Effectiveness of health education in patients with fibromyalgia: a systematic review

Vol. 55 - No. 2 EuropEaN JourNal of physical aNd rEhabilitatioN MEdiciNE 301 REVIEW Effectiveness of health education in patients with fibromyalgia: a systematic review María Carmen GARCÍA-RÍOS 1, Santiago NAVARRO-LEDESMA 2, Rosa María TAPIA-HARO 3, sonia tolEdaNo-MorENo 4, Antonio CASAS-BARRAGÁN 2, María CORREA-RODRÍGUEZ 5 *, María Encarnación AGUILAR-FERRÁNDIZ 1 1Department of Physical Therapy, Instituto de Investigación Biosanitaria Granada (IBIS.Granada), University of Granada (UGR), Granada, Spain; 2Department of Physical Therapy, University of Granada (UGR), Granada, Spain; 3Faculty of Health Science, University of Granada (UGR), Granada, Spain; 4Biomedicina Program of the University of Granada, Department of Physical Therapy, Faculty of Health Science, University of Granada (UGR), Granada, Spain; 5Department of Nursing, Instituto de Investigación Biosanitaria Granada (IBIS.Granada), Faculty of Health Sciences, University of Granada (UGR), Granada, Spain *Corresponding author: María Correa-Rodríguez, Department of Nursing, Instituto de Investigación Biosanitaria Granada (IBIS.Granada), Faculty of Health Sciences, University of Granada, Av Ilustracion 60, 18060, Granada, Spain. E-mail: [email protected] abstract INTRODUCTIONː Fibromyalgia (FM) is a chronic illness characterized by the presence of generalised musculoskeletal pain among other symptoms, which reduce the quality of life of the patient. Clinical interventions such as patient education on central pain management could lead to promising results. The aim of this study is to evaluate the effectiveness of education techniques on the main symptoms such as pain, quality of life, anxiety, functionality or catastrophization in the treatment of FM. EVIDENCE ACQUISITIONː The bibliographic search was carried out on PubMed, Web of Science, Scopus, CINAHL, EMBASE, Medline, ProQuest, Cochrane Plus and PEDro databases. The quality assessment of the selected studies was carried out by means of the PEDro scale, obtaining external and internal validity scores to evaluate the generalizability and the appropriateness of design, conduction, and reporting. EVIDENCE SYNTHESISː The electronic search produced 2,050 articles up to February 2018. After applying the inclusion criteria, 12 articles were identified, without the presence of any RCT of high methodological quality (PEDro≤8; Internal Validity Score [PVI] ≤4). Despite the heterogeneity of the interventions, a significant reduction in the perception of the disease, the catastrophization, pain intensity and anxiety was observed. CONCLUSIONSː Patient education is considered to be the first step in self-management for a patient with FM, but the scientific evidence that supports the effectiveness of education in the reduction of the main symptoms is limited. Future research designed on more solid and homogeneous interventions is required. (Cite this article as: García-Ríos MC, Navarro-Ledesma S, Tapia-Haro RM, Toledano-Moreno S, Casas-Barragán A, Correa-Rodríguez M, et al. Effectiveness of health education in patients with Fibromyalgia: a systematic review. Eur J Phys Rehabil Med 2019;55:301-13. DOI: 10.23736/ S1973-9087.19.05524-2) Key words: Fibromyalgia; Patient education as topic; Pain management; Quality of life. European Journal of Physical and Rehabilitation Medicine 2019 April;55(2):301-13 DOI: 10.23736/S1973-9087.19.05524-2 GARCÍA-RÍOS HEALTH EDUCATION IN PATIENTS WITH FIBROMYALGIA European Journal of Physical and Rehabilitation Medicine April 2019 Vol. 55 - No. 2 © 2019 EDIZIONI MINERVA MEDICA Online version at http://www.minervamedica.it Introduction fibromyalgia (FM) is a chronic disease that is characterized by the existence of a generalized musculoskeletal pain of unclear location, as well as by the difficulties that those who suffer from it have in precisely defining the beginning of this pain.1 Hypersensitivity to pain is frequently expressed through the painful feeling due to pressure on numerous points on the locomotor system that are not seen in healthy people. The pain is defined as continuous and many times tends to settle in muscular structures and tendinous areas, so it can be confused with an inflammatory joint disease during diagnosis. Some of the more frequent factors that worsen the pain are maintained positions, physical loads, emotional activation and weather changes2. Due to the complexity of classifying FM, the American College of Rheumatology (ACR) established clinical classification criteria in 1990, which include generalized pain This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher. COPYRIGHT© 2019 EDIZIONI MINERVA MEDICA GARCÍA-RÍOS HEALTH EDUCATION IN PATIENTS WITH FIBROMYALGIA 302 EuropEaN JourNal of physical aNd rEhabilitatioN MEdiciNE April 2019 of non-pharmacological interventions are consolidated as part of a treatment with cognitive-behavioral focus, physical exercise programs or a combination of both.10 since the main problem in the treatment of FM is heterogeneity, multicomponent treatments centered in part on patient education, suggest greater effectiveness than basic treatments.9 Patient education, which is defined as any set of educational activities planned by qualified professionals and aimed at improving a patient’s health behaviors and/or health status, has as a specific objective to inform and restructure the perceptions regarding the disease.11 To reduce the disparity between the perception of the pain that the patient and the health professional have and its treatment, it is crucial to change the maladaptive perception that patients have of the disease, reconceptualizing the pain, the disease itself and the presented symptoms.12 patients with diffuse chronic musculoskeletal pain who are poorly informed about this pain consider it more threatening and demonstrate less tolerance to it, greater catastrophic thoughts and weaker adaptation strategies.13 this is why patient education, which consists mainly of strategies based on “pain neurophysiology education” among others, is indicted when the clinical picture is dominated by central sensitization, maladaptive cognitions of the pain and the disease, or coping strategies.12, 13 Therefore, patient education techniques emphasize that the patient does not have a life-threatening disease; helping to assure them that FM is a real disease14 and recognizing the legitimacy of the ailment.15 Likewise, patient education should be based on written material or in any other format that provides them with knowledge and information about the nature of the disorder, the planned treatment, strategies and the expected results.14, 15 It is suggested, in the guidelines of the German guide for the management of FM syndrome and based on evidence, that the following basic information be included in patient education: 1) reaffirmation that the symptoms are not caused by an organic disease (such as muscle or joint abnormality) but are based on a functional disorder of the brain (alteration of pain treatment and other external stimuli); 2) symptoms are persistent in the majority of adult patients and complete relief of symptoms is rarely achieved; 3) most patients learn to adapt to the symptoms over time, since the patient can learn to control the symptoms and improve their quality of life in regards to health through self-management strategies.15, 16 Patient education, incorporated into a broader multidisciplinary program, is considered to be not only useful but also necessary for patients with FM as it provides them lasting for at least three months and the observation of pain caused by pressure at specific anatomical sites referred to as soft spots.1 FM can be classified as one of the most common problems of society in general and is considered to be the most frequent cause of diffuse chronic musculoskeletal pain.2 According to the EPISER study (2010) by the Spanish Rheumatology Society, under RCT criteria, FM in Spain has a prevalence of 2.4% of the population over 20 years old, with women being affected more than men; 4.2% versus 0.2% respectively.3 In addition to pain, other symptoms and common clinical manifestations that affect the functionality of the patient and which, in most cases, are closely related to the illness are present in FM.4, 5 In many cases, as a response to this painful experience a pathological anxiety and a continuance of the painful stimulus is produced even when it has already ceased.6 Alterations in mood such as anxiety and also depression correlate with the perception of pain, although the percentage of the latter that coexists with FM is highly variable, revealing both an emotional discomfort in patients diagnosed with FM and lower expectations for the control of their own symptoms. Alterations in sleep patterns, such as the lack of restful sleep or difficulties in sleeping with frequent awakenings, sometimes as a consequence of nocturnal pain, is another of the most common symptoms, correlating with the intensity of the FM syndrome.1 Fatigue is another of the most common manifestations in patients with fibromyalgia and one of the symptoms, which together with pain, directs the life of the patient. This can occur in the form of an exhaustion crisis of intermittent and variable duration in terms of days or more frequently, ongoing, which does not improve at all and predominates over the pain, now becoming chronic fatigue syndrome. All of these nonspecific symptoms, together with many others such as irritable bowel syndrome, morning stiffness or restless leg syndrome, create an important impact on the biological, psychological and social spheres of patients diagnosed with FM.1 Thus, FM has an important impact on the quality of life of the people who suffer from it.7 In many cases it causes severe disabilities as a result of the decline in functional capacity and thus requires retraining in coping and in the development of basic activities of daily life.8 Currently, several drugs are being used to treat each one of the main symptoms in FM.9 However, recent scientific knowledge indicates that a broader multidisciplinary approach is needed, postulating non-pharmacological treatment as an important mainstay to tackle FM. The majority This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher. COPYRIGHT© 2019 EDIZIONI MINERVA MEDICA HEALTH EDUCATION IN PATIENTS WITH FIBROMYALGIA GARCÍA-RÍOS Vol. 55 - No. 2 EuropEaN JourNal of physical aNd rEhabilitatioN MEdiciNE 303 search strategy: “pain education,” “patient programme,” “therapy education,” “fibromyalgia,” “musculoskeletal pain” and “chronic pain.” Terms were established based on initial searches to find keywords (MeSH list) with PubMed. The search strategy for the databases was, with the exception of PEDro: (educat* OR progra* OR pain education OR patient education OR therapy based on education OR educational intervention) AND (fibromyalgia OR chronic pain OR widespread musculoskeletal pain) AND (decrease pain OR reduction pain OR increase quality of life) AND (randomized controlled trial OR clinical trials). The search strategy in PEDro was: educat* pain* and fibromyalgia. Selection criteria To select potentially relevant studies and in order to avoid bias in the selection, the titles and abstracts were reviewed to determine if they met the following inclusion criteria: 1) articles published in scientific journals up to February 2018; 2) full text articles 3) classified as randomized clinical trials (RCTs); 4) focused on the education of patients with fibromyalgia; 5) or the combination of education with other therapeutic interventions; 6) assess variables related to pain, quality of life, functionality or catastrophizing. Exclusion criteria were established as those articles duplicated in the different databases used, conference abstracts and those articles whose PEDro score was <4. Items were searched and extracted by one reviewer. The reviewer registered information relating to identification of outcome measurements, methods (characteristics of the intervention and the control group, technique, description of interventions) and obtained results). Evaluation of the methodological quality of the selected articles The evaluation of the methodological quality of the selected studies was carried out using the PEDro (Physiotherapy Evidence Database)22 scale translated and adapted to Spanish. The Spanish translation and adaption of the PEDro scale has been previously published.23 The methodological criteria were classified as follows: if it is met (1 point) and if it is not met (0 points), selecting only those studies that obtained a PEDro score ≥4. In order to allow a more selective analysis of the methodological quality of with the needed resources to help them optimally manage their life with a chronic disease.17 As has been demonstrated in other rheumatological diseases, patient education is presented as a non-pharmacological aid that can increase the therapeutic adherence of patients to their treatment. Patient education also allows patients diagnosed with FM to be an active part of their treatment process, which has great personal benefits, favoring the adoption of behaviors and knowledge that will lead to bio psychosocial wellbeing and the highest quality of life possible.18 A previous systematic review in Spanish concluded that patient education in itself has not proved to be effective for pain, quality or functionality in patients with FM, but it reported the effectiveness of combining patient education with exercise and active strategies for coping with pain, quality of life and functionality in the short, medium and long term in patients with fM.19 Nevertheless, it should be noted that only five RCT were included in this study. Patient education is postulated as new directions for professionals and researchers, since it seems to be a promising treatment pathway in FM.20 This therapy approach is based on the premise that a better understanding of the nature of their illness may results in improved patient outcomes. Considering that an relevant aspect of the central sensitization mechanism as typically observed in patients with FM, pain education about neurophysiology and central sensitization in FM might restructure unfavorable cognitions and motivate the application of cognitive behavioral strategies to cope with their patients, diminishing patients´ fear and attention toward pain. This is done by explaining patients that they have little chance of controlling peripheral nociceptive input, but may exert volitional control over topdown mechanisms. Therefore, the aim of this study is to evaluate the effectiveness of patient education as a therapeutic tool on aspects such as pain, quality of life, anxiety, functionality or catastrophizing in patients with FM. Evidence acquisition Bibliographic search strategies A systematic review was conducted following the criteria in the PRISMA 2009 declaration on the methodology and conduction of reviews.21 The bibliographic search was carried out in nine electronic databases: PubMed, Web of Science, Scopus, CINAHL, EMBASE, Medline, ProQuest, Cochrane Plus and PEDro. All publications in English and Spanish were included up to February 2018. The following categories were used in the database This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher. COPYRIGHT© 2019 EDIZIONI MINERVA MEDICA GARCÍA-RÍOS HEALTH EDUCATION IN PATIENTS WITH FIBROMYALGIA 304 EuropEaN JourNal of physical aNd rEhabilitatioN MEdiciNE April 2019 ternative sources (searching the reference list of previous studies) were included, resulting in a total of 704 articles. Finally, 14 full-text articles met the inclusion criteria. Those articles with a PEDro score less than 4 were eliminated, leaving a total of N.=12 articles. All articles included were published in English language. Figure 1 shows the flow chart for the process of selection and exclusion of studies. Characteristics of the selected studies Table I27-38 summarizes the characteristics of the selected studies. The studies found through the various search sources contained information that was too heterogeneous and not compatible with quantitative analysis. The extraction and analysis of the data obtained from the studies could not be grouped together, mainly because of the disparity of populations or therapeutic interventions; therefore, it was impossible to calculate the overall effect. The largest sample of patients in the experimental group was N.=10828, 38 and the smallest was N.=15.27 The articles presented a diversity of variables studied in relation to the involvement of FM: Revised Illness Perception Questionnaire (IPQ-R_FM), Pain Catastrophizing Scale (PCS), Fibromyalgia Impact Questionnaire (FIQ), Spatial Summation of Pain (SSP), Pain Pressure Threshold (PPT), Pain Coping Inventory (IPC), Pain and Awareness Surveillance Questionnaire (PVAQ), Tampa Scale of Kinesiophobia the systematic review,24 the internal validity of each study was assessed by using an internal validity score (PVI). Seven representative items of internal validity were identified for the PEDro scale. Criteria 2, 3, 5, 6, 7, 8 and 9 were selected for the total PVI in this study with the assessment of the methodological quality being made according to their PVI in three categories:25 • studies with a PVI of 6-7 are considered to have a high methodological quality; • studies with a PVI of 4-5 are considered to have medium methodological quality; • studies with a PVI of 0-3 are considered to have limited methodological quality. To reduce inter-examiner bias, the quality of the studies was evaluated by two independent reviewers. Inter-rater agreement between two reviewers was calculated using the coefficient κ (>0.7 means high level of agreement between the two reviewers; 0.5-0.7 means a moderate level of agreement, and <0.5, a low level).26 Statistical analysis were performed SPSS version 20.0 (SPSS, Chicago, IL, USA). Criteria for the evaluation of the results The qualitative method recommended by the Cochrane group with the use of evidence levels to synthesize the data was chosen:24 • solid evidence: multiple high quality RCTs; • moderate evidence: multiple low quality RCTs and 1 high quality RCT; • limited evidence: 1 low quality RCT; • contradictory evidence: non-coherent findings in multiple RCTs; • no evidence: no RCT. Evidence synthesis Study selection A literature search was conducted including articles published in scientific journals up to February 2018. The procedure and search strategy in the different databases produced 2,050 articles in 8 databases: 234 from PubMed, 511 from Web of Science, 762 from Scopus, 211 from CINAHL, 50 from Medline, 93 from ProQuest, 71 from Cochrane Plus and 118 from PEDro. After filtering by randomised clinical trials, 772 articles were left. After eliminating those articles that were duplicates, 701 articles were selected to check if they met the previously determined inclusion and exclusion criteria. 3 articles from other alFigure 1.—Flow diagram according to PRISMA system. Titles and summaries identified after database searching (N.=2050) Total number of articles of complete text to determine their eligibility (N.=14) studies included in the qualitative summary (N.=12) Total number of articles of complete text excluded for low PEDro score (N.=2) Titles and summaries identified in other sources (N.=3) Total number of duplicate records eliminated (N.=71) Total number of unique records screened (N.=704) Records excluded (N.=1346) - 197 studies did not compare intervention of interest - 248 studies did not include the population of interest - 901 studies did not assess outcomes of interest Identificationincluded Eligibility Screening This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher. COPYRIGHT© 2019 EDIZIONI MINERVA MEDICA HEALTH EDUCATION IN PATIENTS WITH FIBROMYALGIA GARCÍA-RÍOS Vol. 55 - No. 2 EuropEaN JourNal of physical aNd rEhabilitatioN MEdiciNE 305 ried out. On the other hand, a heterogeneous population as regards the socio-demographic age variable is observed in the analyzed articles, since they include subjects from 18 to 75 years of age, with an average age that lies between 33 and 51 years old. In 6 of the selected studies it is specified that the diagnosis of patients with FM is carried out according to the criteria of the ACR28,29,30,32,333,34. However, no study specifies the time since the diagnosis of the disease. This should be considered, as early diagnosis resulting in early care is known to favor better management of symptoms, which is a positive prognostic factor in the evolution of a patient with fM disease.42 Another important aspect of our research, and one that presents great diversity in the analyzed studies is the education level of the patients. At the time of implementing educational therapy, adherence to it will depend to a large extent on the comprehension capacity of the patient to internalize the conceptualizations regarding the different topics dealt with in different sessions. Characteristics of education interventions The analyzed studies present different characteristics regarding the direction of education and the development of the intervention sessions. In general, they vary in regards to the duration of the sessions or treatment and the implementation of the intervention technique, with the variation being either in the number of repetitions or the amount of time spent on the intervention. In addition, some authors made decisions in terms of the medication to which the participants were subjected during the intervention period and as to whether or not education was combined with other types of therapy. Patients participating in six studies received education as the only intervention, either as neuroscience of pain, physiology of pain or simply centered on the patient.27, 29, 32, 34, 35 Participants in one study received education combined with the practice of routine care for FM patients and with autogenic training.30 The rest of the study participants received education during the intervention with other types of aerobic exercise therapies (strength, flexibility or relaxation therapies),31, 32, 37, 38 combined with training in the pool33 or combined with training in the pool and self-management.36 The 12 articles included in the study show a large variability in the duration of the sessions, with a minimum of 2 educational sessions29 and a maximum of 12 sessions.36 Four of the studies present an average of 4,34 5,30 6,33 731 and 1029 sessions while the rest of the studies do not specify.27, 35, 38 (TKS), EuroQoL-5D Questionnaire (EQ-5D), Adapted Customer Service Receipt Inventory (CSRI), Health Questionnaire (SF36), Adapted chronic pain self-efficacy scale (SE), Swedish version of the Multidimensional Pain Inventory (MPI-S), Arthritis Self-Efficacy Scales – AR and chronic pain (ASES-S), Arthritis Impact Measurement Scales (AIMS), Swedish Quality of Life Questionnaire (QOLS), Nottingham Health Profile (NHP), Visual Analog Scale (EVA), Psychological General Well-Being (PGWB) and Goldberg Scale of anxiety and depression (GADS). Evaluation of the methodological quality Two of the articles, from among those selected, were excluded from the review despite meeting the inclusion criteria due to their low score on the PEDro scale (<4).39, 40 Table II27-40 presents the methodological quality of the analysed studies. Of the twelve articles included in this review: Only one study scored 8/10.Three studies scored 7/10. Two studies scored 6/10.Five studies scored 5/10.A single study scored 4/10. Three of these studies met criteria 2, 3, 5, 7, 8 and 9, and because of this present a PVI of moderate methodological quality.28, 29, 31 However, the remaining nine articles present a PVI of limited nature.27, 30, 32-38 based on this and according to the Cochrane Group,24 the results of this study have limited evidence since there is no RCT of high methodological quality. The agreement between the evaluators according to the coefficient κ it was high (0.81). Characteristics of the participants Some disparity exists in the characteristics of the participants in the selected studies, which presents some difficulties in their analysis. On the one hand, gender presented some heterogeneity within the studies, with a predominance of female patients in most of the studies and male patients in only seven of them, which as previous studies have already reported, may be due to the fact that the disease has a greater effect on females than males.41 this is important since the similarity between the gender of the participants in the intervention avoids certain important differences in terms of the effect of the study variables since previous studies show that there are gender differences in the clinical and psychosocial characteristics of women and men diagnosed with FM, as well as in the impact of the disease on their daily life. However, on the contrary, a certain bias regarding the variables studied is also established, as there is no equal division of men and women among the groups where the intervention is carThis document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher. COPYRIGHT© 2019 EDIZIONI MINERVA MEDICA GARCÍA-RÍOS HEALTH EDUCATION IN PATIENTS WITH FIBROMYALGIA 306 EuropEaN JourNal of physical aNd rEhabilitatioN MEdiciNE April 2019 Table I.— Description de selected articles. Author (year) Variables Experimental Group Control Group Technique Intervention results Van Ittersum et al. (2014)28 Perception of the disease; catastrophe and state of health of patients with fM. IPQ-R_FM; PCS; Dutch version of FIQ. Pain neuroscience education (PNE) (N.=53): 50 women and 3 men; patients in accordance with ACR criteria: ages between 18-65 years. Average 47 years old. Education in relaxation techniques (RE) (N.=52): 48 women and 4 men; patients diagnosed with FM in accordance with ACR criteria: ages between 18-65 years. Average 47 years old. Cognitive approach to written education on the neuroscience of pain. dual evaluation of education pre- (baseline) and postintervention; 6 months follow-up: FIQ, PCS y IPQ-R. Experimental group: 1 educational brochure (15pp) with detailed written explanations and illustrations about the physiology of pain and the mechanism of central sensitization as an explanation based on evidence of their disease. Control group: 1 written training brochure (15pages) on relaxation exercises and instructions on how to perform such exercises; 1 clarifying telephone call. PNE improved the beliefs in a chronic FM chronology (P=0.03; ES=0.50), but it did not affect other domain perceptions of the disease. The total PCS score did not change with time or differ between PNE and RE. No statistically significant differences were observed between PNE and RE on the perceived symptoms and the impact on daily life. Van Oosterwijck et al. (2013)29 Endogenous inhibition of pain in patients with fM. Pressure algometry; SSP; Neurophysiology of Pain Test; PTT; FIQ; ICP; PCS; PVAQ; TSK. Education on physiology of pain (N.=15): 12 women and 3 men; patients in accordance with ACR criteria: ages between 18-65 years. Average of 45 years old. Education in pace self-management techniques (N.=15): 14 women and 1 man; patients in accordance with ACR criteria: ages between 18-65 years. Average 46 years old. intensive education on the physiology of pain Preintervention evaluation (baseline: SSPpressure algometry); intervention (Neurophysiology of Pain Test; PTT); postintervention and 3 month follow-up (SSPpressure algometry; FIQ; ICP; PCS; PVAQ; TSK). Experimental group: 2 educational sessions on the neurophysiology of the nervous system and the pain system in particular; ability of the CNS to increase or decrease its sensitivity to help them cope with persistent pain (power point, pictures, etc.) Control group: 2 individual educational sessions on selfmanagement techniques in daily activities with respect to their symptoms. 30 min per session. At follow-up, average pain scores for the experimental group were lower than those of the control group (P=0,041). Neurophysiology of pain test increased in response to the experimental intervention (P<0.001); but not to the control intervention (P=0.150). Increase of scores in the scale of health and vitality perception in the experimental group (P<0.001). luciano et al. (2013)30 Functional status and well being of patients with fM. FIQ; EQ-5D; CSRI. Psycho-education added to usual practise (N.=108): 105 women and 3 men; FM patients in accordance with ACR criteria: ages between 18-75 years. Average of 55 years old. Usual practise (N.=108): 106 women and 2 men; FM patients in accordance with ACR criteria: ages between 18-75 years. Average of 55 years old. Applied psycho-education treatment and autogenous training. Preintervention evaluation (baseline) and postintervention (6-12 moth intervals) Experimental group: 6 groups of 18 patients maximum; 9 sessions of 2 hours for 2 months. 5 information education sessions (symptoms, causes, psychological pain factors, treatments, etc.). Four sessions of autogenic training linking emotional experience and relaxation. Control group: standard medical attention. At the 12 months follow-up: patients who received psycho-education showed improvement in overall functional status (Cohen d=0.36: 2.49 to 3,81), physical functioning (Cohen d=0.56: 0.08 to 1.00), days feeling good (Cohen d=0.40: 0.16 to 1.02), pain (Cohen d=0.35: 0.04 to 0.80), morning fatigue (Cohen d=0.24: 0.20 to 0.76), and depression (Cohen d=0.30: 0.26 to 0.93). Rooks et al. (2007)31 Symptoms and quality of life in patients with fM. FIQ; SF-36. Beck Depression Inventory; Arthritis SelfEfficacy Scale adapted for FM. Self help Course Group (FSHC) (N.=50): 50 women with FM and 51 years old. Combination group of ST-FSHC (N.=55): 55 women with FM and 50 years old. Aerobic exercise and flexibility group (AE) (N.=51): 51 women; patients with FM and 48 years old. Strength training, aerobic and flexibility exercise group (ST) (N.= 51): 51 women; patients with FM and 50 years old. Education and self-management combined with exercise. Preintervention evaluation (baseline) and postintervention (6 months). Experimental group: FSHC; self-management techniques, symptom management and wellbeing activities (meetings and lectures) 7 sessions 120 min every 2 weeks. ST-FSHC; participation in activities of both groups. Control group: AE; progressively increasing walks and flexibility exercises. ST; strength and resistance training (machine/repetitions combination) and flexibility. Sixty min per session 2 days per week. ST-FSHC reported improvement in social function scores compared to FSHC (median±21.8; CI of 95%, 2.5 at 41.2), mental health (median 13.5±21.9; P<0.001). Control over FM symptoms improved in STFSHC (average difference, 15.2; CI of 95%: 3.6 to 26.9), AE (average difference: 14.5; IC of 95%: 2.6 to 26.3), and ST (average difference, 13.2; IC of 95%, 1.0 to 25.3). King et al. (2002)32 Pain, functional status and well being of fM patients with fM. SE; FIQ; 6MW; Tender Point Count; Exercise group (N.=46) Average of 45 years old. Education group (N.=48) Average of 44 years old. Combination group (N.=37) Average of 47 years old. Women with FM in accordance with ACR criteria; 18 to 65 years old. N.=39 women with FM in accordance with ACR criteria; 18 to 65 years old. Average 47 years old. Education and self-management combined with exercise. Preintervention evaluation (baseline); postintervention (completion) and follow-up (3 months) Group exercise: aerobic exercise (walking, aquasize etc.) gradually increasing. (3 times per week 15-40 min x 12 weeks) Education group: self-management, coping, illness, energy, nutrition, etc. (1 weekly session 2 hours x 12 weeks) Combination group: 2 exercise sessions 1 education session. Control group: notebook, logbook, coping strategies. The combined group increased its self-efficacy in coping with other symptoms from pre-test to posttest and the follow-up when compared to the control group (F [6.65]=3.48, P=0.003]. FIQ and TP number demonstrated important main effects over time, with significant decreases from pre-test to post-test and follow-up. Mannerkorpi et al. (2000)33 Pain, functional status and quality of life of patients with fM. FIQ; SF-36; 6MW; Swedish version of MPI-S; ASES-S; AIMS; QOLS. N.=28 patients; women with FM according to ACR. Average 45 years old. N.= 30 patients; women with FM according to ACR. Average 47 years old. Education combined with pool training Preintervention evaluation (baseline) and postintervention (at 6 months) Experimental group: exercise in the pool once per week 35 min (resistance, flexibility, relaxation); education 6 sessions x 1 hour, brochure-informative book about symptoms, pain strategies etc. Control group: undertaking only education program. The total FIQ score (P=0.017) the distance travelled in 6MW (P<0.0001), the physical functioning of FIQ (P=0.001) and the anxiety (P=0.019) improved in the training group. The SF-36 general health (P=0.022) social functioning (P=0.049); pain severity in MPI-S (P=0.045) also improved in the experimental group with respect to the control group. bosch et al. (2002)34 Quality of life, psychic discomfort. NHP; Mini International Neuropsychiatric Interview. N.=33 female patients with FM according to ACR criteria; between 26 and 67 years old. Average 54 years old. N.=32 female patients with FM according to ACR criteria; between 26 and 67 years old. Average 54 years old. health education. Pre-intervention evaluation (baseline) and postintervention. Experimental group: 4 sessions of health education of 1 hr; 1-week intervals (1 month). Information about illness, relaxation etc. Control group: normal care for FM. In the intervention group, a statistically significant improvement was observed in pain dimension (P=0.003), in comparison with the control; but not in other dimensions. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher. COPYRIGHT© 2019 EDIZIONI MINERVA MEDICA HEALTH EDUCATION IN PATIENTS WITH FIBROMYALGIA GARCÍA-RÍOS Vol. 55 - No. 2 EuropEaN JourNal of physical aNd rEhabilitatioN MEdiciNE 307 Table I.— Description de selected articles. Author (year) Variables Experimental Group Control Group Technique Intervention results Van Ittersum et al. (2014)28 Perception of the disease; catastrophe and state of health of patients with fM. IPQ-R_FM; PCS; Dutch version of FIQ. Pain neuroscience education (PNE) (N.=53): 50 women and 3 men; patients in accordance with ACR criteria: ages between 18-65 years. Average 47 years old. Education in relaxation techniques (RE) (N.=52): 48 women and 4 men; patients diagnosed with FM in accordance with ACR criteria: ages between 18-65 years. Average 47 years old. Cognitive approach to written education on the neuroscience of pain. dual evaluation of education pre- (baseline) and postintervention; 6 months follow-up: FIQ, PCS y IPQ-R. Experimental group: 1 educational brochure (15pp) with detailed written explanations and illustrations about the physiology of pain and the mechanism of central sensitization as an explanation based on evidence of their disease. Control group: 1 written training brochure (15pages) on relaxation exercises and instructions on how to perform such exercises; 1 clarifying telephone call. PNE improved the beliefs in a chronic FM chronology (P=0.03; ES=0.50), but it did not affect other domain perceptions of the disease. The total PCS score did not change with time or differ between PNE and RE. No statistically significant differences were observed between PNE and RE on the perceived symptoms and the impact on daily life. Van Oosterwijck et al. (2013)29 Endogenous inhibition of pain in patients with fM. Pressure algometry; SSP; Neurophysiology of Pain Test; PTT; FIQ; ICP; PCS; PVAQ; TSK. Education on physiology of pain (N.=15): 12 women and 3 men; patients in accordance with ACR criteria: ages between 18-65 years. Average of 45 years old. Education in pace self-management techniques (N.=15): 14 women and 1 man; patients in accordance with ACR criteria: ages between 18-65 years. Average 46 years old. intensive education on the physiology of pain Preintervention evaluation (baseline: SSPpressure algometry); intervention (Neurophysiology of Pain Test; PTT); postintervention and 3 month follow-up (SSPpressure algometry; FIQ; ICP; PCS; PVAQ; TSK). Experimental group: 2 educational sessions on the neurophysiology of the nervous system and the pain system in particular; ability of the CNS to increase or decrease its sensitivity to help them cope with persistent pain (power point, pictures, etc.) Control group: 2 individual educational sessions on selfmanagement techniques in daily activities with respect to their symptoms. 30 min per session. At follow-up, average pain scores for the experimental group were lower than those of the control group (P=0,041). Neurophysiology of pain test increased in response to the experimental intervention (P<0.001); but not to the control intervention (P=0.150). Increase of scores in the scale of health and vitality perception in the experimental group (P<0.001). luciano et al. (2013)30 Functional status and well being of patients with fM. FIQ; EQ-5D; CSRI. Psycho-education added to usual practise (N.=108): 105 women and 3 men; FM patients in accordance with ACR criteria: ages between 18-75 years. Average of 55 years old. Usual practise (N.=108): 106 women and 2 men; FM patients in accordance with ACR criteria: ages between 18-75 years. Average of 55 years old. Applied psycho-education treatment and autogenous training. Preintervention evaluation (baseline) and postintervention (6-12 moth intervals) Experimental group: 6 groups of 18 patients maximum; 9 sessions of 2 hours for 2 months. 5 information education sessions (symptoms, causes, psychological pain factors, treatments, etc.). Four sessions of autogenic training linking emotional experience and relaxation. Control group: standard medical attention. At the 12 months follow-up: patients who received psycho-education showed improvement in overall functional status (Cohen d=0.36: 2.49 to 3,81), physical functioning (Cohen d=0.56: 0.08 to 1.00), days feeling good (Cohen d=0.40: 0.16 to 1.02), pain (Cohen d=0.35: 0.04 to 0.80), morning fatigue (Cohen d=0.24: 0.20 to 0.76), and depression (Cohen d=0.30: 0.26 to 0.93). Rooks et al. (2007)31 Symptoms and quality of life in patients with fM. FIQ; SF-36. Beck Depression Inventory; Arthritis SelfEfficacy Scale adapted for FM. Self help Course Group (FSHC) (N.=50): 50 women with FM and 51 years old. Combination group of ST-FSHC (N.=55): 55 women with FM and 50 years old. Aerobic exercise and flexibility group (AE) (N.=51): 51 women; patients with FM and 48 years old. Strength training, aerobic and flexibility exercise group (ST) (N.= 51): 51 women; patients with FM and 50 years old. Education and self-management combined with exercise. Preintervention evaluation (baseline) and postintervention (6 months). Experimental group: FSHC; self-management techniques, symptom management and wellbeing activities (meetings and lectures) 7 sessions 120 min every 2 weeks. ST-FSHC; participation in activities of both groups. Control group: AE; progressively increasing walks and flexibility exercises. ST; strength and resistance training (machine/repetitions combination) and flexibility. Sixty min per session 2 days per week. ST-FSHC reported improvement in social function scores compared to FSHC (median±21.8; CI of 95%, 2.5 at 41.2), mental health (median 13.5±21.9; P<0.001). Control over FM symptoms improved in STFSHC (average difference, 15.2; CI of 95%: 3.6 to 26.9), AE (average difference: 14.5; IC of 95%: 2.6 to 26.3), and ST (average difference, 13.2; IC of 95%, 1.0 to 25.3). King et al. (2002)32 Pain, functional status and well being of fM patients with fM. SE; FIQ; 6MW; Tender Point Count; Exercise group (N.=46) Average of 45 years old. Education group (N.=48) Average of 44 years old. Combination group (N.=37) Average of 47 years old. Women with FM in accordance with ACR criteria; 18 to 65 years old. N.=39 women with FM in accordance with ACR criteria; 18 to 65 years old. Average 47 years old. Education and self-management combined with exercise. Preintervention evaluation (baseline); postintervention (completion) and follow-up (3 months) Group exercise: aerobic exercise (walking, aquasize etc.) gradually increasing. (3 times per week 15-40 min x 12 weeks) Education group: self-management, coping, illness, energy, nutrition, etc. (1 weekly session 2 hours x 12 weeks) Combination group: 2 exercise sessions 1 education session. Control group: notebook, logbook, coping strategies. The combined group increased its self-efficacy in coping with other symptoms from pre-test to posttest and the follow-up when compared to the control group (F [6.65]=3.48, P=0.003]. FIQ and TP number demonstrated important main effects over time, with significant decreases from pre-test to post-test and follow-up. Mannerkorpi et al. (2000)33 Pain, functional status and quality of life of patients with fM. FIQ; SF-36; 6MW; Swedish version of MPI-S; ASES-S; AIMS; QOLS. N.=28 patients; women with FM according to ACR. Average 45 years old. N.= 30 patients; women with FM according to ACR. Average 47 years old. Education combined with pool training Preintervention evaluation (baseline) and postintervention (at 6 months) Experimental group: exercise in the pool once per week 35 min (resistance, flexibility, relaxation); education 6 sessions x 1 hour, brochure-informative book about symptoms, pain strategies etc. Control group: undertaking only education program. The total FIQ score (P=0.017) the distance travelled in 6MW (P<0.0001), the physical functioning of FIQ (P=0.001) and the anxiety (P=0.019) improved in the training group. The SF-36 general health (P=0.022) social functioning (P=0.049); pain severity in MPI-S (P=0.045) also improved in the experimental group with respect to the control group. bosch et al. (2002)34 Quality of life, psychic discomfort. NHP; Mini International Neuropsychiatric Interview. N.=33 female patients with FM according to ACR criteria; between 26 and 67 years old. Average 54 years old. N.=32 female patients with FM according to ACR criteria; between 26 and 67 years old. Average 54 years old. health education. Pre-intervention evaluation (baseline) and postintervention. Experimental group: 4 sessions of health education of 1 hr; 1-week intervals (1 month). Information about illness, relaxation etc. Control group: normal care for FM. In the intervention group, a statistically significant improvement was observed in pain dimension (P=0.003), in comparison with the control; but not in other dimensions. (To be continued) This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher. COPYRIGHT© 2019 EDIZIONI MINERVA MEDICA GARCÍA-RÍOS HEALTH EDUCATION IN PATIENTS WITH FIBROMYALGIA 308 EuropEaN JourNal of physical aNd rEhabilitatioN MEdiciNE April 2019 educational sessions with the process being previously explained by the therapist.33 In terms of the content employed as a basis for the educational interventions, the definition of FM disease, the symptoms, the course of the disease, the implications, the management of basic daily life activities, the benefits of exercise on the disease and the reconceptualization of misconceptions and myths were many of the topics covered in the analyzed studies. Education centered on the patient and effects of the education The analyzed studies present a large diversity in terms of variables that show the effectiveness of education once The duration of these sessions and the material that guides the educational sessions also present great plurality. Five studies favored education through information imparted by the professionals in change and discussion-debate groups about the patients’ own experiences31, 32, 34, 36, 38 while in two of the studies education was carried out in the form of brochures and informative books.28, 33 In other studies, patients received talks and informative lectures,31 as well as individual informative consultations with professionals when they required them.27 Participants from two other studies received visual information by means of presentations and guided imagery.29, 35 the educational material used in one of the studies was not specified.37 patients in one of the studies carried out self-administered Table I.— Description de selected articles. Author (year) Variables Experimental Group Control Group Technique Intervention results Fors et al. (2000)35 Pain, anxiety. EVa. Education (N.=22) patients; women with FM between 21 and 68 years old. Average 46 years old. Guided imagery (N.=17) patients; women with FM between 21 and 68 years old. Average 46 years old. N.=19 patients; women with FM between 21 and 68 years old. Average 46 years old. Visual patient education. Preintervention evaluation and postintervention Experimental group: education; educational visualization with teaching of natural systems of analgesia in the human body. Guided imagery; program of universal imagery aimed at this confrontation in a relaxed and positive way. (both 30 mins) Control group: interaction speaking about fibromyalgia pain problems. EVA showed significant pain reduction in the education group (51.98 to 37.14 t=4.30 P<0.001) and in the guided imagery group (48.50 to 28.12 t=4.70 P<0.001.) Anxiety in the education group reduced from preevaluation to post evaluation (47.98 to 29.39, t=5.31 P<0.001) Cedraschi et al. (2004)36 Quality of life, functional status, satisfaction, impact of FM. FIQ; French version of PGWB y SF-36; N.=84 patients; 78 women with FM and 6 men according to ACR criteria and mainly between 41 and 50 years old. Average 49 years old. N.=80 patients; 74 women with FM and 6 men according to ACR criteria and mainly between 41 and 50 years old. Average 49 years old. Patient education combined with pool training and selfmanagement. Preintervention evaluation (baseline) and postintervention (6-month follow-up) Experimental group: 12 sessions-6 weeks of pool programs, relaxation, educational sessions and sessions on basic activities of daily life (planning, debate, etc.) Control group: waiting list for the intervention. The treatment group showed significant improvement in PGWB anxiety (P=0.011), vitality (P=0.013) and total scores (P=0.032). The treatment group showed significant improvements in the total FIQ score (P=0.025) The treatment group registered improvement in eight of the nine measures of satisfaction in the areas of “psychosocial factors” and “information.” Hammond et al. (2006)37 Impact of FM self-efficacy. FIQ; Arthritis Self-efficacy Scale. N.=71 patients with FM according to ACR criteria; 63 women and 8 men older than 18 years old. Average of 49 years old. N.=62 patients with FM according to ACR criteria; 57 women and 5 men over 18 years old. Average of 48 years old. Patient education with cognitive behavioral approach combined with exercise. Preintervention evaluation (baseline) (4 months); post- (8 months). Experimental group: sessions of 2 hours-10 weeks; symptoms of FM, self-management, stress management and 15-45 minutes of exercise and postural training, Tai Chi etc. Control group: relaxation 1 hour10 weeks; relaxationbreathing method for FM symptoms. FIQ showed a difference (4 months) between patient education group/3.38 (SD 9.35); relaxation group 0.3 (SD 8.85); P/0.02. In the patient education group, 47% of the respondents reported improvement compared to 13% in the relaxation group. Alamo et al. (2002)27 Pain, anxiety, depression. EVA and Nottingham Health Profile Questionnaire; GHQ. N.=48 patients with chronic musculoskeletal pain (CMD)/FM; 46 women and 3 men between 18 and 65 years old. Average of 39 years old. N.=33 patients with CMD/FM; 32 women and 1 man between 18 to 65 years old. Average of 42 years old. patient focused education. Preintervention evaluation (baseline) and postintervention (6-12 months) Experimental group: Regular care + consultations of 30-45 min. of educational information on FM, mutual discussion. Control group: Regular primary care for patients with FM in spain. Experimental group showed improvement after 12 months with regards to the control in terms of anxiety (GHQ) (DMC 5.8 to 4.7 // FM 6.7 to 4.5), pain intensity (DMC 6.8 to 5.1//FM 7.1 to 6.8), pain as a problem (DMC 3.4 to 3.0//FM 4.5 to 3.1). Demirbag et al. (2012)39 Depression, pain and Quality of Life. Beck questionnaire; EVE; FIQ. N.=51 patients with FM according to ACR criteria; 47 women and 4 men between 19 and 59 years old. Average between 33 to 45 years old. N.=51 patients with FM according to ACR criteria; 47 women and 4 men between 19 and 59 years old. Average between 33 to 45 years old. Patient education combined with exercise. Preintervention evaluation (baseline) and postintervention (1 month). Experimental group: Information on FM, symptoms, control, diagnosis, treatments, etc. (20 min) Low aerobic exercises according to pain localization (15-20 min.) 1 month. Control group: Hand out forms and scales for participation in study. Experimental group showed significant differences between the Beck, FIQ and EVA scores before (20.33±7.4, 67.19±13.9, 7.65±1.44, respectively) and after the intervention (14.20±4.5, 47.58±11.82, 5.41±1.15 respectively); P<0.05. *The selected studies obtained a PEDro score ≥4 (see Table II). FM: fibromyalgia; IPQ-R_FM: Revised Illness Perception Questionnaire; PCS: Pain Catastrophizing Scale; FIQ: Fibromyalgia Impact Questionnaire; ACR: American College of Rheumatology; SSP: Spatial Summation of pain; PTT: pain pressure threshold; ICP: Pain Coping Inventory; PVAQ: Pain and Awareness Surveillance Questionnaire; TSK: Tampa Scale of Kinesiophobia; EQ-5D: EuroQoL-5D questionnaire; CSRI: Adapted Customer Service Receipt Inventory; SF-36: Health Questionnaire; SE: adapted chronic pain self-efficacy scale; 6MW: Six minute walk; MPI-S: Swedish version of the Multidimensional Pain Inventory; ASES-S: Arthritis Self-Efficacy Scales - (AR and chronic pain); AIMS: Arthritis Impact Measurement Scales; QOLS: Swedish Quality of Life Questionnaire; NHP: Nottingham Health Profile; EVA: Visual Analog Scale; PGWB: Psychological General Well-Being; GHQ: Goldberg Scale of anxiety and depression. Table I.— Description de selected articles (continues). This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher. COPYRIGHT© 2019 EDIZIONI MINERVA MEDICA HEALTH EDUCATION IN PATIENTS WITH FIBROMYALGIA GARCÍA-RÍOS Vol. 55 - No. 2 EuropEaN JourNal of physical aNd rEhabilitatioN MEdiciNE 309 provement in the magnitude of the pain. However, the lack of masking and blinding in the participants, therapists and evaluators in these three studies makes the internal validity of these studies limited, and the results obtained may have been compromised and biased. As for the studies that analyzed the impact of education in combination with other therapies, they show a significant improvement in pain and pain catastrophizing. Due to a lack of uniformity by the variability of therapies used in most studies, it is difficult to clarify whether the benefits obtained in pain reduction or in its better acceptance and management is mainly due to education itself or its combination with aerobic exercise, flexibility, relaxation or hydrotherapy, the usual treatment in FM.33, 36, 38 Regarding the rest of the variables involved in the studies, Van Ittersum et al.28 constituted improvements in the perception of the disease as well as the belief in a chronic chronology of it, which helped patients to be able to restructure unfavourable cognitions and therefore decrease the interventions have been made. Prior to the interventions, there is no similarity in either the location of pain in patients, or the subjectivity of its intensity, therefore it is difficult to establish comparisons about the benefits of education on this variable in the articles that analyses it. Four of the studies that addressed the impact of education on pain in a concentrated manner and without combining it with another type of therapy, found statistically significant differences in this variable. Van Oosterwijck et al.29 found a significant improvement in the efficacy of endogenous pain mechanisms in the long term with an intensive educational intervention on the neurophysiology of the nervous system and its ability to increase or decrease its sensitivity and thus help patients to fight persistent pain. Patients, whose interventions were carried out by Bosch et al.,34 Fors et al.35 and Alamo et al.,27 using general health education targeted to the patient, visual education and relaxation, as well as informative consultations on basic aspects of the disease respectively, showed a significant imTable I.— Description de selected articles. Author (year) Variables Experimental Group Control Group Technique Intervention results Fors et al. (2000)35 Pain, anxiety. EVa. Education (N.=22) patients; women with FM between 21 and 68 years old. Average 46 years old. Guided imagery (N.=17) patients; women with FM between 21 and 68 years old. Average 46 years old. N.=19 patients; women with FM between 21 and 68 years old. Average 46 years old. Visual patient education. Preintervention evaluation and postintervention Experimental group: education; educational visualization with teaching of natural systems of analgesia in the human body. Guided imagery; program of universal imagery aimed at this confrontation in a relaxed and positive way. (both 30 mins) Control group: interaction speaking about fibromyalgia pain problems. EVA showed significant pain reduction in the education group (51.98 to 37.14 t=4.30 P<0.001) and in the guided imagery group (48.50 to 28.12 t=4.70 P<0.001.) Anxiety in the education group reduced from preevaluation to post evaluation (47.98 to 29.39, t=5.31 P<0.001) Cedraschi et al. (2004)36 Quality of life, functional status, satisfaction, impact of FM. FIQ; French version of PGWB y SF-36; N.=84 patients; 78 women with FM and 6 men according to ACR criteria and mainly between 41 and 50 years old. Average 49 years old. N.=80 patients; 74 women with FM and 6 men according to ACR criteria and mainly between 41 and 50 years old. Average 49 years old. Patient education combined with pool training and selfmanagement. Preintervention evaluation (baseline) and postintervention (6-month follow-up) Experimental group: 12 sessions-6 weeks of pool programs, relaxation, educational sessions and sessions on basic activities of daily life (planning, debate, etc.) Control group: waiting list for the intervention. The treatment group showed significant improvement in PGWB anxiety (P=0.011), vitality (P=0.013) and total scores (P=0.032). The treatment group showed significant improvements in the total FIQ score (P=0.025) The treatment group registered improvement in eight of the nine measures of satisfaction in the areas of “psychosocial factors” and “information.” Hammond et al. (2006)37 Impact of FM self-efficacy. FIQ; Arthritis Self-efficacy Scale. N.=71 patients with FM according to ACR criteria; 63 women and 8 men older than 18 years old. Average of 49 years old. N.=62 patients with FM according to ACR criteria; 57 women and 5 men over 18 years old. Average of 48 years old. Patient education with cognitive behavioral approach combined with exercise. Preintervention evaluation (baseline) (4 months); post- (8 months). Experimental group: sessions of 2 hours-10 weeks; symptoms of FM, self-management, stress management and 15-45 minutes of exercise and postural training, Tai Chi etc. Control group: relaxation 1 hour10 weeks; relaxationbreathing method for FM symptoms. FIQ showed a difference (4 months) between patient education group/3.38 (SD 9.35); relaxation group 0.3 (SD 8.85); P/0.02. In the patient education group, 47% of the respondents reported improvement compared to 13% in the relaxation group. Alamo et al. (2002)27 Pain, anxiety, depression. EVA and Nottingham Health Profile Questionnaire; GHQ. N.=48 patients with chronic musculoskeletal pain (CMD)/FM; 46 women and 3 men between 18 and 65 years old. Average of 39 years old. N.=33 patients with CMD/FM; 32 women and 1 man between 18 to 65 years old. Average of 42 years old. patient focused education. Preintervention evaluation (baseline) and postintervention (6-12 months) Experimental group: Regular care + consultations of 30-45 min. of educational information on FM, mutual discussion. Control group: Regular primary care for patients with FM in spain. Experimental group showed improvement after 12 months with regards to the control in terms of anxiety (GHQ) (DMC 5.8 to 4.7 // FM 6.7 to 4.5), pain intensity (DMC 6.8 to 5.1//FM 7.1 to 6.8), pain as a problem (DMC 3.4 to 3.0//FM 4.5 to 3.1). Demirbag et al. (2012)39 Depression, pain and Quality of Life. Beck questionnaire; EVE; FIQ. N.=51 patients with FM according to ACR criteria; 47 women and 4 men between 19 and 59 years old. Average between 33 to 45 years old. N.=51 patients with FM according to ACR criteria; 47 women and 4 men between 19 and 59 years old. Average between 33 to 45 years old. Patient education combined with exercise. Preintervention evaluation (baseline) and postintervention (1 month). Experimental group: Information on FM, symptoms, control, diagnosis, treatments, etc. (20 min) Low aerobic exercises according to pain localization (15-20 min.) 1 month. Control group: Hand out forms and scales for participation in study. Experimental group showed significant differences between the Beck, FIQ and EVA scores before (20.33±7.4, 67.19±13.9, 7.65±1.44, respectively) and after the intervention (14.20±4.5, 47.58±11.82, 5.41±1.15 respectively); P<0.05. *The selected studies obtained a PEDro score ≥4 (see Table II). FM: fibromyalgia; IPQ-R_FM: Revised Illness Perception Questionnaire; PCS: Pain Catastrophizing Scale; FIQ: Fibromyalgia Impact Questionnaire; ACR: American College of Rheumatology; SSP: Spatial Summation of pain; PTT: pain pressure threshold; ICP: Pain Coping Inventory; PVAQ: Pain and Awareness Surveillance Questionnaire; TSK: Tampa Scale of Kinesiophobia; EQ-5D: EuroQoL-5D questionnaire; CSRI: Adapted Customer Service Receipt Inventory; SF-36: Health Questionnaire; SE: adapted chronic pain self-efficacy scale; 6MW: Six minute walk; MPI-S: Swedish version of the Multidimensional Pain Inventory; ASES-S: Arthritis Self-Efficacy Scales - (AR and chronic pain); AIMS: Arthritis Impact Measurement Scales; QOLS: Swedish Quality of Life Questionnaire; NHP: Nottingham Health Profile; EVA: Visual Analog Scale; PGWB: Psychological General Well-Being; GHQ: Goldberg Scale of anxiety and depression. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher. COPYRIGHT© 2019 EDIZIONI MINERVA MEDICA