The Impact of a Group-Based Multidisciplinary Rehabilitation Program on the Quality of Life in Patients With Fibromyalgia

Results From the QUALIFIBRO Study

Herlinde Jacobs, MD; Martine Bockaert, MSc; Jan Bonte, MD; Mark D'Haese, MD; Jan Degrande, MD; Line Descamps, MSc; Ulrike Detaeye, MSc; Willem Goethals, MD; Jo Janssens, MSc; Koen Matthys, MD; Lieve Muller, MSc; Hilde Van deWalle, MSc; Ilse Viane, MSc; Barbara Vlieghe, MD; Michiel Grillet, MD; Rachael Asher, MSc; Bernard Grillet, MD, PhD,; Dirk De Bacquer, PhD

Disclosures

J Clin Rheumatol. 2020;26(8):313-319. 

In This Article

Discussion

People with a diagnosis of FM report that the disease has a considerable impact on their daily functioning, both physically and mentally. Compared with expectation from general population statistics, we found indeed markedly lower levels of HRQoL in FM patients and this in each of the 8 SF-36 health status scales. These results are fully in line with those presented by Hoffman and Dukes[4] after a comprehensive systematic review of studies measuring the health status in FM patients with the SF-36 instrument or its shortened version, the SF-12 instrument. They concluded that FM patients showed a remarkably consistent pattern of severe impairment in both physical and mental health status domains. Their health burden may be comparable or even larger than the burden commonly associated with more widely accepted pain conditions such as rheumatoid arthritis.[5] When compared with mental impairment, the slightly more pronounced physical impairment observed in our study was in agreement with observations made in a large sample of 441 Spanish FM patients, indicating that differences in SF-36 scores with healthy controls were larger for the physical domain than for the mental domain.[29]

The impact of the 8-week group-based multidisciplinary program offered to the FM patients in our study proved very beneficial at least in terms of their HRQoL. Benefits were evident both in the short and the long term. Moreover, the 8-week program was very well accepted by the participants, with only 2 patients (2%) leaving before its end. Improvements in quality-of-life levels were statistically and clinically significant on all 8 SF-36 subscales and for both PCS and MCS scores. In a Spanish study, 33 of 41 women with FM fully completed a multidisciplinary rehabilitation program consisting of exercise and psychological therapy based on the Acceptance and Commitment Therapy.[30] The program was offered in group sessions and hence similar to ours. After the 3-month intervention, a significant increase in half of the SF-36 subscales (physical role, bodily pain, vitality, and social functioning) was found.[30] However, in contrast to our study, HRQoL assessment was done only at the end of the program, and hence evidence of its long-term efficacy was lacking.

Our intervention was successful when compared with other rehabilitation programs. Evaluations of specific nonpharmacological treatment programs for FM have yielded conflicting results, reflected by the substantial heterogeneity observed in different meta-analyses.[6,12,31] Reasons for the inconsistencies between studies are clearly multifactorial. Most obviously, intrinsic factors related to the program itself may differ, such as the specific content, duration, intensity, and setting—whether group based or individually oriented. Also, methodological differences such as the specific choice of primary and secondary outcomes, sensitivity of measurement instruments, sample sizes, and attrition rates are very likely to explain a substantial fraction of the observed discrepancies between findings.

There are several possible explanations for the better HRQoL outcome due to our multidisciplinary program in comparison to prior studies. First, during the recruitment process, we ensured that patients had created the right expectation as the program did not focus on pain control or pain treatment. Because of the stigmatizing attitude of many patients' social environment, by which their complaints are often labeled as psychological, many patients are reluctant to stop the search for a strictly medical or pharmacological solution to their problems. Our rehabilitation program aimed at educating the patient about their complaints as well as the underlying factors using a biopsychosocial approach with an emphasis on the effects on HRQoL. The focus lies on lifestyle changes that patients with chronic pain must take to maintain their HRQoL level. This is considered a normal process of adaptation since chronic pain is inherently associated with the threat to valuable life goals and roles. In addition, individual interviews determined the extent to which patients agreed with the treatment (motivation) and how capable they were at creating achievable treatment goals. Second, unlike other studies, we adopted the strategy of specifically reducing waiting times for entering our multidisciplinary program and hence offering hope to the FM patients in the acceptance phase of their condition. Within the month following their diagnosis, all patients were able to attend an information session where they could express interest in joining the study. Third, individual goals were made practical and were prioritized during the treatment. In addition, these goals were sent to the patient's general practitioner to allow for further follow-up. Increasing quality of life by committing to personal goals and reidentifying with valuable roles is congruent with the growing attention for the concept of "psychological flexibility" in the treatment of chronic pain.[32] Psychological flexibility comprised several aspects of acceptance, commitment to valued goals, and mindfulness. The positive result of our acceptance-based intervention on mental and physical well-being is in agreement with previous research findings.[33,34] Finally, the coaching and supportive role of peers may have contributed to the improved levels of HRQoL. Our patients reported that social support was an important aspect of the treatment. Initially, this social support was provided by peers, but partners and family members play an important role as well, which is why we felt that information sessions were vital to our program. We chose to limit the groups to a maximum of 8 patients. As such, necessary adjustments can be made, and a more tailored treatment approach may be achieved. It is also important that the groups are not too small, as excessive one-on-one treatment leads to an individual conversation in which the focus may revert to pain.

Few multidisciplinary rehabilitation programs have been shown to be as beneficial in the long term as ours. In a meta-analysis on 7 randomized trials evaluating multicomponent treatments for FM, Häuser et al.[12] found support for their short-term efficacy, but long-term benefits of HRQoL were small. In the FM patients participating in the Canadian 11-week PASSAGE study, a structured multicomponent interdisciplinary group intervention comparable to our program, short-term but no long-term improvements were observed with regard to the severity of the condition, pain coping strategies, psychological well-being, and both physical and mental components of HRQoL.[35] More recently, long-term effects did not emerge after an education program focusing on self-management in a very large sample of 583 FM patients.[36] Two important factors may explain the better long-term outcome of our rehabilitation program. We involved partners and family by inviting them to an information session. Their support may be a key component in empowering patients to continue achieving their personal treatment goals. Also, at the end of the program, a report was sent to the general practitioner for follow-up and continuity of care. Additionally, an evaluation and feedback moment was scheduled 3 months after completing the program allowing adjustments to the goals if necessary.

In line with previous observations in FM patients, our data confirm the high frequency of negative emotional states such as increased levels of anxiety, depression, and burnout and their strong negative impact on HRQoL, especially its mental dimension.[21,36,37] Patients with depressive feelings seem to have benefited more from our rehabilitation program at 1 year. Fibromyalgia and chronic widespread pain are commonly associated with fatigue and exhaustion. It is hence rather surprising that exposure to burnout has not been evaluated before in FM patients. In our sample, more than a third of patients scored high on the BMS-10 scale; they also reported significantly lower SF-36 MCS values. In a recent study of 119 FM patients who agreed to be part of a pain management program, showing a pain-avoidance pattern was found to be a predictor of worse psychological and physical functioning.[38] The 41% of patients whom we could classify as pain avoiders in our study reported significantly lower SF-36 PCS scores throughout the entire 1-year observation period than those who demonstrated pain persistence.

The apparently unexpected negative correlation between improvements in PCS and MCS scores at 1 year is actually in line with expectation. The standard SF-36 scoring algorithm we applied for obtaining the summary measures was originally derived using an uncorrelated orthogonal factor solution.[25] This structure is confirmed in our database with a near-zero correlation between baseline PCS and MCS scores of r = −0.05. In the general population, higher scores on the individual scales within 1 domain will, under such orthogonal model, theoretically reduce the component score for the other domain, and vice versa. This explains why changes over time in PCS and MCS scores were negatively correlated in our study and why improvements summary scores were less pronounced than improvements in individual scale scores.

Our study is subject to a number of limitations. First, most data gathered in our study were based on self-reporting. However, given the lack of objective clinical markers for FM, evaluating patients' functional state can only rely on self-reported perceptions and symptoms. Second, the representativeness of our sample for the population of FM patients could be questioned. It is not unlikely that the more motivated patients were willing to participate. Also, because most sessions of the 8-week program were organized during weekdays, FM patients at work were most probably less represented. However, we found that the participants in the study had the same characteristics as the other 754 nonparticipating patients diagnosed with FM since 2014 in our hospital; their distributions of age, sex, number of positive tender points, widespread pain index, symptoms severity scale, anxiety, or depression scores were very similar. Still, there might have been a recruitment bias toward individuals who were willing to make the required time investment and toward those being more susceptible to a nonpharmacological approach. Because our patients presented at the physical unit of a large regional hospital, referral bias may have occurred to some extent. However, a study in Spain reported that FM patients recruited from primary care were very similar to FM patients presenting in a rheumatology setting in terms of clinical symptoms, perceived health status, pain coping, and psychosocial features.[39]

Both a baseline and follow-up HRQoL assessment in a control group of FM patients not having participated in any form of structured rehabilitation might have allowed us to evaluate the extent to which the much improved HRQoL levels at 1 year can be attributed specifically to our multidisciplinary rehabilitation program or would rather be a reflection of the spontaneous changes often seen in FM symptomatology. However, in a prospective observational US study in FM patients receiving usual care, mainly based on pharmacological and physical treatment, no changes in HRQoL scores were observed over a period of approximately 2 years.[40] These observations are in line with those from a more recent meta-analysis of randomized clinical trials reporting that no change in FM symptoms was observed in control groups receiving no treatment, in contrast to patients from active treatment groups or even placebo groups.[41]

In conclusion, the group-based multidisciplinary rehabilitation program that we offered to patients with FM seemed very well tolerated and improved their HRQoL both in the short and long term.

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