A Psychological Profile of Fibromyalgia Patients: A Chiropractic Case Study

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A Psychological Profile of Fibromyalgia Patients: A Chiropractic Case Study

ABSTRACT

Background: Fibromyalgia is a chronic condition characterized by widespread musculoskeletal pain and tenderness. Reversible modulation of the pain threshold is believed to contribute to the pathogenesis of this condition, and psychosocial stress is known to alter the pain threshold.

Objective: To describe and compare the psychological profile of fibromyalgia patients attending chiropractic clinics in Australia.

Setting: Chiropractic clinics located in 5 Australian states and the Australian capital territory with practices in inner city, suburban, coastal, and rural areas were included.

Subjects: Chiropractic patients with acute and chronic biomechanical conditions, fibromyalgia, and who were undergoing maintenance care were included in the study.

Method: A case study to explore the psychological profile of fibromyalgia patients was undertaken. The Distress and Risk Assessment Method (DRAM) and Sense of Coherence (SOC) questionnaires were used to ascertain and compare the distress, sense of coherence, and manageability levels of patients with fibromyalgia with patients having maintenance chiropractic care. Purposive sampling of practitioners and convenience sampling of patients fulfilling the study's inclusion criteria were undertaken. Patients were asked to complete two questionnaires and chiropractors to complete one questionnaire and an interview.

Results: While more than half of the patients in the fibromyalgia group were distressed, fewer than 1 in 7 maintenance patients were found to be distressed according to the DRAM questionnaire. With several individual exceptions, fibromyalgia patients also tended to have lower SOC and manageability scores than the maintenance group.

Conclusion: This study supports the view that fibromyalgia may represent a problem of coping with various environmental stresses, including psychosocial stresses. However, owing to individual variation, a diagnosis of fibromyalgia at the clinical level does not accurately predict whether a particular patient is distressed or has a low SOC score. Screening of fibromyalgia patients may help determine whether intensive counseling and stress management by the chiropractor or another health professional should be contemplated. (J Manipulative Physiol Ther 1999;22:454-7)

Key Indexing Terms: Fibromyalgia; Psychological Profile; Pain; Chiropractic

INTRODUCTION

When defined as widespread chronic musculoskeletal pain and tenderness, fibromyalgia is experienced by about 1 in 20 patients encountered in primary medical practice. The two central features underlying fibromyalgia are the presence of tender points and an enhanced perception of a distressing body sensation in the absence of discernible endorgan pathology. Although the cause of fibromyalgia is disputed, it is postulated that patients neither perceive nor respond normally to physical or psychological stresses.( 1) It has been suggested that, although psychological factors may influence pain severity, the central features of fibromyalgia are independent of the psychological status.( 2) Others have proposed that fibromyalgia, rather than constituting a disease entity, should be conceptualized as evidence of difficulty in coping with various types of environmental stress.( 3) Certainly the finding from a study of 12 patients that hypothalamic-pituitary-adrenal axis function appears perturbed in patients with fibromyalgia is consistent with the theory that emotional stress plays a role in the natural history of this condition.( 4) The theory of a dysfunction affecting the pain-modulation system is further supported by the inadequate response of patients having fibromyalgia from antiinflammatory agents and the lack of evidence for a disturbance in muscle, fascia, and other soft tissues.( 5, 6)

Reduced midbrain/brain-stem inhibition of ascending nociceptive impulses could explain both the finding of tender points in apparently normal areas of the body and the lack of segmental distribution of discomfort in fibromyalgia. Physical factors such as poor posture or an unfit state resulting in muscle and ligamentous sprain/strain could send impulses centrally.

Modulation of such primary messages could occur centrally by cognitive or emotional input. Peripheral nociception could thus be modulated by an interplay of complex, psychoemotionally responsive central factors. Certainly, within the framework of monism, emotional or psychological triggers are deemed to potentially have an impact equivalent to that of physical or chemical triggers on well-being. A growing body of evidence shows that information processing within the nervous system, whether triggered by chemical or symbolic events, can alter body function and, possibly, alter structure.( 7-10)

To increase scientific validation for the constructs of mindbody medicine, I explored the possibility that fibromyalgia does represent a problem of coping with various environmental stresses, including psychosocial stresses. I decided to ascertain and compare the sense of coherence (SOC) scores of fibromyalgia and maintenance patients attending chiropractic clinics. An SOC may be described as a coping style characterized by an enduring tendency to see one's life as more or less ordered, predictable, and manageable.( 11) Patients with a low SOC show more distress, and they appraise and cope with stressful situations in ways less likely to resolve or alleviate their distress than patients with a high SOC.( 12)

In addition to comparing the coping style of maintenance and fibromyalgia patients, I compared the distress levels of these patient groups by using the DRAM questionnaire. The DRAM is a first-stage sociopsychological screening procedure recommended as a screening tool to aid clinical appraisal of patients in orthopedic, back, and pain clinics.( 13)

METHOD

A case study to explore the psychological profile of fibromyalgia patients was undertaken. The DRAM and SOC questionnaires were used to ascertain and compare the distress, sense of coherence, and manageability levels of patients with fibromyalgia and of patients undergoing maintenance chiropractic care. The DRAM questionnaire contains two discrete sections, the Zung and Somatic Perception Indexes. Scoring according to the described DRAM method results in an evaluation of patients as normal, at risk, or distressed.( 13) The SOC questionnaire evaluates the ability of the patient to cope; it particularly explores the patient's general life orientation, especially for the dimensions of comprehensibility, manageability, and meaningfulness. An SOC is composed of three elements: comprehensibility, manageability, and meaningfulness. Comprehensibility is high when the patient perceives stimuli arising from the external and internal environments are structured, predictable, and explicable. Meaningfulness is present when challenges confronting the patient are regarded as worthy of investment and engagement. Manageability is high when patients believe they have adequate resources available to manage demands. The questions and their analyses have been described by Antonovsky.( 14)

To ensure maximum variation among the study population, purposive sampling of chiropractic practices was undertaken to include patients from diverse geographical and socioeconomic circumstances and to involve practitioners with various practice philosophies. Chiropractic practices in Victoria, Tasmania, Queensland, New South Wales, The Australian Capital Territory, and South Australia were included. Patients attending practices in inner city, suburban, coastal, and rural areas participated. Eligible chiropractors must have completed at least 5 years of clinical practice. Sixteen chiropractors were invited to participate.

Participating practitioners used convenience sampling of patients. In selecting the patient sample, chiropractors were asked to include adult patients who fulfilled the criteria for one of the following groups:

Group 1: maintenance patients. Inclusion criteria for this group were patients

- designated as presenting for maintenance care by the chiropractor

- who presented for regular chiropractic care even when not symptomatic.

Group 2: Fibromyalgia patients. Patients with widespread chronic pain were considered. Specific inclusion criteria for patients in this group were the presence of( 15, 16)

Diffuse generalized or localized pain, in the absence of local causes that had persisted for 3 or more months.
11 or more tender points, which were defined as
- painful, not just tender, to palpation. Digital pressure of ó 4 kg is usually regarded as sufficient to cause pain in these patients.

- not referred on palpation.

3. The absence of underlying disease.
4. At least one of fatigue, a sleep disturbance, and/or morning stiffness that lasts for < 30 minutes.
We provided clear criteria for categorizing the patient sample and limited the study sample to experienced chiropractors. Beyond these factors, no measures were included to confirm the reliability of the diagnoses of the patient sample. In addition to selecting the patient sample, chiropractors completed a questionnaire about each participating patient and commented on each patient's responses to treatment and the contribution the chiropractors perceived psychosocial stress made to the patient's health status.

All participating patients were asked to complete two questionnaires based on the DRAM( 11) and SOC( 13):

- The first on initiation of therapy/at presentation

- The second either 14 to 21 days after initiation of therapy or on termination of therapy, whichever occurred first.

Patients also were asked to comment on their current stress level (scale 0, absent, to 10, intense) and to indicate how much of their present problem they believed to be attributable to stress (scale 1 [100%] to 7 [0%]).

RESULTS

Ten clinics participated, and 88 patients from these clinics agreed to enter the study. Two thirds of participating patients were undergoing maintenance care; the remainder fulfilled the criteria for fibromyalgia. The majority of patients were between 30 and 60 years of age. The male/female ratio in the maintenance group was 1:1; in the fibromyalgia group, females outnumbered males by 7 to 1.

Fig 1 shows the distribution of maintenance and fibromyalgia patients according to level of distress on the DRAM questionnaire. In the fibromyalgia group, more than half of the patients were distressed, a state experienced by fewer than 1 in 7 maintenance patients. In contrast, more than 1 in 7 fibromyalgia patients and almost half of maintenance patients are normal on the DRAM. Comparison of results on the first and subsequent DRAM questionnaire showed no change in almost half of the fibromyalgia and in almost two thirds of the maintenance patients. Further analysis of distressed patients found that half of the fibromyalgia patients had anxiety and the other half were depressed. In contrast, two thirds of maintenance patients had persistent anxiety.

Fig 2 shows that, although patients are distributed throughout the SOC spectrum, more fibromyalgia patients tend to have a low SOC and more maintenance patients a high SOC score. A similar picture emerges in Fig 3, which shows that a larger proportion of patients with fibromyalgia falls toward the low end of the manageability dimension of the SOC. However, compared to maintenance patients, the manageability dimension of patients with fibromyalgia appears to be less skewed toward lower values than the combined SOC score.

One third of fibromyalgia patients agreed with their practitioner about the extent to which stress contributed to their current problem. Another third of the fibromyalgia patients believed stress played a greater role than that suggested by their chiropractors, and the last third believed stress played a lesser role than that suggested by their chiropractors. The SOC scores of patients who perceived stress as an important contributing factor ranged from 39 to 65, with a manageability score range of 12 to 18. The SOC score of patients who perceived stress as a minor contributing factor ranged from 58 to 78, with a manageability score range of 12 to 23.

DISCUSSION

Although the small sample size makes it precarious to generalize, this study supports the view that fibromyalgia may represent a problem of coping with various environmental stresses, including psychosocial stresses. The research indicates that, compared to maintenance patients, patients in this study with fibromyalgia were more distressed and had lower SOC and manageability scores. However, this study also found that the manageability scores of the fibromyalgia group were less skewed toward low scores than their comparative SOC scores would predict. While those fibromyalgia patients who perceived stress as playing a more substantial role in their condition were more likely to have a lower SOC and manageability score, other fibromyalgia patients who perceived stress as an important contributor were found to have relatively high scores on these measures. While fibromyalgia may present a problem of coping with environmental stresses, individual patient variation makes it impossible at a clinical level to assume the psychological profile of any one patient based on their diagnosis. Because the pain threshold can be reduced by increased psychological stress and anxiety, appreciation of the patient's psychological profile may provide useful management information. This appreciation is more acute when considered in conjunction with the definition of fibromyalgia as a chronic pain syndrome of > 3 months( 1) duration that is characterized by a profound but reversible change in the pain-modulating system. Therefore, use of the DRAM and SOC questionnaires may help in the clinical care of fibromyalgia patients.

Stress-management techniques show some success in the treatment of fibromyalgia. In the short term, aerobic exercise and other stress-management treatments were found to have a positive effect in patients with fibromyalgia.( 17) In the long term, compliance with an aerobic exercise regimen proved a problem. Preliminary findings from a study of 77 patients over a 10-week period suggested that a meditation-based stress reduction program is effective for fibromyalgia patients.( 18) Identification of each patient's psychological profile may help predict which patients are more likely to respond to psychosocial intervention measures. Awareness that a particular patient has a low manageability score may alert the practitioner of the need to specifically focus on enhancing the patient's coping skills. Personal perception of control is regarded as a significant factor in successful coping. While situational variables such as chronicity and overall life stress may modulate the effects of perceived control( 19) so may competent chiropractic care.( 20) Awareness that a patient is distressed may warn the chiropractor that patient progress is likely to be slower than anticipated and that maximum use of nonspecific wellness triggers is required.( 21)

Fibromyalgia remains a difficult condition to treat. Chronic "anxiety-stress" may cause muscle spasm that can be appreciated clinically( 2); therefore, attempts to address the psychological aspects of this condition seem to be consistent with competent clinical care. Such intervention may also benefit other conditions more commonly encountered in patients with fibromyalgia, including Raynaud's phenomenon, tension headaches, migraine, premenstrual tension, jaw pain, irritable bladder, excessive fatigue, anxiety, depression, sicca syndromes, and paresthesia.( 22)

CONCLUSION

The fibromyalgia patients participating in this study were more likely to be distressed, have a poorer sense of coherence, and have a lower manageability score than patients undergoing maintenance care. However, individual patients with fibromyalgia do not necessarily conform to their group's psychological profile. Determination of the DRAM and SOC scores of individual fibromyalgia patients may provide consequently helpful clinical information.

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By Jennifer R. Jamison

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