Lifestyle Redesign ® Intervention for Psychological Well-Being and Function in People With Fibromyalgia: A Retrospective Cohort Study

Abstract

Importance: Fibromyalgia is a complex chronic pain condition for which effective nonpharmacological treatment interventions are lacking.

Objective: To explore the effects of an occupational therapy intervention for fibromyalgia on client-reported outcomes of pain interference, self-efficacy, mood, and function.

Design: Retrospective cohort study using a chart review method.

Setting: Outpatient clinic.

Participants: Twenty-one adults with fibromyalgia (M age = 54 yr).

Intervention: A 10-wk occupational therapy group intervention using a Lifestyle Redesign^® (LRD) approach.

Outcomes and Measures: The Brief Pain Inventory, Pain Self-Efficacy Scale, Beck Depression Inventory (BDI), and the Fibromyalgia Impact Questionnaire (FIQ) or the Revised Fibromyalgia Impact Questionnaire were administered at the first and last sessions of the program.

Results: Between 2015 and 2018, 37 clients entered the program, and 21 completed it. Changes in group averages exceeded the minimal clinically important difference for the BDI and the FIQ. Eighty-one percent of clients who completed the program had a clinically significant improvement on one or more of the outcome measures.

Conclusions and Relevance: The findings demonstrate the potential benefit of occupational therapy as a complementary approach to pharmacological treatment for people with fibromyalgia. Preliminary evidence suggests that a 10-wk occupational therapy group intervention using an LRD approach may reduce symptoms of depression and decrease the impact on daily function for people with fibromyalgia.

What This Article Adds: Occupational therapy should be considered as a nonpharmacological intervention for adults with fibromyalgia to improve psychological well-being and function.

The findings of this study demonstrate the potential benefit of a Lifestyle Redesign® occupational therapy intervention as a complementary approach to the pharmacological treatment of adults with fibromyalgia to improve psychological well-being and function.

Fibromyalgia is a chronic pain condition characterized by widespread, diffuse pain that is often accompanied by symptoms of fatigue, cognitive impairments, and sleep disturbances. Fibromyalgia has a worldwide prevalence ranging from 1.3% to 8.0% and is associated with decreased quality of life and difficulties performing self-care, home management, work, and community activities (Chinn et al., 2016; Pérez‐ de‐Heredia‐Torres et al., 2016). Pharmacological interventions are commonly used despite their limited benefits for symptom management, the risk of adverse events (Hassett & Gevirtz, 2009; Okifuji et al., 2016), and a lack of support for managing the functional or psychological impacts of living with fibromyalgia.

Some practice guidelines recommend nonpharmacological interventions for fibromyalgia (e.g., education, physical activity, cognitive–behavioral therapy) that focus on managing pain, sleep disturbance, stress, and fatigue (Arnold & Clauw, 2017; Fitzcharles et al., 2013; Macfarlane et al., 2017). Holistic, biopsychosocial approaches to symptom management that focus on patient activation and functional abilities rather than reducing pain have also been recommended (Fitzcharles et al., 2013). Occupational therapy is one such holistic approach that focuses on participation while considering biological, psychological, and social factors that modify the pain experience (Lagueux et al., 2018). Such interventions include body mechanic and ergonomic training, work hardening (a program to improve endurance and activity tolerance in preparation for returning to work), graded activity and pacing strategies, environmental modifications, and stress management (Hesselstrand et al., 2015; Lagueux et al., 2018; Poole & Siegel, 2017).

In addition to individual interventions, Lifestyle Redesign^® (LRD) is an occupational therapy program that has been shown to be effective in improving health-related outcomes across a variety of chronic health conditions (Clark et al., 1997; Pyatak et al., 2019; Reeves & Simon, 2016; Simon & Collins, 2017). LRD interventions are multifaceted and include didactic teaching, problem-solving, self-analysis, and goal setting to facilitate self-management (Clark et al., 2015). Informed by this evidence, a fixed-cost, 10-wk, outpatient LRD intervention focusing on improving self-management of fibromyalgia was established. In this study, we explored the preliminary effects of this intervention on pain interference, pain self-efficacy, depression, and overall impact of fibromyalgia on daily life to determine the potential utility of LRD as a viable intervention for people with fibromyalgia.

Method

We conducted a retrospective chart review of all people with fibromyalgia who were referred by their health care provider to receive outpatient LRD between 2015 and 2018. LRD and measures were conducted as part of usual care, and no identifiable information was extracted. Therefore, this study was approved as exempt research by the university’s institutional review board, and consent was not required.

Intervention

The 10-wk LRD program for fibromyalgia was developed by an occupational therapist using evidence-based content identified through a literature review that focused on the lifestyle and behavioral factors most relevant to the management of fibromyalgia. A LRD program for chronic pain that had demonstrated efficacy for improving function, self-efficacy, and quality of life (Simon & Collins, 2017) served as a foundational model. The fibromyalgia curriculum included behavior change strategies, fatigue management, sleep hygiene, eating and exercise routines, stress and depression management, body mechanics training, assertive communication, time management, and long-term goal setting (Reeves, 2020). Clients learned strategies that could be tailored to their personal contexts while reflecting on supports for and barriers to incorporating lifestyle modifications into their daily lives. Individual goals were reviewed at the start of each session, and new goals were set at the end. Weekly 1-hr group sessions varied in size but never exceeded nine clients, and each session was provided at a private pay rate of $15.00.

Outcome Measures

Self-reported outcome measures commonly used in research and clinical practice for people with fibromyalgia (Williams & Arnold, 2011) were administered at the first and last sessions. Pain interference was measured with the Brief Pain Inventory (BPI; Tan et al., 2004), with higher scores indicating more interference during physical and emotional activities. The Pain Self-Efficacy Scale (PSE; Nicholas, 2007; Tonkin, 2008) assessed confidence in performing instrumental activities of daily living, with higher scores indicating higher self-efficacy for pain management. Severity of depression was measured with the Beck Depression Inventory (BDI; Wilson, 2008), on which higher scores indicate more severe depression. The Revised Fibromyalgia Impact Questionnaire (FIQR; Bennett, Friend, et al., 2009) assessed the overall impact of living with fibromyalgia, with higher scores indicating negative impacts on daily life. Some clients completed the original version of the FIQ, and these scores were recoded to match FIQR scoring.

Data Analysis

Using t tests, we compared the baseline measures of clients who dropped out before the final session and those who completed the program. For those who completed the program, we evaluated within-subject changes from baseline to the final session using paired t tests. Clients whose charts had missing data points were excluded from individual outcome analyses, which resulted in different sample sizes for each t test. Statistical analyses were conducted using IBM SPSS Statistics (Version 26), and we set p < .05 as the threshold for statistical significance. Clinical significance was determined using minimal clinically important difference (MCID) values identified in the literature: (1) BPI pain interference, >1-point change (Dworkin et al., 2009; Tan et al., 2004); (2) PSE, 7-point change and moving severity categories (Tardif et al., 2015); (3) BDI, 5-point change, moving severity categories (Dworkin et al., 2009), or a 29.64% decrease (Wilson, 2008); and (4) FIQR, change of 14% or 8.1 points (Bennett, Bushmakin, et al., 2009).

Results

A total of 37 clients were referred to the study, all of whom were receiving pharmacological interventions and almost all of whom were female. Sixteen clients dropped out before the final session, attending an average of 2.8 (SD = 1.4) sessions; 21 individuals (57%) completed the program, attending an average of 8.3 (SD = 1.4) sessions. There were no statistically significant differences in age or baseline measures between these groups (Table 1).

Table 1.

Baseline Descriptive Statistics for Clients Who Completed the Program Versus Clients Who Dropped Out Before the Final Session

Variable	M (SD)		p ^a
Variable	Completed (n = 21)	Dropped Out (n = 16)	p ^a
Age, yr	53.7 (10.0)	50.6 (7.7)	.31
BPI pain interference	6.3 (1.8)	6.0 (2.1)	.68
PSE	23.0 (14.8)	30.5 (11.8)	.14
BDI	20.1 (6.7)	20.1 (10.4)	.99
FIQR total	65.6 (15.6)	58.3 (17.8)	.24

Note. BDI = Beck Depression Inventory; BPI = Brief Pain Inventory; FIQR = Revised Fibromyalgia Impact Questionnaire; PSE = Pain Self-Efficacy Scale.

Paired t tests were used to evaluate differences.

Among those who completed the program, pain self-efficacy, depression, and daily life interference scores showed statistically significant improvement (Table 2). The average improvement in pain self- efficacy of 7.3 exceeded the MCID, and the final session average score was close to improving from moderate to mild impairment. Average improvement on the BDI was −5.4 points, moving from borderline clinical depression to mild mood disturbance; both met MCID recommendations. The decrease of 9.6 points on the FIQR exceeded the MCID. Group changes in pain interference were neither clinically meaningful nor statistically significant (p = .39).

Table 2.

Comparison of Scores on the Four Primary Program Outcome Measures Between Baseline and the Final Session

Scale	n ^a	M (SD)				Change	t	df	95% CI	p ^b
Scale	n ^a	Baseline		Final		Change	t	df	95% CI	p ^b
BPI pain interference	20	6.3	1.8	5.9	2.4	−0.4	0.89	19	[−0.52, 1.29]	.39
PSE	20	23.0	14.7	30.3	16.9	7.3	−2.52	19	[−13.33, −1.22]	.02
BDI	20	20.1	6.7	14.7	10.3	−5.4	3.23	19	[1.90, 8.90]	<.01
FIQR	18	66.2	15.3	56.6	20.8	−9.6	2.67	17	[2.01, 17.10]	.02

Note. BDI = Beck Depression Inventory; BPI = Brief Pain Inventory; CI = confidence interval; FIQR = Revised Fibromyalgia Impact Questionnaire; PSE = Pain Self-Efficacy Scale.

Individual n values vary by outcome measure because of missing data in the chart review.

Paired t tests were used to evaluate differences.

Seventeen (81.0%) clients had clinically meaningful changes in at least one outcome (Table 3). Nearly half reported meaningful improvement on the FIQR (Figure 1A), and more than half demonstrated meaningful improvement in their severity rating of depression (Figure 1C). Despite no meaningful group changes, 6 clients achieved clinically significant improvements in the amount of pain interference, and 5 additional clients’ decreases approached the clinically meaningful threshold (Figure 1B). Clinically significant improvement in pain self-efficacy was reported by 5 clients who exceeded both the 7-point change threshold and change in severity category (Figure 1D). Clients with lower self-efficacy at baseline demonstrated larger improvements at the end of treatment compared with those who started with higher levels of self-efficacy.

Table 3.

Outcome Measures Surpassing the Clinically Meaningful Difference Across Each Individual Client Sorted by Number of MCIDs Met

Participant ID No.	No. of Sessions Attended	BPI Pain Interference	PSE	BDI	FIQR	No. of MCIDs Met^a
9	10	•	•	•	•	4
20	6	•		•	•	3
21	8		•	•	•	3
8	8	•	•			2
13	9			•	•	2
14	8			•	•	2
15	8	•			•	2
18	9	•		•	•	2
19	10		•		•	2
1	9			•		1
3	10	•		•		1
5	9		•			1
6	8			•		1
10	8			•		1
11	8			•		1
12	5		•			1
17	10				•	1
2	6					0
4	8					0
7	9					0
16	8					0

Note. BDI = Beck Depression Inventory; BPI = Brief Pain Inventory; FIQR = Revised Fibromyalgia Impact Questionnaire; MCID = minimal clinically important difference; PSE = Pain Self-Efficacy Scale.

MCIDs: BPI = >1-point change, PSE = 7-point change and category change, BID= 5-point change or category change, Fibromyalgia Impact Questionnaire/FIQR = 14% or 8.1-point change.

Figure 1.

Individual client changes relative to the clinically meaningful threshold for the FIQR (Panel A), BPI pain interference (Panel B), BDI (Panel C), and PSE (Panel D).

Discussion

In this study, we examined the preliminary effects of a 10-wk outpatient LRD intervention on pain interference, self-efficacy, depression, and overall impact for people with fibromyalgia. Most clients reported clinically significant improvement in at least one outcome. Decreasing the severity of depression and reducing the overall impact of fibromyalgia on daily life were the two most frequently improved outcomes. Despite recommendations for the use of nonpharmacological interventions, barriers, including difficulty implementing self-management strategies and health care costs, remain (Arnold & Clauw, 2017; Macfarlane et al., 2017). Previous studies have shown that LRD can support the implementation of self-management and reduce health care costs for people with chronic conditions (Clark et al., 1997, 2012). LRD incorporates cognitive–behavioral approaches with training in symptom management, psychosocial support, and daily life performance (American Occupational Therapy Association, 2020) to increase client activation. Client activation in people with chronic conditions such as fibromyalgia has been shown to improve with self-management skills training (Lorig et al., 2009).

Limitations

These findings should be considered in light of the limitations inherent to a retrospective exploratory study, including the inability to ensure treatment fidelity; evaluate temporal relationships; or account for mediating, moderating, or confounding effects of client demographics and other concurrent interventions. The small sample size increases the risk of overestimating statistical significance and did not allow us to evaluate dose–response relationships; moreover, without a control group, causal effects on outcomes cannot be determined. Despite these limitations, our results provide preliminary support for positive outcomes and data useful for estimating sample sizes for prospective intervention studies.

Implications for Occupational Therapy Practice

The results of this study have the following implications for occupational therapy practice:

LRD is a viable nonpharmacological treatment option for people with fibromyalgia.

LRD for fibromyalgia may decrease the severity of depression and reduce the impact of fibromyalgia on clients’ occupational participation.

For some people with fibromyalgia, LRD may be useful for reducing pain interference and improving self-efficacy in pain management.

Conclusion

This study provides preliminary evidence that, for some people, LRD may reduce the impact of fibromyalgia on occupational participation and the severity of depression while positively influencing pain self-efficacy and perceptions of pain interference in daily life. Prospective intervention trials with larger, more heterogenous client samples are warranted to examine the dose–response relationship and establish the efficacy of LRD as a complement or alternative to pharmacological or individual nonpharmacological treatments.

Footnotes

Acknowledgments

We thank the faculty, staff, residents, and students at the University of Southern California Occupational Therapy Faculty Practice.

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Participant ID No.	No. of Sessions Attended	BPI Pain Interference	PSE	BDI	FIQR	No. of MCIDs Met^a
9	10	•	•	•	•	4
20	6	•		•	•	3
21	8		•	•	•	3
8	8	•	•			2
13	9			•	•	2
14	8			•	•	2
15	8	•			•	2
18	9	•		•	•	2
19	10		•		•	2
1	9			•		1
3	10	•		•		1
5	9		•			1
6	8			•		1
10	8			•		1
11	8			•		1
12	5		•			1
17	10				•	1
2	6					0
4	8					0
7	9					0
16	8					0

Participant ID No.	No. of Sessions Attended	BPI Pain Interference	PSE	BDI	FIQR	No. of MCIDs Met^a
9	10	•	•	•	•	4
20	6	•		•	•	3
21	8		•	•	•	3
8	8	•	•			2
13	9			•	•	2
14	8			•	•	2
15	8	•			•	2
18	9	•		•	•	2
19	10		•		•	2
1	9			•		1
3	10	•		•		1
5	9		•			1
6	8			•		1
10	8			•		1
11	8			•		1
12	5		•			1
17	10				•	1
2	6					0
4	8					0
7	9					0
16	8					0

Participant ID No.	No. of Sessions Attended	BPI Pain Interference	PSE	BDI	FIQR	No. of MCIDs Met^a
9	10	•	•	•	•	4
20	6	•		•	•	3
21	8		•	•	•	3
8	8	•	•			2
13	9			•	•	2
14	8			•	•	2
15	8	•			•	2
18	9	•		•	•	2
19	10		•		•	2
1	9			•		1
3	10	•		•		1
5	9		•			1
6	8			•		1
10	8			•		1
11	8			•		1
12	5		•			1
17	10				•	1
2	6					0
4	8					0
7	9					0
16	8					0