Effectiveness of body awareness interventions in fibromyalgia and chronic fatigue syndrome: A systematic review and meta-analysis

Summary

Objectives

Patients with long-lasting pain problems often complain of lack of confidence and trust in their body. Through physical experiences and reflections they can develop a more positive body- and self-experience. Body awareness has been suggested as an approach for treating patients with chronic pain and other psychosomatic conditions. The aim of this systematic review is to assess the effectiveness of body awareness interventions (BAI) in fibromyalgia (FM) and chronic fatigue syndrome (CFS).

Methods

Two independent readers conducted a search on Medline, Cochrane Central, PsycINFO, Web of knowledge, PEDro and Cinahl for randomized controlled trials.

Results

We identified and screened 7.107 records of which 29 articles met the inclusion criteria. Overall, there is evidence that BAI has positive effects on the Fibromyalgia Impact Questionnaire (FIQ) (MD −5.55; CI −8.71 to −2.40), pain (SMD −0.39, CI −0.75 to −0.02), depression (SMD −0.23, CI −0.39 to −0.06), anxiety (SMD −0.23, CI −0.44 to −0.02) and Health Related Quality of Life (HRQoL) (SMD 0.62, CI 0.35–0.90) when compared with control conditions. The overall heterogeneity is very strong for FIQ (I² 92%) and pain (I² 97%), which cannot be explained by differences in control condition or type of BAI (hands-on/hands-off). The overall heterogeneity for anxiety, depression and HRQoL ranges from low to moderate (I² 0%–37%).

Conclusions

Body awareness seems to play an important role in anxiety, depression and HRQoL. Still, interpretations have to be done carefully since the lack of high quality studies.

Introduction

Medically unexplained symptoms (MUS) are somatic symptoms that cannot be (adequately) explained by organic findings or where no clear organic etiology can be identified after an appropriate medical examination. Fibromyalgia (FM), irritable bowel syndrome (IBS), Chronic Fatigue Syndrome (CFS) and non-cardiac chest pain are all examples of clusters of symptoms, which belong under the broad umbrella of MUS. Approximately one third (30–50%) of individuals who visits the general practitioner is diagnosed with MUS (Buffington, 2009, Landelijke Stuurgroep Mul, 2010). Most complaints disappear after a few days to weeks. In 20–30% of the cases, these complaints remain for a longer period (Landelijke Stuurgroep Mul, 2010). Besides the high prevalence in health care, they are also responsible for a significant proportion of disability in workforce (Henningsen et al., 2003). Moreover, these individuals usually have merged symptoms making them even more restricted in their daily functioning and causing an even longer period of symptoms or complaints (Landelijke Stuurgroep Mul, 2010). These patients usually present with back pain, headache, chest pain, fatigue, pain in arms and legs, gastro-intestinal symptoms, joint pain and dizziness (Van Dieren and Vingerhoets, 2007). Bodily sensations are often hyper-present, difficult to express in words, meaningless and mentally unprocessed, fitting the concept of what Verhaeghe calls actualpathology (Verhaeghe and Vanheule, 2005, Verhaeghe, 2011). The inability to express inner experiences in words (i.e. alexithymia) and consequently the lack of mental processing (i.e. mentalization) are both crucial factors in MUS (Verhaeghe and Vanheule, 2005). Arousal derived from within the body (i.e. proprioception and interoception) cannot be processed (enough) by mental representations or constructions, leading to a more ‘body-oriented’ coping strategy. Symptoms represent this strategy and are attempts to handle the arousal coming from inside the body. Commonalities across the different MUS include over-representation of females and individuals who had to deal with negative experiences in the past (Van Houdenhove and et al., 2001). Although it may have an insidious onset, symptoms usually occur suddenly (after a precipitating event) and have a variable course (Buffington, 2009).

Fibromyalgia (FM) and Chronic Fatigue Syndrome (CFS) are both part of a broad category of ‘functional somatic symptoms’ or MUS. In psychiatric diagnosis they were previously referred to as ‘undifferentiated somatoform disorder’ but are recently – in DSM-V – redefined as ‘somatic symptom disorder’ (American Psychiatric Association, 2013a, American Psychiatric Association, 2013b). They show an overlap in symptoms, causes and treatments, making it difficult to establish an accurate diagnosis, until now made on the basis of criteria (Table 1). For instance, although only 18% of patients with FM had been diagnosed with CFS, 80% of patients with CFS had received a diagnosis of FM (Aaron et al., 2000). Where all individuals with CFS report fatigue, 86% of individuals with FM do too. And conversely; while all individuals with FM report arthralgia, 88% of individuals with CFS do too (Kanaan et al., 2007). Considering the demonstrated overlap and the increasing tendencies toward a similar treatment approach of these syndromes we will take the “lumper” point of view by examining CFS and FM as an entity (Wessely and White, 2004). Disorders – such as fibromyalgia and chronic fatigue syndrome – which are characterized by chronic, medically unexplained fatigue, exercise and stress intolerance are associated with physical, mental, social and professional inability (Van Houdenhove and Luyten, 2008). Although the significant negative impact on quality of life, there is still a lack of understanding of the predisposing, precipitating and perpetuating factors. This lack of understanding creates not only confusion for patients and caregivers, but also a lack of recognition, problematic interactions between (medical) disciplines, feelings of meaninglessness or stigmatization and a negative impact on the employability or social participation of these patients (Van Dieren and Vingerhoets, 2007). There is often little spontaneous improvement of symptoms in FM/CFS and there is still a need for effective approaches in the management of this population. To date, most research has been focused on exercise therapy and cognitive behavior therapy (CBT) in FM/CFS, with limited and moderate effect (Van Houdenhove and Luyten, 2008, Hsu et al., 2010). The lack of emphasis upon psychological stress regulation within the ‘traditional therapies’ is a possible cause for the minimal effect on pain. Van Houdenhove and et al. (2001) findings show that “CFS and FM may remain (at least in part) frustrating because a substantial subgroup of patients may need a more comprehensive therapeutic approach, including experiential/psychodynamic and systemic psychotherapy, and/or adequate psychopharmacological support (p.26)”. Also important to note is that in addition to physical symptoms patients with long-lasting pain often complain of lack of confidence and trust in their body along with feelings of depression and/or anxiety (Gyllensten et al., 2010). Anxiety and depression are therefore the most common comorbidities in these populations (Henningsen et al., 2003). Perpetuating factors such as affective, personality and behavioral factors are essential – maybe even key factors – within therapy, which indirectly supports the assumption of a need for a more comprehensive approach (Van Houdenhove and Luyten, 2008, Van Houdenhove et al., 2004). Besides, therapists are often not aware of what is ‘hidden’ in bodily symptoms and can be referred to as the inner experience and meaning-bestowing. This aspect has to some extent been studied from more phenomenological points of view, but still deserves more attention in order to understand the relationship between bodily symptoms and life experiences for patients with musculoskeletal disorders and pain (Gyllensten et al., 2010).