The impact of a meditation-based stress reduction program on fibromyalgia

Cervical myofascial pain and headache

Myofascial pain is a common cause of regional chronic pain. Myofascial trigger points can refer pain to the head and face in the cervical region, thus contributing to cervicogenic headache. When identified properly, cervical myofascial pain is a treatable component of headache management. This article reviews current literature on the pathophysiology, diagnosis, and management of cervical myofascial pain.

The influence of age on fibromyalgia symptoms

OBJECTIVES

Studies of the influence of age on health and well-being in chronically ill patients have produced mixed findings. This study examined young (20-39), middle-aged (40-59), and older (60-85) individuals with fibromyalgia (FMS), a chronic pain condition. The purpose of this study was to determine whether there were differences among the age groups in symptomatology and to examine potential mediating psychosocial variables.

METHODS

Participants were 600 (95% female, mean age = 54, SD = 11) diagnosed FMS patients who were members of a health maintenance organization. Multivariate analyses of covariance were used to examine differences.

RESULTS

There were significant differences among the age groups in most of the variables: With increasing age symptom duration increased but FMS symptomatology decreased. No age differences were found among the psychosocial mediators. The results suggest that the effects of FMS decrease over time.

Focused review: myofascial pain

Myofascial pain is defined as pain that originates from myofascial trigger points in skeletal muscle. It is prevalent in regional musculoskeletal pain syndromes, either alone or in combination with other pain generators. The appropriate evaluation and management of myofascial pain is an important part of musculoskeletal rehabilitation of regional axial and limb pain syndromes. This article reviews the current hypotheses regarding the pathophysiology of myofascial trigger points and muscle pain. A critical evidence-based review of the pharmacologic, nonpharmacologic, alternative medicine, and exercise treatments of myofascial pain is provided, as well as future research directions. OVERALL LEARNING OBJECTIVE: To review critically the state of the art knowledge of myofascial pain, including pathophysiology and comprehensive management. Areas of future research are identified.

Opinions and practices of medical rehabilitation professionals regarding prayer and meditation

OBJECTIVE

To assess the attitudes and practices of professionals in the field of physical medicine and rehabilitation (PM&R) regarding prayer and meditation.

DESIGN

A national mail survey that included questions about the use of a number of complementary and alternative therapies.

PARTICIPANTS

The survey was mailed to 7,479 physicians, nurses, physical therapists, and occupational therapists who specialize in PM&R, and 1221 (17%) returned completed surveys.

RESULTS

Although the majority of respondents endorsed prayer as a legitimate health care practice, there was greater belief in the benefits of meditation. Older respondents were more likely to recommend meditation to their patients and more likely to meditate themselves. Gender differences that were observed in opinions and practices are better interpreted as differences in professional specialty. In general, nurses and occupational therapists responded more positively toward meditation and prayer than did physicians and physical therapists. Personal use of a technique was the strongest predictor of professional behaviors. Attitude was a stronger predictor of professional use or referral for prayer than meditation, but correlations between attitude and behavior were generally weak for both techniques. Despite their acceptance of these techniques, the vast majority of rehabilitation professionals did not refer their patients for meditation or religious consultation.

CONCLUSIONS

Although there were significant relationships among beliefs, and personal and professional behaviors regarding these techniques, a large part of the variance in professional behaviors was not accounted for by age, gender, opinion, or personal behavior, indicating that other influences exert a stronger effect on professional practice decisions.

What do we really know about mindfulness-based stress reduction?

OBJECTIVE

Mindfulness-Based Stress Reduction (MBSR) is a clinical program, developed to facilitate adaptation to medical illness, which provides systematic training in mindfulness meditation as a self-regulatory approach to stress reduction and emotion management. There has been widespread and growing use of this approach within medical settings in the last 20 years, and many claims have been made regarding its efficacy. This article will provide a critical evaluation of the available state of knowledge regarding MBSR and suggestions for future research.

METHODS

A review of the current literature available within the medical and social sciences was undertaken to provide an evaluation regarding what we know about the construct of mindfulness, the effectiveness of MBSR, and mechanisms of action.

RESULTS

There has been a paucity of research and what has been published has been rife with methodological problems. At present, we know very little about the effectiveness of this approach. However, there is some evidence that suggests that it may hold some promise.

CONCLUSIONS

The available evidence does not support a strong endorsement of this approach at present. However, serious investigation is warranted and strongly recommended.

Mind-body medicine. An introduction and review of the literature

MBM is a well-established phenomenon in modern medicine. If one accepts a model of mind/body that is truly nondualistic, it could be said that the MBM phenomenon is inherent to medicine. Because of its popularity and efficacy for common chronic conditions, MBM may have its greatest presence in primary care medicine. The flourishing of MBM techniques resulting from the public's enthusiastic embrace of these therapies has created a great need for rigorous scientific examination. The MBM literature may be said to be in its adolescence, having grown out of its early years of enthusiastic case reports and small studies, but not yet fully grown into a broad catalogue of large controlled experimental trials. Nevertheless, clinical trials suggest that certain MBM therapies are effective in improving quality of life, anxiety, and pain intensity for a variety of conditions. There is moderate evidence to suggest these techniques improve chronic pain, headache, insomnia, and other common conditions. There is preliminary evidence to suggest these techniques may affect coronary artery disease and cancer. MBM techniques ultimately may prove to be most effective in combinations or in conjunction with traditional treatment.

Fibromyalgia: patient perspectives on symptoms, symptom management, and provider utilization

Two surveys of individuals with fibromyalgia were conducted to assess the frequency and prevalence of symptoms (N = 99) as well as healthcare providers, medications, and self-care activities used to manage one's fibromyalgia (N = 54). The pervasiveness of symptoms was striking, with 24 various symptoms ranging from cognitive to intestinal problems occurring in at least 75% of the respondents. Significant correlations were present between health status and both physical (P = .002) and psychological (P =.008) symptoms. There was also a significant correlation between the total number of symptoms and the degree of life disruption attributed to fibromyalgia (P =.015). A variety of healthcare professionals were seen, with internists, family physicians, and rheumatologist most frequently used. Although at least 80% of the respondents reported difficulty with anxiety, confusion, irritability, depression, and cognitive difficulties, less than 10% of the respondents reported seeing a psychiatrist. Most frequently used medications were: amitriptyline, (fluoxetine HCl) Prozac, ibuprofen (Motrin), sertraline HCI (Zoloft), and zolpidem (Ambein). Self-care activities used with the most success were walking, stretching, and exercising. These studies indicate the need for more research and support for healthcare providers as well as patients with fibromyalgia.

Evaluation of a Wellness-Based Mindfulness Stress Reduction intervention: a controlled trial

PURPOSE

To determine if participation in a Wellness-Based Mindfulness Stress Reduction intervention decreases the effect of daily hassles, psychological distress, and medical symptoms.

DESIGN

A randomized controlled trial of a stress reduction intervention with a 3-month follow-up.

SETTING

A university setting in West Virginia.

SUBJECTS

A total of 103 adults, with 59 in the intervention group and 44 in the control group. Eight-five percent of subjects completed the intervention. Fifty-nine percent and 61% of the intervention and control subjects completed the study, respectively.

INTERVENTION

The intervention consisted of an 8-week group stress reduction program in which subjects learned, practiced, and applied "mindfulness meditation" to daily life situations. The control group received educational materials and were encouraged to use community resources for stress management.

MEASURES

The Daily Stress Inventory assessed the effect of daily hassles, the Revised Hopkins Symptom Checklist measured psychological distress, the Medical Symptom Checklist measured number of medical symptoms, and a Follow-up Questionnaire measured program adherence.

RESULTS

Intervention subjects reported significant decreases from baseline in effect of daily hassles (24%), psychological distress, (44%), and medical symptoms (46%) that were maintained at the 3-month follow-up compared to control subjects (repeated measures analysis of variance [ANOVA]; p < .05).

CONCLUSIONS

Self-selected community residents can improve their mental and physical health by participating in a stress reduction intervention offered by a university wellness program.

Mindfulness-based stress reduction and health-related quality of life in a heterogeneous patient population

This study examined the effects of mindfulness-based stress reduction (MBSR) on health-related quality of life and physical and psychological symptomatology in a heterogeneous patient population. Patients (n=136) participated in an 8-week MBSR program and were required to practice 20 min of meditation daily. Pre- and post-intervention data were collected by using the Short-Form Health Survey (SF-36), Medical Symptom Checklist (MSCL) and Symptom Checklist-90 Revised (SCL-90-R). Health-related quality of life was enhanced as demonstrated by improvement on all indices of the SF-36, including vitality, bodily pain, role limitations caused by physical health, and social functioning (all P<.01). Alleviation of physical symptoms was revealed by a 28% reduction on the MSCL (P<.0001). Decreased psychological distress was indicated on the SCL-90-R by a 38% reduction on the Global Severity Index, a 44% reduction on the anxiety subscale, and a 34% reduction on the depression subscale (all P<.0001). One-year follow-up revealed maintenance of initial improvements on several outcome parameters. We conclude that a group mindfulness meditation training program can enhance functional status and well-being and reduce physical symptoms and psychological distress in a heterogeneous patient population and that the intervention may have long-term beneficial effects.

Test of a nursing intervention to promote adjustment to fibromyalgia

PURPOSE

This was a test to detect whether a 4-week cognitive behavioral nursing program was effective in increasing adjustment to fibromyalgia (FM) and if the treatment effect would last over time.

DESIGN

This was a control and treatment group experimental longitudinal study with outcome measures obtained at pretest and every 3 months for 1 year.

SAMPLE

A sample of 71 subjects continued their participation throughout the first year of the study.

FINDINGS

Treatment subjects had improved posttreatment adjustment and symptom severity compared to control subjects. When subjects with high pretest psychosocial distress (n = 5) were removed from the analysis, these findings were statistically significant.

IMPLICATIONS FOR NURSING PRACTICE

The article can provide direction for developing new comprehensive nursing intervention for patients seen with orthopaedic problems. The intervention schedule may help nurses expand their use of interventions for FM patients. Orthopaedic nurses are especially suited for this challenge.

Stress and rheumatic diseases

This study was done to review the literature concerning the influence of minor and major stress factors on onset and course of rheumatoid arthritis (RA), juvenile chronic arthritis (JCA), systemic lupus erythematosus (SLE), and fibromyalgia syndrome (FS). Major life events and chronic minor stress seem to be very important factors in JCA and are significantly associated with the onset of the disease. With respect to RA and FS, stress may be a provoking factor but the data in the literature are equivocal. However, during the course of the disease, minor stress aggravates SLE, FS, JCA, and RA. Patients with FS and RA may profit from psychological therapies. Optimistic and confronting coping strategies were found most frequently and perceived to be most effective. Very important for psychological function is the social background, especially the functioning of the family is of outstanding importance for clinical and psychological outcome.

Mindfulness of movement as a coping strategy in multiple sclerosis. A pilot study

This study investigated the effectiveness of a short course of mindfulness of movement to help with symptom management in eight people with multiple sclerosis. Progress was compared to a control group who were asked to continue with their current care. Each participant received six individual one-to-one sessions of instruction. They were also provided with audio and videotape aides. Each participant was assessed on a test of balance, pre- and post-intervention, and at 3-month follow-up. All participants completed a rating of change of 22 symptoms relevant to multiple sclerosis. A close relative or friend was also asked to assess independently the degree of change. The mindfulness group reported improvement over a broad range of symptoms. This was verified by the relatives' independent rating and maintained at 3 month follow-up. The control group showed no improvement but instead tended towards a deterioration on many of the items. The physical assessment of balance also showed a significant improvement for the mindfulness group. This improvement was maintained at 3 month follow-up. In conclusion, training in mindfulness of movement appeared to result in improved symptom management for this group of people with multiple sclerosis. This was a pilot study, using small numbers, so the results need to be treated with caution. Several improvements to the experimental design are suggested. The role of individual therapeutic ingredients is discussed.

A randomized, wait-list controlled clinical trial: the effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients

OBJECTIVE

The objective of this study was to assess the effects of participation in a mindfulness meditation-based stress reduction program on mood disturbance and symptoms of stress in cancer outpatients.

METHODS

A randomized, wait-list controlled design was used. A convenience sample of eligible cancer patients enrolled after giving informed consent and were randomly assigned to either an immediate treatment condition or a wait-list control condition. Patients completed the Profile of Mood States and the Symptoms of Stress Inventory both before and after the intervention. The intervention consisted of a weekly meditation group lasting 1.5 hours for 7 weeks plus home meditation practice.

RESULTS

Ninety patients (mean age, 51 years) completed the study. The group was heterogeneous in type and stage of cancer. Patients' mean preintervention scores on dependent measures were equivalent between groups. After the intervention, patients in the treatment group had significantly lower scores on Total Mood Disturbance and subscales of Depression, Anxiety, Anger, and Confusion and more Vigor than control subjects. The treatment group also had fewer overall Symptoms of Stress; fewer Cardiopulmonary and Gastrointestinal symptoms; less Emotional Irritability, Depression, and Cognitive Disorganization; and fewer Habitual Patterns of stress. Overall reduction in Total Mood Disturbance was 65%, with a 31% reduction in Symptoms of Stress.

CONCLUSIONS

This program was effective in decreasing mood disturbance and stress symptoms in both male and female patients with a wide variety of cancer diagnoses, stages of illness, and ages. cancer, stress, mood, intervention, mindfulness.

A meta-analysis of fibromyalgia treatment interventions

OBJECTIVE

To evaluate and compare the efficacy of pharmacological and nonpharmacological treatments of fibromyalgia syndrome (FMS).

METHODS

This meta-analysis of 49 fibromyalgia treatment outcome studies assessed the efficacy of pharmacological and nonpharmacological treatment across four types of outcome measures-physical status, self-report of FMS symptoms, psychological status, and daily functioning.

RESULTS

After controlling for study design, antidepressants resulted in improvements on physical status and self-report of FMS symptoms. All nonpharmacological treatments were associated with significant improvements in all four categories of outcome measures with the exception that physically-based treatment (primarily exercise) did not significantly improve daily functioning. When compared, nonpharmacological treatment appears to be more efficacious in improving self-report of FMS symptoms than pharmacological treatment alone. A similar trend was suggested for functional measures.

CONCLUSION

The optimal intervention for FMS would include nonpharmacological treatments, specifically exercise and cognitive-behavioral therapy, in addition to appropriate medication management as needed for sleep and pain symptoms.

Physical and other non-pharmacological interventions for fibromyalgia

There is little empirical evidence for the effectiveness of physical and other non-pharmacological approaches to the management of fibromyalgia. Although a number of studies have been conducted into such approaches, many of these are uncontrolled, and relatively few randomized controlled trials of appropriate size and methodological rigour have been carried out. This chapter provides an overview of the evidence available under the following headings: exercise, EMG biofeedback training, electrotherapy and acupuncture, patient education and self-management programmes, multimodal treatment approaches, and other interventions. It is hard to reach firm conclusions from the literature, owing to the variety of interventions that have been evaluated and the varying methodological quality of the studies concerned. Nonetheless, in terms of specific interventions, exercise therapy has received a moderate degree of support from the literature, and has been subjected to more randomized studies than any other intervention. In contrast, there is little or no evidence available for most types of electrotherapy. In terms of overall management strategies, a multimodal programme of management, including physical, psychological and educational components and delivered in a multidisciplinary setting, has gained some support from descriptive and experimental studies, and accords with current understanding of the aetiology and clinical features of fibromyalgia. There is a clear need for further systematic evaluation of the effectiveness of non-pharmacological treatment approaches in fibromyalgia.

A psychological profile of fibromyalgia patients: a chiropractic case study

BACKGROUND

Fibromyalgia is a chronic condition characterized by widespread musculoskeletal pain and tenderness. Reversible modulation of the pain threshold is believed to contribute to the pathogenesis of this condition, and psychosocial stress is known to alter the pain threshold.

OBJECTIVE

To describe and compare the psychological profile of fibromyalgia patients attending chiropractic clinics in Australia.

SETTING

Chiropractic clinics located in 5 Australian states and the Australian capital territory with practices in inner city, suburban, coastal, and rural areas were included.

SUBJECTS

Chiropractic patients with acute and chronic biomechanical conditions, fibromyalgia, and who were undergoing maintenance care were included in the study.

METHOD

A case study to explore the psychological profile of fibromyalgia patients was undertaken. The Distress and Risk Assessment Method (DRAM) and Sense of Coherence (SOC) questionnaires were used to ascertain and compare the distress, sense of coherence, and manageability levels of patients with fibromyalgia with patients having maintenance chiropractic care. Purposive sampling of practitioners and convenience sampling of patients fulfilling the study's inclusion criteria were undertaken. Patients were asked to complete two questionnaires and chiropractors to complete one questionnaire and an interview.

RESULTS

While more than half of the patients in the fibromyalgia group were distressed, fewer than 1 in 7 maintenance patients were found to be distressed according to the DRAM questionnaire. With several individual exceptions, fibromyalgia patients also tended to have lower SOC and manageability scores than the maintenance group.

CONCLUSION

This study supports the view that fibromyalgia may represent a problem of coping with various environmental stresses, including psychosocial stresses. However, owing to individual variation, a diagnosis of fibromyalgia at the clinical level does not accurately predict whether a particular patient is distressed or has a low SOC score. Screening of fibromyalgia patients may help determine whether intensive counseling and stress management by the chiropractor or another health professional should be contemplated.

Self-management of fibromyalgia: the role of formal coping skills training and physical exercise training programs

There has been growing interest in the use of formal self-management training programs for people with fibromyalgia (FM). In these programs, health care professionals serve as trainers and provide education about FM and guided instruction in specific self-management strategies. A review of the literature on formal self-management training programs for FM suggests that they can be divided into groups: 1) those emphasizing training in coping skills (e.g., relaxation, activity pacing, and problem-solving techniques), and 2) those emphasizing training in physical exercise (e.g., cardiovascular fitness, strength, and endurance training). In this article, we review studies that have tested the efficacy of both types of programs. In addition, we identify key individual and contextual variables that are related to outcome and highlight future directions in the research and development of self-management programs.

Differential responses by psychosocial subgroups of fibromyalgia syndrome patients to an interdisciplinary treatment

OBJECTIVES

To evaluate differential treatment responses among 3 empirically derived, psychosocial subgroups of patients with fibromyalgia syndrome to a standard interdisciplinary treatment program.

METHOD

Patients were classified into 1 of 3 psychosocial groups on the basis of their responses to the Multidimensional Pain Inventory. Forty-eight patients completed a 6 one-half-day outpatient treatment program consisting of medical, physical, occupational, and psychological therapies spaced over a period of 4 weeks (3 sessions the first week followed by 1 session per week for the next 3 consecutive weeks).

RESULTS

Statistically significant reductions were observed in pain, affective distress, perceived disability, and perceived inteference of pain in the patients characterized by poor coping and high level of pain ("dysfunctional" group). In contrast, individuals who were characterized by interpersonal difficulties ("interpersonally distressed" group) exhibited poor responses to the treatment. "Adaptive copers," the third group, revealed significant improvements in pain but due to low pretreatment levels of affective distress and disability showed little improvement on these outcomes.

CONCLUSIONS

The results provided support for the hypothesis that customizing treatment based on patients' psychosocial needs will lead to enhanced treatment efficacy. They also emphasize the importance of using appropriate outcome criteria, as low levels of problems at baseline are not likely to show significant changes following any treatment.

Interdisciplinary treatment for fibromyalgia syndrome: clinical and statistical significance

OBJECTIVES

The primary purposes of the study were to: evaluate the treatment efficacy of an outpatient, interdisciplinary treatment program for fibromyalgia syndrome (FMS); examine whether treatment gains would be sustained for 6 months following the treatment; assess whether improvements were clinically significant; and delineate the factors associated with clinically significant improvement in pain severity.

METHODS

Sixty-seven FMS patients completed a 4-week outpatient program consisting of medical, physical, psychologic, and occupational therapies. Six-month followup data were available for 66% of treated patients.

RESULTS

Comparisons between pretreatment and posttreatment measures revealed significant improvements in pain severity, life interference, sense of control, affective distress, depression, perceived physical impairment, fatigue, and anxiety; however, there was no improvement in interpersonal relationships or general activities. Clinically significant improvement in pain severity, using the Reliable Change Index, was obtained by 42% of the sample and was predicted by the pretreatment levels of depression, activity, perceived disability, solicitous responses of significant others, and idiopathic onset. Pretreatment level of pain severity was not a significant predictor of the degree of pain improvement. Comparisons among pretreatment, posttreatment, and 6-month followup data revealed that the patients maintained treatment gains in pain, life interference, sense of control, affective distress, and depression. However, the quadratic polynomial analysis revealed that relapse occurred in the subjective rating of fatigue.

CONCLUSIONS

The results suggest that, overall, an outpatient interdisciplinary treatment program was effective in reducing many FMS symptoms. Treatment gains tended to be maintained for at least 6 months. However, there were large individual differences in response to treatment. These results suggest that identification of subgroups of FMS patients and their specific clinical characteristics may be useful for maximizing treatment efficacy.

Mind-body therapies for primary care physicians

Evidence is accumulating that mental and emotional processes can affect disease states. Mind-body therapies are effective adjuncts to conventional medical treatments, and they are easy to teach and learn. This article offers a review of relevant literature and introduces several mind-body techniques.

Cognitive behavioral control of arthritis pain

Cognitive-behavioral approaches appear to offer a viable alternative for the management of arthritis pain. Controlled studies have documented the efficacy of CBT protocols for managing pain in individuals having OA and RA. Preliminary studies examining the efficacy of CBT for FM patients have also yielded encouraging results. A number of clinical and research issues need attention if CBT is to be incorporated into rheumatology practice settings. These issues include identifying the most important components of CBT, developing strategies for matching CBT interventions to patients' readiness for behavior change, testing the efficacy of different therapy formats (e.g., individual versus group), broadening the scope of CBT to address issues other than pain, and insurance reimbursement.

Assessment of functional limitation and disability in patients with fibromyalgia

Fibromyalgia syndrome (FMS) is characterized by diffuse widespread musculoskeletal pain. The aims of this literature study were to review measures and instruments used to assess functional limitations and disability in patients with FMS. A 10-year search was done on Medline, CATS, and CINAHL. Of the 73 articles found, only standardized instruments and tests permitting quantification were included. Reviews, trials of medication therapy, epidemiological studies, and measures of the psychological and impairment level were excluded. The articles were divided into cross-sectional and longitudinal studies. No studies evaluating the reliability, validity or sensitivity of the functional tests applied to the FMS were found. Of the disability instruments reviewed, only the Arthritis Impact Measurement Scales and Fibromyalgia Impact Questionnaire were evaluated for reliability and validity for the FMS population. The Arthritis Self-Efficacy Scales and Quality of Life Scale proved their sensitivity, detecting change in a controlled longitudinal study.

A randomized, double-blind crossover trial of fluoxetine and amitriptyline in the treatment of fibromyalgia

OBJECTIVE

To study the effect of fluoxetine (FL) and amitriptyline (AM), alone and in combination, in patients with fibromyalgia (FM).

METHODS

Nineteen patients with FM completed a randomized, double-blind crossover study, which consisted of 4 6-week trials of FL (20 mg), AM (25 mg), a combination of FL and AM, or placebo. Patients were evaluated on the first and last day of each trial period. Outcome measures included a tender point score, the Fibromyalgia Impact Questionnaire (FIQ), the Beck Depression Inventory (BDI) scale, and visual analog scales (VAS) for global well-being (1 completed by the physician and 1 by the patient), pain, sleep trouble, fatigue, and feeling refreshed upon awakening.

RESULTS

Both FL and AM were associated with significantly improved scores on the FIQ and on the VAS for pain, global well-being, and sleep disturbances. When combined, the 2 treatments worked better than either medication alone. Similar, but nonsignificant, improvement occurred in the BDI scale, the physician global VAS, and the VAS for fatigue and feeling refreshed upon awakening. Trends were less clear for the tender point score.

CONCLUSION

Both FL and AM are effective treatments for FM, and they work better in combination than either medication alone.

A cost-effective approach to the diagnosis and treatment of fibromyalgia

The diagnosis of teh myalgic patient can prove to be challenging for even the most experienced of clinicians. The differential diagnosis includes many diseases that often present with weakness as well as pain. The diagnosis of fibromyalgia may now be made using the positive features of the patient's illness and classified according to well-defined criteria. The process is facilitated by the demonstration of FTPs that are quite specific for the condition. The elicitation of tenderness over these points is highly reliable and valid owing to high intrarater and interrater agreements observed in multiple studies. An algorithmic approach to differential diagnosis is presented. In addition, a stepwise approach to treatment based on published studies and geared to functional outcome measures in put forward in an attempt to encourage a cost-effective approach to care of these difficult patients.

Mind-body medicine in primary care. Implications and applications

A growing body of research in basic and clinical science confirms that psychological states and interventions affect physiologic and pathophysiologic processes and the outcome of clinical illness. This evidence is reviewed in detail, with special attention paid to those findings that have particular relevance for primary care physicians. Specific guidelines are offered for incorporating mind-body principles and techniques into primary care practice.

Perceived control: a comparison of women with fibromyalgia, rheumatoid arthritis, and systemic lupus erythematosus using a Swedish version of the Rheumatology Attitudes Index

This study compared the attitudes of women with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), or fibromyalgia (FM) regarding their perceptions of control and ability to cope with their disease. We also report the validation of a Swedish version of the Rheumatology Attitudes Index (RAI). One hundred thirty-nine women participated in the study by completing the RAI two or three times along with several other self-report and disease severity measures. The Swedish version RAI was found to have acceptable reliability, evidence of validity, sensitivity to change, and two distinct factors of internality and helplessness. In general, patients with RA or SLE perceived higher control over their symptoms than those with FM. FM patients who participated in a self-management experimental program significantly changed their scores on the RAI in a positive direction.