Clinical Contributions

Multidisciplinary Group Intervention for Fibromyalgia: A Study of Psychiatric Symptom and Functional Disability Outcomes.
By Arne Beck, PhD; George Breth, MD; Jennifer Ellis, MBA; Rob Hays, MD, MA; Colleen Miller, RNP; Noah Reaven, PhD

Note: This is a follow-up to an article previously printed in The Permanente Journal (Summer 2000). Click here for original article.

 

Abstract Objective: To assess psychiatric symptoms and functional impairment in patients with fibromyalgia after they participated in a half-day group clinic administered by the rheumatology department at Kaiser Permanente in Colorado. Methods: Questionnaires were given to 184 patients at the beginning of the group clinic and by telephone interview 11 to 23 months after completion of the group clinic. Questionnaires assessed demographics, psychiatric symptoms, functional impairment, work disability, and history of physical or emotional trauma and physical, emotional, or sexual abuse. Results: Questionnaire responses indicated that patients had statistically significantly less anxiety (p = 0.002), depression (p < 0.001), panic (p = 0.029), pain (p = 0.003), restless sleep (p < 0.001), stiffness (p < 0.001), nervousness/tenseness (p < 0.001) after attending the group clinic. Number of missed work days significantly decreased (p = 0.003), and patients' ability to do their jobs was also significantly improved (p < 0.001). However, neither interference in five major life domains nor instrumental activities of daily living improved. Number of visits to primary and specialty care also decreased significantly (p < 0.005). Conclusions: In fibromyalgia patients referred to a rheumatology department, a multidisciplinary group clinic intervention may effectively improve outcomes in both mental health and functional status. This group clinic model may also reduce medical utilization and associated costs.

Introduction

Fibromyalgia syndrome (FMS) is a chronic widespread pain syndrome often associated with fatigue, sleep disturbance, functional impairment, and psychiatric comorbidity.

We previously described psychiatric comorbidity and functional disability in 184 patients seen in the rheumatology department's multidisciplinary group clinic at Kaiser Permanente (KP) Colorado from November 1998 through August 1999.¹ Using an electronic questionnaire, we identified many patients with psychiatric disorders, including depressive illness, bipolar disorder, and general anxiety disorder as well as functional impairment severe enough to interfere with several major life domains. We also described the therapeutic interventions developed to address the needs documented by the questionnaire.¹

Methods

The 184 patients described previously were diagnosed with FMS by using established criteria, including a tender-point examination, and were referred to the rheumatology department. The group clinic intervention consisted of one four-hour session that included an overview of the diagnosis and treatment of FMS; behavioral guidelines for restorative sleep, relaxation, and exercise; and discussion of medication as well as of physical therapy treatment for fibromyalgia. A behavioral medicine specialist regularly attended the clinic and provided intervention or referral for mental health services as necessary.

A prospective observational (ie, outcomes) study design was used. Inclusion criteria were a confirmed diagnosis of FMS, attendance at the FMS group clinic from November 1998 through August 1999, and completion of the baseline assessments. The only exclusion criterion was refusal to complete the baseline questionnaire. Comprehensive convenience sampling was used; all available patients meeting the inclusion criteria were included. No control group was used; all study participants received the intervention. Telephone follow-up data collection procedures were approved by the KP Northern California Institutional Review Board. Follow-up data were collected on 99 of the 184 patients (53.8%) via a telephone interview conducted by a research assistant during the period June 2000 through October 2000.

Variables collected at baseline included age and gender; employment and disability status; frequency of exercise; history of physical or emotional trauma and physical, emotional, or sexual abuse; medications used currently and in the past; and three validated self-reported measures of functional status and psychiatric disorders. These included the Illness Intrusiveness Ratings Scale,² the Fibromyalgia Impact Questionnaire (FIQ),³ and the Quick PsychoDiagnostics Panel (QPD).⁴ The Illness Intrusiveness Scale measures the degree to which an illness interferes with major life domains such as work, recreation, and family and social relationships. The FIQ was designed to measure the impact of FMS on instrumental activities of daily living, eg, shopping, meal preparation, walking several blocks, or driving a car; and the common symptoms associated with FMS, such as pain and fatigue. The QPD is an automated tool for diagnosing and assessing severity of several psychiatric disorders, including major depression, generalized anxiety disorder, and bipolar disorder. Baseline questionnaires were administered via the POV Box, a handheld device, equipped with a liquid crystal display (LCD) screen displaying questions and a keypad with numeric and true/false buttons for entering responses.

With the exception of age, gender, and medication use, the same variables were collected at follow-up. Follow-up measures were obtained 11 to 23 months after the group clinic.

All statistical analyses were performed using SAS Version 8.0. Primary analyses involved assessing changes from baseline to follow-up on the Illness Intrusiveness Ratings Scale, the FIQ, and the QPD. Because the data were not normally distributed, the Wilcoxon signed rank test, the nonparametric test analogous to the paired t test, was used to assess change in these measures. A significance level (alpha) of 0.05 was used to analyze results shown in Tables 1, 2, 3. Because multiple tests were performed, a more conservative threshold for statistical significance (level of 0.01) also was used to analyze the results. All tests were two-tailed.

Results

To test for potential bias in the follow-up data, we conducted analyses comparing baseline measures for those who completed the follow-up interviews with baseline for those lost to follow-up. No statistically significant differences in the primary outcomes of psychiatric symptoms and functional status were observed, findings suggesting minimal bias in the data for patients who completed the follow-up assessment.

The pre- and postintervention means, absolute and relative changes or differences, confidence intervals, and p values for all primary endpoints are presented in Tables 1, 2, 3. Because the data were not normally distributed, the 5% and 95% quartiles are displayed in lieu of the 95% confidence intervals. The attached tables demonstrate improvement in outcomes achieved for several of the measures.

Statistically significant positive changes were seen in several of the FIQ items, even when using a significance level of 0.01. The number of days of work missed in the last week due to FMS averaged 0.7 fewer days, or 49% (p = 0.003). On a scale from 0 to 10, FMS interfered 3.2 points less, a 60% reduction, with patients' ability to do their jobs (p < 0.001). On the same scale, pain averaged 15% lower at follow-up (p = 0.003); patients' ratings on restfulness upon waking improved 11% (p = 0.001), stiffness decreased 16% (p < 0.001), symptoms of tenseness and nervousness decreased 19% (p < 0.001), and depression decreased 14% (p = 0.001). None of the instrumental activities of daily living were significantly improved.

As assessed by the QPD (Table 2 ), statistically significant reductions were seen in symptoms of anxiety (1.9-point decrease, or 19%; p = 0.002); depression (2.3-point decrease, or 23%; p < 0.001); and panic disorder (1.3-point decrease, or 16%; p = 0.029). Interference in five major life domains, assessed by the Illness Intrusiveness Ratings Scale, was not improved at follow-up (Table 3 ).

Although no formal cost analysis was conducted, analysis was done of primary and selected medical specialty care (eg, family practice, internal medicine, neurology, neurosurgery, gastroenterology, physical medicine, and rheumatology) utilization changes from six months before the group clinic to six months after the group clinic. Results showed a reduction in mean visits from 4.4 to 3.5 (p < 0.005) and a slight (though nonsignificant) increase in mental health visits (1.05 to 1.18).

Discussion

Baseline questionnaire results obtained from our sample of FMS patients showed a high prevalence of major depression and anxiety, significant functional disability, and a history of past physical or emotional trauma and physical, emotional, or sexual abuse.¹ These findings are consistent with what has been reported in the literature.^5-10

The results of our follow-up assessment indicate that the FMS group clinic was associated with statistically significant improvement in symptoms of anxiety, depression, and panic as well as in pain, restful sleep, stiffness, nervousness, and tenseness. Days of work missed showed a statistically significant decrease, and patients' ability to do their jobs also showed statistically significant improvement. However, neither interference in five major life domains nor instrumental activities of daily living improved at follow-up. Finally, a statistically significant decrease in primary and specialty care visits also was observed.

Several studies^11-13 have evaluated educational and behavioral interventions in patients with fibromyalgia: Among them, a six-month group therapy program consisting of behavior modification, stress reduction techniques, and strategies to improve fitness conducted at the University of Oregon showed improvement in tender points and fibromyalgia impact questionnaire items.¹¹ A study at the University of California at San Diego found improvement in depression scores, self-reported and observed pain behaviors, and myalgia scores in FMS patients as a result of behavioral and educational interventions.¹² A 1.5-day interdisciplinary program conducted at the Mayo Clinic showed improvement in FIQ and Multidimensional Pain Inventory scores.¹³

Limitations

Because all patients referred to the rheumatology department with a confirmed diagnosis of FMS were enrolled in the group clinic, the results are representative of the population of FMS patients referred for specialty care. However, these results may not be representative of the larger population of patients managed in primary care who have less severe FMS and who would probably be less functionally impaired and at less risk for psychiatric disorders than those referred to a rheumatologist.

Because we used a single-cohort, pre-post design, factors other than or in addition to the group clinic, such as spontaneous symptom remission, could have been associated with the improvement in patient outcomes. However, fibromyalgia symptoms do not typically improve with time without some type of clinical intervention,¹⁴ an observation which suggests that the group clinic did contribute to the improved outcomes.

 

	Practice Tips
	Fibromyalgia, a widespread chronic pain syndrome, is associated with psychiatric symptoms, significant fatigue, and sleep disturbance, which interfere with activities of daily living including work and recreation.
	Components of an effective group clinic for the treatment of fibromyalgia include education about diagnosis and treatment, discussion of guidelines for achieving restful sleep, guidelines for physical therapy treatment, guidelines for relaxation and stress management, overview of medications as well as an assessment of and prompt intervention for psychiatric comorbidity.
	Upon follow-up improvement in psychiatric symptoms such as depression, anxiety and panic, nervousness and tenseness, as well as functional parameters such as work ability and number of missed days was demonstrated in this group of patients. These patients are representative of fibromyalgia patients referred for specialty care.
	This particular group of difficult-to-treat patients made significant progress while at the same time requiring fewer primary care and specialty visits. This is especially noteworthy in a patient population known for high care utilization.
	Although we cannot definitely conclude that this improvement occurred as a result of this one time intervention the literature does not suggest improvement in fibromyalgia symptoms over time.

Conclusion

Our group clinic model for the routine care of FMS in the rheumatology department appeared to be associated with improved outcomes in functional status and psychiatric symptoms while showing improved utilization of primary and specialty care services. These findings suggest that the group clinic is a potentially cost-effective model for fibromyalgia care. Important future endeavors include further follow-up data, validation of our experience in other practice settings, and consideration of a more rigorous randomized controlled trial of FMS group intervention in the practice of rheumatology.

Acknowledgments

Supported by a grant from the Kaiser Permanente Colorado Research and Development Fund, the Kaiser Permanente Garfield Memorial Fund Depression Initiative, and an unrestricted Educational Grant from Eli Lilly and Company.

Scott Rosenberg, MS, of Point-of-View Survey Systems, Inc, provided programming asssistance.

We acknowledge team members of the Departments of Rheumatology and Behavioral Health. Audrey Keller, MHA, of the Clinical Management Consulting Department provided assistance with analysis of medical and behavioral health utilization data.

References

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