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1 119 Journal of Exercise Physiologyonline June 2018 Volume 21 Number 3 Editor-in-Chief Official Research Journal of Tommy the American Boone, PhD, Society MBA of Review Exercise Board Physiologists Todd Astorino, PhD Julien Baker, ISSN PhD Steve Brock, PhD Lance Dalleck, PhD Eric Goulet, PhD Robert Gotshall, PhD Alexander Hutchison, PhD M. Knight-Maloney, PhD Len Kravitz, PhD James Laskin, PhD Yit Aun Lim, PhD Lonnie Lowery, PhD Derek Marks, PhD Cristine Mermier, PhD Robert Robergs, PhD Chantal Vella, PhD Dale Wagner, PhD Frank Wyatt, PhD Ben Zhou, PhD Official Research Journal of the American Society of Exercise Physiologists ISSN JEPonline Mood States, Depressive Symptoms, and Physical Function in Women with Fibromyalgia Khaled Omar Mohamad El Tassa 1, Neiva Leite 2, Suelen Meira Góes 3, Diogo Homann 2, André Luiz Félix Rodacki 2, Ana Claudia Kapp Titski 2, Joice Mara Facco Stefanello 2 1 Department of Physical Education/UNICENTRO University, Irati, Brazil, 2 Department of Physical Education/Federal University of Paraná, Curitiba, Brazil, 3 School of Physical Therapy/University of Saskatchewan, Saskatoon, Canada ABSTRACT Tassa KOME, Leite N, Góes SM, Homann D, Rodacki ALF, Titski ACK, Stefanello JMF. Mood States, Depressive Symptoms, and Physical Function in Women with Fibromyalgia. JEPonline 2018; 21(3): This study investigated relationship among moods states, depressive symptoms, and physical function in women with fibromyalgia (FM). Twenty-eight women with FM and 17 healthy women (Control) were evaluated. The Brunel Mood Scale (BRUMS), Beck Depression Inventory (BDI), Health Assessment Questionnaire (HAQ), and the Visual Analog Scales for pain intensity were applied. Threshold painful sensibility was assessed by algometry. Physical function was evaluated by Field-Based Fitness Tests, and by peak torque (extension and flexion of the knee joint) through maximal voluntary isometric contractions. The FM group showed poorer scores in BDI and BRUMS instruments compared to the Control group. Also, the FM group showed reduced physical performance in tests assessing lower limb strength (P<0.05). Regarding moods states, there were correlations between depressive symptoms and tension (r = 0.41; P<0.05), depressive symptoms and confusion (r = 0.60; P<0.05), the 30-sec Chair Stand Test and tension (r = 0.38; P<0.05), and knee extension peak torque and anger (r = 0.45; P<0.05) in the FM group. The findings indicate that women with FM had poorer mood states, greater severity of depressive symptoms, and reduced physical function, yet depressive symptoms were not associated with physical function. Key Words: BRUMS, Chronic Pain, Depression

2 120 INTRODUCTION Fibromyalgia (FM) is a rheumatologic condition characterized by widespread chronic pain and reduced pain threshold (47). Marques et al. (32) indicate that the literature shows values of FM prevalence in the general population between 0.2 and 6.6% and values between 2.4 and 6.8% in women. The consequences of FM are exacerbated by a large number of comorbidities and a sedentary lifestyle that lead to declines in physical abilities, functional impairment, and increased risk for disability (18,19,25,42). Several psychopathological disorders are associated with FM (2), which has shown a substantial frequency of psychiatric diseases (6). The prevalence of depression in FM, for instance, is between 20 to 80% (14), and depressive symptoms without a formal diagnosis affect around 40% of these patients (28). The prevalence of mood disorders is also common in subjects with musculoskeletal chronic pain, which is related to pain severity and impairment of quality of life (12). Patients with FM have higher depressive mood state scores when compared to other rheumatic conditions (35). In addition, higher changes in mood states are observed in individuals with FM and diagnosis of depression when compared to individuals without depression symptoms (10). In view of the importance of this psychological factor in FM, systematic measurement of mood disorders has been recommended by rheumatologists to assess the severity of patients with FM (23). The presence of depressive symptoms has been associated with functional deficits in patients with FM, which leads to reduced pain threshold and, consequently, a higher pain perception as well as a negative impact on quality of life (1). Indeed, individuals with chronic pain and depressive symptoms show greater disability and lower levels of physical performance (3). Depressive symptoms may contribute to a lack of motivation and energy that can result in less physical activity. Negative cognitions may also lead to pain beliefs that inhibit optimal function (15). In addition, mood state has been described as an effective predictor of physical and athletic performance and success in either or both (7). Given that depressive symptoms and negative mood might influence physical performance and the expectation of individuals with FM to demonstrate a reduction in functionality, it is reasonable to explore the relationship between the psychological factors and physical function (by application of field-based fitness tests) in individuals with FM. Therefore, the aim of this study was to investigate the relationship between mood states, depressive symptoms, and physical performance in women with FM. METHODS Subjects This descriptive cross-sectional case-control study included women diagnosed with FM as defined by the American College of Rheumatology criteria (47). The age and body mass index (BMI) of the FM group were 44.8 ± 5.5 yrs and 27.2 ± 4.2 kg m -2, respectively. They were invited to participate in this study after a routine hospital visit. The Control group was composed of age- and BMI-matched control women invited from the local community (age: 43.4 ± 4.7 yrs old; BMI: 28.8 ± 5.8 kg m -2 ).

3 The following inclusion criteria were used for both groups: Individuals between 18 to 50 yrs of age with a BMI between 18.5 to 39.9 kg m -2. In addition, a number of exclusion criteria were applied for both groups including: (a) post-menopausal; (b) the presence of osteoarthritis or rheumatoid arthritis; (c) non-treated heart, pulmonary, and/or neurological diseases; (d) uncontrolled changes in thyroid; (e) history of fractures; (f) joint surgery; or (g) other medical problems during the 6 months preceding the start of this study that could interfere in the results. The presence of any of the exclusion criteria was verified on the patients medical records for individuals with FM and through self-reported information by the Control group. Initially, 139 women with FM and 35 Control women were invited. But, after inclusion and exclusion criteria were applied, the final sample consisted of 28 women with FM and 17 women in the Control group. Procedures All subjects signed an informed consent form, which was approved by the University Ethics Committee for Human Research (EC/CH: ). The assessments were conducted in 2 sessions. In the first visit, depressive symptoms, moods states, and perceived functionality questionnaires were fulfilled. Also, the physical tests and maximum isometric voluntary contraction (MIVC) tests familiarization were performed during the 1st visit of the subjects assessments. During the 2nd visit, pain intensity and pain threshold were measured prior to the subjects executing the MIVC tests. Pain Threshold and Pain Intensity Assessment Four visual analogue scales (10 cm) ranging from 0 (no pain) to 10 (the worst pain imaginable) were applied to measure the pain intensity. The four scales comprised a unique section with the purpose of measuring self-reported pain. Subjects selected the choice that best represented the pain intensity for each situation. Three of the scales assessed the weaker, stronger, and mean pain intensity the subject had in the week prior to data collection, and the fourth scale evaluated the current pain intensity on the day of assessment. The four measurements provided a sense of overall pain intensity in contrast to a single measurement, which helps to avoid an underestimate and/or overestimate (26). Thus, pain intensity was calculated as the average of the four scales (weaker pain intensity + stronger pain intensity + mean pain intensity + current pain intensity)/4. In order to measure pressure pain threshold (PPT) of the lower limb, a dial algometer (FPK 20 algometer, Wagner Instruments) was used. The probe (1 cm 2 ) was placed perpendicular to the vastus medialis muscle (at 2/3 on the line from the anterior superior iliac spine to the lateral side of the patella), and the pressure was applied. The subjects were instructed to say stop when the sensation of pressure became the very first sensation of pain of which the procedure was immediately terminated. A single trained evaluator conducted the PPT clinical measurement in both groups. Moods States Assessment The Brazilian version of Brunel Mood Scale BRUMS (38) was used to measure the mood states of subjects. The BRUMS, adapted from Profile of Mood States (POMS) - a 65-item instrument (33) was developed to permit rapid measurement of mood states in both adults and adolescents (41). The Brazilian version of the BRUMS consists of 24 simple indicators of mood states that consist of 6 subscales: (1) tension; (2) depression; (3) vigor; (4) fatigue; (5) 121

4 confusion; and (6) anger. Values of each subscale range from 0 to 16, in which the higher the value the higher is the mood state expression. Depressive Symptoms Assessment The validated version of Beck Depression Inventory (BDI) for the Brazilian population (20) was used. This instrument is widely used in several countries and determines the intensity of depression symptoms in both psychiatric patients and non-clinical population (20,21). The BDI scores range from 0 to 63. In non-diagnosed samples, as the sample evaluated in the present study, the recommended cut-off points are 15 (normal or mild depression), 16 to 20 (dysphoria), and >20 (depression) (21). Self-Reported Functionality The translated and validated Brazilian version of Health Assessment Questionnaire (HAQ) was used to measure functionality (13). The HAQ is a self-reported instrument used to assess the perception of the subject s performance in 20 different daily living activities. Each question offers 4 options to answer 0 to 3, in which 0 = Without any difficulty ; 1 = With some difficulty ; 2 = With much difficulty ; and 3 = Unable to do. Physical Function Assessment Physical function was measured by 4 fitness tests: (a) the 6-Minute Walk Test to evaluate aerobic fitness (4); (b) the Sit and Reach Test to evaluate flexibility (44); (c) the 8-ft Up and Go Test to determine balance, agility, and mobility (37); and (d) the 30-sec Chair Stand Test to evaluate lower limbs muscle strength (37). Except for the 6-Minute Walk Test, which was performed only once, the other tests were each performed twice, and the best performance was chosen for the analysis. In addition, subjects were encouraged to perform knee flexion and extension maximum isometric voluntary contractions (MIVC), from which peak torque was calculated. The MIVC tests were performed with the subjects in a recumbent posture with the joint (dominant limb) positioned at approximately 90. The proximal segments were firmly secured and stabilized by velcro straps and the experimenters ensured that additional movements were not used in order to improve performance (8). Data were collected by a load cell (Model CZC500, Kratos, São Paulo, Brazil) firmly attached to an adjustable pole that permitted alignment perpendicular to the tested segment. An adjustable cuff was used to attach the cable to the subject. The perpendicular distance between the load cell and the joint center was determined and used to calculate net joint torques. Subjects were instructed to produce torque as fast and hard as possible and sustain the contraction for approximately 2 to 3 sec. Three maximal trials (with a 1-min rest period between each trial) were performed. The trial with the highest peak torque was used for further analysis. The force-time signals were sampled with a frequency of 1 KHz, amplified (Kratos, model IK-1C, São Paulo, SP, Brazil) and converted to digital signals with the aid of a 16 bit A/D card (National Instruments, model NI USB 6218, Austin, TX, USA) and, then, stored on a personal computer. Raw torque data were low pass filtered with a Butterworth second order recursive filter set at 20 Hz. Peak torque was determined as the highest torque value obtained after the onset of the voluntary contraction, and it was calculated using a customized routine on Matlab - Mathworks Inc., version

5 123 Statistical Analyses Initially, descriptive statistics were performed and the normality condition of variables was tested using the Shapiro-Wilk test. Pearson's correlation coefficient and Student s t-test for independent samples were used to analyze the parametric data. Spearman s correlation coefficient and the Mann-Whitney U-test were used for non-parametric data. The statistical procedures were calculated using the 7.0 STATISTICA statistical package (STATSOFT Inc., Tulsa, OK, USA). Significance was set at P<0.05. RESULTS Table 1 shows the mean and standard deviation of sample general characteristics comparing the Control and FM groups. Women with FM had reduced pain threshold and greater pain intensity (P<0.01) when compared to the healthy women in the Control group. Also, the FM group showed higher HAQ scores (P<0.01) and diminished performance (P<0.01) in physical tests that required large torques around the lower limb joints (30-sec Chair Stand and the 8-ft Up and Go Tests) than the Control group. In the MVIC tests, both knee flexion and extension peak torque were lower in the FM group compared to the Control group (P<0.01). In the assessment of psychological outcomes, the FM group showed higher depressive symptoms severity when evaluated by the BDI and higher scores in all negative factors (tension, depression, confusion, anger, and fatigue) as well as a lower score in the positive factor (vigor) of the mood states when evaluated by the BRUMS compared to the Control group (P<0.05). Table 1. Sample General Characteristics. Variables Control (n = 17) Fibromyalgia (n = 28) P Age (yrs) 43.4 ± ± Body Weight (kg) 71.3 ± ± Height (cm) ± ± BMI (kg m -2 ) 28.8 ± ± WC (cm) 92.1 ± ± Thigh Pain Threshold (kg cm -2 ) 7.5 ± ± 1.4 <0.01 Pain Intensity (0-10) 1.2 ± ± 1.7 <0.01 HAQ (0-3) 0.24 ± ± 0.63 <0.01

6 124 Table 1. Continued Physical Function 6-Minute Walk (m) ± ± Sit and Reach (cm) 22.7 ± ± ft Up and Go (sec) 5.7 ± ± 1.1 < sec Chair Stand (nº stands) 12.9 ± ± 2.7 <0.01 Knee Extension Peak Torque (Nm) ± ± <0.01 Knee Flexion Peak Torque (Nm) ± ± 4.28 <0.01 BRUMS - Mood States Tension (0 to 16) 4.2 ± ± 4.6 <0.05 Depression (0 to 16) 2.4 ± ± 3.9 <0.05 Vigor (0 to 16) 8.7 ± ± 3.3 <0.05 Fatigue (0 to 16) 3.3 ± ± 4.7 <0.05 Confusion (0 to 16) 2.1 ± ± 4.3 <0.05 Anger (0 to 16) 0.8 ± ± 3.8 <0.05 BDI (0 to 63) 10.4 ± ± 10.0 <0.05 Values are expressed as mean ± standard deviation; BMI = Body Mass Index; WC = Waist Circumference; HAQ = Health Assessment Questionnaire; BDI = Beck Depression Inventory; Student s t-test for independent samples and the Mann Whitney U-test were used Since the FM group showed poorer psychological outcomes and impaired physical function, Person s correlation analysis was performed in order to verify the relationship among these psychological outcomes and physical function with FM symptoms in the FM group. Pain intensity showed a positive correlation with depressive symptoms (r = 0.45; P<0.05) and negative correlation with 6-Minute Walk Test distance (r = -0.38; P<0.05). It was also observed that the higher the pain intensity the longer the time expended to accomplish the 8- ft Up and Go Test (r = 0.40; P<0.05). The results are shown in Table 2.

7 Table 2. Correlations among the Subscales of Mood States, Depressive Symptoms and Physical Function with Pain Characteristics for the Control Group and Fibromyalgia Group. Control (n = 17) Fibromyalgia (n = 28) Thigh Pain Threshold Pain Thigh Pain Threshold Pain Thigh Pain Threshold Pain HAQ Physical Function 6-Minute Walk * Sit and Reach ft Up and Go * 30-sec Chair Stand Knee Extension Peak Torque Knee Flexion Peak Torque BRUMS Tension Depression Vigor * Fatigue Confusion Anger BDI * Pain variable means pain intensity. HAQ = Health Assessment Questionnaire. BDI = Beck Depression Inventory. Pearson s correlation and Spearman s correlation tests were used (*P<0.05). 125 There were no correlations between depressive symptoms using the BDI and physical function, yet positive correlations were found between depressive symptoms and tension mood state (r = 0.41; P<0.05) and between depressive symptoms and confusion mood state (r = 0.60; P<0.05). Considering the possible relationships between the mood state subscales

8 and physical function characteristics, there was a positive correlation between depressive mood state and knee flexion peak torque (r = 0.54; P<0.05). In addition, tension mood state was positively correlated with 30-sec Chair Stand Test performance (r = 0.38; P<0.05) as well as anger mood state was related to knee extension peak torque (r = 0.45; P<0.05). The results are shown in Table Table 3. Correlations among the Subscales of Mood States and Depressive Symptoms with the Physical Function Variables for the Fibromyalgia Group. Fibromyalgia (n = 28) BRUMS BDI Tension Depression Vigor Fatigue Confusion Anger BDI * * 0.32 HAQ Minute Walk Sit and Reach ft Up and Go sec Chair Stand * Knee Extension Peak Torque Knee Flexion Peak Torque * * BDI = Beck Depression Inventory; HAQ = Health Assessment Questionnaire. Pearson s correlation and Spearman s correlation tests were used (*P<0.05). DISCUSSION Depressive Symptoms in Fibromyalgia Group In the present study, the FM group reported greater severity of depressive symptoms and had poorer mood state scores when compared to the Control group. In addition, the physical performance tests showed muscle strength (the 30-sec Chair Stand Test) as well as mobility and agility (the 8-ft Up and Go Test) deficits. Women with FM also had lower peak torque in both knee extension (around 30%) and knee flexion (around 56%) when compared to the Control group, which is in agreement with earlier studies (17,19,42).

9 Our results showed that the FM group exhibited possible status of depression, considering the BDI cut-off adopted for populations without a previous diagnosis of depression (21). The mean values of the BDI in the FM group in the present study are similar to the findings from our previous study (24), but are slightly higher than the results reported by other studies (27,36,40), which could be related to the different socioeconomic aspects. Since depression is a frequent comorbidity in individuals with FM (14) of which approximately 40% of these patients report depressive symptoms (28), pain may have played an important part in the subjects clinical condition. We found a positive correlation between pain intensity and depressive symptoms, which indicates the higher the pain the higher the severity of the depressive symptoms in women with FM. The association between pain and depression might exist due to the overlapping of the pathophysiological process (30). Also, depression is associated with the magnitude of neuronal activation in brain regions that process the affective-motivational dimension of pain (16). An explanation for the higher pain perception in patients with FM and concomitant depressive symptoms may be the tendency of depression in subjects with FM to adopt a cognitive style defined by catastrophizing in which the subject perceives the pain as unbearable (22). Depressive Symptoms and Functionality Depression has been associated with difficulties in the performance of several motor tasks that causes a great impact on the activities of daily living and in the quality of life (9,43). On the other hand, a high level of physical fitness is generally associated with a lower level of depressive symptoms in women with FM (39). In fact, the depressive symptoms have been described as independent predictors of tests (such as the 6-Minute Walk and the 30-sec Chair Stand Test) (27) as well as an association with self-reported impaired functionality in individuals with FM (24). In addition, recent findings have indicated that women with FM, when classified in accordance with a fitness test battery, exhibit poorer depression status than women without FM. This suggests that physical performance can be a valuable discriminative tool for the severity of symptoms in FM patients (11). Interestingly, though, in the present study, there was no relationship between depressive symptoms and physical function performance. While depression symptoms are present more often than not in patients with FM, not every patient with FM has a diagnosis of depression (31), which may explain the lack of finding a relationship between symptoms and physical function. Also, the association between these two factors appears to be weak and in inconsistent in individuals with FM, which differs from the observations in healthy adults (39). Regarding mood states, the FM group had poorer scores in all subscales when compared to the Control group. Although studies performed in Brazil that assess mood states in FM subjects are scant, the results found in the present study are similar to the findings of a Brazilian research paper by Brandt et al. (10). No doubt it should be obvious that in FM patients with widespread musculoskeletal chronic pain, fatigue, non-restorative sleep, headache (45), anxiety, and depression (9,46), the higher the number of symptoms the greater the likelihood of interference with mood states (10). Hence, in the present study, some subscales of mood states (such as tension and confusion) showed positive and significant correlations with the BDI score in the FM group. 127

10 The mood states are also factors which may favor or impair motor performance, especially in the athletic performance environment. For instance, the subjects mood status appears to be an effective predictor of the participation in athletics (7). Thus, when comparing individuals who did or did not use any sports modality, the use of Profile of Mood States (POMS) instrument generally reflects greater success in performance when there is the manifestation of higher values of vigor (positive factors) and lower values of tension, depression, fatigue, confusion, and anger that are associated with a depressed state (29), which represents what was commonly known as iceberg profile (34). It is possible that women with FM manifesting the depressed state become more susceptible to not performing in accordance with their skill level. We found that in the FM group both tension and anger showed a positive correlation with tests that demand strength in knee extension (Knee Extension Peak Torque and 30-sec Chair Stand) and, interestingly, a positive correlation was found between depression (subscale of BRUMS) and the knee flexion peak torque. More research is needed to investigate whether a possible depressed mood state, specifically in the chronic pain population, influences the accomplishment of certain physical tasks or a set of tasks that reflect the activities of the daily life. Limitations in this Study This study has several limitations. The number of subjects assessed is a relatively small sample. Thus, it is best to allow for a moderate generalizability of these findings to a similar population of subjects. Although there were a few relationships between psychological and physical variables, this study highlights the effort executed to identify possible associations among mood states, depressive symptoms, and physical function (particularly with reference to physical function by field-based fitness tests). The subjects physical activity per se was not evaluated. There is an association between physical exercise and lower values of depression in patients with FM, and the level of depression is positively associated with physical inactivity (5). CONCLUSIONS The findings in this study indicate that women with fibromyalgia had poorer mood states, greater severity of depressive symptoms, and reduced physical function and yet, their depressive symptoms were not associated with physical function. While some components of mood states (e.g., tension and anger) were associated with the physical function of women with fibromyalgia, more studies are needed to elucidate this topic of research. 128

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