Pain Severity and Health-Related Quality of Life Among Patients With Fibromyalgia: The Mediating Role of Sleep Quality and Pain Acceptance
Keywords:
Fibromyalgia, Pain Severity, Health-Related Quality of Life, Sleep Quality, Pain Acceptance, Structural Equation ModelingAbstract
Objective: This study aimed to examine the relationship between pain severity and health-related quality of life among patients with fibromyalgia and to determine the mediating roles of sleep quality and pain acceptance in this relationship.
Methods and Materials: This descriptive-correlational cross-sectional study was conducted using a structural equation modeling approach. The statistical population included adult patients with fibromyalgia who referred to rheumatology clinics, pain management centers, and specialized outpatient clinics in Tehran, Iran. A total of 286 patients were selected through convenience sampling based on the inclusion and exclusion criteria. Data were collected using a demographic and clinical information form, the Brief Pain Inventory–Short Form, the Pittsburgh Sleep Quality Index, the Chronic Pain Acceptance Questionnaire–Revised, and the 36-Item Short Form Health Survey. Data were analyzed using SPSS and AMOS software. Descriptive statistics, Pearson correlation coefficients, and structural equation modeling were used to examine the relationships among the study variables. The bootstrap method with 5,000 resamples was applied to test the significance of indirect effects.
Findings: The inferential findings showed that pain severity had a significant positive effect on poor sleep quality (β = 0.52, p < .001) and a significant negative effect on pain acceptance (β = -0.47, p < .001). Poorer sleep quality significantly predicted lower health-related quality of life (β = -0.31, p < .001), while pain acceptance significantly predicted higher health-related quality of life (β = 0.29, p < .001). Pain severity also retained a significant direct negative effect on health-related quality of life (β = -0.31, p < .001). Bootstrap analysis confirmed the significant indirect effects of pain severity on health-related quality of life through sleep quality (β = -0.16, p < .001) and pain acceptance (β = -0.14, p < .001).
Conclusion: The findings indicate that pain severity reduces health-related quality of life among patients with fibromyalgia both directly and indirectly through poorer sleep quality and lower pain acceptance, highlighting the importance of integrated interventions targeting pain management, sleep regulation, and acceptance-based coping.
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References
Alpuente, A., Torres‐Ferrús, M., Caronna, E., & Pozo‐Rosich, P. (2024). The State of Art on the Use of Patient Reported Outcomes in Migraine. Current Opinion in Neurology, 37(3), 271-282. https://doi.org/10.1097/wco.0000000000001267
Ana Cecília Rosatelli de Freitas, B., Vilarino, G. T., Souza, L. C. d., Dominski, F. H., Branco, J. H. L., & Andrade, A. (2023). Effects of Resistance Training on Sleep of Patients With Fibromyalgia: A Systematic Review. Journal of Health Psychology, 28(11), 1072-1084. https://doi.org/10.1177/13591053231172288
Byeon, H. (2024). Holistic Approaches to Mitigating Psychological Distress in Gynecological Cancer Patients. World journal of psychiatry, 14(11), 1766-1771. https://doi.org/10.5498/wjp.v14.i11.1766
Calles‐Plata, I., Ortíz‐Rubio, A., Pérez-Gisbert, L., Torres‐Sánchez, I., Calvache‐Mateo, A., Valenza, M. C., & Heredia‐Ciuró, A. (2025). Psychometric Properties of the Spanish Version of the Swallowing Quality of Life Questionnaire in Fibromyalgia Patients. Healthcare, 13(22), 2948. https://doi.org/10.3390/healthcare13222948
Campos, R. P., Vázquez, I., & Vilhena, E. (2024). Psychological Factors and Health-Related Quality of Life in Fibromyalgia Patients. Health Psychology Report. https://doi.org/10.5114/hpr/187335
Elkalla, M. A., Ali, Y., Ewais, M. M., Taha, A., & Sherif, M. (2025). Efficacy and Safety of Interventions for Fibromyalgia Syndrome Comorbid With Irritable Bowel Syndrome: Systematic Review. Clinical Rheumatology, 45(1), 41-59. https://doi.org/10.1007/s10067-025-07861-7
Fernández‐Feijoo, F., Samartin-Veiga, N., & Carrillo‐de‐la‐Peña, M. T. (2022). Quality of Life in Patients With Fibromyalgia: Contributions of Disease Symptoms, Lifestyle and Multi-Medication. Frontiers in psychology, 13. https://doi.org/10.3389/fpsyg.2022.924405
Foustoukos, T. L., Blanchard, M., & Hügle, T. (2024). Evidence-Based Self-Management Strategies for Fibromyalgia: Foundations for Digital Therapeutic Applications (Preprint). https://doi.org/10.2196/preprints.67523
Frede, N., Rieger, E., Lorenzetti, R., Venhoff, A. C., Kanne, A. M., Finzel, S., Jandova, I., Glaser, C., Thiel, J., Voll, R., & Venhoff, N. (2023). Sleep Behaviour Differs in Women and Men With Psoriatic Arthritis and Axial Spondyloarthritis With Impact on Quality of Life and Depressive Symptoms. RMD Open, 9(2), e002912. https://doi.org/10.1136/rmdopen-2022-002912
Islam, Z., D’Silva, A., Raman, M., & Nasser, Y. (2022). The Role of Mind Body Interventions in the Treatment of Irritable Bowel Syndrome and Fibromyalgia. Frontiers in Psychiatry, 13. https://doi.org/10.3389/fpsyt.2022.1076763
James, L., Hailey, L., Suribhatla, R., McGagh, D., Amarnani, R., Bundy, C., Kirtley, S., O’Sullivan, D., Steinkoenig, I., White, J. P. E., Vivekanantham, A., & Coates, L. C. (2024). The Impact of Psoriatic Arthritis on Quality of Life: A Systematic Review. Therapeutic Advances in Musculoskeletal Disease, 16. https://doi.org/10.1177/1759720x241295920
Kaambwa, B., Woods, T.-J., Natsky, A. N., Bulamu, N. B., Mpundu‐Kaambwa, C., Loffler, K. A., Sweetman, A., Catcheside, P., Reynolds, A. C., Adams, R., & Eckert, D. J. (2024). Content Comparison of Quality-of-Life Instruments Used in Economic Evaluations of Sleep Disorder Interventions: A Systematic Review. Pharmacoeconomics, 42(5), 507-526. https://doi.org/10.1007/s40273-023-01349-5
Kang, J. H., Choi, S.-E., Park, D.-J., & Lee, S. S. (2022). Disentangling Diagnosis and Management of Fibromyalgia. Journal of Rheumatic Diseases, 29(1), 4-13. https://doi.org/10.4078/jrd.2022.29.1.4
Kim, S. M., Park, J. M., Seo, H. J., Kim, J., Noh, J. W., & Kim, H. L. (2022). Effects of Mindfulness-Based Stress Reduction on Adults With Sleep Disturbance: An Updated Systematic Review and Meta-Analysis. BMJ open, 12(11), e058032. https://doi.org/10.1136/bmjopen-2021-058032
Latocha, K. M., Løppenthin, K., Al-Bazy, S. A., Albrechtsen, T. L., Jensen, H. E., Østergaard, M., Jennum, P., Esbensen, B. A., & Christensen, R. (2022). Impact of Nonpharmacologic Interventions Targeting Sleep Disturbances or Disorders in Patients With Inflammatory Arthritis: A Systematic Review and Meta‐Analysis of Randomized Trials. Arthritis care & research, 74(12), 2108-2118. https://doi.org/10.1002/acr.24731
Martin, J., Hart, N. H., Bradford, N., Naumann, F., Pinkham, M. B., Pinkham, E. P., & Holland, J. (2023). Prevalence and Management of Sleep Disturbance in Adults With Primary Brain Tumours and Their Caregivers: A Systematic Review. Journal of Neuro-Oncology, 162(1), 25-44. https://doi.org/10.1007/s11060-023-04270-1
Mengi, A. (2023). The Relationship Between Eating Behaviors and Functional Status in Female Patients Diagnosed With Fibromyalgia. Galician Medical Journal, 30(2), E202323. https://doi.org/10.21802/gmj.2023.2.3
Mohamed, R. S., Hamed, S. M., & Atya, W. K. (2024). The Effect of Self-Care Support Program on Knowledge, Health Status and Sleep Disturbance Among Patients With Fibromyalgia. Egyptian Journal of Nursing and Health Sciences, 5(1), 119-134. https://doi.org/10.21608/ejnhs.2024.347650
Nguyen, M., Huang, F. F., & O’Neill, S. (2021). Patient-Reported Outcomes for Quality of Life in SLE: Essential in Clinical Trials and Ready for Routine Care. Journal of clinical medicine, 10(16), 3754. https://doi.org/10.3390/jcm10163754
Nizard, J., & Berna, F. (2025). Fibromyalgia: Do I Tackle You With Complementary Medicines? Pain Reports, 10(4), e1278. https://doi.org/10.1097/pr9.0000000000001278
Pathak, A., Rai, J., Singh, R., & Bhatt, G. C. (2023). Effectiveness of Rehabilitation Strategies in Primary Fibromyalgia Syndrome: A Systematic Review and Meta-Analysis. British Journal of Pain, 17(4), 375-399. https://doi.org/10.1177/20494637231168021
phansila, n., Sittiwet, C., & Wongkongdech, R. (2022). Comparison of Effects of Medicinal Cannabis or Standard Palliative Care on Quality of Life of Patients With Cholangiocarcinoma in Northeast Thailand. F1000research, 11, 20. https://doi.org/10.12688/f1000research.75060.1
Silva, L. C. d., Dittgen, M., Meroni, R., Romero, E. A. S., Rossettini, G., Villafañe, J. H., & Corbellini, C. (2024). Exercise Training for Women With Fibromyalgia Syndrome. Topics in Geriatric Rehabilitation, 40(2), 147-157. https://doi.org/10.1097/tgr.0000000000000435
Singh, R., Kumar, N., Rastogi, A., Endukuru, C. K., Joshi, A., & Mishra, S. S. (2021). Impact of Sleep Disturbances and Autonomic Dysfunction on the Quality of Life of Patients With Fibromyalgia. Journal of Basic and Clinical Physiology and Pharmacology, 32(6), 1021-1029. https://doi.org/10.1515/jbcpp-2020-0007
Soares, C. N., Bajbouj, M., Schoof, N., Kishore, A., & Caetano, C. (2025). Impact of Sleep Disturbances on Health-Related Quality of Life in Postmenopausal Women: A Systematic Review. Menopause, 33(1), 118-128. https://doi.org/10.1097/gme.0000000000002633
Steen, J., Kannan, V., Zaidi, A., Cramer, H., & Ng, J. Y. (2024). Mind-Body Therapy for Treating Fibromyalgia: A Systematic Review. Pain Medicine, 25(12), 703-737. https://doi.org/10.1093/pm/pnae076
Toumi, R. O., Kassaw, C., & Демарева, В. (2025). Gender Disparities in Cognitive Impairment Across Neurological Autoimmune Disorders: A Systematic Review. Frontiers in Neurology, 16. https://doi.org/10.3389/fneur.2025.1555407
Trujillo-Muñoz, P. J., Sánchez‐Ojeda, M. A., Rodríguez-Huamán, E. C., Mezyani-Haddu, K., Hoyo-Guillot, I., & Navarro-Prado, S. (2025). Effects of Physical Exercise on Symptoms and Quality of Life in Women in Climacteric: A Systematic Review and Meta-Analysis. Healthcare, 13(6), 644. https://doi.org/10.3390/healthcare13060644
Ueda, M., Tetsunaga, T., Tetsunaga, T., Nishida, K., Takatori, R., Shitozawa, H., Uotani, K., Shinohara, K., Oda, Y., & Ozaki, T. (2024). Insomnia Among Patients With Chronic Pain: A Retrospective Study. Medicine, 103(32), e39113. https://doi.org/10.1097/md.0000000000039113
Wang, Y., Liu, P., Li, Z., Wu, S., Long, M., Li, Y., Jiao, J., & Xie, Z. (2025). Quality of Life, Pain, Depression, Fatigue and Sleep in Patients With Remission or Mild Fibromyalgia: A Comparison With Remission or Low Disease Activity Rheumatoid Arthritis and Healthy Controls. BMC Musculoskeletal Disorders, 26(1). https://doi.org/10.1186/s12891-025-08323-6
Whale, K., Dennis, J. A., Wylde, V., Beswick, A. D., & Gooberman‐Hill, R. (2022). The Effectiveness of Non-Pharmacological Sleep Interventions for People With Chronic Pain: A Systematic Review and Meta-Analysis. BMC Musculoskeletal Disorders, 23(1). https://doi.org/10.1186/s12891-022-05318-5
Wilk, M., Zimba, O., Haugeberg, G., & Korkosz, M. (2024). Pain Catastrophizing in Rheumatic Diseases: Prevalence, Origin, and Implications. Rheumatology International, 44(6), 985-1002. https://doi.org/10.1007/s00296-024-05583-8
Wu, Y.-Q., Long, Y., Peng, W., Gong, C., Liu, Y.-Q., Peng, X.-M., Zhong, Y.-B., Luo, Y., & Wang, M. (2023). The Efficacy and Safety of Telerehabilitation for Fibromyalgia: Systematic Review and Meta-Analysis of Randomized Controlled Trials. Journal of medical Internet research, 25, e42090. https://doi.org/10.2196/42090
Кугушева, Т. В. (2024). Effectiveness and Safety of Cannabis-Based Products for Medical Use in Patients With Fibromyalgia Syndrome: A Systematic Review. Exploratory Research in Clinical and Social Pharmacy, 16, 100524. https://doi.org/10.1016/j.rcsop.2024.100524
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