|Ahead of print publication
Comparative role of Affective–Cognitive behavior therapy and Jacobson's progressive muscular relaxation in managing pain among patients with fibromyalgia
MT Lakshmi Saranya1, R Sreehari2, CB Mithun3, PI Sangeetha2
1 Department of Clinical Psychology, Clinical Psychologist, International Modern Hospital, Dubai, United Arab Emirates
2 Department of Clinical Psychology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
3 Department of Rheumatology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
|Date of Submission||01-Mar-2021|
|Date of Acceptance||26-Jul-2021|
|Date of Web Publication||21-May-2022|
MT Lakshmi Saranya,
Department of Clinical Psychology, Clinical Psychologist, International Modern Hospital, Dubai
United Arab Emirates
Source of Support: None, Conflict of Interest: None
Background: Fibromyalgia (FM) is a rheumatologic disease that advances with chronic pain and disability and represents one of the most common causes of chronic and diffuse pain in the population. Objective: An observation study was conducted to compare the role of an individually administered form of Affective Cognitive Behavioural Therapy (ACBT) with Jacobson's Progressive Muscular Relaxation (JPMR) in changing the scores of Pain and FM impact among patients with FM.
Method: Patients receiving ACBT and JPMR were allocated to two groups by licensed clinical psychologists until each group had a sample of 10 each. Both groups received 6 individual sessions (once in every two weeks). A baseline assessment was done to assess the Pain and FM impact prior to the intervention. Post and follow up assessments were carried one week and one month after the intervention respectively. Post scores of both groups were compared with baseline scores.
Results: The current study revealed that ACBT is associated with impressive improvements in Pain reduction and FM Impact among the patients with FM.
Conclusion: Considering the effect of ACBT in reducing the Pain and FM Impact scores, ACBT shall be considered as an add-on psychological intervention along with the pharmacological management to yield better outcomes in FM patients. However, more research including randomized control trails are required to confirm its effectiveness.
Keywords: ACBT, Fibromyalgia, Fibromyalgia Impact, JPMR, Pain
|How to cite this URL:|
Lakshmi Saranya M T, Sreehari R, Mithun C B, Sangeetha P I. Comparative role of Affective–Cognitive behavior therapy and Jacobson's progressive muscular relaxation in managing pain among patients with fibromyalgia. Indian J Rheumatol [Epub ahead of print] [cited 2022 Jun 26]. Available from: https://www.indianjrheumatol.com/preprintarticle.asp?id=345785
| Introduction|| |
Fibromyalgia (FM) is a rheumatologic disease characterized by widespread musculoskeletal pain, multiple tender points, sleep disturbance, fatigue, and stiffness that advances with chronic pain and disability and represents one of the most common causes of chronic and diffuse pain in the population. In FM, the pain is chronic and the International Association for the Study of Pain defines chronic pain as the “pain when it persists beyond 3 months in the absence of a tissue lesion and not associated with the protective function of the body.”
The prevalence of FM has been estimated to be about 2%–4% of the world population. In women, the mean prevalence rate was 4.2% and in men 1.4% with a female–male ratio of 3:1. The total prevalence of chronic pain in India is 13%, of which 37% have moderate chronic pain and 63% have severe chronic pain.
FM also includes symptoms such as sleep disturbances, exhaustion, depression, anxiety, problems with memory and concentration, headaches, numbness/tingling, and others. Their quality of life is impaired which leads to multidimensional impairment. The evaluation and management of chronic pain conditions like FM is a challenging issue in health care as it causes various forms of psychopathology. Hence, a comprehensive evaluation of the multiple symptom domains associated with FM and the impact of FM on multidimensional aspects of function should be a routine part of the care of FM patients.,
This condition has been traditionally difficult for health-care providers to treat with medications. Hence, the treatment of FM requires a multidisciplinary approach and should include changes in lifestyle, nonpharmacological treatment, and pharmacological interventions aiming at pain relief, and improvement in sleep quality and mood disorders. A systematic review of randomized controlled trials on relaxation as treatment for chronic musculoskeletal pain concludes that relaxation could be effective for pain management. Many relaxation techniques such as guided imagery, hypnotherapy, and progressive muscular relaxation (PMR) have been reported to be effective for treating patients with chronic pain without organic basis. As FM is predominantly a chronic pain condition, relaxation techniques are likely to be helpful for FM symptoms. In FM, Jacobson's PMR (JPMR) has added benefit of emphasizing to the patient the difference between muscles that are tensed and those that are relaxed since many patients persistently tense their muscles, unknowingly which can contribute to their pain.
Melzak and Wall's theory has acknowledged the contributions played by thoughts, moods, and behaviors in the overall experience of pain. Psychological interventions which focus on the cognitive and affective components along with relaxation training have been widely researched for its effectiveness in managing pain. Cognitive therapy scrutinizes the thinking process that impacts one's awareness of pain as well as one's reactions to the presence of pain. Cognitive behavior therapy (CBT) has been operated on to provoke direct pain relief and developments in functional status and quality of life. CBT with elicitation of Affect which is termed affective CBT (ACBT) was found useful in treating patients with FM. ACBT not only delivers more detailed CBT but also accentuates emotional awareness and acceptance in patients. Although the efficacy was proven in a randomized controlled trial in the USA, no subsequent studies have been done to generalize the findings to other populations. Being a disease with chronic pain, FM turns out to be a great concern for the patients, health professionals, and society and adversely impacts the quality of life. Therefore, this study aims to assess the effectiveness of ACBT in treating patients with FM in Indian settings with the main objective of comparing the changes in pain and FM impact scores between FM patients receiving ACBT and those receiving JPMR.
| Subjects and Methods|| |
Participants who met the American College of Rheumatology criteria for FM were recruited from the Department of Rheumatology, Amrita Institute of Medical Sciences, Kochi. Twenty-four patients were screened based on inclusion and exclusion criteria, and a total of twenty participants were enlisted in the study. The study consisted of two groups: one receiving ACBT and the other receiving JPMR. The eligible FM patients were assigned to the two groups based on odd–even allocation method with a minimum of ten patients in each group. Participants were assessed at baseline before the initiation of the treatment (pre treatment phase), 1 week after the completion of the intervention (post treatment phase), and 1 month after the completion of intervention (follow-up phase) [Flowchart 1]. The assessment was done by a clinical psychologist who was blinded to the study in order to avoid rater bias. Approval was obtained from the Ethics Committee of the institute, and written informed consent was obtained from each participant enrolled in this study.
FM patients who were on pharmacological treatment for at least 3 months and having no clinically significant improvement, age range from 18 to 60 years (all adult patients excluding geriatric patients to avoid the interference from age-related body pains), both male and female were included in the study.
Patients with any unstable medical or psychiatric illness, pain from traumatic injury or structural or regional rheumatic disease, rheumatoid arthritis, inflammatory arthritis, autoimmune disease, psychoactive substance dependence, pregnancy (as the pregnancy-associated states might prevent them from doing the JPMR or other activity schedules prescribed in the ACBT), and those who had undergone any psychotherapy prior to the baseline assessment were excluded in the study.
All participants were subjected to the following:
Sociodemographic details including gender, occupation, socioeconomic status, education, marital status, and other details such as presence of marital conflicts and FM duration were recorded. The Brief Pain Inventory was given which allowed patients to rate the severity of their pain and the degree to which their pain restricts with common scopes of feeling and job. The Revised FM Impact Questionnaire (FIQR), an updated version of the FIQ that has good psychometric properties, was used to assess the effect of FM on the various aspects of the patients' lives.
FM patients who were refractory to the first-line pharmacological treatment, Duloxetin at a dose of 60 mg per day for at least 3 months, were included in the study. The background pharmacological treatment was continued throughout the study period. No additional pharmacological therapies were added during the study duration. Both interventions were given by the same clinical psychologist in order to avoid any bias in the intervention. ACBT is a 6-session, individually administered, manualized intervention designed for patients with functional somatic symptoms. The treatment manual allows for adaptation and adjustment to the individual pattern of symptoms and life situations presented by the patients.
JPMR was also presented for six sessions in 2-week intervals. JPMR involves tensing and releasing the tension from a number of different muscle groups. They are advised to be careful not to tense any muscle so tightly that it hurts. The goal of tensing is to help them focus their attention on each specific muscle group. Tensing is done for about 5–8 s and is sufficient to experience sensations of tension in that muscle group. Following tension, each muscle group is relaxed with respective instructions. This procedure of alternate tensing and relaxing is continued till the whole-body muscles are completely relaxed.
Criteria for improvement
In this study, patients reporting a 30% reduction of pain in the Brief Pain Inventory (BPI) Scale, after the completion of intervention (post treatment and follow-up) was considered as improvement. The primary outcome was defined as the pain score measured using BPI and the secondary outcome was considered as the FM impact score measured using FIQR. Participants were considered as dropout who completed the initial assessment but then failed to adhere to the sessions. Participants who attended the initial session, or intervention, but no follow-up were considered as loss to follow-up.
The data were treated using the Statistical Package for the Social Sciences (SPSS version 16.0) (IBM, Armonk, New York, United States). Descriptive statistics (mean and standard deviation [SD]) and nonparametric tests were used in the study. Wilcoxon signed-rank test was used to test the statistical significance of the changes in the pain score and impact of FM in individuals with FM before and after giving ACBT and JPMR. Mann–Whitney U-test was used to compare the scores of pain and FM impact between the two groups. In order to understand the general pattern of the participants, qualitative data were analyzed. The two groups were analyzed in terms of the change in BPI and FIQR scores. Blanchard and Schwartz formula was calculated for analyzing the percentage of therapeutic change in the two groups.
| Results|| |
A statistical comparison between the two groups and detailed distribution of the sample with respect to the sociodemographic details of the study participants are given in [Table 1]. There were no major differences between the two groups in terms of sociodemographic variables.
Changes in pain
Wilcoxon signed-rank test was used to analyze within-group differences of pain scores in preintervention (before the intervention), post (1 week after 6 sessions), and follow-up phase (1 month after the intervention). The pain severity mean scores (pre) for the ACBT and JPMR groups were 7.78 (SD: 1.2) and 6.80 (SD: 1.15), respectively, during the baseline assessment. In the ACBT group, the pain severity mean score reduced to 4.56 (SD: 1.88, P = 0.007), and in the JPMR group, pain decreased to 6.43 (SD: 1.99, P = 0.496) during postevaluation. However, the score reductions did not show much change in the follow-up period. There was a significant difference in the pain severity score between ACBT and JPMR in the pre–post phase. In pre–follow-up phase, patients in the ACBT group reported a significant difference in the reduction of pain severity (P > 0.01). This was not observed in the JPMR group.
Pain interference in the ACBT group decreased from score of 7 to 4.11 (SD: 1.83, P = 0.007) during the post phase and in the JPMR group from 7.57 to 7.14 (SD: 1.34). Pain interference at follow-up phase (ACBT group) further decreased to 3.33 (SD: 1.58, P = 0.248), whereas in the JPMR group, it increased to 7.43 (SD: 1.13, P = 0.521). When the mean score of pain interference for the ACBT was compared to the follow-up scores of the same group, the changes were found to be significant (P = 0.007). The results showed that the ACBT intervention is effective in sustaining the improvement in reducing the pain severity scores during pre–post–follow-up phase among FM patients (P < 0.01). In the JPMR group, the difference between the pain interference pre–post–follow-up scores was not significant (P = 0.521).
The FM impact function score (pre) for the ACBT group in the pre–post phase decreased from 22.67 (SD: 4.33) to 12.67 (SD: 5.22, P = 0.008), while in the JPMR group, scores decreased from 23.29 (SD: 4.54) to 23.14 (SD: 4.413, P = 0.833). FM impact function score further decreased to 11.22 (SD: 4.27, P = 0.079) at follow-up phase in the ACBT group while it went up to 23.71 (SD: 4.27, P = 0.102) in the other group. The mean scores of FM impact function changes from post to follow-up were not significant in both the groups. However, we could understand that there was a reduction of the impact of FM on patients in the ACBT group during the pre–post phase which was also sustained to the follow-up period.
FM overall impact score (pre) for the ACBT group decreased from 14.56 (SD: 3.844) to 8.33 (SD: 3.64) while that of JPMR was 15.29 (SD: 2.752) with a mild reduction to 15.14 (SD: 2.795) in pre–post phase. Result showed that the ACBT intervention is effective in reducing the FM overall impact scores among FM patients (P = 0.008) and JPMR is not (P = 0.783) effective. FM overall impact score further decreased to 7.44 (SD: 3.468, P = 0.233) at follow-up phase in the ACBT group while it increased to 16.00 (SD: 2.160, P = 0.109) in the other group. Changes from post to follow-up were not significant in both the groups. However, there was better results in the ACBT group in the pre–post–follow-up phase (P = 0.008). Therefore [Table 1], ACBT was effective in reducing the FM overall impact, but JPMR was not.
The BPI pain severity mean score of the ACBT group (pre) was 7.90 and JPMR group was 6.80 (P = 0.096), which showed that the groups were statistically not different at baseline. Likewise, the mean score of the pain severity in the ACBT group (post phase) was 4.56 and that of the JPMR group was 6.43 (P = 0.096). However, the difference in the pain severity scores in the ACBT and JPMR groups during pre–post phase was not statistically significant. The same trend was observed in follow-up scores, with a mean of 4.89 for the ACBT group and 5.71 for the JPMR group (P = 0.411).
Pain interference mean scores (pre) of the ACBT group was 7.20 and of the JPMR group was 7.30 (P = 0.877). The post score of the ACBT group was 4.11 and of the JPMR group was 7.14 (P = 0.005). Thus, the results revealed that the ACBT group has more reduction in pain interference scores than JPMR. Similarly, the BPI pain interference (follow-up) mean score of the ACBT group is 3.33 and that of the JPMR group is 7.43 (P = 0.001).
The mean of the ACBT group (pre) in FM impact function score was 23.30 and that of the JPMR group was 24.30 (P = 0.569), which indicated that the scores in both the groups were statistically different at the baseline. Likewise, the mean of the ACBT group (post) in FM impact function score was 12.64 and that of the JPMR group was 23.17 (P = 0.002). The same trend was seen for the follow-up scores as well, with a score of 11.22 for the ACBT group and 23.71 for the other group (P = 0.001). Thus, the FM impact function scores show a statistically significant difference between the ACBT and JPMR groups at post and follow-up periods, which means that the ACBT intervention was more effective compared to JPMR in reducing the FM impact function scores.
The mean of the ACBT group (pre) in FM overall impact scores is 15.00 and that of the JPMR group is 16.10 (P = 0.383) which indicates that the groups are statistically not different at the baseline measurement. The mean of the ACBT group (post) in FM overall impact score is 8.33 and that of the JPMR group is 15.14 (P = 0.003). The same trend has been observed in the follow-up scores, with a score of 7.44 for ACBT group and 16.00 for the other group (P = 0.001).
The mean of the ACBT group (pre) in FM impact symptom score was 35.00 and that of the JPMR group was 38.80 (P = 0.272), which indicates that the two groups were statistically different at the baseline [Table 2]. The mean of the ACBT group (post) in FM impact symptom score was 19.78 and that of the JPMR group was 36.71 (P = 0.004). Result showed that ACBT was more effective compared to JPMR in reducing the FM impact symptom scores. The follow-up mean score was 10.247 for the ACBT group and 8.182 for the other group (P = 0.020). Thus, from [Table 3], it is clear that the ACBT intervention was more effective compared to JPMR in reducing the FM impact symptom scores.
|Table 2: Comparison of pain severity, pain interference, and fibromyalgia function mean scores in pre-post and follow-up phases within affective-cognitive behavior therapy and Jacobson's progressive muscular relaxation groups|
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|Table 3: Comparison of pain severity and pain interference, fibromyalgia impact, and fibromyalgia overall impact scores between affective-cognitive behavior therapy and Jacobson's progressive muscular relaxation groups|
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Percentage of therapeutic change in pain and fibromyalgia impact
The raw scores and percentage of therapeutic change of pain [Table 4] and FM impact [Table 5]) for each participant as well as the mean of percentage change for each group in general were computed. For the ACBT group, the mean of the percentage change in pain from pre to post phase was −42.55 whereas in the JPMR group was +4.71. The mean of the percentage change of pain in the ACBT group from the pre to follow-up phase was −45.33 and in the JPMR group was +3.28. With regard to FM impact scores, the mean of the percentage of change from pre to post phase was −43.86 and in the JPMR group was +4.46. The mean of the percentage change of FM impact in the ACBT group from the pre to follow-up phase was −50.60 and in the JPMR group was +1.65. The results revealed that there was a significant reduction in pain and FM impact scores in the ACBT group compared to the JPMR group.
|Table 4: Raw score and percentage of therapeutic change in pain (from the Brief Pain Inventory Scale)|
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|Table 5: Raw score and percentage of therapeutic change in fibromyalgia impact (from the Fibromyalgia Impact Questionnaire Scale)|
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| Discussion|| |
The present study was aimed at comparing the ACBT effectiveness with that of JPMR in reducing the pain scores and FM impact among patients with FM. The current study revealed that majority of the FM patients were middle-aged females (n = 13), who were mostly school educated, hailing from lower-middle class (n = 17), and married females [Table 1]. Nineteen participants out of twenty were female. This is in accordance with an established study which has found that women are at three times the odds of men for having been diagnosed with FM., Although most of our participants were in marital relationship, majority of them were found to have marital conflicts (n = 14). The demographic characteristics of this study are consistent with earlier researches indicating middle age, less education, being divorced, and being disabled, as factors which make people susceptible to FM.
Pain severity and interference significantly reduced in the ACBT group compared to that of JPMR, indicating that it is more effective in reducing the intensity of pain as well as the interference on daily activities in FM. This is in line with the randomized controlled trial study conducted by Woolfolk et al. in FM patients using ACBT which reported less pain and overall better functioning than control patients at post treatment and follow-up. ACBT is an improved version of CBT that was tried in patients with various forms of somatization in 2006 by Allen et al. and was found to be very effective in reducing the symptoms. The pain reduction and better outcome in functioning could be attributed to the fact that ACBT addresses facilitation of emotional awareness, cognitive restructuring, and interpersonal communication which, in turn, adds on to the treatment efficacy. Poor awareness of emotions leads to unresolved negative affective states that prolong the physiological arousal. ACBT helps in dealing effectively with the emotions that are suppressed or denied. An enhancement of mood is associated with greater decreases in pain intensity. However, the improvement was not significant in the follow-up phase which raises the question whether additional booster sessions are required to maintain the therapeutic change that was attained.
In the JPMR group, there was a minimal reduction in the mean scores of pain severity and interference in post phase which was not significant, however, the mean interference score increased in the follow-up phase. A systematic review of the use of relaxation in chronic pain management suggests that although the pain outcome can improve, the usefulness of relaxation reduces over time. Being a technique to induce deep muscle relaxation, progressive muscle relaxation could serve as the substrate of behavioral intervention for chronic pain. PMR reduces the muscular tension and makes the body relax, but as it does not address the psychological factors that may predispose and maintain FM, its effectiveness may impede over time.
There is no significant difference between the ACBT and JPMR groups in pain severity, interference, FM overall impact, FM impact function, and FM impact severity in the baseline assessment, indicating that the groups are matched and that the change is not due to the effect of any confounding factors. Along with pain, as the patients with FM have other symptoms, including sleep disruption, fatigue, depression, anxiety, memory and concentration problems, headaches, numbness/tingling, and others, FM impact has to be evaluated to know the effectiveness of any interventions., These multiple symptoms may have a negative impact on daily life, restricting participants' functioning and emotional well-being leading to disability in multiple dimensions., In the post and follow-up assessment, there is a significant difference between the ACBT and JPMR groups in FM overall impact, FM impact function, and FM impact severity with low mean scores in the ACBT group, indicating that it is more effective in reducing the associated symptoms as well as enhancing the functioning of FM patients. This could again be accounted for by the fact that ACBT is an emotionally focused behavioral intervention that is designed to help the patient access, process, and accept both affective and cognitive responses.
Although there is a dearth of studies using ACBT in FM, evidence with other CBT techniques in FM management suggests that it is useful in reducing the FM symptoms and their impact on quality of life. The rationale for using CBT is based on the links between chronic pain and psychological factors. CBT can be used as an adjunctive therapy, particularly with patients who present with an emotionally disturbed or dysfunctional profile. There is considerable overlap between CBT and behavioral interventions like relaxation training. Some of these relaxation techniques have evidence for effectiveness in the absence of a cognitive therapy element as it alleviates that distress associated with stress response in FM patients. However, this is contradictory to the results of our study which suggests that relaxation alone without emphasizing cognitive and emotional elements is less effective. CBT protocol that included PMR and autogenic training as a central aspect of treatment was effective in reducing the pain severity when compared to augmented medical care. However, ACBT tends to be more productive than traditional CBT in terms of outcome measures as it addresses the implicit, irrational, nonverbal, and emotional aspects of patients with FM.
| Conclusion|| |
ACBT is found to be associated with better reductions in pain and its interference in the daily lives of FM patients compared to JPMR. However, more studies are required using these interventions to confirm its effectiveness in managing FM. Given that, to our knowledge, there were no studies done in India using any psychological interventions for managing FM, this study is one of the first attempts to compare the role of ACBT and JPMR for managing FM. The findings of the study support the usefulness of ACBT as a feasible and acceptable therapeutic method in the treatment of FM. The effectiveness of elicitation and exploration of affect along with other cognitive-behavioral techniques may have added to the therapeutic strength of this approach. However, the unique factors that contribute to the effectiveness of ACBT warrant further investigation. We concluded that ACBT can be used as an adjunct to the pharmacological treatment for better outcome in FM.
Small sample size was one of the major limitations of our study. The study was single blinded than double blinded. The confounding factors such as support system and coping styles were not taken into consideration as there was limitation in the number of variables to be included due to the small size of the sample. The majority of the participants in the study were female which may be due to the fact that FM is predominant in females. However, this raises the question whether the results can be generalized to male population affected with FM. The long-term maintenance of the improvement could not be ascertained as the study follow-up was only for 1 month.
| Future directions|| |
This study could be replicated with a larger sample size and longer duration of follow-up. As studies using ACBT in FM are relatively few, more research has to be carried out to confirm the results obtained in the current study. Randomized control trials using rigorous statistical methods to control confounding variables need to be conducted in order to confirm the efficacy of ACBT in the management of FM. Qualitative studies could also be done to understand the unique components of ACBT that contribute to better outcome in terms of pain reduction and overall functioning in FM. Moreover, FM patients could be compared with patients with other somatization disorders to look for similar etiology pattern across somatization disorders as clinical features of these conditions overlap.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, et al.
The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken) 2010;62:600-10.
Vanasse A, Courteau M, Courteau J, Carrier N. Chronic pain and depression: A complex epidemiological picture. In: Mental Health and Pain. Paris: Springer; 2014. p. 81-97.
Turkyilmaz AK, Kurt EE, Karkucak M, Capkin E. Sociodemographic characteristics, clinical signs and quality of life in patients with fibromyalgia. Eurasian J Med 2012;44:88-93.
Dureja GP, Jain PN, Shetty N, Mandal SP, Prabhoo R, Joshi M, et al.
Prevalence of chronic pain, impact on daily life, and treatment practices in India. Pain Pract 2014;14:E51-62.
Lee JW, Lee KE, Park DJ, Kim SH, Nah SS, Lee JH, et al.
Determinants of quality of life in patients with fibromyalgia: A structural equation modeling approach. PLoS One 2017;12:e0171186.
Sansone RA, Sansone LA. Chronic pain syndromes and borderline personality. Innov Clin Neurosci 2012;9:10-4.
Arnold LM. Biology and therapy of fibromyalgia. New therapies in fibromyalgia. Arthritis Res Ther 2006;8:212.
Pagano T, Matsutani LA, Ferreira EA, Marques AP, Pereira CA. Assessment of anxiety and quality of life in fibromyalgia patients. Sao Paulo Med J 2004;122:252-8.
Braz Ade S, de Paula AP, Diniz Mde F, de Almeida RN. Non-pharmacological therapy and complementary and alternative medicine in fibromyalgia. Rev Bras Reumatol 2011;51:269-82.
Persson AL, Veenhuizen H, Zachrison L, Gard G. Relaxation as treatment for chronic musculoskeletal pain – A systematic review of randomised controlled studies. Phys Ther Rev 2008;13:355-65.
Woolfolk RL, Allen LA. Treating Somatization: A Cognitive-Behavioral Approach. New York: Guilford Press; 2007.
Jacobson E. Progressive Relaxation. 2nd
ed. Oxford, England: University of Chicago Press; 1938.
Jeffrey S, McClelland T, Carus C, Graham C. Relaxation and chronic pain: A critical review. Int J Ther Rehabil 2016;23:289-96.
Hassett AL, Cone JD, Patella SJ, Sigal LH. The role of catastrophizing in the pain and depression of women with fibromyalgia syndrome. Arthritis Rheum 2000;43:2493-500.
Friedberg F, Williams DA, Collinge W. Lifestyle-oriented non-pharmacological treatments for fibromyalgia: A clinical overview and applications with home-based technologies. J Pain Res 2012;5:425-35.
Woolfolk RL, Allen LA, Apter JT. Affective-cognitive behavioral therapy for fibromyalgia: A randomized controlled trial. Pain Res Treat 2012;2012:937873.
Cleeland CS, Ryan KM. Pain assessment: Global use of the brief pain inventory. Ann Acad Med Singap 1994;23:129-38.
Bennett RM, Friend R, Jones KD, Ward R, Han BK, Ross RL. The Revised Fibromyalgia Impact Questionnaire (FIQR): Validation and psychometric properties. Arthritis Res Ther 2009;11:R120.
Blanchard EB, Schwarz SP, Neff DF. Two-year follow-up of behavioral treatment of irritable bowel syndrome. Behav Ther 1988;19:67-73.
White KP, Speechley M, Harth M, Ostbye T. The London Fibromyalgia Epidemiology Study: The prevalence of fibromyalgia syndrome in London, Ontario. J Rheumatol 1999;26:1570-6.
Allen LA, Woolfolk RL, Escobar JI, Gara MA, Hamer RM. Cognitive-behavioral therapy for somatization disorder: A randomized controlled trial. Arch Intern Med 2006;166:1512-8.
Bradley LA. Pathophysiology of fibromyalgia. Am J Med 2009;122:S22-30.
Dunford E, DClinPsy MT. Relaxation and mindfulness in pain: A review. Rev Pain 2010;4:18-22.
Galvez-Sánchez CM, Duschek S, Reyes Del Paso GA. Psychological impact of fibromyalgia: Current perspectives. Psychol Res Behav Manag 2019;12:117-27.
Henriksson KG. Pathogenesis of fibromyalgia. J Musculoskelet Pain 1993;1:3-16.
Bennett R, Nelson D. Cognitive behavioral therapy for fibromyalgia. Nat Clin Pract Rheumatol 2006;2:416-24.
Dadabhoy D, Crofford LJ, Spaeth M, Russell IJ, Clauw DJ. Biology and therapy of fibromyalgia. Evidence-based biomarkers for fibromyalgia syndrome. Arthritis Res Ther 2008;10:211.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]