Meta analysisEffectiveness of body awareness interventions in fibromyalgia and chronic fatigue syndrome: A systematic review and meta-analysis
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).
Section snippets
Body awareness interventions
Body-oriented approaches, which facilitate the development of internal integration, the felt experience of inner connectivity and skills for authentically expressing internal phenomena can offer a possible solution. In the past clinicians assumed that an increased body awareness (BA) would lead to somatosensory amplification, more severe anxiety symptoms, hypochondria and thus an unfavorable clinical outcome (such as more pain). Mehling et al. (2009) show some findings that seem to contradict
Information from ‘within’ the body
According to converging evidence from functional imaging studies, subjective bodily experiences are processed and established through the interoceptive network (Critchley et al., 2004, Craig, 2009). The interoceptive system is activated via stimuli such as heartbeat, hunger, thirst, sexual arousal, light or sensual touch. This afferent input from small-diameter fibers (A-delta and C) follow the lamina 1 spinothalamocortical tract and project information of the physiological condition of the
Objective of the study
It can be concluded that FM and CFS – as part of MUS – are complex disorders that still frustrate patient and caregiver. Although the main complaints are rather somatic of origin, also personality traits such as alexithymia and cognitive processing (mentalization) play an important role in this population. Finally, current treatments are either psychological-oriented or body-oriented approaches. Cognitive behavioral therapy and exercise therapy are the most commonly used interventions with only
Methods
Studies were identified by a comprehensive computerized search on Medline, Cinahl, PEDro, Web of Knowledge, PsycINFO and Cochrane Central. Since Pubmed is a very large database and to not miss studies, a preliminary search was carried out. Pubmed was searched using MeSH terms and free text words on pathology and intervention and also the Cochrane Highly Sensitive Search Strategy for identifying randomized trials in Medline was used (see Table 2). On Cinahl, PEDro, Web of Knowledge, PsycINFO and
Results
7.107 articles were identified and screened. Based on title and abstract, 149 articles met the inclusion criteria. Fifty studies were withheld after removing duplicates (85 studies) and studies which were excluded after consulting a third person (14 studies). Five studies reported on body awareness as an outcome and were assigned to the “primary studies” group, whereas 45 studies reported only on secondary outcomes (“secondary studies” group). Based on the full-text, we excluded 22 studies not
Discussion
The aim of this systematic review and meta-analysis was to assess the effectiveness of BAI in FM and CFS. We conducted a search on Medline, Cochrane Central, PsycINFO, Web of Knowledge, PEDro and Cinahl. A total of 29 randomized controlled trials were included. We were able to pool data from 18 trials, which revealed a positive significant effect in favor of BAI on the FIQ, pain, anxiety, depression and HRQoL (Figure 5). However, there is a strong overall heterogeneity on the FIQ and pain which
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