeks. The patient reported 90% reduction in dizzy spells and full resumption of independent activities including driving and athletics. Results are discussed in the context of behavioral problems associated with BPV and application of behavioral methods to the complaint of dizziness.

Adjustment to spinal cord injury: stage theory revisited.

To better understand adjustment following spinal cord injury (SCI), 106 subjects from two samples (N = 53 each) were administered the SCL-90-R, a symptom checklist, and the Multidimensional Health Locus of Control scales. Sample 1 subjects were admitted for rehabilitation during 1981 to 1982 and sample 2 subjects were admitted during 1984 to 1986. Sample 2 subjects entered rehabilitation programs more quickly after injury and reported more anxiety, phobic anxiety, and hostility than sample 1 subjects. Within each sample, there was no evidence for a relationship between age or time since injury and health beliefs or psychological distress. This study does not support stage theory for adjustment after catastrophic injury, but does suggest the importance of understanding the impact of social policy changes in adjustment following spinal cord injury.

Psychological screening in rheumatoid arthritis.

Our objective was to examine the utility of the Symptom Checklist-90-R (SCL-90-R) as a psychological screening instrument for patients with rheumatoid arthritis (RA). Subjects were 81 male and 3 female patients with classic or definite RA who were categorized into 3 anatomic stage groups based on roentgenograms. Erythrocyte sedimentation rates, joint counts, and the SCL-90-R were obtained on all subjects. In addition, rheumatologists were surveyed, and items were analyzed to identify potential disease related items on the SCL-90-R. Both the survey and the item analyses supported the utility of the SCL-90-R as a psychological screening instrument in a population with RA.

Psychological symptoms in primary fibromyalgia syndrome: relationship to pain, life stress, and sleep disturbance.

Twenty-five subjects with primary fibromyalgia syndrome and 22 subjects with rheumatoid arthritis were compared on measures of psychological distress, pain, health status, life stress, sleep disturbance, and coping strategies. Higher levels of psychological distress were found in the primary fibromyalgia syndrome group, but the degree of life stress was shown to be a significant covariate.

Rehabilitation. Psychology's greatest opportunity?

Rehabilitation is one of the fastest growing areas in the health industry. Supported by several key pieces of legislation, psychologists have established themselves as integral health care providers in rehabilitation. Although psychologists have benefited from legislated membership in rehabilitation, most individual psychologists and the psychological associations have failed to recognize the importance of public policy for the practice of psychology. Escalating health care costs have resulted in major revisions in the manner in which health insurers reimburse treatment. Medicare, the major federal health insurance provider, increasingly has been viewed as a model for the provision of all health care. The historic exclusion of psychologists from Medicare has limited the scope of psychologists' practice and the growth of professional psychology. The recent inclusion of psychologists in Medicare improves but does not solve practice and policy issues confronting psychology. Knowledge of national health policy formulation and greater participation by psychologists in health policy is necessary to secure the scope of professional practice most psychologists expect.

Coping with arthritis pain. A review of the literature.

Pain associated with arthritis is the primary reason patients with arthritis seek medical attention. The complex and multidimensional nature of pain among arthritis patients is examined. Self-reports of pain, the impact of pain, cognitive factors associated with pain, and the treatment of arthritis pain are reviewed. Psychosocial pain management programs emphasizing improved coping appear to be important as an adjunct to medical treatment. Implications for future research are discussed.

Fibromyalgia: a rehabilitation approach. A review.

Primary fibromyalgia syndrome, a myofascial disorder, is characterized by diffuse pain and tender points. Effective long term rehabilitation interventions for this disorder have not been demonstrated. The current rehabilitation interventions of fibromyalgia are evaluated and the psychologic consequences are summarized.