# Stress Management as a Clinical Approach to the Complementary Treatment of Fibromyalgia
## 3 Results  
The review question was constructed following the PICO format (population/patient, intervention, comparator and outcome): \"Adult patients with a clinical diagnosis of Fibromyalgia (P), Pharmacological treatment plus stress management and control techniques (I), Pharmacotherapy (C), Pharmacological interventions combined with various stress control techniques decrease pain perception (O)\" (Figure 1). Below is a table that shows the search strategy used to select the 13 selected articles (Table 2). The total number of valid articles is summarized in the Appendix A.  
Methodological quality of the studies: the presence of interviewer or observer bias was relatively frequent, since some of the selected studies were not blinded, or they were partially blinded due to the complexity that full blinding would entail. In some trials, the sample presented was quite limited, which may influence their results, making it inconclusive. Effect of interventions: five studies incorporated cognitive behavioral therapy (CBT) into the intervention. The combined data show how this type of treatment resulted in a marked improvement in patient quality of life (\(p<0.001\)) [10]. Above all, there was a \begin{table}
\begin{tabular}{c c c c c c c c} \hline \hline
**Item Criteria** & **Psicodoc** & **Cochrane** & **Psycinfo** & **MedPsych/Pubmed** & **Scopus** & **WOS** & **Total** \\ \hline Identified & 2 & 41 & 25 & 9 & 36 & 41 & 112 \\ Duplicates & 2 & 14 & 8 & 8 & 15 & 12 & 59 \\ Title & 2 & 4 & 3 & 4 & 7 & 4 & 24 \\ \hline Abstract Text complete Valid & 1 & 2 & 1 & 2 & 6 & 4 & 16 \\ \hline \hline \end{tabular}
\end{table} 
Table 2: Databases consulted. Figure 1: Flow diagram. significant improvement in terms of depression (\(p<0.001\)-\(p=0.0003\)), anxiety (\(p<0.044\)-\(p=0.0416\)), vital exhaustion, sleep, strategies of coping, adherence to treatment and, therefore, greater pain control and reduction in severity (\(p=<0.007\)) [10; 11; 12; 13; 14]. Regarding sleep, cognitive behavioral therapy did not bring a full recovery, but the clinical benefits it obtained are of great relevance, since it improved sleep quality and self-efficacy when dealing with pain [12]. CBT provided in person vs. online was also compared. Through these studies it was possible to observe how the participants of the first group presented optimal results earlier. In contrast, the online group obtained greater self-efficacy and also presented a sustained improvement at 6 and 12 months of follow-up. This was due to the ability that these individuals developed to perform this type of technique at home without the need for a professional [12; 13]. Interventions that use Tai Chi and/or mindfulness: two studies published by [PERSON] demonstrate how carrying out this type of intervention in individuals suffering from fibromyalgiagia was able to reduce its impact (\(p<0.001\)). The interventions reduced perceived pain (\(p<0.001\)), stress (\(p<0.001\)), anxiety (\(p<0.001\)) and depression (\(p<0.001\)), in addition to improving coping skills (\(p<0.001\)) and quality of life of the patient (\(p<0.001\)). [PERSON] also compared this method with aerobic exercise, administered with the same intensity and duration; the individuals belonging to the experimental group reported a greater benefit (\(p=0.03\)), significantly improving their self-efficacy (\(p<0.005\)) [16; 17]. Another study published by Davis MC in 2013 demonstrates how mindfulness is not capable of significantly reducing pain. However, it improved the effectiveness of coping with pain (\(p<0.0001\)), the ability of patients to participate in various social activities despite their symptoms (\(p<0.0008\)) and their greater efficiency when facing stressful situations (\(p<0.0007\)), as well as decreasing the feeling of loneliness perceived by the patient (\(p<0.0003\)) [15].