There is an increasing interest in the role of psychological factors in fibromyalgia, and studies have been published on associated psychological variables, psychopathological explanations, assessment instruments and psychological intervention programs [1
]. Suhr (2003) considered psychological factors to be important for understanding the subjective and objective cognitive disorders of fibromyalgia patients [3
]. Various investigations have centered on the relationship of fibromyalgia with pain, depression, anxiety and quality of life. The Copenhagen declaration in 1992 described psychological patterns frequently associated with fibromyalgia, such as anxiety and depression, and there is a growing interest in this aspect among professionals of different fields [4
]. Nevertheless, many authors consider that psychological factors are more frequently the result than the cause of pain and disability in fibromyalgia, and this issue remains controversial [4
Some symptoms of fibromyalgia are similar to those observed during depression, and antidepressants have been administered to fibromyalgia patients to treat sleep disorders and pain symptoms [4
]. Review of the literature on the association between fibromyalgia and depression reveals two divergent research lines. Hudson and others [5
] believe that a direct association cannot be established between fibromyalgia and depression, whereas Gruber and others (1996) [6
] propose a common etiology for fibromyalgia and depression. Significant differences in psychological state between patients with fibromyalgia and depression were reported in a study on fibromyalgia, pain intensity and duration and psychological alterations; the results of depression and anxiety questionnaires indicated that the somatic expression of depression differed between the two patient groups [7
]. The relationship between depression and fibromyalgia remains controversial. Although antidepressants can reduce pain and fatigue in fibromyalgia, the effects of these drugs vary in degree and duration among patients [7
Various authors have indicated that patients with fibromyalgia are more depressed than healthy controls and that their perception of psychological distress or depression is similar to that of depressed patients [8
]. Moreover, levels of psychological distress (depression, anxiety) have been correlated with cognitive findings in both groups of patients (fibromyalgia and depression) [10
] observed a higher degree of anxiety in fibromyalgia patients than in healthy controls or other groups of patients with painful disease, for example, rheumatoid arthritis. Anxious individuals usually have a respiratory dysfunction that generates more work in the upper chest, and the resulting minimum diaphragmatic activity may exacerbate symptoms in patients with fibromyalgia or chronic fatigue syndromes. Although anxiety is known to be an immediate symptom of hyperventilation, it is controversial whether or not hyperventilation and anxiety in patients with fibromyalgia result from a broader alteration. In this context, Peter et al. [14
] reported that education to reduce the effects of hyperventilation can reduce fibromyalgia symptoms, including pain, fatigue and emotional distress.
Dysfunction of the autonomic nervous system may explain the different clinical manifestations of fibromyalgia. The hyperactive sympathetic nervous system of these patients becomes incapable of responding to different stressing stimuli, which would explain the continuous tiredness and the morning rigidity of these patients [15
]. Likewise, incessant sympathetic activity may explain the sleeping disorders, anxiety, pseudo Raynaud's phenomenon, dry syndrome and intestinal irritability [2
]. The other defining characteristics of fibromyalgia such as diffuse pain, painful sensitivity to palpation and paresthesia may also be explained by “sympathetically maintained pain". This neuropathic pain is characterized by a perception of pain regardless of the presence of stimuli, accompanied by paresthesias and allodynia, which are characteristic of patients with fibromyalgia [16
Patients frequently report sleeping disorders as well as depression, and both factors are known to have a strong association with cognitive disruption [17
] and to play an important role in the reduced quality of life reported by fibromyalgia patients. There is a high prevalence of sleeping problems in this population. In many cases, pain and fatigue disappear with sleep. However, paradoxically, patients with fibromyalgia awake with intensified muscle rigidity, pain and marked fatigue [19
]. Shaver et al. [21
] described a vicious circle of pain, poor sleep, fatigue and increased pain in overt fibromyalgia. Bigatti et al. [22
] concluded that sleep predicts subsequent pain in these patients but may be related to depression due to pain and physical dysfunction.
The quality of life of patients with fibromyalgia is especially impaired in relation to physical function, intellectual activity and emotional state, influencing their working capacity and social relationships [23
]. Backman [24
] affirmed that psychosocial factors are related to two dimensions of experience: psychological (cognitive, affective) and social (interacting with others, performing daily activities). According to this author, psychosocial factors influence the perception of pain, which in turn influences psychological wellbeing and social participation.
Various studies have demonstrated the efficacy of biofeedback acupuncture to reduce pain symptoms in fibromyalgia [25
]. However, we could find no studies that address the effects of manual therapy on the autonomic nervous system or the possible benefit of this type of alternative therapies as a complement to pharmaceutical treatment of hyperautonomic alterations and derived disorders (anxiety and depression). With this background, the objective of this study was to determine the effects of craniosacral therapy on anxiety, depression, pain, sleep quality and quality of life in fibromyalgia patients up to 1-year post-treatment.