1Some 39% of patients with fibromyalgia reported a moderate improvement in their mood while 29% reported a slight improvement after receiving the psychological intervention via their mobile phones.
2Some 4% of patients reported a great improvement in their involvement in daily activities, while 15% indicated a moderate improvement and 30%, a slight improvement.
3The interference of pain in social relations was reduced slightly for 39% of patients, while it was re-duced moderately for 11%.
4Although 26% and 24% of patients respectively achieved a moderate and a slight improvement with re-gard to levels of physical pain, 29% reported a moderate deterioration and 12%, a slight deterioration.
Each of the female patients was assessed twice per day through a questionnaire that they received on their mobile telephones. This enabled us to know their levels of pain, mood, level of activity and the interference of pain in their daily functioning. Based on this assessment patients received information every day on a psycho-logical exercise that they could practice at home whenever they needed it. This study provides novel evidence that shows preliminary results on the efficacy of an Internet-delivered psychological intervention to promote self-care in patients with chronic pain.
Fibromyalgia is a syndrome featuring chronic pain of unknown origin, often accompanied by fatigue, sleep dis-orders, mood disorders and concentration difficulties, among other problems. In Spain, its prevalence among the general population is estimated at around 2.45% and it is more frequent among women aged between 60 and 69 years of age (Font Gayà et al., 2020). Prospective studies indicate that the disease follows a chronic pathway, with little improvement at 5-7 years of follow-up (White et al., 2002). As for its socioeconomic im-pact, it is calculated at, on average, between 9 and 12 visits per year to the doctor, with a yearly cost of almost 13,000 million euros in Spain (Cabo-Meseguer et al., 2017). . In comparison with other disorders, patients with fibromyalgia present a higher degree of labour absenteeism and consumption of pharmaceutical drugs that are, for the most part, ineffective.
The experience of pain for these patients is complex and includes conduct-related, cognitive and affective fac-tors that affect their quality of life. For this reason, psychological approaches have centred their efforts on reducing the incapacity caused by the pain, emotional malaise and maladaptive confrontational strategies, rather than seeking direct reduction of the pain (Roditi and Robinson, 2011). Cognitive-behavioural therapies, relaxation, psychoeducational interventions, behavioural treatments and programmes based on mindfulness have proven effective in reducing sleep problems, depression, functional status and catastrophising by patients (Glombiewski et al., 2010). However, the evidence of decades of clinical trials shows that the results are mod-est and suggests that a large part of the variation in pain and other related variables remains unresolved with the treatments available (Morley et al., 2013). Recent review studies indicate that just 13% of patients with fibromyalgia present a significant reduction in their symptoms after receiving cognitive-behavioural treatments (Bernardy et al., 2018).
In recent years, efforts have been made with the aim of improving psychological treatments for fibromyalgia. In this sense, information and communication technologies (ICT), such as virtual reality, augmented reality, the Internet, and mobile apps can provide clinical psychology with new tools for assessment and treatment. These technologies offer numerous benefits: they reduce barriers for access to health services, they increase the effi-ciency of treatments, and they promote self-care, a key aspect to be taken into account in chronic conditions.
Our objective is to study the usefulness of ICT-supported interventions for the evaluation and treatment of fibromyalgia. Using these technologies, we provide information and evidence-based psychological tools for fibromyalgia patients, with the aim of improving their quality of life.
1. The impact of psychological interventions on levels of pain and its interference in daily life
The experience of pain for patients with fibromyalgia is complex and includes behavioural, cognitive and affec-tive factors that affect the quality of life of those who suffer from it. For this reason, the psychological ap-proaches have centred their efforts on reducing the incapacity caused by the physical pain and emotional suf-fering, as well as on promoting strategies to help manage pain better. Although these treatments do not seek to directly reduce pain levels, they do try to reduce the interference that the pain causes in patients’ daily lives.
In this project, we developed a psychological intervention using an Internet app that serves to evaluate and monitor the influence of pain on the life of patients with chronic pain. The participants were 40 patients with fibromyalgia, diagnosed by a rheumatologist. Of these patients, 73.2% have suffered fibromyalgia for over 10 years, 14.6% from 5 to 10 years and 12.2% for fewer than five years.
The app’s contents were developed following the recommendations of the Initiative on Methods, Measure-ment, and Pain Assessment in Clinical Trials, IMMPACT (Dworkin et al., 2005) and it facilitates monitoring of the patient over 30 days, through two daily recordings with short questions on mood, pain intensity and conse-quences on daily life, work and social relations (figure 1). These questions have been adapted from question-naires validated for measuring pain and related variables, using their most representative items. It is important to point out that the instructions, number of answers, and the text labels for the answer options in the original questionnaires, have been adapted in the app to optimise its use on mobile devices and increase the homoge-neity of the items.
The psychological treatment programme integrates cognitive-behavioural treatment techniques, acceptance and mindfulness tools, and emotional regulation strategies that have shown evidence in the treatment of chronic pain. The therapeutic components of the programme are: psychoeducation; motivation for change; behavioural activation and regulation of activity pace; acceptance of pain and mindfulness, cognitive flexibility and prevention of relapses. A protocol of short interventions was developed that integrates strategies from all of these components. Every day, patients were provided with psychological exercises, taking into account how they felt at that moment in time and what their preferences were, thus personalising and increasing the effi-ciency of the psychological intervention. The interventions use videos, images and text so that patients can perform the exercises in a completely self-administered way and without the need for support from a specialist practitioner (figure 2).
With regard to levels of physical pain, although 26% and 24% of patients achieved a moderate and a slight im-provement respectively, 29% reported a moderate deterioration in their pain levels and 12% a slight deteriora-tion. As for the interference of pain in their social relations, 39% of patients achieved a slight improvement and 11% a moderate improvement.
2. Is it possible to improve a patient’s mood despite their pain?
Some 39% of fibromyalgia patients reported a moderate improvement in mood while 29% reported a slight improvement after receiving the psychological intervention via their mobile telephones. Although 18% of pa-tients reported a slight deterioration and 11% a moderate deterioration, the data show that the majority of patients achieved some improvement in their mood with respect to the start of the intervention.
3. The importance of being active and changes in activity levels
The pain present in fibromyalgia, because it is an aversive experience, leads to behaviour such as inactivity or the interruption of activities. Clinical guides affirm that following an adequate activity pace, combining patterns of activity and rest, may help to alleviate the pain, improve the overall sensation of wellbeing and physical functioning, as well as lead to an increase in positive emotions that contribute to the improvement of the general mood (Racine et al., 2020).
As for changes in activity levels, some 4% of patients reported a great improvement in their involvement in their daily activities, 15% indicated a moderate improvement, and 30%, a slight improvement. However, 22% of patients reported a moderate deterioration and 18% a slight deterioration. Improvements in activity levels re-fer to an increase in involvement in significant activities, while deterioration indicates a reduction in these ac-tivities. Often, physical pain is associated with inactivity due to the fear of pain and fatigue associated with performing activities.
Clinically significant changes were observed in mood and in the interference of pain in everyday life in half of the patients. Taking into account that this was an Internet-delivered psychological intervention that was com-pletely self-administered, and with a limited duration, the results are promising.
The main benefits of these types of applications are that they allow an individual profile to be obtained of the experience of pain, because they collect information on a daily basis and at the very time that the pain episode is being experienced; their use via mobile devices and tablets is easy, and they provide assistance for patients at the time that they need it.
Although we have seen that many patients have achieved improvements in the majority of variables, there are others who show no changes or even show some degree of deterioration. These results are in line with the published literature. The evidence on Internet-delivered psychological treatments for fibromyalgia is still lim-ited. A recent review study has found that these types of treatments have shown a certain efficacy (with low or moderate effects) in reducing negative moods and the disability caused by pain in relation with the need for waiting lists and habitual treatments. However, no statistically significant differences were found in reduction of pain and acceptability of treatments (Bernardy et al., 2019). Furthermore, due to the scarcity of studies pub-lished on this subject, it has not been possible to compare psychological treatments with the support of a ther-apist and those that are completely self-applied. The data on these types of treatments for other psychological disorders indicate that, in general, treatments with support are more effective than unguided interventions with regard to reducing the severity of symptoms. Therefore, it is to be expected that Internet-delivered treat-ments that are self-administered will obtain more limited results. It is necessary to continue investigating to identify what profiles of patients benefit most from these types of interventions and how to strengthen their effects.
As for the limitations of this study, it is necessary to point out that this is a preliminary study with a reduced sample of participants. Future studies should replicate the results in randomised controlled studies and com-pare these new results with those reached by other types of interventions. Furthermore, they should also in-clude follow-up to analyse whether the results are maintained over time.
Although the current guidelines for pain management have the objective of incorporating ICT into patient care, to date research combining these efforts in patients with chronic pain has been limited. The results achieved in our study encourage us to continue exploring the use of new technologies with this population, in order to improve access and the dissemination of psychological treatments.
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