August 19, 2019
Participating in a flower-arranging course may improve both pain and psychiatric symptoms for patients with fibromyalgia, new research suggests.
The findings highlight the potential benefits of floristry as occupational therapy to improve the quality of life of patients with fibromyalgia.
Coinvestigator Howard Amital, MD, head of the Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, and professor of medicine at the Sackler Faculty of Medicine, Tel-Aviv University, Israel, noted that flower arranging is particularly effective because it's a "multistimulation therapy."
It affects different senses that "all coincide and produce a very positive effect on the patient," Amital told Medscape Medical News.
He added that it's important for clinicians to hear about nonpharmacologic therapies for fibromyalgia, which is why he sought to have the study published in a medical journal.
The findings were published online in the July issue of the Israel Medical Association Journal.
Fibromyalgia is characterized by chronic, widespread pain and fatigue and is often accompanied by somatic syndromes such as irritable bowel and migraines. Patients may also present with mood and anxiety disorders.
Worldwide, fibromyalgia affects 2% to 4% of the population. It mostly affects women.
Little is known about the pathogenesis of the syndrome, so treatments primarily focus on alleviating pain and improving quality of life. Experts recommend a multimodel approach that includes aerobic exercise and cognitive-behavioral therapy in addition to pharmacologic regimes.
The current observational study included 61 adult female patients (mean age, 51 years) who had been diagnosed with fibromyalgia.
The women completed a 12-week flower design course that included weekly sessions under the supervision of a trained florist. The participants learned to create flower bouquets that they could take home.
Two consecutive groups participated in the study. The first group participated from week 1 to week 12, and the second, from week 12 to week 24.
At baseline, 12 weeks, and at study completion (week 24), the researchers measured a number of fibromyalgia disease-activity indices. Assessment tools included the 36-item Short Form Survey (SF-36), the Brief Pain Impact Questionnaire (BPI), the Visual Analogue Scale (VAS), tender-point count, and the Fibromyalgia Impact Questionnaire (FIQ).
The study also assessed depression, using the Hamilton Depression Rating Scale (HDRS), and anxiety, using the Hamilton Anxiety Rating Scale (HAMA).
The two groups were similar with regard to mental and physical health at baseline, but the VAS score was significantly higher in group 1, the first group to complete the course, than in group 2 (mean, 8 vs 7, respectively; P = .01).
There were no between-group differences in use of serotonin-norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, or pregabalin (Lyrica, PF Prism CV). However, the participants in group 1 reported significantly higher use of cannabis (46.7% vs 13.3%; P = .010).
Results showed statistically significant improvements in the SF-36 physical and mental health components, VAS scores, FIQ scores, and HAMA and HDRS scores for the entire study population (all, P < .05), which Amital said is "quite amazing."
However, tender-point counts remained unaffected, which was not surprising, Amital noted. Tender points "are not discriminatory enough" and reflect a limited aspect of the syndrome, which also includes unrefreshing sleep, fatigue, and cognitive impairment, he added.
When evaluating the groups separately, the researchers found a significant improvement in all study measures except tender-point count during the course. There was a slight decline in improvement in group 1 after their course ended (weeks 12 to 24), but the measurements did not return to starting levels.
"These study participants still kept the positive effect," said Amital.
However, he added that, as with any intervention, especially for patients with fibromyalgia, "you need to do maintenance" to preserve the optimal effect.
Participating in a floristry course combines art therapy with exposure to a natural element, flowers, both of which have been shown to be beneficial.
For example, studies have shown that self-expression through creative art therapy alleviates psychiatric symptoms for patients presenting with trauma and depression. Engaging with natural elements — for example, flowers and houseplants indoors and parks and forests outdoors — is believed to promote relaxation, reduce blood pressure and heart rate, and improve stress levels and mood.
Amital is now planning to start a flower arranging course for patients with fibromyalgia and other rheumatic conditions at the Sheba Medical Center, which is the largest hospital in Israel.
"I thought it would be a good platform to show that even though it's a bit different from the conventional way of education and thinking that we physicians are usually exposed to, it does have a positive effect and has no side effects," he said.
Commenting on the findings for Medscape Medical News, Clayton Jackson, MD, former president of the Academy of Integrative Pain Management and clinical assistant professor of family medicine and psychiatry, University of Tennessee College of Medicine, Memphis, noted that the study had some limitations, including its small size and its observational, nonblinded design.
However, he said the intervention shows promise, and the results "add to the evidence base that there are multiple interventions that can be helpful for patients with chronic pain."
Jackson, who was not involved with the research, stressed that fibromyalgia is "particularly problematic" with respect to symptom relief.
"This study is interesting because it's a non-opioid and nonpharmacological approach to a difficult pain management problem in patients with fibromyalgia," Jackson said. "Anything nonpharmacological that can be shown to work is incredibly interesting because it might have implications for other pain syndromes."
Unlike other types of occupational therapy, floral design "might be multisensory in its effect" in fibromyalgia, Jackson added.
"There's social contact, there's visual stimulation from the flowers, there's tactile stimulation of arranging in certain ways, and then there's potentially an element of aromatherapy, because flowers are aromatic," he said.
One theory of pain is that "pleasant sensory experiences may help to block unpleasant sensory experiences," said Jackson.
Amital and Jackson have disclosed no relevant financial relationships.