Introduction
Fibromyalgia syndrome (FMS) is a very common and chronic musculoskeletal disease characterized by extensive pain and the presence of specific tender point sites in the absence of any inflammatory or musculoskeletal abnormality. This syndrome is associated with symptoms such as fatigue, insomnia, morning stiffness, anxiety, and depression. It is more common in women than in men. Stress seems to play a important role in regulating some key processes in FMS, leading to increased symptoms, including pain. The perception of pain consists of two sensory and affective dimensions. The sensory dimension indicates the severity of pain while the affective dimension indicates the unpleasantness of pain. FMS is often comorbid with other diseases which causes overlapping syndromes, such as chronic fatigue syndrome. Chronic fatigue is a complex and debilitating disorder. 
Psychological empowerment can be effective in relieving FMS. Empowerment is one of the general principles of health promotion. Psychological interventions for controlling stress, reducing chronic fatigue, and empowerment include stress management programs. Since pharmacotherapy has not been able to treat FMS, this study aims to assess the effect of cognitive-behavioral stress management (CBSM) therapy on pain perception, chronic fatigue, and psychological empowerment of women with FMS.

Methods
This is a randomized clinical trial with a pre-test/post-test design. The study population consists of all women suffering from FMS who visited the rheumatology specialists in Tabriz, Iran, in 2023. Of these, 36 eligible patients were selected using a convenience sampling method and were randomly assigned to two groups of 18 including intervention (received CBSM therapy at 10 sessions of 90 minutes) and control (no intervention). Data collection tools included McGill pain questionnaire (MPQ), the Chalder fatigue scale (CFS), and Thomas and Velthouse’s psychological empowerment scale (PES). Multivariate analysis of covariance (MANCOVA) was used to compare the groups. The Kolmogorov-Smirnov test was used to examine the normality of distribution. The results indicated that the data distribution was normal (P<0.05) and all the assumptions for MANCOVA were confirmed.

Results 
Table 1 presents the descriptive statistics of the study variables.




Tables 2, 3, 4 show the results of MANCOVA for the study variables. As can be seen, the main effect of intervention was significant on the components of MPQ, CFS, and PES in the post-test. Thus, CBSM therapy was effective in improving pain perception, reducing chronic fatigue, and improving psychological empowerment of women with FMS.










Conclusion
The CBSM training can improve pain perception (sensory, affective, evaluative, and miscellaneous), reduce chronic fatigue (psychological and physical), and increase psychological empowerment (competence, self-determination, impact, meaning) of women with FMS.

Ethical Considerations

Compliance with ethical guidelines
This study considered all ethical principles and has ethical approval from the Islamic Azad University, Ahar Branch (Code: IR.IAU.TABRIZ.REC.1402.274) and was registered by the Iranian Registry of Clinical Trials (ID: IRCT20231122060140N1). 

Funding
This article was extracted from the master’s thesis of Elmira Sharghi at the Department of Clinical Psychology, Faculty of Psychology, Islamic Azad University, Ahar Branch. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. 

Authors contributions
Conceptualization and editing: Elmira Sharghi; investigation: Ebrahim Nouri; Supervision: Hossein Rostami

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgments
The authors would like to thank the staff of rheumatology centers in Tabriz and all participants for their cooperation in this study.


 

1. Conversano C, Carmassi C, Bertelloni CA, Marchi L, Micheloni T, Carbone MG, et al. Potentially traumatic events, post-traumatic stress disorder and post-traumatic stress spectrum in patients with fibromyalgia. Clinical and Experimental Rheumatolog. 2019; 37 Suppl 116(1):39-43. [PMID]
2. Galvez-Sánchez CM, Muñoz Ladrón de Guevara C, Montoro CI, Fernández-Serrano MJ, Duschek S, Reyes Del Paso GA. Cognitive deficits in fibromyalgia syndrome are associated with pain responses to low intensity pressure stimulation. Plos One. 2018; 13(8):e0201488. [DOI:10.1371/journal.pone.0201488] [PMID] [PMCID]
3. Marques AP, Santo ASDE, Berssaneti AA, Matsutani LA, Yuan SLK. Prevalence of fibromyalgia: Literature review update. Revista Brasileira de Reumatologia. 2017; 57(4):356-63. [DOI:10.1016/j.rbre.2017.01.005] [PMID]
4. Heidari F, Afshari M, Moosazadeh M. Prevalence of fibromyalgia in general population and patients, A systematic review and meta-analysis. Rheumatology International. 2017; 37(9):1527-39. [DOI:10.1007/s00296-017-3725-2] [PMID]
5. Miró E, Diener FN, Martínez MP, Sánchez AI, Valenza MC. [Fibromyalgia in men and women: Comparison of the main clinical symptoms (Spanish)]. Psicothema. 2012; 24(1):10-5. [PMID]
6. Calandre EP, Rico-Villademoros F. The role of antipsychotics in the management of fibromyalgia. CNS Drugs. 2012; 26(2):135-53. [DOI:10.2165/11597130-000000000-00000] [PMID]
7. Cassisi G, Sarzi-Puttini P, Casale R, Cazzola M, Boccassini L, Atzeni F, et al. Pain in fibromyalgia and related conditions. Reumatismo. 2014; 66(1):72-86. [DOI:10.4081/reumatismo.2014.767] [PMID]
8. Bjørklund G, Dadar M, Chirumbolo S, Aaseth J. Fibromyalgia and nutrition: Therapeutic possibilities? Biomedicine & Pharmacotherapy. 2018; 103:531-8. [DOI:10.1016/j.biopha.2018.04.056] [PMID]
9. Ram PR, Jeyaraman M, Jeyaraman N, Nallakumarasamy A, Khanna M, Gupta A, et al. Beyond the pain: A systematic narrative review of the latest advancements in fibromyalgia treatment. Cureus. 2023; 15(10):e48032. [DOI:10.7759/cureus.48032]
10. Franco KFM, Miyamoto GC, Franco YRDS, Salvador EMES, do Nascimento BCB, Menten LA, et al. Is pilates more effective and cost-effective than aerobic exercise in the treatment of patients with fibromyalgia syndrome? A randomized controlled trial with economic evaluation. European Journal of Pain. 2023; 27(1):54-71. [DOI:10.1002/ejp.2039] [PMID]
11. Manojlović D, Kopše EI. The effectiveness of aerobic exercise for pain management in patients with fibromyalgia. European Journal of Translational Myology. 2023; 33(3):11423. [DOI:10.4081/ejtm.2023.11423] [PMID] [PMCID]
12. Malin K, Littlejohn GO. Stress modulates key psychological processes and characteristic symptoms in females with fibromyalgia. Clinical and Experimental Rheumatology 2013; 31(6 Suppl 79):S64-71. [PMID]
13. Davoodi M, Shameli L, Hadianfard H. The effectiveness of acceptance and commitment therapy on chronic fatigue syndrome and pain perception in people with multiple sclerosis. Iranian Journal of Psychiatry and Clinical Psychology. 2019; 25 (3):250-65. [DOI:10.32598/ijpcp.25.3.250]
14. Chisari C, Chilcot J. The experience of pain severity and pain interference in vulvodynia patients: The role of cognitive-behavioural factors, psychological distress and fatigue. Journal of Psychosomatic Research,. 2017; 93:83-9. [DOI:10.1016/j.jpsychores.2016.12.010] [PMID]
15. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. Journal of Health and Social Behavior. 1983; 24(4):385-96. [DOI:10.2307/2136404] [PMID]
16. Soleymani P, Kazemi R, Taklavi S, Narimani M. [Effectiveness of group acceptance and commitment therapy on perceived stress and pain perception of women with fibromyalgia. Journal of Anesthesiology and Pain. 2020; 11(2):68-79. [Link]
17. Sarkhel S. Kaplan and Sadock's synopsis of psychiatry: Behavioral sciences/clinical psychiatry, 10th edition. Indian Journal of Psychiatry. 2009; 51(4):331. [PMCID]
18. Schutzer SE, Liu T, Tsai CF, Petyuk VA, Schepmoes AA, Wang YT, et al. Myalgic encephalomyelitis/chronic fatigue syndrome and fibromyalgia are indistinguishable by their cerebrospinal fluid proteomes. Annals of Medicine. 2023; 55(1):2208372. [DOI:10.1080/07853890.2023.2208372] [PMID] [PMCID]
19. Institute of Medicine. Beyond myalgia encephalomyelitis/chronic fatigue syndrome. Washington: National Academies Press; 2015. [DOI:10.17226/19012]
20. Veauthier C, Hasselmann H, Gold SM, Paul F. The Berlin treatment algorithm: Recommendations for tailored innovative therapeutic strategies for multiple sclerosis-related fatigue. The EPMA Journal. 2016; 7(1):25. [DOI:10.1186/s13167-016-0073-3] [PMID] [PMCID]
21. Bai Z, Luo S, Zhang L, Wu S, Chi I. Acceptance and commitment therapy (ACT) to reduce depression: A systematic review and meta-analysis. Journal of Affective Disorders. 2020; 260:728-37. [DOI:10.1016/j.jad.2019.09.040] [PMID]
22. Rajabi G, Zolmajd Z. [Psychometric properties of the Persian version of the family empowerment scale (Persian)]. Iranian Journal of Psychiatry and Clinical Psychology. 2018; 24(2):216-29.  [DOI:10.32598/ijpcp.24.2.216]
23. Mohammadi Nasab R, Fakhimi Azar S, Pasban M, Bohloli N. [Determining the psychological factors affecting the ability of nurses - A case study of Al-Ghadir Naja hospital (Persian)]. Journal of Police Medicine. 2021; 10(3):177-84. [Link]
24. Bashar FR, Vahedian-Azimi A, Salesi M, Hajiesmaeili M, Shojaei S, Farzanegan B, et al. Spiritual health and outcomes in muslim ICU patients: A nationwide cross-sectional study. Journal of Religion and Health. 2018; 57(6):2241-57. [DOI:10.1007/s10943-017-0543-5] [PMID]
25. Vahedian-Azimi A, Rahimi Bashar F, Amini H, Salesi M, Alhani F. [Effect of family-centered empowerment model on quality of life in adults with chronic diseases: A systematic review and meta-analysis study (Persian)]. Journal of Hayat. 2018; 24(2):152-73. [Link]
26. Zaeri S, Neasi A, Khaje N. [The effectiveness of stress management training on psychological empowerment and job burnout (Persian)]. Iran Occupational Health. 2020; 17(1):610-21. [Link]
27. Antoni MH, Baggett L, Ironson G, LaPerriere A, August S, Klimas N, et al. Cognitive-behavioral stress management intervention buffers distress responses and immunologic changes following notification of HIV-1 seropositivity. Journal of consulting and Clinical Psychology. 1991; 59(6):906-15. [DOI:10.1037//0022-006X.59.6.906] [PMID]
28. Bhattacharya S, Goicoechea C, Heshmati S, Carpenter JK, Hofmann SG. Efficacy of cognitive behavioral therapy for anxiety-related disorders: A meta-analysis of recent literature. Current Psychiatry Reports. 2023; 25(1):19-30. [DOI:10.1007/s11920-022-01402-8] [PMID] [PMCID]
29. Shokoohi Nejad N, Bayat M R, Zanganeh Motlagh F. [Comparing the effectiveness of cognitive therapy based on mindfulness and compassion therapy on automatic negative thoughts, psychological symptoms, pain intensity, and quality of life in patients with fibromyalgia (Persian)]. Journal of Arak University Medical Sciences. 2022; 25(1):156-73. [DOI:10.32598/jams.25.1.6744.1]
30. Jahanshahi Hesari N, Asgari P, Naderi F, Heidari A. Effectiveness of positive mindfulness therapy and emotion-focused cognitive-behavioral therapy in improving pain perception and sleep quality in fibromyalgia patients. International Journal of Musculoskeletal Pain Prevention. 2021; 6(4):564-72. [DOI:10.52547/ijmpp.6.4.564]
31. Jafari M, Sabahi P, Jahan F, Sotodeh Asl N. Effectiveness of cognitive-behavioral stress management for depression, anxiety, cognitive emotion regulation, and quality of life in patients with irritable bowel syndrome: A quasi-experimental study.  Jundishapur Journal of Chronic Disease Care. 2022; 11(2):e122098. [DOI:10.5812/jjcdc.122098]
32. Zisopoulou T, Varvogli L. Stress management methods in children and adolescents: Past, present, and future. Hormone Research in Paediatrics. 2023; 96(1):97-107. [DOI:10.1159/000526946] [PMID]
33. Melzack R. The McGill Pain Questionnaire: Major properties and scoring methods. Pain. 1975; 1(3):277-99. [DOI:10.1016/0304-3959(75)90044-5] [PMID]
34. Dworkin RH, Turk DC, Revicki DA, Harding G, Coyne KS, Peirce-Sandner S, et al. Development and initial validation of an expanded and revised version of the Short-form McGill Pain Questionnaire (SF-MPQ-2). Pain. 2009; 144(1-2):35-42. [DOI:10.1016/j.pain.2009.02.007] [PMID]
35. Khosravi M, Sadighi S, Moradi S, Zendehdel K. [Persian-McGill pain questionnaire; translation, adaptation and reliability in cancer patients: a brief report (Persian)]. Tehran Univerity Medical Journal. 2013; 71(1):53-8. [Link]
36. Chalder T, Berelowitz G, Hirsch S. Development of a fatigue scale. Journal of sychosomatic Research. 1993; 37(2):147-53. [DOI:10.1016/0022-3999(93)90081-P] [PMID]
37. Afrozeh F, Askarizadeh G, Towhidi A. [The effectiveness of cognitive-behavioral stress management training on chronic fatigue and death anxiety in women under the cure of dominating (Persian)]. Iranian Journal of Psychiatric Nursing. 2019; 7(4):58-63. [DOI:10.21859/ijpn-07408]
38. Thomas KW, Velthouse AB. Cognitive element of emprowment: an interpretive model of intrinsic task motivation. Academy of Management Journal. 1990; 15(4):666-81. [DOI:10.5465/amr.1990.4310926]
39. Emrahi A, Ghalavandi H, Seyyed Abbaszadeh MM. [Investigating the relationship between the quality of work life and organizational socialization with organizational learning and cognitive empowerment among Urmia University employees (Persian)]. Educational Leadership and Management. 2013; 8(2):9-26. [Link]
40. Dortaj A, Aliakbari Dehkordi M, aser Moghadasi A, Alipour A. [The effectiveness of acceptance and commitment therapy on distress tolerance, pain perception and interleukin-12 in patients with multiple sclerosis (Persian)]. Quarterly of Applied Psychology. 2021; 15(1):49-72. [DOI:10.52547/apsy.2021.216250.0]
41. Hajilou M, Ahadi H, Seirafi MR, Shahbeigi S, Rafiepoor A. The effectiveness of stress management training based on cognitive-behavioral model on quality of life in patiens with MS. Journal of Psychological Science. 2019; 17(72):893-97. [Link]
42. Taylor P, Dorstyn DS, Prior E. Stress management interventions for multiple sclerosis: A meta-analysis of randomized controlled trials. Journal of Health Psychology. 2020; 25(2):266-79. [DOI:10.1177/1359105319860185] [PMID]
43. Prados G, Miró E, Martínez MP, Sánchez AI, Lami MJ, Cáliz R. Combined cognitive-behavioral therapy for fibromyalgia: Effects on polysomnographic parameters and perceived sleep quality. International Journal of Clinical and Health Psychology. 2020; 20(3):232-42. [DOI:10.1016/j.ijchp.2020.04.002] [PMID] [PMCID]
44. Taub C, Fisher H, Amiel C, Jutagir D, Bouchard L, Gudenkauf L, et al. Baseline pain intensity and pain interference moderate effects of cognitive behavioral stress management on leukocyte inflammatory gene expression in women with breast cancer. The Journal of Pain. 2017; 18(4):S81. [DOI:10.1016/j.jpain.2017.02.279]
45. Matsumoto K, Hamatani S, Shimizu E. Effectiveness of videoconference-delivered cognitive behavioral therapy for adults with psychiatric disorders: Systematic and meta-analytic review. Journal of Medical Internet Research. 2021; 23(12):e31293. [DOI:10.2196/31293] [PMID] [PMCID]
46. Liu J, Gill NS, Teodorczuk A, Li ZJ, Sun J. The efficacy of cognitive behavioural therapy in somatoform disorders and medically unexplained physical symptoms: A meta-analysis of randomized controlled trials. Journal of Affective Disorders. 2019; 245:98-112. [DOI:10.1016/j.jad.2018.10.114] [PMID]
47. Melzack R, Wall PD. Pain mechanisms: A new theory. Science. 1965; 150(3699):971-9. [DOI:10.1126/science.150.3699.971] [PMID]
48. Abniki E, Abolghasemi A, Abbasi M, Moazzez R, Jalali R. [The effect of group cognitive-behavioral intervention in stress management on improved hardiness and self-control in depressed women (Persian)]. Clinical Psychology Studies. 2015; 5(19):99-118. [Link]
49. Taheri S, Sajjadian T. Effectiveness of mindfulness based cognitive therapy on fatigue symptoms (Persian)]. Career and Organizational Counseling. 2017; 9(30):145-71. [Link]
50. Hosseini Fard A, Tabarai F. [Effectiveness of stress management group training using cognitive-behavioral method on job burnout and anxiety of Behshahr nurses (Persian)]. Paper presented in: International research conference in behavioral and social sciences. 2016 March 6; İstanbul, Turkey. [Link]
51. Cooper CL, Campbell Quick J. Stress and chronic fatigue syndrome. In: Cooper CL, Campbell Quick J, editors. The handbook of stress and health: a guide to research and practice. Hoboken: Wiley; 2017. [DOI:10.1002/9781118993811.ch8]
52. Villani D, Grassi A, Cognetta C, Cipresso P, Toniolo D, Riva G. The effects of a mobile stress management protocol on nurses working with cancer patients: A preliminary controlled study. Studies in Health Technology and Informatics. 2012; 173:524-8. [PMID]
53. Sembajwe G, Wahrendorf M, Siegrist J, Sitta R, Zins M, Goldberg M, et al. Effects of job strain on fatigue: Cross-sectional and prospective views of the job content questionnaire and effort--reward imbalance in the GAZEL cohort. Occupational and Environmental Medicine. 2012; 69(6):377-84. [DOI:10.1136/oem.2010.063503] [PMID]
54. Lopez C, Antoni M, Penedo F, Weiss D, Cruess S, Segotas MC, et al. A pilot study of cognitive behavioral stress management effects on stress, quality of life, and symptoms in persons with chronic fatigue syndrome. Journal of Psychosomatic Research. 2011; 70(4):328-34. [DOI:10.1016/j.jpsychores.2010.11.010] [PMID] [PMCID]
55. Ghafari S, Ahmadi F, Nabavi S. [Effects of applying hydrotherapy on fatigue in multiple sclerosis patients (Persian)]. Journal of Mazandaran University of Medical Sciences. 2008; 18(66):71-81. [Link]
56. Taormina RJ, Law CM. Approaches to preventing burnout: the effects of personal stress management and organizational socialization. Journal of Nursing Management. 2000; 8(2):89-99. [DOI:10.1046/j.1365-2834.2000.00156.x] [PMID]
57. Anagnostouli M, Babili I, Chrousos G, Artemiadis A, Darviri C. A novel cognitive-behavioral stress management method for multiple sclerosis. A brief report of an observational study. Neurological Research. 2019; 41(3):223-6. [DOI:10.1080/01616412.2018.1548745] [PMID]
58. Lin R, Yu DS, Chau PH, Li PW. Effects of an empowerment-based educative psycho-behavioral program on neuropsychiatric symptoms among persons with mild cognitive impairment: A mixed methods study. International Journal of Nursing Studies. 2023; 137:104381. [DOI:10.1016/j.ijnurstu.2022.104381]
59. Lin RSY, Yu DSF, Chau PH, Li PWC. Effects of an empowerment-based educative psycho-behavioral program on neuropsychiatric symptoms among persons with mild cognitive impairment: A mixed methods study. International Journal of Nursing Studies. 2023; 137:104381. [DOI:10.1016/j.ijnurstu.2022.104381] [PMID]
60. Mehrabian F, Baghizadeh K, Alizadeh I. The relationship between empowerment, occupational burnout, and job stress among nurses in Rasht medical education centers: A dataset. Data in Brief. 2018; 20:1093-8. [DOI:10.1016/j.dib.2018.08.176] [PMID] [PMCID]
61. Huang J, Jiang D, Wang X, Liu Y, Fennie K, Burgess J, Williams AB. Changing knowledge, behavior, and practice related to universal precautions among hospital nurses in China. Journal of Continuing Education in Nursing. 2002; 33(5):217-24. [DOI:10.3928/0022-0124-20020901-07] [PMID]
62. Qamari Givi  H, Nader M, Dehghani F. [Investigating the effectiveness of cognitive rehabilitation in restoring the executive functions of obsessive-compulsive patients (Persian)]. Clinical Psychology Quarterly. 2014; 16(4):102-28. [Link]
63. Blair C, Zelazo PD, Greenberg MT. The measurement of executive function in early childhood. Developmental Neuropsychology. 2005; 28(2):561-71. [DOI:10.1207/s15326942dn2802_1] [PMID]