A pilot study of health and wellness coaching for fibromyalgia

Abstract

Background
The purpose of this study was to test the hypothesis that a health and wellness coaching (HWC)-based intervention for fibromyalgia (FM) would result in sustained improvements in health and quality of life, and reductions in health care utilization.

Methods
Nine female subjects meeting American College of Rheumatology criteria for a diagnosis of primary FM were studied. The HWC protocol had two components, which were delivered telephonically over a twelve-month period. First, each patient met individually with a coach during the 12 month study at the patient’s preference of schedule and frequency (Range:22–32 × 45-min sessions). Coaches were health professionals trained in health and wellness coaching tasks, knowledge, and skills. Second, each patient participated in bimonthly (first six months) and monthly (second six months) group classes on self-coaching strategies during the 12 month study. Prior to the intervention, and after 6 months and 12 months of coaching, the Revised Fibromyalgia Impact Questionnaire (FIQR) was used to measure health and quality of life, and the Brief Pain Inventory-Short Form (BPI) was used to measure pain intensity and interference with function. Total and rheumatology-related health encounters were documented using electronic medical records. Data were analyzed using repeated measures ANOVA.

Results
All nine patients finished the HWC protocol. FIQR scores improved by 35 % (P = 0.001). BPI scores decreased by 32 % overall (P = 0.006), 31 % for severity (P = 0.02), and 44 % for interference (P = 0.006). Health care utilization declined by 86 % (P = 0.006) for total and 78 % (P < 0.0001) for rheumatology-related encounters.

Conclusion
The HWC program added to standard FM therapy produced clinically significant improvements in quality of life measures (FIQR), pain (BPI), and marked reductions in health care utilization. Such improvements do not typically occur spontaneously in FM patients, suggesting that HWC deserves further consideration as an intervention for FM.

Full text

R E S E A R C H A R T I C L E Open Access
A pilot study of health and wellness
coaching for fibromyalgia
Kevin V. Hackshaw
1,9*
, Marcal Plans-Pujolras
2
, Luis E. Rodriguez-Saona
3
, Margaret A. Moore
4,5,6
, Erika K. Jackson
4
,
Gary A. Sforzo
7
and C. A. Tony Buffington
8
Abstract
Background: The purpose of this study was to test the hypothesis that a health and wellness coaching (HWC)-
based intervention for fibromyalgia (FM) would result in sustained improvements in health and quality of life, and
reductions in health care utilization.
Methods: Nine female subjects meeting American College of Rheumatology criteria for a diagnosis of primary FM
were studied. The HWC protocol had two components, which were delivered telephonically over a twelve-month
period. First, each patient met individually with a coach during the 12 month study at the patient’s preference of
schedule and frequency (Range:22–32 × 45-min sessions). Coaches were health professionals trained in health and
wellness coaching tasks, knowledge, and skills. Second, each patient participated in bimonthly (first six months) and
monthly (second six months) group classes on self-coaching strategies during the 12 month study. Prior to the
intervention, and after 6 months and 12 months of coaching, the Revised Fibromyalgia Impact Questionnaire (FIQR)
was used to measure health and quality of life, and the Brief Pain Inventory-Short Form (BPI) was used to measure
pain intensity and interference with function. Total and rheumatology-related health encounters were documented
using electronic medical records. Data were analyzed using repeated measures ANOVA.
Results: All nine patients finished the HWC protocol. FIQR scores improved by 35 % (P= 0.001). BPI scores
decreased by 32 % overall (P= 0.006), 31 % for severity (P= 0.02), and 44 % for interference (P= 0.006). Health care
utilization declined by 86 % (P= 0.006) for total and 78 % (P< 0.0001) for rheumatology-related encounters.
Conclusion: The HWC program added to standard FM therapy produced clinically significant improvements in
quality of life measures (FIQR), pain (BPI), and marked reductions in health care utilization. Such improvements do
not typically occur spontaneously in FM patients, suggesting that HWC deserves further consideration as an
intervention for FM.
Keywords: Fibromyalgia, Healthcare costs, Motivational interviewing, Health behavior intervention, Pain
management
Background
Fibromyalgia (FM) is a member of a class of disorders
called “medically unexplained symptoms,”“functional
somatic syndromes,”or “central sensitivity syndromes,”
that present significant diagnostic and therapeutic
challenges to medicine [1]. The estimated prevalence
of FM in the US in 2005 was about 2 %, affecting an
estimated 5 million adults [2, 3]. Fibromyalgia remains
undiagnosed in as many as 3 out of 4 people with the
condition, and the time from onset of symptoms to
diagnosis averages 5 years, resulting in delayed and
potentially suboptimal treatment [2]. The economic
impact of FM is enormous; current estimates suggest
that as many as 25 % of FM patients in the US receive
some form of disability or injury compensation [3, 4].
The estimated socio-economic costs for FM are probably
in the tens of billions of dollars when one considers work
absenteeism, lost productivity, health care utilization
* Correspondence: Kevin.Hackshaw@osumc.edu
1
Internal Medicine and Molecular Biochemistry, The Ohio State University,
Columbus, USA
9
Division of Immunology/Rheumatology, William Davis Medical Research
Center, Wexner Medical Center, The Ohio State University, 480 Medical
Center Drive, Columbus, OH 43210-1228, USA
Full list of author information is available at the end of the article
© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Hackshaw et al. BMC Musculoskeletal Disorders (2016) 17:457
DOI 10.1186/s12891-016-1316-0
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

(including medication costs), legal fees and litigation,
and other costs. Various reports suggest that overall
healthcare costs of FM are more than twice the amount
for people without FM [5, 6]. As White et al. concluded,
“Effective treatment, through improvements in diagnosis,
management, and pharmaceutical intervention, could
result in reduced direct and indirect costs”[5].
Two factors that determine the subsequent health and
quality of life of FM patients are a positive diagnosis and
effective treatment [7]. We recently reported that a positive
diagnosis can be provided and objective assessment of
disease activity determined for FM patients using infra-
red microspectroscopy and chemometrics [8]. This ap-
proach, which represents an advance over traditional
methods of clinical diagnosis, currently is undergoing
further validation, refinement and approval before be-
ing introduced into clinical practice.
Current treatment options include variable combinations
of pharmacological and nonpharmacological treatments
such as exercise and cognitive behavioral therapy (CBT)
[9]. The European League Against Rheumatism (EULAR)
has issued strong recommendations for the use of tricyclic
antidepressants, serotonin-noradrenaline reuptake in-
hibitors, serotonin reuptake inhibitors, gamma-amino
butyric acid analogues like gabapentin and pregabalin,
and only weak recommendations for non-pharmacological
therapies such as aerobic exercise, CBT and combination
therapy [10]. These recommendations suffer from lack of
head to head comparisons of pharmacological versus non-
pharmacological treatments [11]. The absence of strong
recommendations for non-pharmacologic treatments is
perplexing given that many of these modalities have been
shown to be effective in this patient population, and have
the potential to provide considerable health care cost
savings [12, 13]. A recent meta-analysis found only one
pharmacologic treatment (amitriptyline) had a significant
effect on as many as three of six core FM dimensions
(i.e., pain, sleep disturbance, fatigue, affective symptoms,
functional deficit and cognitive impairment), whereas non-
pharmacologic therapies routinely had multidimensional
targets [14]. A recent trial evaluated 12-month treatment
patterns and outcomes for 1700 patients starting new medi-
cations for FM. Patients reported approximately 20 out-
patient visits annually at baseline and 21.2 visits during the
year following initiation of FM specific therapy. Number of
days absent from work went from 27.7 to 25.0 after new
pharmaceutical therapy, but the number of days in bed and
days patients received disability income increased from 38.4
to 40.6, and 96.6 to 98.2, respectively [15]. These disap-
pointing outcomes of FM medications illustrate that
there is an unmet need to explore the roles for non-
pharmacologic FM therapies to reduce health care costs
and improve quality of life, as well as to provide more
patients access to these therapies [16].
A recent systematic review has documented the effective-
ness of health and wellness coaching (HWC) for a variety
of chronic medical conditions [17–20]. The HWC ap-
proach employs health professionals trained in patient-
centered coaching competencies. These include coaching
tasks, knowledge, and skills. Coaching competencies are
based upon evidence-based theories of behavior change,
self-determination, self efficacy, self regulation, positive
psychology, and motivational interviewing [21].
The US-based National Consortium for Credentialing
Health & Wellness Coaches completed a best-practices
job task analysis to enable a national health and wellness
coach certification [22]. HWC helps patients or clients
identify a personal vision of thriving mentally and physically
while assisting in developing autonomous motivation, im-
proving positive emotions, resources, and self-efficacy, and
sustaining changes in mindset and behavior that generate
improved health and well-being [23]. HWC behavior
change techniques have been applied in specific chronic
conditions, and meta-analyses have identified significant
improvements in pain, fatigue, depression, anxiety, and
stress in a variety of clinical populations [18–20, 24]. The
cited literature evaluated HWC in patients with cancer
pain, post myocardial infarction, and chronic low back pain.
Many of the comorbid symptoms these individuals suffer
from are similar to the signs of distress in FM, includ-
ing fatigue, depression, anxiety and stress. Statistically
significant improvement was seen in all settings using
validated questionnaires of functional improvement in-
cluding BPI, which we used in our current study. In
addition, telephone coaching has been demonstrated to
result in significant clinical improvement [24]. Accordingly,
HWC appears to be a treatment strategy that might prove
effectivel for patients with FM. Hence the purpose of this
studywastoexploreeffectsofaHWC-basedintervention
for subjects with FM on outcomes related to health, quality
of life and health care costs as documented by subjective
global improvement and health care utilization.
Methods
All study related activity was conducted after obtaining
informed consent and in accordance with The Ohio State
University Institutional Review Board.
Subject recruitment
Ten female subjects meeting American College of
Rheumatology (ACR) criteria for a diagnosis of primary
FM were recruited from The Ohio State University (OSU)
Rheumatology clinics located in Columbus OH. Subjects
were approached during routine clinic visits with KVH
between September 2013 and December 2013 and asked
about their willingness to participate in a wellness coaching
program. The first ten individuals who accepted this
commitment were enrolled in the studies. No financial
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inducements were provided to patients. One individual
elected to withdraw prior to study initiation due to
pregnancy-related concerns about the time commitment.
None of the individuals recruited were taking any medica-
tions other than FDA approved FM medications. There
were no changes (additions or change in dosage) to the
patients’medications during the 1 year study period.
Inclusion/exclusion criteria
All patients met the following criteria: Age 18 –65 years
with history of FM and meeting current ACR criteria.
Excluding patients older than 65 helped minimize the
chance that pain complaints could be confounded by
comorbid osteoarthritis. Onset of FM required that no
preceding “physical trauma”or infection were identified
as the primary initiating factor in their FM diagnosis.
Patients’entire healthcare was based at OSU Hospitals.
Medical evaluation
All subjects received an initial medical evaluation by a
board-certified rheumatologist specializing in FM (KVH).
Evaluation included medical history and prior family history
(specifically to identify and exclude individuals whose
disease appeared subsequent to some physical, infectious,
or emotional insult (e.g., divorce, death in immediate
family,etc.).Medicalhistory evaluated the quality and
severity of the individual’s pain using visual analog testing
and other scales listed below. Physical examination in-
cluded weight, blood pressure, body mass index, and
quantitation of number of tender points (manual and
dolorimetry) as described by the ACR [25, 26].
The Revised Fibromyalgia Impact Questionnaire [27]
was used to measure physical functioning, work status,
depression, anxiety, sleep, pain, stiffness, fatigue, and well-
being. The Brief Pain Inventory-Short Form (BPI) [28] was
used to measure pain intensity and interference with
function. Both assessments were completed prior to
commencement of the coaching protocol, and after 6
and 12 months of coaching. We expected improve-
ments in symptom scores at six and twelve months as
the benefits of wellness behaviors were experienced
based on prior experiences with the HWC approach.
Coaching protocol
The FM coaching protocol was delivered telephonically
as the coaches and clients did not reside in the same area.
There were no in-person coaching sessions. The protocol
had two components, biweekly private telephone sessions
and 18 group telephone sessions over the 12 month
period. All study participants [9] participated in the group
sessions. The number of private sessions was determined
by the the client, not the coach.
Telephonic coaching has been found to be an effective
means for behavior change while also providing a
convenience for the patient and clinician. Appel et al.
demonstrated that weight loss by over 400 obese, at-
risk patients was just as effectively achieved using tele-
phonic coaching compared to a condition including
in-person sessions [29].
First, each patient met individually with a coach for
45-min private sessions. The timing and number of
coaching sessions was based on patient choice and avail-
ability, ranging from once to four times per month, for a
total range of 22–32 sessions (Table 1).
Second, each patient was scheduled for twice monthly
(first six months) and then monthly (second six months)
group classes on self-coaching strategies. Attendance at
the group classes is shown in Table 2.
Individual sessions were delivered by four health and
wellness coaches, who completed a professional coach
training program consisting of 125 live hours of training
in coaching competencies over at least 18 months. The
coaches were health professionals with Bachelor’s and
Master’s level degrees in areas such as health promotion
or nursing, or had advanced exercise physiology certifi-
cations. Coaching was delivered as a facilitative (non-dir-
ective) patient-centered process following a standard
health and wellness coaching definition set forth in a
meta-analysis [23] and using well defined coaching tech-
niques and strategies [30]. Patients consistently worked
with only one coach for individual private sessions and
developed a personal relationship with that coach over
the 12-month period. Patients were encouraged to focus
the coaching session on topics that would improve their
well-being and quality of life; they received support from
their coaches for healthy eating, sleep, relaxation, exer-
cise, self-compassion, and mindfulness activities.
Coach 1 had assigned clients with very active lives
(Table 1). All clients (whether they attended group sessions
or not) were provided with recordings of the sessions. The
kick-off meeting was conducted on December 3, 2012 to
provide an introduction to Wellcoaches, the project proto-
col and the underlying theories such as self-compassion
and mindfulness. Led by MM and KVH, all participants
Table 1 Frequency of individual coaching sessions per patient
Coach 1 Coach 2 Coach 3 Coach 4
Client 1 32 sessions
Client 2 30 sessions
Client 3 22 sessions
Client 4 23 sessions
Client 5 27 sessions
Client 6 32 sessions
Client 7 24 sessions
Client 8 28 sessions
Client 9 29 sessions
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and coaches were invited to attend. EKJ, four coaches and
five participants joined the call, and those who did not at-
tend were provided with a recording.
Recorded 20–30 minute educational webinars on self-
coaching topics were provided to patients, encouraging
them to engage in “rewiring their brains,”i.e., their thinking
and feeling patterns, and personal wellness habits. Twelve
self-coaching topics and the sequence with which they were
discussed are listed in Table 3. Self-coaching topics were
then explored in group coaching sessions, led by one of the
four coaches, over the first six months. In the second six-
month period, group coaching sessions further reviewed
the twelve topics and how the concepts had been, or could
continue to be, practically applied in daily living. Patients
also were encouraged to write about their personal learning
and progress in a journal.
Health care utilization
Patient total and rheumatology health care encounters
were documented using the Integrated Health Information
Systems at The Ohio State University Hospitals for the
periods 12 months prior to the HWC intervention, dur-
ing the 12 month period of the intervention, and for
12 months after the intervention. Encounters included
any interaction that involved provider or patient care
associate (nurse, medical assistant, etc.) that resulted in
a documented electronic chart entry. Thus, encounters
included, but were not limited to, any and all office visits,
telephone exchanges or email messages which would be re-
corded through OSU’s Medical Center Mychart platform,
and refill requests. Total health care encounters included
all such encounters involving the totality of a patient’scare
at OSU Hospitals. Rheumatology Specific Encounters
included subspecialty specific calls and telephone messages,
refill requests, etc. that were specific only to a patient’s
rheumatology related condition.
Statistical analysis
Group data were evaluated using repeated-measures one-
way ANOVA, except for health care encounters, which
were not normally distributed. These data were analyzed
using the Friedman non-parametric repeated measures
one-way ANOVA test. Numbers in Table 5 are scores. The
percent changes from baseline were calculated using the
formula(baselinescore–6 (or 12) month score)/baseline
score. All data were analyzed using commercial statistical
software; [31] P< 0.05 was considered to be significant.
Results
Baseline characteristics of the participants is shown in
Table 4.
Although all nine patients finished the HWC protocol,
complete data sets were available from eight patients
because one patient did not return 12-month question-
naires; 12-month values for this patient were imputed
to be the mean of the other patients’12-month results.
Results of HWC on the FIQR are presented in Fig. 1.
One-way repeated measures ANOVA revealed a signifi-
cant reduction in both domains between baseline and
the 6 month evaluation, which was sustained at the
12 month evaluation.
Numerical results for the FIQR, BPI, including the se-
verity and interference subscales, are presented in Table 5,
and for total and rheumatology-related health care en-
counters in Table 6. Statistically and clinically significant
effects of HWC coaching were identified on all measured
parameters. There was no change in number of tender
points from baseline to end of study.
Both 6 and 12 month results were significantly different
from 0 and not different from each other.
Discussion
This was a one year pilot study of the effectiveness of a
HWC intervention for 9 female clients with FM recruited
from a university rheumatology practice. The study resulted
in three significant findings. First, we found that comple-
menting usual care with HWC led to a significant decrease
in the overall FIQR score, suggesting overall improvement
in quality of life. Bennett and colleagues previously sug-
gested that FIQ changes of 14 % or greater from baseline
value may be clinically meaningful [32]. We noted improve-
ments of 37 and 35 % at 6 and 12 months, respectively,
supporting the beneficial impact of the HWC intervention.
Second, we found significant improvements in the BPI, and
its severity and interference subscales, at 6 months, which
Table 2 Group coaching sessions with number of participants
A123456789101112131415161718
B8756567524 6 3 4 5 5 4 3 3
A = Group coaching session. B = Number of participants
Table 3 Self-coaching topics employed in webinars and group
coaching sessions
Month Topic
1 Self-compassion and Self esteem
2 Taming Frenzy and Mindfulness
3 Focus and Positivity
4 Body Intelligence and Motivation
5 Strengths and Curiosity
6 Creativity and Relationships
7 Self-compassion and Self-esteem
8 Frenzy and Mindfulness
9 Focus and Positivity
10 Body Intelligence and Motivation
11 Strengths and Curiosity
12 Creativity and Relationships
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were sustained at 12 months. Third, we identified large,
highly statistically significant reductions in both total and
rheumatology-related health care encounters recorded in
the integrated health information system network.
As stated in the title, this was a pilot study to determine
if HWC had any effect on the measured parameters in
patients with FM. To our knowledge, this is the first
time HWC has been applied to FM, so no sample size
calculation could be performed. The present data will
be useful for such calculations for future randomized
controlled trials comparing HWC to other approaches
for treatment for FM. This was the approach recom-
mended by our statistical consultant.
Integrating diverse domains of psychological research
and theory, health and wellness coaches help clients con-
sider what it means personally to thrive mentally and phys-
ically, and envision a desired future that is fuel for their
autonomous motivation [33]. HWC helps clients develop
higher levels of positive emotions, which have been shown
to improve cognitive function, resilience and immune
system function, and to reduce incidence of physical
symptoms and disease [34]. The coaching relationship
is then designed to leverage enhanced self-motivation
and positive emotions to improve self-efficacy. Clients
experiment with behavior changes using a growth mindset
(focus on learning versus success or failure) tailored to their
personal circumstances so that they discover a combination
of lifestyle behaviors that they can sustain and that lead to
improved health and well-being. The HWC approach can
yield significant long-term improvements in health and
quality of life, as documented in a recent systematic review
[17]. To date, positive HWC outcomes include reduced
hemoglobin A1C, weight loss, increased smoking cessation
rates, enhanced mood and exercise participation, reduced
anxiety post-myocardial infarction, and improved physical
and behavioral health, and healthy behavior [17, 35].
Moreover, wellness coaching using private telephone
sessions has led to improved health status and health
behaviors in patients with chronic conditions [36]. Ac-
cording to the present results, FM also may be effect-
ively treated using HWC.
The HWC approach compares favorably with current
pharmacological treatments for FM. For example, Arnold,
et al., [37] reported results of a 12 week study comparing
Table 4 Baseline characteristics of subjects
Subject Ethnicity Education Level Age Weight Height BMI BP PIS Tender Points Marital Status Work Status INS Baseline FIQR
1 W PC 46 133 5’4 22.8 110/80 41 14/18 M E I 50.8
2 W PC 29 137 5’1 25.9 108/63 27 14/18 M E I 40.8
3 W C 53 123 5’5 20.5 110/71 56 18/18 M NE I 53.0
4 W C 57 160 5’5 26.6 161/99 55 14/18 M NE I 74.6
5 W PC 25 105 5’5 17.5 110/70 27 18/18 M E I 39.5
6 W C 49 143 5’2 26.2 102/78 16 18/18 M NE I 44.8
7 W PC 59 155 5’4 26.6 132/82 19 18/18 D E I 26.0
8 W C 57 130 5’5 21.6 124/94 22 18/18 M NE I 57.8
9 W C 27 113 5’2 20.7 102/60 17 16/18 S E I 55.7
Race/Ethnicity –W(White).WorkStatus–E–Employed outside of the home, NE –not employed. M = Married, S = Single, D = Divorced. INS (Insurance) –I = Commercial
Insurance, Education Level: C = College, PC = Post College. PIS = Pain Interference Score
Fig. 1 Effect of one year of Health and Wellness Coaching on Revised Fibromyalgia Impact Questionnaire (FIQR) scores. Change in patient scores
is presented in Panel A, and Mean ± S.D. reduction in scores is presented in Panel B. Significant improvement in scores (FIQR P= 0.001) and
reduction of fibromyalgia impact (FIQR reduction P= 0.006 were identified) using 1-way repeated measures ANOVA (n=9)
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duloxetine with placebo in 207 patients (89 % female) with
FM. As in the present study, they used the FIQ and the
BPI as outcome measures. The results of HWC coaching
were comparable to duloxetine for both the FIQR and for
severity and interference scales of the BPI. More recently,
Gilron, et al., [38] evaluated the efficacy of four different
therapeutic regimens for FM; placebo, pregabalin,
duloxetine, and pregabalin + duloxetine over a 6 week
trial period. The baseline FIQ score was 45.2 ± 1.9. At
6 weeks, the FIQ scores (% improvement) were 42.9 ±
2.3 (5.1 %; placebo), 37.4 ± 2.3 (17.2 %; pregabalin),
36.0 ± 2.4 (20.4 %; duloxetine) and 29.8 ± 2.5 (34.1 %;
pregabalin + duloxetine).
Arnold et al., examined FM responder definitions in
an attempt to identify those that were most sensitive in
identifying response to treatment. After reviewing a
number of indices, they concluded that greater than or
equal to 30 % reduction in pain and greater than or
equal to 10 percent improvement in physical function
was most consistent with clinically significant improve-
ments [39]. Both of these threshold were exceeded in our
study.
There have been several evaluations of behavioral medi-
cine approaches to FM, including CBT [12, 13, 40, 41]
and acceptance and commitment therapy (ACT). Previous
studies have reported improvements following interven-
tions that incorporated CBT techniques for patients with
FM and related functional somatic syndromes. For ex-
ample, Fjorback and colleagues reported a significant
decrease in total health care utilization with the use of
CBT-like techniques and thus the potential to signifi-
cantly reduce overall health care costs in individuals
with these disorders [42]. Luciano and colleagues [43]
compared the effectiveness of ACT on pain acceptance
as a mediator of treatment outcomes and functional
status in FM patients. Patients were randomly assigned
to a group–based form of ACT, recommended pharma-
cological treatment (pregablin + duloxetine) or wait list.
The primary end point was functional status measured
withtheFIQ.BaselineFIQinthe3groupswere68.2,
69.0 and 65.9 respectively. After treatment, FIQ scores
were 48.7, 63.4 and 67.7 representing 28.6, 8.1 and~ −2.7 %
improvement. At 6 –month follow-up, values were 49.5,
65.1, and 67.4, representing improvements of 27.4 %
(ACT), 5.9 % (pregabalin + duloxetine) and −2.3 % (wait
list). In contrast, there have been no prior reports to our
knowledge of a HWC intervention similar to our design as
an approach to treatment of FM. Our results of >35 %
FIQR improvement equal or exceed outcomes of current
pharmacological treatments and ACT, and support further
study of HWC as an effective complementary intervention
for patients with FM.
The high economic burden of FM in western countries
has been well documented. Multiple studies have shown
escalating annual costs in FM patients as opposed to other
control groups of patients. In one study, health care
utilization, medication and work loss estimates for FM were
$5163, relative to $2486 in overall employee samples from
1998 data [44]. In another study, Berger, et al., [45] reported
that FM patients were more likely to have received various
combinations of pain-related medication. They also found
that the mean number of physician appointments was 4
times higher, and mean total direct costs 3 times higher,
among patients with FM than in a comparison group
($9573 versus $3291). Interestingly, Boonen and colleagues
[46] found that FM patients referred for subspecialist care
had an even higher utilization of health care resources with
more productivity loss and higher average annual total
costs than did patients with conditions such as low back
pain or ankylosing spondylitis (£7813 versus £3205).
We found a highly statistically significant decreases in
health care utilization by the entire group during and
following the HWC intervention. We currently are more
than 12 months post coaching intervention, and can report
that these patient’s provider contact remains minimal.
These observations suggest sustained improvement for an
Table 5 Effects of health and wellness coaching on patient factors [% reduction from baseline]
Measure 0 6 12 P
Revised Fibromyalgia Impact Questionnaire 49.4 ± 13.8
a
31.0 ± 13.2 [37.2 %] 32.2 ± 12.7 [34.8 %] 0.001
Brief Pain Inventory (BPI) 56.7 ± 18.1 37.0 ± 17.7 [34.7 %] 38.7 ± 20.9 [31.7 %] 0.006
BPI severity 4.8 ± 1.2 3.2 ± 1.6 [33.3 %] 3.3 ± 2.1 [31.3 %] 0.02
BPI interference 4.5 ± 2.3 2.8 ± 2.1 [37.8 %] 2.5 ± 2.2 [44.4 %] 0.002
a
Mean ± Std. dev
Table 6 Effects of health and wellness coaching on patient health care utilization factors [% reduction from baseline]
Measure 12 months prior to intervention During 12-month intervention 12 months after intervention P
Health care encounters - total 11 (3, 16)
a
3 (2, 9) [72.7 %] 1.5 (1, 5) [86.4 %] 0.006
b
Health care encounters - rheumatology 4.5 (3,6) 2 (2, 3) [55.6 %] 1 (0.25, 1) [77.8 %] <0.0001
c
a
Median (25
th
,75
th
percentiles)
b
Friedman test
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additional 12 months, perhaps as a function of the individ-
uals internalizing self –coaching skills that have been sus-
tained following the year of HWC intervention. Thus, our
findings, albeit in a very small cohort, strongly suggest the
opportunity for HWC to significantly increase health care
cost savings over time, and provide a strong impetus for
further studies of HWC in a larger cohort using more strin-
gent tools to analyze the cost effectiveness of the interven-
tion from both health care and overall societal impact
perspectives. For example, our institution utilizes multiple
patient call centers staffed by nurses in a ratio of 1 nurse
per 3 physicians to receive and log in phone calls from pa-
tients during the workday. The rheumatology call center
averages 210 calls per workday. Although the cost of tele-
phone encounters has not yet been quantified, each phone
call at our institution during the most recent three month
monitoring period averaged 3 minutes and 18 s. Although
length of phone calls by specific disease state are not avail-
able, there is unanimous agreement among our call center
staff that individuals with FM who call in with health re-
lated concerns require a much lengthier discussion than do
individuals who might call in with osteoarthritis or low
back pain-related questions, for example.
In our pilot study, conclusions were based on encounters
tabulated through our integrated health information service
for those subjects who received the entirety of their health
care in OSU Hospitals System. We did not address eco-
nomic impact outside health care, such as productivity
or absenteeism. Further studies with a larger cohort will
be required to assess the non health care impacts of
HWC further, [42] and to conduct a detailed cost analysis
of the intervention to determine the overall economic im-
pact, following the approach to costing procedure described
by Luciano and colleagues [43].
The clients in our study averaged 24 individual coaching
sessions at a cost ($75 session fee paid to coaches), or ap-
proximately $1800 per patient. The group sessions cost
approximately $300 per client ($150 fee paid to coach for
18 group coaching sessions), for a total cost of $2100 per
patient over the course of one year.
The cost of seeing a health professional 4 times a year
would average between $73 dollars and $108 dollars
based on whether the Evaluation and Management coding
wasdesignatedasLevel3or4(https://www.cms.gov/
Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/MLN-Publications-Items/CMS124
3514.html). If we estimate the average cost at approxi-
mately $90 per visit, over the course of one year, total
cost of visits would be $360 ($720 for 2 years). This
figure does not include cost of medications. In that we
noted a decrease in encounters over time by partici-
pants in the study makes us optimistic that the HWC
intervention could translate into a decrease in overall
provider visits, decreased absenteeism at work, greater
work productivity and decreased medication utilization.
It is intriguing to speculate that positive gains achieved
by HWC could potentially be sustained for even longer
periods by periodic interventions for the purposes of
reinforcement.
The patients were not incentivized financially to partici-
pate. They also did not pay for the individual or group
sessions. The coaching costs were paid for entirely by the
research organizations. In our small cohort, we had excel-
lent compliance with patients attending many sessions over
the course of 12 months. We surmise that engagement
level was high because patients were deriving personal
benefits. We recognize that we had a highly educated
cohort in this study. In addition, all of our patients
were insured. Future studies will seek to address what
sort of adherence rate(s) might be achieved with lower
income individuals, or from individuals that may not
have the same level of education background as our
current cohort.
There are a number of limitations to our pilot study.
First of all, there was no way to determine how much
“buy in”each subject had for HWC. All subjects partici-
pated in one-on-one coaching sessions, ranging from a
total of 22 to 32 sessions, but in group sessions, as would
be expected in a group of diverse personalities and life cir-
cumstances, some patients attended more group sessions
than did others, and some were more “vocal”and seemingly
more engaged than others. The only way to differentiate
the impact of group sessions versus individual sessions
would be to design a similar prospective study contrasting
2 group sessions per month versus one-on-one sessions
and reevaluate all measurable indicators of impact on FM.
Additionally, we were limited in the number of variables
that could be tested by the small sample size. For example,
the pharmacological aspects of treatment were not tightly
controlled in this study. Subjects were basically maintained
on “usual care”without major changes to their typical
analgesic or neuropathic regimen. This standardized
maintenance of usual care was achieved since all indi-
viduals were under the management of one of us
(KVH). However, with a larger sample size and in-
creased power it would be possible to control and test
the effects of medication on efficacy of coaching. In
addition, physical activity levels of subjects were not
rigorously assessed during this study. It is possible that
subjective overall improvement may have been en-
hanced by increased physical activity on the part of the
participants. Future research can evaluate whether
subjects make any changes to their overall physical ac-
tivity level during the course of coaching, perhaps as a
result of variable combinations of improved ability to
cope with pain levels and a positive overall improve-
ment in pain. It would also be of interest to see if sleep
was positively or negatively affected during the course
Hackshaw et al. BMC Musculoskeletal Disorders (2016) 17:457 Page 7 of 9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

of coaching. Having a set monitoring period with an acti-
meter for subjects could help to answer these questions.
We cannot determine what effect receiving attention
from coaches on a regular basis conveyed on the treat-
ment cohort. Future studies that include two groups of
demographically matched subjects with one group bereft
of group coaching on self coaching techniques will help
determine whether individual coaching coupled with
group coaching is more effective than coaching without
it in terms of pain reduction, cost reduction, quality of
life indicators, etc. It is our intent to conduct a larger
controlled trial that will also compare pharmacological
and HWC by themselves and the combined effects of
both with the end goal being to develop the most effective,
evidence based treatment for individuals with FM by test-
ing combinations of medication and HWC protocols.
Conclusions
In summary, addition of a HWC program to pharmaco-
logic management of patients with FM therapy produced
clinically significant improvements in patient quality of life
measures (FIQR), reduction in pain (BPI) severity and inter-
ference, and marked reductions in health care utilization.
Further studies of these interventions are essential to im-
prove the quality of life of FM patients and to reduce the
economic burden of FM on our societies. More emphasis
on non-pharmacologic intervention may need to be done
in the future to include HWC techniques as part of stand-
ard treatment for FM rather than considering them as
adjunctive therapy.
Abbreviations
ACR: American college of rheumatology; ACT: Acceptance and commitment
therapy; ANOVA: Analysis of variance; BPI: Brief pain inventory; CBT: Cognitive
behavioral therapy; EULAR: European league against rheumatism; FDA: Food
and drug administration; FIQR: Revised fibromyalgia impact questionnaire;
FM: Fibromyalgia; HWC: Health and wellness coaching; OSU: The Ohio State
University
Acknowledgements
We thank Francesca Madiai, Ph.D. for a critical review of manuscript.
Availability of data and materials
The datasets generated during and/or analysed during the current study are
available from the corresponding author on reasonable request.
Authors’contributions
KH participated in study conception, study design, recruitment of subjects,
provided direct patient care and drafted manuscript. MP provided statistical
analyses. LRS provided statistical analyses. MM participated in study conception,
study design and supervised coaching efforts. EJ participated in study design
and supervised all coaching sessions. GS participated in interpretation of results
and participated in drafting manuscript. CB conceived of the study, participated
in study design, recruitment of subjects and drafting of manuscript. All authors
read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable.
Ethics approval and consent to participate
This study was approved by the Biomedical Sciences Institutional Review
Board of The Ohio State University on October 9, 2013. Protocol number is
2013H0143. This approval is issued under The Ohio State University’s OHRP
Federalwide Assurance #00006378. Informed consent for the publication of
this data was obtained from all participants.
Author details
1
Internal Medicine and Molecular Biochemistry, The Ohio State University,
Columbus, USA.
2
Nestlé-Purina, 3916 Pettis Road, Saint Joseph 64503, MO,
USA.
3
Food Science and Technology, College of Food Agriculture and
Environmental Science, The Ohio State University, 110 Parker Food Science
and Technology Building, 2015 Fyffe Road, Columbus, OH 43210, USA.
4
Wellcoaches Corporation, Wellesley, USA.
5
Institute of Coaching, McLean
Hospital, a Harvard Medical School affiliate, Belmont, USA.
6
National
Consortium for Credentialing Health & Wellness Coaches, San Diego, USA.
7
Exercise & Sport Sciences, 323 Center for Health Sciences, Ithaca College,
Ithaca, NY 14850, USA.
8
Veterinary Clinical Sciences, The Ohio State University
College of Veterinary Medicine, Columbus, USA.
9
Division of Immunology/
Rheumatology, William Davis Medical Research Center, Wexner Medical
Center, The Ohio State University, 480 Medical Center Drive, Columbus, OH
43210-1228, USA.
Received: 4 June 2016 Accepted: 28 October 2016
References
1. Yunus MB. Editorial review: an update on central sensitivity syndromes and the
issues of Nosology and psychobiology. Curr Rheumatol Rev. 2015;11:70–85.
2. Arnold LM, Clauw DJ, McCarberg BH, FibroCollaborative. Improving the
recognition and diagnosis of fibromyalgia. Mayo Clin Proc. 2011;86:457–64.
3. Smith HS, Harris R, Clauw D. Fibromyalgia: an afferent processing disorder leading
to a complex pain generalized syndrome. Pain Physician. 2011;14:E217–45.
4. Wolfe F. The fibromyalgia syndrome: a consensus report on fibromyalgia
and disability. J Rheumatol. 1996;23:534–9.
5. White LA, Birnbaum HG, Kaltenboeck A, Tang J, Mallett D, Robinson RL.
Employees with fibromyalgia: medical comorbidity, healthcare costs, and
work loss. J Occup Environ Med. 2008;50:13–24.
6. Thompson JM, Luedtke CA, Oh TH, Shah ND, Long KH, King S, et al. Direct
medical costs in patients with fibromyalgia: cost of illness and impact of a brief
multidisciplinary treatment program. Am J Phys Med Rehab. 2011;90:40–6.
7. Clauw DJ. Fibromyalgia: a clinical review. JAMA. 2014;311:1547–55.
8. Hackshaw KV, Rodriguez-Saona L, Plans M, Bell LN, Buffington CAT.
A bloodspot-based diagnostic test for fibromyalgia syndrome and
related disorders. Analyst. 2013;138:4453–62.
9. Arnold LM, Gebke KB, Choy EH. Fibromyalgia: management strategies for
primary care providers. Int J Clin Pract. 2016;70:99–112.
10. Carville SF, Arendt-Nielsen L, Bliddal H, Blotman F, Branco JC, Buskila D, et al.
EULAR evidence-based recommendations for the management of
fibromyalgia syndrome. Ann Rheum Dis. 2008;67:536–41.
11. Nuesch E, Hauser W, Bernardy K, Barth J, Juni P. Comparative efficacy of
pharmacological and non-pharmacological interventions in fibromyalgia
syndrome: network meta-analysis. Ann Rheum Dis. 2013;72:955–62.
12. Richmond J, Berman BM, Docherty JP, Goldstein LB, Kaplan G, Keil JE, et al.
Integration of behavioral and relaxation approaches into the treatment of
chronic pain and insomnia. JAMA. 1996;276:313–8.
13. Williams D, Cary M, Glazer L, Rodriguez A, Clauw D. Randomized controlled
trial of CBT to improve functional status in fibromyalgia. Am Coll Rheum.
2000;43:S210.
14. Perrot S, Russell IJ. More ubiquitous effects from non-pharmacologic than
from pharmacologic treatments for fibromyalgia syndrome: a meta-analysis
examining six core symptoms. Eur J Pain. 2014;18:1067–80.
15. Robinson RL, Kroenke K, Williams DA, Mease P, Chen Y, Faries D, et al.
Longitudinal observation of treatment patterns and outcomes for patients
with fibromyalgia: 12-month findings from the reflections study. Pain Med.
2013;14:1400–15.
16. Clauw DJ, Crofford LJ. Chronic widespread pain and fibromyalgia: what we know,
and what we need to know. Best Pract Res Clin Rheumatol. 2003;17:685–701.
17. Kivela K, Elo S, Kyngas H, Kaariainen M. The effects of health coaching on
adult patients with chronic diseases: a systematic review. Patient Educ
Couns. 2014;97:147–57.
Hackshaw et al. BMC Musculoskeletal Disorders (2016) 17:457 Page 8 of 9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

18. Thomas ML, Elliott JE, Rao SM, Fahey KF, Paul SM, Miaskowski C. A randomized,
clinical trial of education or motivational-interviewing-based coaching
compared to usual care to improve cancer pain management. Oncol Nurs
Forum. 2012;39:39–49.
19. O’Neil A, Hawkes AL, Atherton JJ, Patrao TA, Sanderson K, Wolfe R, et al.
Telephone-delivered health coaching improves anxiety outcomes after
myocardial infarction: the ‘ProActive Heart’trial. Eur J Prev Cardiol. 2014;21:30–8.
20. Duijts SF, Faber MM, Oldenburg HS, van Beurden M, Aaronson NK.
Effectiveness of behavioral techniques and physical exercise on
psychosocial functioning and health‐related quality of life in breast cancer
patients and survivors—a meta-analysis. Psycho-Oncol. 2011;20:115–26.
21. Moore M, Phillips E, Hanc J. Organize your emotions, optimize your life:
decode your emotional DNA- and thrive. Harvard University Press; 2016.
22. Jordan M, Wolever RQ, Lawson K, Moore M. National training and education
standards for health and wellness coaching: the path to national
certification. Global Adv Health Med. 2015;4:46–56.
23. Wolever RQ, Simmons LA, Sforzo GA, Dill D, Kaye M, Bechard EM, et al.
A systematic review of the literature on health and wellness coaching:
defining a key behavioral intervention in healthcare. Glob Adv Health
Med. 2013;2:38–57.
24. Iles R, Taylor NF, Davidson M, O’Halloran P. Telephone coaching can increase
activity levels for people with non-chronic low back pain: a randomised trial.
J Physiother. 2011;57:231–8.
25. Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, et al.
The American College of Rheumatology preliminary diagnostic criteria for
fibromyalgia and measurement of symptom severity. Arthritis Care Res.
2010;62:600–110.
26. Wolfe F, Smyth HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL,
Tugwell P, Campbell SM, Abeles M, Clark P, Fam AG, Farber SJ, Fiechtner JJ,
Franklin CM, Gatter RA, Harnaty D, Lessard J, Lichtbroun AS, Masi AT, Mccain
GA, Reynolds WJ, Romano TJ, Russell IJ, Sheon RP. The American College of
Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis
Rheum. 1990;33:160–72.
27. Bennett RM, Friend R, Jones KD, Ward R, Han BK, Ross RL. The revised
fibromyalgia impact questionnaire (FIQR): validation and psychometric
properties. Arthritis Care Res. 2009;11:R120.
28. Cleeland CS. The brief pain inventory user guide. Houston: The University of
Texas; 2009.
29. Appel LJ, Clark JM, Yeh HC, Wang N-Y, Coughlin JW, Daumit G, Miller ER,
Dalcin A, Jerome GJ, Geller S, Noronha G, Pozefsky T, Charleston J, Reynolds
JB, Durkin N, Rubin RR, Louis TA, Brancati FL. Comparative effectiveness of
weight-loss interventions in clinical practice. NEJM. 2011;365:1959–68.
30. Moore M, Tschannen-Moran R, Jackson E. Coaching pyschology manual.
2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2015.
31. GraphPad. Prism version 6.00 for Mac. La JollaCaliforniaUSA:GraphPadSoftware.
32. Bennett RM, Bushmakin AG, Cappelleri JC, Zlateva G, Sadosky AB. Minimal
clinically important difference in the fibromyalgia impact questionnaire.
J Rheumatol. 2009;36:1304–11.
33. Moore M, Tschannen-Moran B. Coaching psychology manual. Wolters
Kluwer Health/Lippincott, Williams & Wilkins; 2010.
34. Moore M, Hammerness P. Organize your mind, organize your life: train your
brain to get more done in less time. Harlequin; 2012.
35. Prochaska JO, Evers KE, Castle PH, Johnson JL, Prochaska JM, Rula EY, et al.
Enhancing multiple domains of well-being by decreasing multiple health risk
behaviors: a randomized clinical trial. Popul Health Manag. 2012;15:276–86.
36. Dennis SM, Harris M, Lloyd J, Davies GP, Faruqi N, Zwar N. Do people with
existing chronic conditions benefit from telephone coaching? A rapid
review. Aust Health Rev. 2013;37:381–8.
37. Arnold LM, Lu Y, Crofford LJ, Wohlreich M, Detke MJ, Iyengar S, et al.
A double-blind, multicenter trial comparing duloxetine with placebo in
the treatment of fibromyalgia patients with or without major depressive
disorder. Arthritis Rheum. 2004;50:2974–84.
38. Gilron I, Chaparro LE, Tu D, Holden RR, Milev R, Towheed T, et al.
Combination of pregabalin with duloxetine for fibromyalgia: a randomized
controlled trial. Pain. 2016. doi:10.1097/j.pain.0000000000000558.
39. Arnold LM, Williams DA, Hudson JI, et al. Development of responder
definitions for fibromyalgia clinical trials. Arthritis Rheum. 2012;64:885–94.
40. Keefe FJ. Cognitive behavioral therapy for managing pain. Clin Psychol.
1996;49:4–5.
41. Keefe FJ, Surwit RS, Pilon RN. Biofeedback, autogenic training, and progressive
relaxation in the treatment of Raynaud's disease: a comparative study. J Appl
Behav Anal. 1980;13:3–11.
42. Fjorback LO, Arendt M, Ornbol E, Walach H, Rehfeld E, Schroder A, et al.
Mindfulness therapy for somatization disorder and functional somatic
syndromes: randomized trial with one-year follow-up. J Psychosom Res.
2013;74:31–40.
43. Luciano JV, Guallar JA, Aguado J, Lopez-Del-Hoyo Y, Olivan B, Magallon R, et
al. Effectiveness of group acceptance and commitment therapy for
fibromyalgia: a 6-month randomized controlled trial (EFFIGACT study). Pain.
2014;155:693–702.
44. Robinson RL, Birnbaum HG, Morley MA, Sisitsky T, Greenberg PE, Wolfe F.
Depression and fibromyalgia: treatment and cost when diagnosed
separately or concurrently. J Rheumatol. 2004;31:1621–9.
45. Berger A, Dukes E, Martin S, Edelsberg J, Oster G. Characteristics and
healthcare costs of patients with fibromyalgia syndrome. Int J Clin Pract.
2007;61:1498–508.
46. Boonen A, van den Heuvel R, van Tubergen A, Goossens M, Severens JL,
van der Heijde D, et al. Large differences in cost of illness and wellbeing
between patients with fibromyalgia, chronic low back pain, or ankylosing
spondylitis. Ann Rheum Dis. 2005;64:396–402.
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