Effectiveness, cost-utility, and benefits of a multicomponent therapy to improve the quality of life of patients with fibromyalgia in primary care: A mixed methods study protocol

Effectiveness of a Multicomponent Program for Fibromyalgia Patients in a Primary Care Setting (FIBROCARE Program): A Pragmatic Randomized Controlled Trial

Background/Objectives: Multicomponent, non-pharmacological therapies are the preferred first-line treatments for fibromyalgia (FM), but little is known about them in primary care settings. Our study assessed the effectiveness of the FIBROCARE Program in improving the quality of life, functional impact, mood, and pain of people with FM. Methods: We conducted a pragmatic, randomized controlled trial that was not blinded for both patients and the professionals delivering the treatments in the study groups. We compared a group receiving non-pharmacological multicomponent group therapy (MT) based on health education, physical exercise, and cognitive-behavioral therapy with another group receiving the usual clinical care. The MT group was treated in the primary care context in Catalonia (Spain) through 12 consecutive weekly sessions. Both groups were followed up with at the end of the MT group sessions and 6 and 12 months after the group sessions with the Short-Form 36 (SF-36) v2 Health Survey questionnaire, the Hospital Anxiety and Depression Scale (HADS-A and HADS-D), the Visual Analog Scale, and the Revised Fibromyalgia Impact Questionnaire (ClinicalTrials.gov: NCT04049006). Results: Improvements in pain intensity, functional impact, physical health, fatigue, and emotional problems that affect daily activities in the MT group lasted up to 12 months. Benefits measured by the SF-36 Mental Health dimension and the HADS-A subscale were lost after 6 months. Effects on the SF-36 Social Functioning dimension and HADS-D present at 6 months persisted for up to 12 months. Generally, the longer the time since the FM diagnosis, the better was a patient's mood. Conclusions: The FIBROCARE Program effectively improves all the studied health outcomes except patient mood, since anxiety symptoms persist. The program should reinforce patient psychological support overall, focusing particularly on the years initially after diagnosis.

Effectiveness of the SYNCHRONIZE + Brief Intervention in Improving Mediterranean Diet Adherence, Nutritional Quality and Intake Pattern in Persons with Fibromyalgia and Chronic Fatigue Syndrome

BACKGROUND

Multidisciplinary lifestyle interventions are being researched to treat fibromyalgia. However, the impact of nutrition as a key treatment component is little studied. This study aimed to evaluate the effectiveness of the SYNCHRONIZE + lifestyle multidisciplinary intervention in improving adherence to the Mediterranean diet, nutrition quality and dietary intake pattern in persons with fibromyalgia and chronic fatigue syndrome.

METHODS

A pragmatic randomized clinical trial was conducted in primary care. Data were collected using the 17-item energy-restricted Mediterranean Adherence Screener (er-MEDAS), the food frequency questionnaire (sFFQ) and the 24 h recall questionnaire (24 HR), in addition to chrono-nutritional, anthropometric, and body composition data, at baseline and 3-, 6-, and 12- month follow-up visits, and statistically analyzed.

RESULTS

A total of 158 participants were evaluated. Results showed the effectiveness of the intervention in improving adherence to the Mediterranean diet. The adherence depended on the group-time interaction being positive and significant at 3 and 6 months post-intervention in the INT group and on the participant age and educational level. Specifically, the intake of legumes, fruits, vegetables, nuts and blue fish was increased, while the intake of sweets and pastries, butter and cream and red and processed meat was reduced. Furthermore, the intake of chips and candies was also reduced, and the consumption of fermented food (yogurts, cheese, kefir) increased. Thus, general diet quality improved. Interestingly, the intake of key nutrients such as protein and iron increased. Furthermore, the number of night eaters was decreased significantly. Muscle mass index was also improved in the intervention group. These results were maintained in the medium to long term.

CONCLUSION

SYNCHRONIZE + is a brief, low-cost, multidisciplinary intervention effective in improving adherence to the Mediterranean diet and improving nutritional and dietary intake patterns in persons with fibromyalgia and chronic fatigue syndrome. Further evaluation of the effect on quality of life and symptoms is needed.

Effectiveness of a brief multicomponent intervention to improve physical activity level and functional capacity in fibromyalgia and chronic fatigue syndrome (Synchronize+)

Introduction

Fibromyalgia (FM) and chronic fatigue syndrome (CFS) are complex central sensitization syndromes that represent an important public health problem. Low cardiorespiratory fitness and muscle function with habitual intolerance to efforts are common characteristics of FM and CFS. This study aimed to examine the effect of a brief multicomponent intervention based on physical activity (PA), nutrition, and chronobiology on movement behaviors (PA, sedentary and sleep time), muscle strength, and cardiorespiratory capacity.

Methods

randomized controlled trial was conducted in primary healthcare in Catalonia. A total of 143 individuals with FM or FM and CFS concomitantly (age 50.8, SD 8.1; 94.4% women) were randomly allocated to the intervention (IG, n = 69) or control (CG, n = 74) groups. The IG participated in a brief multicomponent (PA, nutrition, and chronobiology) group-based intervention (4 sessions, 3 h/session) while the CG received usual primary care practice. Primary outcome measure was PA measured by the REGICOR-Short Physical Activity Questionnaire. Secondary outcomes were sedentary (International Physical Activity Questionnaire) and sleep time (Pittsburgh Sleep Quality Index), upper- and lower-body muscle strength (handgrip and sit-to-stand test, respectively), and aerobic capacity (6-min walk test). Data were collected at baseline and 3 months post-intervention.

Results

The IG showed positive differences at 3-month follow-up, with highly appreciably PA levels, less sedentary time, and significantly improved sleep time. Significant between-group differences were also observed at 3 months, with better health values in the IG: PA and sleep time (370.3 ± 307.0 vs. 195.9 ± 289.1 min/week and 6.1 ± 1.6 vs. 5.5 ± 1.8 h/night, respectively) and less sedentary time (266.2 ± 153.3 vs. 209.4 ± 199.9 min/day). The IG also showed higher upper limb strength and significant lower-body strength both between and within groups, as well as significantly improved cardiorespiratory capacity.

Conclusion

The Synchronize + multicomponent program implemented at primary healthcare has shown short-term effectiveness in improving 24-h movement behaviors and health outcomes in individuals with FM, with or without CFS. This intervention may be a first step in educating and motivating people with FM and CFS to adopt an active lifestyle, leading to improved health. Long-term follow-up will determine whether the changes are maintained over time and their impact on quality of life and healthcare costs.

Nutrition and Chronobiology as Key Components of Multidisciplinary Therapeutic Interventions for Fibromyalgia and Associated Chronic Fatigue Syndrome: A Narrative and Critical Review

Fibromyalgia (FM) is often accompanied by chronic fatigue syndrome (CFS). It is a poorly understood disorder that mainly affects women and leads to chronic pain, fatigue, and insomnia, among other symptoms, which decrease quality of life. Due to the inefficiency of current pharmacological treatments, increasing interest is being directed towards non-pharmacological multicomponent therapies. However, nutrition and chronobiology are often overlooked when developing multicomponent therapies. This narrative and critical review explore the relevance of nutritional and chronobiological strategies in the therapeutic management of FM and the often-associated CFS. Reviewed literature offers scientific evidence for the association of dietary habits, nutrient levels, body composition, gut microbiota imbalance, chronobiological alterations, and their interrelation with the development and severity of symptoms. This review highlights the key role of nutrition and chronobiology as relevant and indispensable components in a multidisciplinary approach to FM and CFS.

Usefulness of a Multicomponent Group Intervention Program for Fibromyalgia Patients in Primary Care: A Qualitative Study of Health Professionals

OBJECTIVE

To explore the perceptions and experiences of health professionals who participated in a multicomponent program for fibromyalgia (FM) patients based on health education, physical exercise and cognitive-behavioral therapy.

METHODS

In this qualitative, descriptive study that was based on a pragmatic and utilitarian approach, we conducted two focus groups (FGs) with 12 professionals (nurses and general practitioners) from the primary healthcare system of Spain who had been trained as FM experts. A thematic content analysis was carried out.

RESULTS

The findings were organized into four key domains, each with explanatory emerging themes. Overall, the professionals positively valued the program for the knowledge gain it offered, its integrated approach, the group effect and other benefits to patients. Work overload and peers' lack of acknowledgement of the program's value were identified as barriers. A reduction in the amount of content in each session, the creation of quality-of-care indicators and the promotion of the new professional role (FM expert) were proposed.

CONCLUSIONS

The FM experts supported the program and recognized its usefulness. To implement the program within the primary healthcare system, the program needs to be adjusted to accommodate professionals' and patients' reality, and institutional health policies must be improved by providing training on FM to the healthcare community.

Cost-utility of a multicomponent intervention for fibromyalgia versus usual care: a pragmatic randomised controlled trial

OBJECTIVE

To perform an economic evaluation on a multicomponent intervention programme for patients with fibromyalgia syndrome compared with usual clinical practice in primary care.

DESIGN

A cost-utility analysis was conducted alongside a pragmatic randomised controlled trial (ClinicalTrials.gov: https://clinicaltrials.gov/ct2/show/record/NCT04049006) from a societal perspective, a human capital approach, and a 1-year time horizon.

PATIENTS

Patients diagnosed with fibromyalgia  syndrome from the public health system in south Catalonia, Spain.

METHODS

Crude and adjusted incremental cost- utility ratios were estimated to compare the treatment strategies based on cost estimations (direct medical costs and productivity losses) and quality-adjusted life years. One-way and 2-way deterministic sensitivity analyses were performed.

RESULTS

The final analysed sample comprised 297 individuals, 161 in the intervention group and 136 in the control group. A crude incremental cost-utility ratio of € 1,780.75 and an adjusted ratio of € 851.67 were obtained, indicating that the programme  significantly improved patients' quality of life with a cost-increasing outcome that fell below the cost-effectiveness threshold. The sensitivity analysis  confirmed these findings when  varying large cost components, and showed dominance when increasing session attendance.

CONCLUSION

The proposed multicomponent intervention programme was cost-effective compared with usual care for fibromyalgia, which supports its addition to standard practice in the regional  primary care service.

Effectiveness and health benefits of a nutritional, chronobiological and physical exercise primary care intervention in fibromyalgia and chronic fatigue syndrome: SYNCHRONIZE + mixed-methods study protocol

INTRODUCTION

Chronic pain, fatigue and insomnia are classic symptoms of fibromyalgia (FM) and chronic fatigue syndrome (CFS) and seriously affect quality of life. Nutrition and chronobiology are often overlooked in multicomponent approach despite their potential. This study aims to evaluate the effectiveness of a multidisciplinary group intervention based on nutrition, chronobiology, and physical exercise in the improvement of lifestyle and quality of life in FM and CFS.

METHODS

Mixed-methods study based on a randomized clinical trial and qualitative analysis with a descriptive phenomenological approach. The study will be conducted in primary care in Catalonia. The control group will follow the usual clinical practice and the intervention group the usual practice plus the studied intervention (12 hours over 4 days). The intervention based on nutrition, chronobiology and physical exercise will be designed considering participants' opinions as collected in 4 focus groups. To evaluate effectiveness, EuroQol-5D, multidimensional fatigue inventory, VAS pain, Pittsburgh Sleep Quality Index, erMEDAS-17, biological rhythms interview of assessment in neuropsychiatry, REGICOR-Short, FIQR and Hospital Anxiety and Depression Scale questionnaires will be collected at baseline, and at 1, 3, 6, and 12 months post-intervention. Food intake, body composition, resistance and, strength will also be evaluated. The effect size will be calculated using Cohen d and logistic regression models will be used to quantify the impact of the intervention by adjusting for different variables.

DISCUSSION

It expected that the intervention will improve the patients' quality of life, fatigue, pain and insomnia, as well as food and physical exercise habits, providing effectiveness evidence of a new therapy in addressing these syndromes in Primary Heath Care. Improvements in the quality of life will have a positive socioeconomic impact by reducing health expenditure on recurrent medical consultation, medication, complementary medical tests, etc and favor the maintenance of an active working life and productivity.

Patients' Lived Experience in a Multicomponent Intervention for Fibromyalgia Syndrome in Primary Care: A Qualitative Interview Study

Fibromyalgia syndrome (FMS) disrupts patients' biopsychosocial spheres. A multicomponent intervention (MCI) program, which combined health education, cognitive behavioral therapy, and physical activity, was conducted in South Catalonia's primary care centers with the aim of improving symptom self-management and quality of life. A qualitative interview study was carried out to understand patients' lived experiences during the intervention program. Sampled purposively, 10 patients were interviewed via phone calls and face-to-face. The encounters were audio-recorded, verbatim transcribed, and analyzed through thematic analysis. As a result, four themes emerged: legitimizing fibromyalgia through the MCI, the MCI as a socializing experience, learning how to live with FMS through the MCI, and room for improving the MCI. Participants agreed on the program being an insightful experience that promoted illness knowledge and acceptance and that improved their coping skills and symptom self-management. The inclusion of additional psychological guidance, expressive psychological group therapy, and providing relatives with information were proposed for enhancing the program. Our findings have contributed to gaining insight into the subjective impact of the MCI and identifying new therapeutic targets to tailor the program to patients' needs, which will hopefully increase its effectiveness and improve their quality of life.

Patients' appraisals about a multicomponent intervention for fibromyalgia syndrome in primary care: a focus group study

PURPOSE

To assess fibromyalgia patients' experiences and appraisals about a multidisciplinary intervention programme, in Catalonia's primary care, regarding its format and contents, benefits, and health impact in the short and long term.

METHOD

Qualitative interpretative research design through hermeneutic phenomenology perspective. Two focus groups discussions were conducted in February and July 2020. The purposive heterogeneous sample included 19 fibromyalgia patients who attended a multicomponent programme. In addition, thematic analysis on the verbatims was performed.

RESULTS

Findings were organized into five main domains with an explanatory theme each. Overall, the informants valued the programme as a positive experience due to its holistic approach, health benefits, suffering relief, group effect, and fibromyalgia legitimacy promotion. Detected improvable aspects focused on extending the timeframe, including family members as beneficiaries, deepening the thematic contents, and getting regular access to this healthcare service. Furthermore, the intervention was considered feasible to be incorporated into usual clinical care.

CONCLUSION

the programme fulfilled users' expectations about results and procedure and showed promise as a treatment strategy to reinforce the usual practice. Our findings suggest a broad perspective on fibromyalgia patients' suffering, which urges us to adjust the intervention programme to their real health needs.

Self-management for chronic widespread pain including fibromyalgia: A systematic review and meta-analysis

BACKGROUND

Chronic widespread pain (CWP) including fibromyalgia has a prevalence of up to 15% and is associated with substantial morbidity. Supporting psychosocial and behavioural self-management is increasingly important for CWP, as pharmacological interventions show limited benefit. We systematically reviewed the effectiveness of interventions applying self-management principles for CWP including fibromyalgia.

METHODS

MEDLINE, Embase, PsycINFO, The Cochrane Central Register of Controlled Trials and the WHO International Clinical Trials Registry were searched for studies reporting randomised controlled trials of interventions adhering to self-management principles for CWP including fibromyalgia. Primary outcomes included physical function and pain intensity. Where data were sufficient, meta-analysis was conducted using a random effects model. Studies were narratively reviewed where meta-analysis could not be conducted Evidence quality was rated using GRADE (Grading of Recommendations, Assessment, Development and Evaluations) (PROSPERO-CRD42018099212).

RESULTS

Thirty-nine completed studies were included. Despite some variability in studies narratively reviewed, in studies meta-analysed self-management interventions improved physical function in the short-term, post-treatment to 3 months (SMD 0.42, 95% CI 0.20, 0.64) and long-term, post 6 months (SMD 0.36, 95% CI 0.20, 0.53), compared to no treatment/usual care controls. Studies reporting on pain narratively had greater variability, however, those studies meta-analysed showed self-management interventions reduced pain in the short-term (SMD -0.49, 95% CI -0.70, -0.27) and long-term (SMD -0.38, 95% CI -0.58, -0.19) compared to no treatment/usual care. There were few differences in physical function and pain when self-management interventions were compared to active interventions. The quality of the evidence was rated as low.

CONCLUSION

Reviewed studies suggest self-management interventions can be effective in improving physical function and reducing pain in the short and long-term for CWP including fibromyalgia. However, the quality of evidence was low. Future research should address quality issues whilst making greater use of theory and patient involvement to understand reported variability.

Cost-utility analysis of a multicomponent intervention for fibromyalgia syndrome in primary care versus usual clinical practice: study protocol for an economic evaluation of a randomised control trial

INTRODUCTION

Fibromyalgia syndrome (FMS) imposes a high cost on society. The significant economic burden from the use of healthcare and, especially, social resources is a spur to revising the usual clinical care (UCC) and to improving treatment strategies. FMS has a deleterious effect on the quality of life (QOL) and productivity, which considerably increase the indirect costs to society. This study reports an economic evaluation comparing the cost and health benefits in a multicomponent intervention programme and UCC of patients with FMS who attend primary healthcare centres of the Gerència Territorial Terres de L'Ebre region of Catalonia, Spain. This article is linked to the pre-results of a randomised control trial study on the implementation of this intervention programme (ClinicalTrials.gov: NCT04049006).

METHOD AND ANALYSIS

A cost-utility analysis will be conducted from a societal perspective. Quality-adjusted life years will be calculated from the results of the SF-36 questionnaire, a QOL measurement instrument. Direct and indirect healthcare costs will be obtained from official prices and reports published by the Spanish Public Health Administration and the National Statistics Institute. The incremental cost-utility ratio will be estimated to compare the two healthcare practices. Deterministic sensitivity analysis will also be used to compare different cost scenarios, modifying the items with the highest weight in the cost composition.

ETHICS AND DISSEMINATION

The Clinical Research Ethics Committee of the IDIAPJGol Institute approved this study on 25 April 2018 (code P18/068) in accordance with the Helsinki/Tokyo Declaration. Information will be provided orally and in writing to participants, and their informed consent will be required. Participant anonymity will be guaranteed. The dissemination strategy includes publications in scientific journals and presentations in local and national media and at academic conferences. Trial registration number: NCT04049006; Pre-results.

Assessing the benefits on quality of life of a multicomponent intervention for fibromyalgia syndrome in primary care: patients' and health professionals' appraisals: a qualitative study protocol

INTRODUCTION

Fibromyalgia syndrome (FMS) is a complex condition still scarcely understood and with ambiguity when prescribing treatment. Both patients and healthcare providers can supply valuable information for the development of new treatment strategies. The qualitative narrative analysis of participant's accounts is potentially helpful to reveal new insights about their opinions, needs, and experiences and, consequently, to model healthcare interventions accurately. International treatment guidelines suggest a promising future for multicomponent intervention (MI) approaches for FMS. This study aims to assess the benefits of a MI for patients with FMS in the context of primary care (PC) in Terres de L'Ebre, Catalonia (Spain). Furthermore, it is intended to detect the overall perception of effectiveness and to understand patients' lived experience and its impact on the quality of life.

METHOD AND ANALYSIS

Qualitative research from a socioconstructivism paradigm perspective and a Hermeneutic Phenomenological method. For data collection, four focus group discussions (FGDs) of 8-12 people (2 FGDs of patients and 2 of professionals) and 10-12 key informant interviews with the participants in the MI group will be carried out. All the information will be recorded and verbatim transcribed to perform an interpretive thematic analysis.

ETHICS AND DISSEMINATION

This study protocol has been approved by the Clinical Research Ethics Committee from the IDIAPJGol Institute, on 25 April 2018 (code P18/068), according to the Declaration of Helsinki/Tokyo. All participants will receive oral/written information about the study, and they will be required to sign an informed consent sheet. Data anonymity will be guaranteed. Dissemination will be carried out through publications in scientific journals, presentations in academic meetings, workshops and through the local and national media.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT04049006; Pre-results.

Effectiveness of the integrated care model Salut+Social in patients with chronic conditions: A mixed methods study protocol

INTRODUCTION

Integrated care models aim to provide solutions to fragmentation of care by improving coordination. This study will evaluate the effectiveness of a new integrated care model (Salut + Social), which will promote the coordination and communication between social and healthcare services in southern Catalonia (Spain) to improve quality of life, adherence to treatment and access to medical services for patients with chronic conditions, and also to reduce caregiver burden. Additionally, we will evaluate the experience of caregivers, health professionals and social workers with the new model implemented.

METHODS AND ANALYSIS

A clinical trial using mixed methodology will be carried out. The intervention consists of improving the coordination between the social and healthcare sectors during a 6-month period, by means of information and communication technology (ICT) tools that operate as an interface for the integrated care model. The study subjects are primary care patients with chronic health and social conditions that can benefit from a collaborative and coordinated approach. A sample size of 141 patients was estimated. Questionnaires that assess quality of life, treatment adherence, medical service and caregiver burden will be used at baseline and at 6, 9, and 12 months after the beginning of the study. The principal variable is quality of life. For statistical analysis, comparisons of means and proportions at different time points will be performed. A discussion group and semi-structured interviews will be conducted with the aim of improving the care model taking into account the opinions of professionals and caregivers. A thematic content analysis will be carried out.

ETHICS AND DISSEMINATION

This study protocol has been approved by the Clinical Research Ethics Committee of the Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (code P17/100). Articles will be published in international, peer-reviewed scientific journals.

TRIAL REGISTRATION

Clinical-Trials.gov: NCT04164160.