Abstract
Fibromyalgia (FM) is one of the most common chronic rheumatic disorders (Jones et al., 2015). It is characterized by widespread muscular and soft tissue pain, fatigue, and multiple areas of localized tenderness (i.e., tender points; Wolfe et al., 2010). FM affects as much as 2%–8% of the general population, or approximately 10 million people (Jones et al., 2015).
The symptoms of FM challenge people’s engagement in valued occupations (Farin, Ullrich, & Hauer, 2013; Henriksson, Liedberg, & Gerdle, 2005; Lindberg & Iwarsson, 2002; Stamm et al., 2014). For example, compared with healthy women, women with FM have significantly more difficulty with daily activities, particularly hygiene and bathing, and require more assistance to perform these activities (Pérez-de-Heredia-Torres, Huertas Hoyas, Sánchez-Camarero, Pérez-Corrales, & Fernández de-las-Peñas, 2016). Qualitative studies have found that FM interferes with relationships with families and friends; limits participation in occupational performance, including work and leisure; and prevents participation in physical activity (Arnold et al., 2008).
FM’s varied symptoms and the multiple systems involved make intervention with people with FM a challenge. People with FM are often referred to occupational therapy for management of pain and fatigue, exercise, and occupational performance deficits (Sim & Adams, 2003). An understanding of the effectiveness of interventions targeted at improving these outcomes can help occupational therapy practitioners select evidence-based interventions to treat people with FM.
Unfortunately, although many systematic reviews and meta-analyses have been conducted, no consensus has been reached on the most effective nonpharmacological interventions for FM. Moreover, although many of the interventions in these reviews are within the scope of occupational therapy practice as defined in the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; American Occupational Therapy Association [AOTA], 2014), the most recent reviews included studies published before December 2011 (Nüesch, Häuser, Bernardy, Barth, & Jüni, 2013) or included only cognitive–behavioral therapies (Bernardy, Klose, Busch, Choy, & Häuser, 2013).
Thus, the purpose of this review was to summarize evidence focused on interventions and outcomes that are of interest to occupational therapy practitioners. Specifically, the review was completed to answer the following focused question: What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice that address occupational performance, pain, fatigue, depression, and sleep in people with FM?
Method
This review was conducted as part of the AOTA Evidence-Based Practice (EBP) Project. The methodology consultant to the AOTA EBP Project, as well as AOTA staff and the authors, developed the search terms for the systematic review. Terms were reviewed by the advisory group to ensure they would collect relevant articles from each database. A medical research librarian with experience in completing systematic review searches confirmed the search strategy and completed all searches. Table 1 lists the search terms, and the search strategy is outlined in Supplemental Appendix 1 (available online at http://otjournal.net; navigate to this article, and click on “Supplemental Materials”).
Search Terms for Fibromyalgia
Note. ADLs = activities of daily living; AAROM = active assistive range of motion; AROM = active range of motion; EMG = electromyography; IADLs = instrumental activities of daily living; NCV = nerve conduction velocity; PROM = passive range of motion.
Databases and sites searched included MEDLINE, PsycINFO, CINAHL, OTseeker, and Ergonomics Abstracts. Also included were sources of consolidated evidence-based medicine reviews such as the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and the Database of Abstracts of Reviews of Effects. In addition, reference lists from articles in the databases and relevant journals were hand searched as needed to confirm that all appropriate articles were included.
Studies included in this review were published in English between January 2000 and July 2014 and were considered peer-reviewed scientific literature as defined by Sackett, Rosenberg, Gray, Haynes, and Richardson (1996). To be included, studies had to have adult participants with a diagnosis of FM and to report on an intervention approach within the scope of occupational therapy practice. The intervention did not have to be provided by, or include, an occupational therapy practitioner. However, the intervention had to be one that could be provided within the scope of occupational therapy as defined in the Framework (AOTA, 2014).
The initial citation and abstract search yielded 322 articles related to FM. Duplicates among the multiple databases, articles that were included in a systematic review, and articles that did not meet any of the inclusion criteria were removed. At this point, the authors also decided to limit the review to Level I studies. The authors divided the remaining 176 titles and abstracts according to two broad themes for further review: psychoeducational interventions and physical activity interventions. The full-text versions of potential articles were retrieved, and the review team made further exclusions on the basis of the predetermined exclusion criteria. A summary of article exclusions with reasoning is presented in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram (Moher, Liberati, Tetzlaff, & Altman, 2009) in Figure 1.
Flow diagram of fibromyalgia studies included in the systematic review.
Results
A total of 42 articles were included in the final review, 10 systematic reviews or meta-analyses and 32 randomized controlled trials (RCTs). Because the review was done for the purpose of informing practice guidelines, systematic reviews were included so as not to redo work that had already been done. Each article included in the review was summarized in an evidence table that displays the method, intervention details, and major findings. Particular attention was given to the outcomes that addressed function (e.g., scores on the Fibromyalgia Impact Questionnaire [FIQ]), pain, depressive symptoms, sleep, and fatigue. The FIQ is a self-report outcome measure used in the majority of the studies; it measures participation in instrumental activities of daily living (IADLs; Williams & Arnold, 2011).
Psychoeducational Interventions
Thirteen articles evaluated psychoeducational interventions. These interventions were divided into the following subcategories: cognitive–behavioral (n = 3), self-management (n = 2), relaxation and stress management (n = 5), and emotional disclosure (n = 3). An integrated summary of the findings for each subcategory follows, and a detailed summary of each study can be found in Supplemental Table 1 (online).
Cognitive–Behavioral.
Cognitive–behavioral interventions use cognitive techniques to modify behavior and dysfunctional thoughts. One systematic review and meta-analysis (Bernardy, Füber, Köllner, & Häuser, 2010) found evidence that cognitive–behavioral therapy (CBT) was effective for reducing depressed mood but found no evidence for improvements in pain, fatigue, sleep, and quality of life (usually measured by the FIQ) at postintervention and at follow-up. A later Cochrane review by the same group reported that CBT had small benefits in decreasing pain, negative mood, and function both postintervention and at long-term follow-up (Bernardy et al., 2013).
In addition, an RCT that compared CBT combined with drug therapy with two other intervention arms—education combined with the same drug therapy and CBT with a placebo—found that improvements in pain and function in the CBT group were similar to those in the combination group (Ang, Jensen, et al., 2013). CBT also resulted in significant improvements in function compared with the education plus drug therapy group but no difference in pain. No differences were found between the groups for FIQ scores and depression.
Self-Management.
A Cochrane review by Bernardy et al. (2013), which included 3 studies on self-management interventions, did not find evidence for the effectiveness of self-management programs for improving pain, mood, or function. Two RCTs, Camerini and Schulz (2012) and Hunt and Bogg (2000), were not included in the Bernardy et al. review. Camerini and Schulz examined a web-based intervention in which participants were randomly assigned to one of three groups that differed in level of interactivity with the website. No differences were found between the groups in knowledge gained, empowerment, or improvements in symptoms or function. The Hunt and Bogg RCT involved a face-to-face group intervention that used educational and behavioral approaches. No significant improvements were found in pain, fatigue, or sleep after the intervention. Thus, regardless of format, these two self-management interventions did not result in significant changes compared with control conditions, similar to Bernardy et al.’s results.
Relaxation and Stress Management.
The relaxation and stress management category included interventions that teach relaxation such as mindfulness interventions and guided imagery (GI). Three studies focused on mindfulness interventions. Lauche, Cramer, Dobos, Langhorst, and Schmidt’s (2013) meta-analysis of 6 articles found small short-term effects, but low quality of evidence, for mindfulness-based stress reduction on quality of life (FIQ or SF–36 Health Survey) and pain. The analysis found no long-term effects compared with usual care or active control conditions, and no evidence was found of improvements in fatigue, sleep, or depression. One RCT (Parra-Delgado & Latorre-Postigo, 2013) examined an 8-week weekly group mindfulness intervention. Compared with the control group, the intervention group had significant improvements in FIQ scores immediately postintervention and improvements in depression at 3-mo follow-up. Another RCT involved an online mindfulness intervention with a focus on addressing pain, coping, and social relations (Davis & Zautra, 2013). This study found improvements in pain, social function, and stress coping in the intervention condition compared with the control condition.
Two RCTs examined the effectiveness of guided imagery; both were from the same group of researchers. The GI intervention consisted of listening to three 20-min relaxation and GI audiotapes. In the earliest study (Menzies, Taylor, & Bourguignon, 2006), the intervention group showed significant improvements in FIQ score and self-efficacy for pain and other symptoms compared with the control group. In the most recent study (Menzies, Lyon, Elswick, McCain, & Gray, 2014), the GI group had significantly improved pain and less fatigue, depression, and stress than the usual-care group.
Emotional Disclosure.
Emotional disclosure is an intervention in which people write or talk about events that triggered strong emotional thoughts (Gillis, Lumley, Mosley-Williams, Leisen, & Roehrs, 2006). In 2 RCTs, participants wrote about events that evoked strong emotional or stressful feelings. The control conditions were a neutral writing condition (Broderick, Junghaenel, & Schwartz, 2005) or usual care (Gillis et al., 2006). Broderick et al. (2005) found reduced pain and fatigue after emotional disclosure under controlled laboratory conditions at 4 mo postintervention, but these improvements were not maintained at 10-mo follow-up. Gillis et al. (2006), who used an at-home written disclosure intervention, reported improvements in sleep and marginal improvements in FIQ score at 3-mo follow-up that were not statistically apparent postintervention or at 1-mo follow-up. The disclosure group had an immediate increase in negative mood, but this decrease disappeared at 3 mo.
In a 3rd RCT (Hsu et al., 2010), the written disclosure intervention was accompanied by affective awareness exercises and group educational sessions on pain management. The intervention group had improvements in pain, fatigue, FIQ score, and pain threshold compared with the control group. All improvements, except fatigue, were maintained at 6-mo follow-up.
Physical Activity
A wide variety of physical activity interventions from 21 studies were included in the physical activity category. The interventions were organized into seven subcategories, with some studies evaluating physical interventions across multiple subcategories, as reflected in Supplemental Table 2 (online). These subcategories were combined or mixed exercise (n = 6); strength training used independently of any other exercise (n = 2); aerobic exercise used independently of any other exercise (n = 2); aquatic exercise (n = 1); exercise combined with a modality such as massage (n = 4); Tai Chi, yoga, and Pilates (n = 5); and activity-based interventions, including home exercise and coaching activities (n = 3).
Combined or Mixed Exercise.
The combined or mixed exercise subcategory included 6 studies in which the intervention involved more than one type of exercise such as aerobics in conjunction with strengthening or water exercise combined with flexibility and strengthening exercises. Busch, Barber, Overend, Peloso, and Schacter’s (2007) Cochrane review included 34 RCTs that compared exercise with a nonexercise or untreated control condition. Of the 34 RCTs, 11 evaluated combined exercises, but Busch et al. concluded that not enough studies used an untreated control condition to reach a conclusion regarding the benefits of combined exercise. A meta-analysis (Kelley, Kelley, & Jones, 2011) included 9 RCTs that compared aerobic exercise, pool-based exercise, supervised strength training, and home-based low-impact aerobics with nonexercise control conditions. The results suggested that exercise improves tender points in people with FM.
Two RCTs included only female participants and evaluated different combinations of exercise. One study combined aerobic, strength, and flexibility exercises (Sañudo, Galiano, Carrasco, de Hoyo, & McVeigh, 2011), and the other combined water- and land-based strength and aerobic exercise programs (Latorre et al., 2013). In both studies, the exercise interventions resulted in improved symptoms and FIQ scores compared with no exercise or usual care.
In addition to these studies, an RCT comparing the effect of aerobic exercise and strengthening exercise on pain reported that both aerobic and strengthening exercise was effective for pain reduction (Hooten, Qu, Townsend, & Judd, 2012). In contrast, another RCT with four arms (exercise–drug, diet recall–drug, placebo–exercise, placebo–diet recall) concluded that none of the combinations improved FM symptoms, FIQ scores, or pain, but the two exercise conditions reduced fatigue (Jones et al., 2008).
Strength Training.
Two Cochrane reviews (Busch et al., 2007, 2013) included a total of 5 studies of resistive exercise. Busch et al. (2007) included 3 RCTs on resistive exercise and concluded that strength training improved pain, tender points, depression, and symptoms reported on the FIQ. Busch et al. (2013) included 2 additional RCTs on resistive exercise and concluded that moderate- to high-intensity resistance training was safe for people with FM and that it improved FIQ scores, pain, self-reported physical function, and strength. However, the authors noted that the evidence was of low quality. In addition, the 2013 review reported that moderate resistance training was not as effective as aerobic training in reducing pain and improving sleep but was superior to flexibility exercise training.
Aerobic Exercise.
The Busch et al. (2007) Cochrane review also evaluated the effectiveness of aerobic exercise. The review, which included 15 RCTs on aerobic exercise, concluded that moderate-intensity aerobic training appeared to have beneficial effects on well-being and FIQ scores but little effect on tender points. An RCT not included in the Busch et al. review compared Nordic walking at moderate to high intensity with low-intensity walking (Mannerkorpi, Nordeman, Cider, & Jonsson, 2010). FIQ function initially improved in the high-intensity group, but that group had no improvement in total FIQ score or pain compared with the low-intensity group, and improvements were not maintained at 6-mo follow-up.
Aquatic Exercise.
A 2014 Cochrane review (Bidonde et al., 2014) included 16 RCTs that compared aquatic exercise with either land-based exercise or a different aquatic exercise program as a control. Results indicated that aquatic exercise improved multidimensional function (self-report questionnaire and FIQ), self-reported physical function (FIQ and SF–36), pain, and stiffness when compared with a control condition.
Exercise Combined With a Modality.
Two RCTs included an exercise program combined with a modality. One combined aerobic exercise, massage, ischemic pressure, and thermal therapy (Casanueva-Fernández, Llorca, Rubió, Rodero-Fernández, & González-Gay, 2012), and the other combined stretches with self-massage using dowels and tennis balls (Field, Delage, & Hernandez-Reif, 2003). The participants in the Field et al. (2003) study had improved mood, lower anxiety, and lower pain compared with the relaxation control group, and the participants in the Casanueva-Fernández et al. (2012) study had improved overall health perception and social functioning.
Two additional RCTs evaluated the effect of exercise combined with transcutaneous electrical nerve stimulation (TENS) or chiropractic treatment. Mutlu, Paker, Bugdayci, Tekdos, and Kesiktas (2013) added TENS to the first 3 wk of a program that combined aerobics, stretching, and strengthening. This RCT included a separate exercise arm with no TENS. Both groups had improvements in tender point count, pain, and FIQ score. The 2nd RCT (Panton et al., 2009) compared resistance training plus chiropractic treatment with resistance training alone. Both groups had improved strength, tender points, and FIQ scores. Thus, the addition of chiropractic services did not appear to provide greater change in pain, tender points, or FIQ scores, but it did appear to increase adherence to the resistance training program.
Tai Chi, Yoga, and Pilates.
Two RCTs using a Tai Chi–based intervention were included in this category. Both RCTs examined Tai Chi with an educational or nonexercise control arm and involved 12 wk of Yang-style Tai Chi (Jones et al., 2012; Wang et al., 2010). Participants in both RCTs had improved FIQ scores and decreases in pain.
Two Level I studies evaluated the effectiveness of yoga. Carson et al. (2010) randomized female participants into 8 wk of a yoga program designed for people with FM or a wait list control condition. In addition to improved FIQ scores, participants had improvements in pain, pain coping strategies, fatigue, stiffness, depression, memory, anxiety, tenderness, balance, and environmental sensitivity. Da Silva, Lorenzi-Filho, and Lage (2007) compared relaxing yoga and relaxing yoga with touch. Both groups had improved pain and FIQ scores, but no differences were found between groups.
One RCT evaluated the effectiveness of Pilates in women with FM (Altan, Korkmaz, Bingol, & Gunay, 2009). This RCT compared 12 wk of Pilates (1 hr 3×/wk) with a relaxation and stretching home exercise program. Improvements in both FIQ and pain scores were found at the end of the intervention.
Activity-Based Interventions.
Motivational interviewing (MI) was evaluated in an RCT to assess whether it could be used to increase aerobic activity and improve FIQ scores and pain ratings (Ang, Kaleth, et al., 2013). MI participants received an exercise prescription and two supervised exercise sessions and were instructed to continue exercising 3–4 days/wk (30-min sessions). After the initial instruction, participants received six phone calls designed to motivate them to exercise. Results indicated that the MI technique produced short-term benefits but did not result in long-term (6-mo) benefits when compared with an education control.
The same MI participants were later evaluated and reported on in a 2nd article (Kaleth, Saha, Jensen, Slaven, & Ang, 2013) that evaluated the relationship between moderate to vigorous physical activity ≥10 metabolic-equivalent hr/wk above usual activities and outcomes related to FM. Results indicated that participants who increased and sustained moderate to vigorous activity for a 12-wk period experienced improvement in FIQ scores. An RCT that used 60-min group sessions designed to increase physical activity in people with FM found no differences in function and pain compared with an FM education group (Fontaine, Conn, & Clauw, 2011).
Multidisciplinary Interventions
FM affects both the physical and the psychological aspects of people’s lives, and this complexity has led to the development of multidisciplinary interventions. Three systematic reviews and meta-analyses and 5 RCTs evaluated the effectiveness of multidisciplinary interventions (Supplemental Table 2).
One systematic review of 17 studies found that multicomponent interventions decreased pain (measured using a visual analog scale or 10-point numerical scale) and increased physical fitness (6-min walk test) and function (FIQ; Burckhardt, 2006). A subsequent systematic review and meta-analysis by Häuser, Bernardy, Arnold, Offenbächer, and Schiltenwolf (2009) reviewed 9 RCTs and found evidence postintervention for reduced pain, fatigue, and depressive symptoms and improved quality of life but not sleep. However, other than effects on physical fitness, other improvements were not maintained long term. Nüesch et al. (2013) conducted a meta-analysis of pharmacological and nonpharmacological interventions. For nonpharmacological interventions, they reported that the multicomponent interventions (combination of exercise and psychological interventions), followed by CBT and aerobic exercise, were more effective in improving pain and quality of life. The evidence for effects on fatigue or sleep was inconclusive.
Of the 5 RCTs, 4 reported improvements in function (Castel et al., 2013; Lera et al., 2009; Martín et al., 2012; van Eijk-Hustings et al., 2013), 1 reported improvements in pain (Martín et al., 2012), and 2 reported improved sleep (Castel et al., 2013; Martín et al., 2012). Two of these RCTs reported improvements in depressive symptoms (Castel et al., 2013; Martín et al., 2012), and 1 reported no difference (Hamnes, Mowinckel, Kjeken, & Hagen, 2012) between the multidisciplinary group and the control group.
Discussion
This systematic review focused on the effectiveness of interventions within the scope of occupational therapy practice for people with FM. On the basis of our review, we found small benefits of CBT in improving pain, depressed mood, and function; low-quality evidence and short-term effects for mindfulness-based stress reduction interventions; and no evidence for self-management interventions. The evidence for the use of emotional disclosure is limited. Strong evidence exists for the use of physical activity to improve pain and function. Moderate evidence was found for short-term effects of multidisciplinary interventions on pain, depressive symptoms, and function.
Studies varied with regard to number of participants, types of intervention (especially physical activity), and length of interventions. However, the majority of studies included the FIQ as an outcome measure. As stated earlier, the FIQ measures function (IADLs, including preparing meals, housework, walking, yard work), overall impact, and symptoms (pain, fatigue, tiredness, stiffness, anxiety, and depression; Williams & Arnold, 2011). Many of the studies were by foreign researchers; thus, some interventions might not be supported by the U.S. health care system because people with FM may have limited outpatient visits. Thus, some of the interventions included in this review might be delivered as a small part of an occupational therapy intervention or may be recommended by occupational therapists postdischarge, such as through community exercise programs.
Risk of Bias
The majority of the RCTs used random-sequence generation, but it was almost impossible to blind the participants to group allocation. However, several studies used blinded assessors or self-report questionnaires. In addition, many of the studies in both the psychoeducational and physical activity intervention categories had relatively few participants and high dropout rates, and very few studies included men. Full details of the risk of bias for the studies included in this review are reported in Supplemental Tables 3 and 4 (online).
In addition to bias, in many of the studies that examined interventions in which physical activity was involved, participants were followed for ≤12 wk, making it difficult to know whether they could sustain the activity and continue to improve. Because of the large number of systematic review and meta-analysis articles included, it was difficult to discuss differences in short- and long-term effects of interventions. Often, studies reporting immediate postintervention outcomes were included in the review articles and thus not discussed as single studies. However, if the longer term follow-up studies were not covered in the systematic reviews, we included them in this review, which made it hard to examine and compare short- and long-term outcomes resulting from a single research intervention. Another limitation was the number of different interventions and how to differentiate them; we relied on the systematic reviews by Bernardy et al. (2013), Busch et al. (2007), and Glombiewski et al. (2010) to help categorize them. However, it is possible that some interventions could have been placed in multiple categories.
Implications for Occupational Therapy Practice and Research
The results of this systematic review have the following implications for occupational therapy practice and research:
People with FM should be encouraged to engage in a combination of strength and aerobic exercises to improve global well-being, decrease pain and tender points, and improve symptoms such as depression.
Traditional strengthening programs are safe to perform, but Tai Chi, yoga, and Pilates are also effective for pain reduction and improved function.
Aquatic exercise appears to have an effect on pain, and clients who prefer a water-based exercise should be encouraged to participate.
Psychoeducational interventions seem to be less effective, but multidisciplinary interventions appear to improve function, pain, and depressive symptoms. Occupational therapy practitioners could develop and lead comprehensive multidisciplinary programs in centers serving people with FM.
Cognitive–behavioral interventions seem to have a small benefit for pain and function.
Self-management programs do not appear to be effective. Slight benefits were seen for guided imagery and mindfulness interventions and emotional disclosure, but the improvements generally were not maintained long term.
In view of the evidence for physical activity interventions, researchers could investigate the effectiveness of interventions modeled after the Lifestyle Redesign intervention to promote participation in physical activities (Clark et al., 2015).
Occupational therapy researchers could also investigate the effectiveness of psychoeducational interventions specifically designed to address client-identified goals.
Supplemental Materials
Supplementary material for Effectiveness of Occupational Therapy Interventions for Adults With Fibromyalgia: A Systematic Review
Supplementary material, sj-pdf-1-aot-10.5014_ajot.2017.023192.pdf for Effectiveness of Occupational Therapy Interventions for Adults With Fibromyalgia: A Systematic Review by Janet L. Poole and Patricia Siegel in The American Journal of Occupational Therapy
Supplementary material for Effectiveness of Occupational Therapy Interventions for Adults With Fibromyalgia: A Systematic Review
Supplementary material, sj-pdf-2-aot-10.5014_ajot.2017.023192.pdf for Effectiveness of Occupational Therapy Interventions for Adults With Fibromyalgia: A Systematic Review by Janet L. Poole and Patricia Siegel in The American Journal of Occupational Therapy
Footnotes
Acknowledgments
We thank Marian Arbesman and Deborah Lieberman for their support and assistance with this systematic review. We also thank Fabiola Contreras for her assistance in formatting tables and references. Portions of this article were presented at the 2015 AOTA Annual Conference & Expo in Nashville, TN.
*
Indicates studies that were included in the systematic review.
References
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
