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Pain education to women with fibromyalgia using the DolorÔmetro game

ABSTRACT

BACKGROUND AND OBJECTIVES:

Doubts and questions about the general aspects of pain, maladaptive beliefs, knowledge about pain neurophysiology, and its impact on exercise are common in fibromyalgia patients. This study aimed to evaluate the knowledge about pain in women with fibromyalgia through the DolorÔmetro game.

METHODS:

A quasi-experimental study with a qualitative and quantitative approach. Twenty women with a clinical diagnosis of fibromyalgia and aged 18 to 60 years were evaluated. The patients answered two questions at the beginning and end of the game. The intervention consisted of the use of 9 cards from the six domains of the game DolorÔmetro to motivate discussions about the theme.

RESULTS:

The sample had a mean age of 50.6±9.6 years and a diagnostic time of 6.5±4.6 years. The number of hits and errors in each domain was observed. In the “acceptance” domain, four errors were found in statement 1 and twelve in statement 2. In the “attitudes” domain, only two in statement 4 and one in statement 8. In the “kinesiophobia” domain, all errors were only in statement 2. In the “knowledge” domain, nineteen women missed statement 3. In the “anxiety” domain, fifteen women missed statement 1. Finally, in the “catastrophic” domain, ten women missed statement 2.

CONCLUSION:

Conducting an education in pain, lasting in one hour in a single moment, contributed to the participants expressing their doubts and previous questions and after the moment of education, however doubts persisted in the domains of acceptance, kinesiophobia, knowledge and anxiety.

Keywords:
Chronic pain; Fibromyalgia; Health education; Physiotherapy; Rheumatology

RESUMO

JUSTIFICATIVA E OBJETIVOS:

As dúvidas e questionamentos sobre os aspectos gerais da dor, crenças mal adaptativas, conhecimento sobre neurofisiologia da dor e seu impacto na realização de exercícios são comuns nas pacientes com fibromialgia. O objetivo deste estudo foi avaliar o conhecimento sobre dor em mulheres com fibromialgia, por meio do jogo DolorÔmetro.

MÉTODOS:

Estudo quase-experimental com abordagem quali-quantitativa. Foram avaliadas 20 mulheres com diagnóstico clínico de fibromialgia com idade de 18 a 60 anos. As pacientes responderam duas perguntas no momento inicial e final do jogo. A intervenção consistiu no uso de 9 cartas a partir dos 6 domínios aceitação, atitudes, cinesiofobia, conhecimento, ansiedade e catastrofismo, do jogo DolorÔmetro para motivar as discussões sobre a temática.

RESULTADOS:

A média de idade foi 50,6±9,6 anos e o tempo diagnóstico de 6,5±4,6 anos. Foi avaliado o número de acertos e erros de cada domínio. No domínio “aceitação” foram 4 erros na afirmação 1 e 12 erros na afirmação 2. No domínio “atitudes”, 2 na afirmação 4 e 1 na afirmação 8. No domínio “cinesiofobia”, nenhum acerto na afirmação 2. No domínio “conhecimento”, 19 erraram a afirmação 3. No domínio “ansiedade”, 15 erraram a afirmação 1. No domínio “catastrofismo” 10 erraram a afirmação 2.

CONCLUSÃO:

Realizar educação em dor, com duração de uma hora em único momento, contribuiu para as participantes expressarem suas dúvidas e questionamentos prévios e após o momento de educação, porém persistiram dúvidas referentes aos domínios aceitação, cinesiofobia, conhecimento e ansiedade.

Descritores:
Dor crônica; Educação em saúde; Fibromialgia; Fisioterapia; Reumatologia

INTRODUCTION

Education on pain neurophysiology is a strategy that teaches the biological process of pain and its relationship with central sensitization11 Nijs J, Torres-Cueco R, van Wilgen CP, Girbes EL, Struyf F, Roussel N, et al. Applying modern pain neuroscience in clinical practice: criteria for the classification of central sensitization pain. Pain Physician. 2014;17(5):447-57.

2 Van Oosterwijck J, Meeus M, Paul L, De Schryver M, Pascal A, Lambrecht L, et al. Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: a double-blind randomized controlled trial. Clin J Pain. 2013;29(10):873-82.
-33 Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3 Suppl):S2-15. in patients with chronic musculoskeletal pain such as fibromyalgia (FM), which can influence the poorly adaptive and negative cognitions related to pain, reducing it and improving movement behavior and performance11 Nijs J, Torres-Cueco R, van Wilgen CP, Girbes EL, Struyf F, Roussel N, et al. Applying modern pain neuroscience in clinical practice: criteria for the classification of central sensitization pain. Pain Physician. 2014;17(5):447-57.,44 Moseley L. Reconceptualising pain according to modern pain science. Phys Ther Rev. 2007;12(3):169-78..

FM treatment is interdisciplinary, combining pharmacological and non-pharmacological treatments55 Macfarlane GJ, Kronisch C, Dean LE, Atzeni F, Häuser W, Fluß E, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 2017;76(2):318-28., such as aerobic exercise55 Macfarlane GJ, Kronisch C, Dean LE, Atzeni F, Häuser W, Fluß E, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 2017;76(2):318-28., resistance exercise66 Silva HJA, Assunção Júnior JC, de Oliveira FS, Oliveira JMP, Figueiredo Dantas GA, Lins CAA, et al. Sophrology versus resistance training for treatment of women with fibromyalgia: a randomized controlled trial. J Bodyw Mov Ther. 2019;23(2):382-9., cognitive-behavioral therapy77 Karlsson B, Burell G, Anderberg UM, Svärdsudd K. Cognitive behaviour therapy in women with fibromyalgia: a randomized clinical trial. Scand J Pain. 2015;9(1):11-21., drugs88 Souza Oliveira LH, Mattos RS, Castro JB, Barbosa JS, Chame F, Vale RG. Effect of supervised physical exercise on flexibility of fibromyalgia patients. Rev Dor. 2017;18(2):145-9., as well as pain education22 Van Oosterwijck J, Meeus M, Paul L, De Schryver M, Pascal A, Lambrecht L, et al. Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: a double-blind randomized controlled trial. Clin J Pain. 2013;29(10):873-82.. The latter produces changes in the therapist-patient relationship, where the patient becomes the protagonist in the therapeutic process, which is why socio-educational interventions are recommended by international guidelines in the treatment of FM99 Mendez SP, Sá KN, Araújo PC, Oliveira IA, Gosling AP, Baptista AF. Elaboration of a booklet for individuals with chronic pain. Rev Dor. 2017;18(3):199-211..

Educational games are tools that contribute to the learning process and building knowledge and can be used as an intervention tool for pain education1010 Valentim JC, Meziat-Filho NA, Nogueira LC, Reis FJ. ConheceDOR: the development of a board game for modern pain education for patients with musculoskeletal pain. BrJP. 2019;2(2):166-75.. The DolorÔmetro game is a board game that uses cards of six domains developed from the most used scales and questionnaires for pain assessment, suitable for the approach to pain education of women participating in the dance project1111 Araújo JT, Rocha CF, Farias GM, Cruz RS, Assunção Júnior JC, Silva HJ, et al. Experience with women with fibromyalgia who practice Zumba. Case reports. Rev Dor. 2017;18(3):266-9.,1212 Assunção Júnior JC, de Almeida Silva HJ, da Silva JFC, da Silva Cruz R, de Almeida Lins CA, de Souza MC. Zumba dancing can improve the pain and functional capacity in women with fibromyalgia. J Bodyw Mov Ther. 2018;22(2):455-9., due to constant questions and concerns about the general aspects of pain and its impact on the performance of the exercises. This study aimed to assess the knowledge about pain in women with FM, using the DolorÔmetro game.

METHODS

A quasi-experimental study with a qualitative and quantitative approach. Twenty women diagnosed with FM, aged 18 to 60 years, were selected according to the classification criteria of the American College of Rheumatology1313 Heymann RE, Paiva E dos S, Helfenstein M Jr, Pollak DF, Martinez JE, Provenza JR, et al. Brazilian consensus on the treatment of fibromyalgia. Rev Bras Reumatol. 2010;50(1):56-66.. The exclusion criteria were refusal to participate and not answering all questions.

Pain education was conducted in the group activities room at the Physiotherapy School Clinic of a public university. The education session lasted one hour, held in a single moment during the dance extension project.

The pain education activity used the DolorÔmetro game, whose Portuguese version can be accessed through the link https://drive.google.com/drive/folders/1gnxEn7FbDZ1U4Ik7wuH0U5K1NoNqYEg7. The game consists of six domains: acceptance, attitudes, anxiety, kinesiophobia, knowledge, and catastrophizing, with answer cards that have specific scores, and a board. Only the answer cards were used, disregarding the score and the board. From the domains, nine answer cards were selected for convenience, which were considered “true” or “false” by the participants. Then, the answers were quantified, and the pain education activity started.

In order to know the women’s opinion before starting the game, with the purpose of analyzing their pain perception, the following question was asked: “What does pain do to you”? In the end, another question was asked to analyze what they understood about the general aspects of pain: “What did you learn from that moment”? The patients wrote the answers on a sheet of paper.

The qualitative data were analyzed, categorizing the answers into two subgroups, social and personal dimensions, based on Bardin’s content analysis.

All patients signed the Free and Informed Consent Term (FICT) before the beginning of the study.

The Research Ethics Committee of the School of Health Sciences of Trairi approved this study under opinion No. 3.130.248 (CAAE 61904216.9.0000.5568).

RESULTS

Table 1 shows the clinical and sociodemographic characteristics of the patients, with a mean age of 50.6±9.6 years and with an FM clinical diagnosis time of 6.5±4.6 years.

Table 1
Clinical and sociodemographic characteristics of patients

Table 2 shows the patients’ reports regarding the first question before the pain education activity. In the personal dimension, the words that most stood out were of emotional origin, such as sadness, stress, unhappiness, and discouragement. In the social dimension, words that refer to the difficulty in carrying out work and daily activities, such as interfering, preventing, and failing.

Table 2
"What does pain do to you"?

Regarding the DolorÔmetro game, the number of hits and errors in each domain was observed. In the “acceptance” domain, four errors were found in statement 1, and 12 errors in statement 2. In the “attitudes” domain, few errors were found, only in statements 4 and 8. In the “kinesiophobia” domain, all errors were just in statement 2. In the “knowledge” domain, 19 missed statement 3. In the “anxiety” domain, 15 missed statement 1. Finally, in the “catastrophizing” domain, 10 missed statement 2, as shown in table 3.

Table 3
Number of hits and errors of patients referring to the six domains of the DolorÔmetro game

Table 4 shows the participants’ reports regarding the second question. Regarding the personal dimension, terms about learning, awareness, acquired knowledge, and understanding about pain were highlighted. In the social dimension, the importance of participating in lectures was emphasized.

Table 4
"What did you learn from this moment"?

DISCUSSION

The patients presented a high level of unfamiliarity in the domains of acceptance, kinesiophobia, knowledge, and anxiety, which proves the importance of pain education in patients with chronic pain.

Regarding the first question “what does the pain do to you?” in the social dimension, it was possible to observe that pain interferes in daily activities and work, as a result of daily attitudes and behaviors having a direct connection with the individual’s capacity to improve their levels of activity and performance1414 Nijs J, Van Houdenhove B. From acute musculoskeletal pain to chronic widespread pain and fibromyalgia: application of pain neurophysiology in manual therapy practice. Man Ther. 2009;14(1):3-12..

The impact of pain in the personal dimension, especially of emotional origins, such as sadness, discouragement, unhappiness, and stress, making the emotional balance difficult in the face of the symptomatology stood out, reflecting directly in the perspective of improving the symptomatic condition11 Nijs J, Torres-Cueco R, van Wilgen CP, Girbes EL, Struyf F, Roussel N, et al. Applying modern pain neuroscience in clinical practice: criteria for the classification of central sensitization pain. Pain Physician. 2014;17(5):447-57.

2 Van Oosterwijck J, Meeus M, Paul L, De Schryver M, Pascal A, Lambrecht L, et al. Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: a double-blind randomized controlled trial. Clin J Pain. 2013;29(10):873-82.
-33 Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3 Suppl):S2-15.,1010 Valentim JC, Meziat-Filho NA, Nogueira LC, Reis FJ. ConheceDOR: the development of a board game for modern pain education for patients with musculoskeletal pain. BrJP. 2019;2(2):166-75.,1111 Araújo JT, Rocha CF, Farias GM, Cruz RS, Assunção Júnior JC, Silva HJ, et al. Experience with women with fibromyalgia who practice Zumba. Case reports. Rev Dor. 2017;18(3):266-9.,1313 Heymann RE, Paiva E dos S, Helfenstein M Jr, Pollak DF, Martinez JE, Provenza JR, et al. Brazilian consensus on the treatment of fibromyalgia. Rev Bras Reumatol. 2010;50(1):56-66. and limiting the process of self-care and coping reactions. For this reason, education on the pain neurophysiology is considered a strategy that aims to reconceptualize pain and change patients’ inappropriate cognitions1515 van Ittersum WM, van Wilgen CP, van der Schans CP, Lambrecht L, Groothoff JW, Nijs J. Written pain neuroscience education in fibromyalgia: a multicenter randomized controlled trial. Pain Pract. 2014;14(8):689-700., being able to understand and remember in the long term the content used in pain education22 Van Oosterwijck J, Meeus M, Paul L, De Schryver M, Pascal A, Lambrecht L, et al. Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: a double-blind randomized controlled trial. Clin J Pain. 2013;29(10):873-82..

As for the second question, “what did you learn from that moment?” regarding the personal dimension, the most emphasized terms were learning, awareness, acquired knowledge, and understanding related to pain. Understanding and knowledge about pain are essential points in the treatment in order to improve the way they will deal with the FM symptoms. In the social dimension, the importance of participating in lectures that approach education on pain neurophysiology was described, emphasizing the importance of exchanging knowledge with the mediators of the discussion and among the participants.

In accordance with the terms reported, a study that conducted a pain education session concluded that patients showed improvement in pain understanding and less intention to catastrophizing when compared to the control group1616 Meeus M, Nijs J, Van Oosterwijck J, Van Alsenoy V, Truijen S. Pain physiology education improves pain beliefs in patients with chronic fatigue syndrome compared with pacing and self-management education: a double blind randomized controlled trial. Arch Phys Med Rehabil. 2010;91(8):1153-9.. Thus, the review1717 Geneen LJ, Martin DJ, Adams N, Clarke C, Dunbar M, Jones D, et al. Effects of education to facilitate knowledge about chronic pain for adults: a systematic review with meta-analysis. Syst Rev. 2015;4:132. that aimed to determine the level of evidence of educational interventions on the psychosocial results showed that studies using education on pain neurophysiology as a form of intervention provided a significant improvement in the concepts of catastrophizing and knowledge about pain.

Regarding the quantitative results, it was possible to analyze the participants’ knowledge about the pain neurophysiology from the answers given to the game domains. In the “anxiety” domain, there were 15 wrong answers in one statement and “kinesiophobia” 20 wrong answers in just one statement, and it was necessary to explain the two statements to the group. The data of this study are similar to another1818 Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011;92(12):2041-56., which after the education on pain neurophysiology, showed a decrease in reports of anxiety, stress, and pain catastrophizing, which are also closely related to the kinesiophobia aspect in chronic pain1818 Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011;92(12):2041-56..

Regarding the “knowledge” domain, 19 women missed statement 3 that stated that the brain is capable of producing substances that reduce pain. Thus, it was possible to observe the importance of providing pain education and its benefits, as patients were able to understand the neurophysiological aspects22 Van Oosterwijck J, Meeus M, Paul L, De Schryver M, Pascal A, Lambrecht L, et al. Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: a double-blind randomized controlled trial. Clin J Pain. 2013;29(10):873-82., as well as to address a review on the use of pain education as an efficient tool for the patient to acquire the knowledge on the topic1919 Marris D, Theophanous K, Cabezon P, Dunlap Z, Donaldson M. The impact of combining pain education strategies with physical therapy interventions for patients with chronic pain: a systematic review and meta-analysis of randomized controlled trials. Physiother Theory Pract. 2019;28:1-12 [Epub ahead of print]..

Finally, in the “acceptance” domain, 16 errors were observed, having a relationship with the perception that each patient has about their pain and the necessary adjustments for their daily life2020 Luciano JV, Martínez N, Penãrrubia-María MT, Fernández-Vergel R, García-Campayo J, Verduras C, et al. Effectiveness of a psychoeducational treatment program implemented in general practice for fibromyalgia patients: a randomized controlled trial. Clin J Pain. 2011;27(5)383-91.. In addition, in the answers to the second question, the participants were more aware of their pain and the importance of the knowledge acquired during the game to help them to accept their condition.

Regarding the interaction of patients with the intervention, it was possible to observe a good adherence that provided a moment of relaxation and knowledge construction about their pain and the FM implications, so that they can actively participate in the treatment, and the awareness about the aspects of pain, as addressed in the game domains. In the same line, other studies support the conclusion that interventions combined with pain education have a moderate to great effect on the construction of their knowledge1919 Marris D, Theophanous K, Cabezon P, Dunlap Z, Donaldson M. The impact of combining pain education strategies with physical therapy interventions for patients with chronic pain: a systematic review and meta-analysis of randomized controlled trials. Physiother Theory Pract. 2019;28:1-12 [Epub ahead of print].,2020 Luciano JV, Martínez N, Penãrrubia-María MT, Fernández-Vergel R, García-Campayo J, Verduras C, et al. Effectiveness of a psychoeducational treatment program implemented in general practice for fibromyalgia patients: a randomized controlled trial. Clin J Pain. 2011;27(5)383-91..

The present study had some limitations, such as the small sample and the intervention in a collective space, since the conversation shared among the participants may have interfered in the moment of expressing personal answers about the questions asked.

CONCLUSION

Pain education helped the participants to express their concerns before and after the moment of education. Educating patients about their health condition, especially about understanding pain, is a powerful component in the treatment process, although there are some concerns regarding the acceptance, kinesiophobia, knowledge and anxiety domains in women with fibromyalgia.

REFERENCES

  • 1
    Nijs J, Torres-Cueco R, van Wilgen CP, Girbes EL, Struyf F, Roussel N, et al. Applying modern pain neuroscience in clinical practice: criteria for the classification of central sensitization pain. Pain Physician. 2014;17(5):447-57.
  • 2
    Van Oosterwijck J, Meeus M, Paul L, De Schryver M, Pascal A, Lambrecht L, et al. Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: a double-blind randomized controlled trial. Clin J Pain. 2013;29(10):873-82.
  • 3
    Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3 Suppl):S2-15.
  • 4
    Moseley L. Reconceptualising pain according to modern pain science. Phys Ther Rev. 2007;12(3):169-78.
  • 5
    Macfarlane GJ, Kronisch C, Dean LE, Atzeni F, Häuser W, Fluß E, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 2017;76(2):318-28.
  • 6
    Silva HJA, Assunção Júnior JC, de Oliveira FS, Oliveira JMP, Figueiredo Dantas GA, Lins CAA, et al. Sophrology versus resistance training for treatment of women with fibromyalgia: a randomized controlled trial. J Bodyw Mov Ther. 2019;23(2):382-9.
  • 7
    Karlsson B, Burell G, Anderberg UM, Svärdsudd K. Cognitive behaviour therapy in women with fibromyalgia: a randomized clinical trial. Scand J Pain. 2015;9(1):11-21.
  • 8
    Souza Oliveira LH, Mattos RS, Castro JB, Barbosa JS, Chame F, Vale RG. Effect of supervised physical exercise on flexibility of fibromyalgia patients. Rev Dor. 2017;18(2):145-9.
  • 9
    Mendez SP, Sá KN, Araújo PC, Oliveira IA, Gosling AP, Baptista AF. Elaboration of a booklet for individuals with chronic pain. Rev Dor. 2017;18(3):199-211.
  • 10
    Valentim JC, Meziat-Filho NA, Nogueira LC, Reis FJ. ConheceDOR: the development of a board game for modern pain education for patients with musculoskeletal pain. BrJP. 2019;2(2):166-75.
  • 11
    Araújo JT, Rocha CF, Farias GM, Cruz RS, Assunção Júnior JC, Silva HJ, et al. Experience with women with fibromyalgia who practice Zumba. Case reports. Rev Dor. 2017;18(3):266-9.
  • 12
    Assunção Júnior JC, de Almeida Silva HJ, da Silva JFC, da Silva Cruz R, de Almeida Lins CA, de Souza MC. Zumba dancing can improve the pain and functional capacity in women with fibromyalgia. J Bodyw Mov Ther. 2018;22(2):455-9.
  • 13
    Heymann RE, Paiva E dos S, Helfenstein M Jr, Pollak DF, Martinez JE, Provenza JR, et al. Brazilian consensus on the treatment of fibromyalgia. Rev Bras Reumatol. 2010;50(1):56-66.
  • 14
    Nijs J, Van Houdenhove B. From acute musculoskeletal pain to chronic widespread pain and fibromyalgia: application of pain neurophysiology in manual therapy practice. Man Ther. 2009;14(1):3-12.
  • 15
    van Ittersum WM, van Wilgen CP, van der Schans CP, Lambrecht L, Groothoff JW, Nijs J. Written pain neuroscience education in fibromyalgia: a multicenter randomized controlled trial. Pain Pract. 2014;14(8):689-700.
  • 16
    Meeus M, Nijs J, Van Oosterwijck J, Van Alsenoy V, Truijen S. Pain physiology education improves pain beliefs in patients with chronic fatigue syndrome compared with pacing and self-management education: a double blind randomized controlled trial. Arch Phys Med Rehabil. 2010;91(8):1153-9.
  • 17
    Geneen LJ, Martin DJ, Adams N, Clarke C, Dunbar M, Jones D, et al. Effects of education to facilitate knowledge about chronic pain for adults: a systematic review with meta-analysis. Syst Rev. 2015;4:132.
  • 18
    Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011;92(12):2041-56.
  • 19
    Marris D, Theophanous K, Cabezon P, Dunlap Z, Donaldson M. The impact of combining pain education strategies with physical therapy interventions for patients with chronic pain: a systematic review and meta-analysis of randomized controlled trials. Physiother Theory Pract. 2019;28:1-12 [Epub ahead of print].
  • 20
    Luciano JV, Martínez N, Penãrrubia-María MT, Fernández-Vergel R, García-Campayo J, Verduras C, et al. Effectiveness of a psychoeducational treatment program implemented in general practice for fibromyalgia patients: a randomized controlled trial. Clin J Pain. 2011;27(5)383-91.

Publication Dates

  • Publication in this collection
    03 June 2020
  • Date of issue
    Jan-Mar 2020

History

  • Received
    02 Oct 2019
  • Accepted
    30 Mar 2020
Sociedade Brasileira para o Estudo da Dor Av. Conselheiro Rodrigues Alves, 937 Cj2 - Vila Mariana, CEP: 04014-012, São Paulo, SP - Brasil, Telefones: , (55) 11 5904-2881/3959 - São Paulo - SP - Brazil
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