Psychometric properties of the Spanish version of the mindful attention awareness scale (MAAS) in patients with fibromyalgia.

0.16 MB·English

by  Cebolla, Ausias

Cebollaetal.HealthandQualityofLifeOutcomes2013,11:6
http://www.hqlo.com/content/11/1/6
RESEARCH Open Access
Psychometric properties of the Spanish version of
the mindful attention awareness scale (MAAS) in
patients with fibromyalgia
Ausias Cebolla1, Juan V Luciano2, Marcelo Piva DeMarzo3, Mayte Navarro-Gil4 and Javier Garcia Campayo5*
Abstract
Background: Mindful-based interventions improve functioning and quality oflife in fibromyalgia (FM) patients. The
aim of thestudy is to perform a psychometric analysis of the Spanish version of theMindfulAttention Awareness
Scale (MAAS) in a sample of patients diagnosed with FM.
Methods: The following measures were administered to 251Spanish patients withFM: theSpanish version of
MAAS, the Chronic Pain Acceptance Questionnaire, thePainCatastrophising Scale, theInjustice Experience
Questionnaire, the Psychological Inflexibility in PainScale, the Fibromyalgia Impact Questionnaireand theEuroqol.
Factorial structure was analysed using Confirmatory Factor Analyses(CFA). Cronbach's αcoefficientwas calculated
to examine internal consistency, and the intraclass correlationcoefficient(ICC) was calculated to assess the
test-retest reliability ofthe measures.Pearson’scorrelationtests were run to evaluate univariate relationships
between scores onthe MAAS and criterion variables.
Results: The MAAS scores inour samplewere low (M=56.7; SD=17.5). CFA confirmed a two-factor structure, with
thefollowing fit indices [sbX2=172.34 (p<0.001), CFI=0.95, GFI=0.90, SRMR=0.05,RMSEA=0.06. MAASwas
found to have high internal consistency (Cronbach’sα=0.90) and adequate test-retestreliability ata 1–2 week
interval (ICC=0.90). It showed significant and expectedcorrelations withthe criterion measureswith theexception
ofthe Euroqol (Pearson=0.15).
Conclusion: Psychometric properties oftheSpanish versionof theMAASin patients withFM are adequate. The
dimensionality oftheMAAS found in this sample and directionsfor future research are discussed.
Keywords: Mindfulness, MAAS, Reliability, Validity, Fibromyalgia
Background Mindfulness-based therapies have been demonstrated
In the last 20 years, an increasing number of studies to be effective for the treatment of many disorders, in-
have been dedicated to research on mindfulness and the cluding chronic pain conditions [4-6]. The mechanisms
use of mindfulness training as a clinical intervention for underlying the effects that mindfulness training has on
diverse physical and mental disorders. Mindfulness health are diverse and include increased attention con-
refers to an awareness that emerges by paying attention trol, increased awareness of inner experiences, increased
to purpose and to the present moment and non- emotional regulation, and changes in the concept of self
judgmentally focusing on the unfolding of one’s immedi- orinbodyawareness[7].
ate experience [1,2]. Mindfulness is a skill that can be Mindfulness training in the treatment of fibromyalgia
taught usingseveraluniquely designed techniques[3]. (FM) has been shown to decrease pain symptoms and to
improve overall quality of life; as such, mindfulness
training is considered a promising supplement to
*Correspondence:[email protected] current interventions [4,8-10]. Despite these findings,
5DepartmentofPsychiatry,MiguelServetHospital&UniversityofZaragoza,
there is still a lack of understanding of the mechanisms
InstitutoAragonésdeCienciasdelaSalud,ReddeActividadesPreventivasy
dePromocióndelaSalud(REDIAPP),Zaragoza,Spain that underlie the mitigating effects of mindfulness on
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reproductioninanymedium,providedtheoriginalworkisproperlycited.
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pain symptoms. Research studies on such mitigating examine the psychometric properties of the Spanish ver-
effects suggest that mindfulness alters the contextual sion of the MAAS in a sample of patients diagnosed
evaluation of pain [5], reduces pain catastrophising and with fibromyalgia.
pain sensitivity [6], reduces psychopathological symp-
toms [11,12], and alters pain-related anxiety [13]. These Method
results have not been contradicted in the three years Sampleandprocedure
sincetheirdiscovery [9]. Sample size was calculated according to the recommen-
Recent findings suggest that pain acceptance, which is ded 10:1 ratio of the number of subjects to the number
promoted by mindfulness interventions, improves func- of test items [29]. Participants were recruited from the
tioning and life quality. However, there is still a lack of Pain Clinic (Santander, Spain) and the Fibromyalgia Unit
reliable and valid instruments to assess relevant pro- ofthe Miguel ServetHospital, Zaragoza(Spain). Recruit-
cesses in such interventions [14]. It is assumed that if ment took place during the year 2010. To be included in
mindfulness is a learned skill, then a measure of mind- thestudy,patientshadtobediagnosedwithfibromyalgia
fulness should demonstrate both incremental validity by a rheumatologist according to American College of
[15]andsensitivitytochange.Furthermore,theexpected Rheumatology (ACR) criteria [30]. Patients were exclu-
changes (for example, improvement in quality of life or dediftheyhadamedicalorpsychiatricdisorderthatim-
decrease in symptoms) should be directly related to peded their ability to correctly answer the questionnaire.
changesinmindfulness. The sample consisted of 251 participants (10 men and
There are several questionnaires that measure mind- 241 women), with a mean age of 52.4 years (SD=8.4;
fulness, with the two the most commonly used being the Range=31–70). One patient was excluded as a result
Five-Facets Mindfulness Questionnaire (FFMQ) [16] and of being diagnosed with schizophrenia, which, in the
the Mindful Attention Awareness Scale (MAAS) [17]. clinician’s point of view, limited the reliability of the
The FFMQ is considered one of the most complete questionnaire. On average, participants had suffered from
questionnaire because it measures five component skills FMfor7.9years(SD=2.3;range=1–20),and122partici-
of mindfulness: observing, describing, acting with aware- pants(48.8%)hadbeengrantedaninvaliditypension.The
ness, nonjudging of inner experience and nonreactivity majority of patients (N=231; 92.4%) were taking one or
to inner experience. However, the MAAS is the most more prescription drug. More than half of the patients
popularscalemeasuringmindfulness,withover350cita- (N=131; 52.4%) suffered from some form of psychiatric
tions in the Web of Science [18]. The MAAS has shown morbidity, as assessed by the MINI Psychiatric Inter-
theoretically consistent relationships to brain activity view [31] (mainly depression and anxiety). A group of
[19], treatment outcome in mindfulness-based inter- 21 patients (8.4%) were also diagnosed with Posttrau-
ventions (MBIs) [20] and mediation of targeted MBI matic Stress Disorder. The study questionnaires and pro-
outcomes [21]. tocol were approved by the Ethical Committee of the
TheauthorsthatdevelopedtheMAASdefinemindful- regional health authority, and patients signed a con-
ness as “the presence or absence of attention to, and sent form attesting to their willingness to participate in
awareness of, what is occurring in the present moment”. thestudy.
The MAAS is a 15-item scale developed to measure the
frequency of mindful states in daily life. Translated var- Instruments
iants of this scale have been validated in several lan- Mindfulattentionawarenessscale(MAAS)
guages, including Spanish [22], Chinese [23], Swedish The MAAS is a 15-item instrument measuring the gen-
[24],Turkish [25]andFrench[26]. eral tendency to be attentive to and aware of one’s
The original Spanish scale was validated and devel- experiences in daily life [17]. Using a 6-point Likert-
oped in a sample of Spanish non-clinical participants. type scale (ranging from almost always to almost
[22]. Within the clinical population, the MAAS has been never), respondents rated how often they experienced
validated only in a sample of cancer patients [27]. The acting as if they were on automatic pilot, being pre-
validation of scales in specific clinical samples is import- occupied, and not paying attention to the present mo-
ant for research on mindfulness due to the recognised ment (e.g.: “I could be experiencing some emotion and
need for using valid measures inthe assessment ofinter- not be conscious of it until some time later”)..The scale
ventions. In a recent study, the Five Facets of Mindful- showed an internal consistency of 0.82 and exhibited
ness Inventory was validated in a sample of patients significant convergent and discriminant validity. Scores
diagnosed with fibromyalgia. The results from this study on the MAAS were significantly higher in mindfulness
showed that the data taken from the patient sample had practitioners than in matched community controls. The
a similar factorial structure to data taken from a healthy Spanish version of the MAAS was used, and it has re-
sample [28]. The purpose of the present study is to cently been shown to have good test-retest reliability
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and internal consistency in a sample of healthy Spanish item of the scale focuses on the patient's ability to carry
subjects [22]. outmuscularactivities.Thenexttwoitemsofthescaleask
patients to indicate the number of days in the past week
Chronicpainacceptancequestionnaire(CPAQ) that they felt good and the number of instances that they
The CPAQ is a 20-item questionnaire designed to meas- missed work. Finally, the last seven items (i.e., ability to
ure pain acceptance (e.g.: “It’s OK to experience pain”) work, pain, fatigue, morning tiredness, stiffness, anxiety
[32]. All items are rated on a Likert-type scale, ranging and depression) are measured with visual analogue scales.
from 0 (never true) to 6 (always true). The Spanish ver- TheSpanishversionofthisscalehasbeenvalidated[41].
sion of the scale has been validated [33], showing suffi-
cient test-retest reliability andinternal consistency. Statisticalanalyses
Demographic data were analysed using the descriptive
Paincatastrophizingscale(PCS) statistics of mean, standard deviation (SD) and range.
ThePCSisa13-itemscaledesignedtoassessindividuals’ Prior to conducting the statistical analyses, we examined
catastrophising cognitions by asking them to reflect on data for univariate and multivariate outliers. In order to
thoughts or feelings associated with present painful detect the presence of univariate outliers, the frequency
experiences (e.g.: “When I’m in pain Ifeel Ican’t go on”) distributions of each item was examined (values≥3
[34]. Each item is scored on a Likert-type scale, which standard deviations from the mean indicate univariate
ranges from 0 (not at all) to 4 (always). The Spanish ver- outliers). Screening for multivariate outliers was by car-
sion of this scale has been validated, [35] showing suffi- ried out by means of the Mahalanobis distance scores
cienttest-retestreliabilityandinternalconsistency. for all cases (D2); A D2 probability≤0.01 indicates the
existence of multivariate outliers [42]. We did not detect
Injusticeexperiencequestionnaire(IEQ) any outliers, therefore all cases were retained for the
The IEQ is a 12-item questionnaire that measures the statisticalanalyses.
frequency with which patients have thoughts concern- We used Confirmatory Factor Analysis (CFA) to ana-
ing the unfairness of their illness (e.g.: “My life will lyse the dimensionality of the MAAS. We propose a
never be the same”) [36]. Each question is answered one-factor model (with all items loading on one latent
using a 5-point scale, which ranges from 0 (never) to 4 factor) and a two-factor model (Factor 1: items 1, 2, 4, 5,
(all the time). The Spanish version of this scale has 7, 8, 9, 10, 11, 14, and 15; Factor 2: items 3, 6, 12, and
been validated, [37] showing sufficient test-retest reli- 13) previously found with a principal component ana-
ability and internal consistency. lysis. EQS software for Windows version 6.1 [43] was
used to conduct the CFA. The maximum likelihood
Thepsychologicalinflexibilityinpainscale(PIPS) with robust correction method was used to adjust for
The PIPS [14] is a 12-item scale developed to assess tar- distributional problems in the data set. Although a
get variables in exposure and acceptance-oriented treat- model with a non-significant chi-square estimate is
ments of chronic pain (e.g.: “I postpone things because generally considered a model with good fit, Hu and
of my pain”). We used the total scores resulting from Bentler [44] recommended combinational rules to
this instrument in the final analyses of this study. The evaluate model fit. Therefore, we analysed the follow-
Spanish version of PIPS has been validated by our group ing indices (values in parentheses denote goodness of
“(personal communication)”. fit standards): Comparative Fit Index and Goodness of
Fit Index (CFI and GFI>0.90) and Root Mean Square
EuroQol(EQ-5D) Error of Approximation and Standardized Root Mean-
The EQ-5D is a questionnaire composed of 7 items Square Residual (RMSEA and SRMR<0.08). The
developed to measure a unique health status score [38]. Satorra–Bentler chi-square is a chi square fit index
The EQ-5D covers 5 dimensions of health: mobility, that corrects the statistic under distributional viola-
self-care, usual activities, pain/discomfort and anxiety/ tions. To reduce the sensitivity of chi-square to sam-
depression. Each dimension is evaluated in 3 categories ple size, the index is divided by the degrees of
(no problem, moderate problems, or extreme problems). freedom. Ratios of 3 or smaller are indicative of an
Inthepresent study,weusedavalidated Spanishversion acceptable fit of the model [45]. We selected these
ofEQ-5D[39]. statistics to measure fit because previous research cor-
roborated their performance and stability [46].
Fibromyalgiaimpactquestionnaire(FIQ) We examined the internal consistency, test-retest, and
TheFibromyalgiaImpactQuestionnaire(FIQ)isa10-item construct validity of the MAAS. Cronbach's α coefficient
self-report questionnaire developed to measure the func- [47] was used to analyse the internal consistency of the
tional impairment of fibromyalgia patients [40]. The first scale.Correcteditem-totalcorrelations,inwhichanitem
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is correlated with the total scale score excluding itself, Results
were tested for each item. Consistency of the MAAS All items were examined in terms of mean, standard de-
total score over time (test-retest reliability) was assessed viation, skewness and kurtosis. Univariate values
using the Intraclass Correlation Coefficient (ICC). Con- approaching at least 2.0 for skewness and 7.0 for kur-
struct validity was examined by correlating the MAAS tosis indicate marked non-normality [42]. On the basis
with theoretically related and unrelated constructs. Pear- of the values displayed in Table 1, the data appear to
son’s correlations were performed to evaluate univariate shownormality.
relationships between the MAAS and the following cri- AsshowninTable1,descriptivestatisticswerecomputed
terion variables: chronic pain acceptance, pain catastro- for all MAAS items. The mean total score on the MAAS
phising, perceived injustice, pain inflexibility, global was 56.7 (SD=17.5; range 18–90). The highest score was
function and quality of life. We used effect size criteria obtainedforitem5,whichasksaboutthesubject’stendency
outlined by Cohen [48] to evaluate the substantive sig- not to notice feelings of physical tension and discomfort
nificance of correlations (i.e., large correlations are those untilthesesymptomsgrab hisorher attention.Thelowest
>0.50, medium correlations range from 0.30 to 0.49, and score was obtained for item 6, which asks about the ten-
small correlationsrangefrom 0.10 to0.29). dencytoforgetthenameofapersonimmediately.
Table1Means(M),standarddeviation(SD),95%ConfidenceIntervals(95%CIs),standardisedfactorloadings(λone-factor
solution),correcteditem-totalcorrelations(rtot),skewnessandkurtosisforallMAASitems
MAASitems(Spanishtranslationbetweenparentheses) M(SD) 95%CIs λ rtot Skewness Kurtosis
1.Icouldbeexperiencingsomeemotionandnotbeconsciousofituntilsometime 4.39(1.6) 4.1-4.6 0.53 0.53 -.44 −1.22
later(Puedoestarexperimentandoalgunaemociónynoserconscientehasta
algúntiempodespués)
2.Ibreakorspillthingsbecauseofcarelessness,notpayingattention,orthinkingof 4.15(1.7) 3.9-4.3 0.60 0.59 -.30 −1.38
somethingelse(Rompooderramocosaspordescuido,pornoprestaratención
oporpensarenotracosa).
3.Ifinditdifficulttostayfocusedonwhat’shappeninginthepresent(Encuentro 3.34(1.7) 3.1-3.5 0.60 0.59 .32 −1.13
difícilpermanecerfocalizadoenloqueestáocurriendoenelpresente).
4.ItendtowalkquicklytogetwhereI’mgoingwithoutpayingattentiontowhatI 3.82(1.8) 3.5-4 0.59 0.62 -.08 −1.50
experiencealongtheway(Tiendoaandarrápidamenteparallegaradondequiero
irsinprestaratenciónaloqueexperimentoalolargodelcamino).
5.Itendnottonoticefeelingsofphysicaltensionordiscomfortuntiltheyreallygrab 4.61(1.7) 4.4-4.8 0.44 0.42 -.83 -.82
myattention(Tiendoanonotarlatensiónfísicaoelmalestarhastaquerealmente
despiertamiatención).
6.Iforgetaperson’snamealmostassoonasI’vebeentolditforthefirsttime(Olvido 2.14(1.6) 1.9-2.3 0.34 0.32 1.32 .37
elnombredeunapersonacasitanprontocomomelodicenporprimeravez).
7.ItseemsthatIam“runningonautomaticpilot,”withoutmuchawarenessofwhat 3.31(1.8) 3-3.5 0.81 0.76 .32 −1.29
I’mdoing(Parecequellevepuestoel“pilotoautomático”sinserconscientedelo
queestoyhaciendo).
8.Irushthroughactivitieswithoutbeingreallyattentivetothem.(Hagolasactividades 4.01(1.7) 3.7-4.2 0.80 0.72 -.18 −1.46
diariascorriendosinestarrealmenteatentoaellas).
9.IgetsofocusedonthegoalIwanttoachievethatIlosetouchwithwhatI’mdoing 4.37(1.8) 4.1-4.6 0.81 0.76 -.55 −1.28
rightnowtogetthere(Estoytancentradoenlametaquequieroalcanzarquepierdo
lanocióndeloqueestoyhaciendo).
10.Idojobsortasksautomatically,withoutbeingawareofwhatI'mdoing(Hagotareas 4.08(1.8) 3.8-4.3 0.82 0.75 -.28 −1.47
otrabajosautomáticamentesinserconscientedeloqueestoyhaciendo).
11.Ifindmyselflisteningtosomeonewithoneear,doingsomethingelseatthe 3.81(1.7) 3.6-4 0.47 0.45 .03 −1.52
sametime.(Meencuentroamímismoescuchandoaalguienmientrashagoalgoal
mismotiempo).
12.Idriveplaceson“automaticpilot”andthenwonderwhyIwentthere(Conduzcoa 3.47(1.9) 3.2-3.7 0.66 0.65 .14 −1.52
sitiosconel“pilotoautomático”yentoncesmepreguntoquéhagoallí).
13.Ifindmyselfpreoccupiedwiththefutureorthepast(Meencuentroamímismo 3.04(1.8) 2.8-3.2 0.42 0.42 .50 −1.14
preocupadoporelfuturooelpasado).
14.Ifindmyselfdoingthingswithoutpayingattention(Meencuentroamímismo 3.68(1.7) 3.4-3.9 0.80 0.76 .10 −1.39
haciendocosassinprestaratención).
15.IsnackwithoutbeingawarethatI’meating(Picoteosinserconscientedeloque 4.52(1.9) 4.2-4.7 0.49 0.48 -.81 −1.01
estoycomiendo).
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Confirmatoryfactoranalysis(CFA) adults sample studied in the original validation study
Theoriginalone-factormodel[16]showedgoodfitindices (17) (N=436; M=4.20, SD=.69) is significantly lower
[ X2=185.43 (p<0.001); CFI=0.94; GFI=0.89; SRMR= (t=−4.592; gl=685; p <0.001). These data show a ten-
sb
0.05; RMSA=0.07 (0.05-0.08)]. The two-factor model, dencyofFMpatientstobelessawareoftheirexperience
based on a previous exploratory factor analysis, obtained in daily life, acting more on “autopilot” and paying less
slightly better fit indices [ X2=172.34 (p<0.001), CFI= attention to the present moment than healthy popula-
sb
0.95, GFI=0.90, SRMR=0.05, RMSEA=0.06 [0.05-0.08]]. tion does. A descriptive analysis of the items and the
The factor loadings of all MAAS items are shown in total score showed a tendency of FM patients to be less
Table1. aware of their experience in daily life, acting more on
“autopilot” and paying less attention to the present mo-
Reliability mentthanhealthypopulationdoes.
Cronbach’s α for the MAAS was 0.90, indicating a The results found using CFA are largely consistent
high degree of internal consistency. Corrected item- with those reported in previous studies [17,22-27,49]. In
total r correlation coefficients ranged between 0.32 and the current sample,theone-andtwo-factormodelsboth
0.76. With regard to temporal stability, a subsample of show adequate fit; however, we decided to retain the
162 patients from the original sample was randomly one-factor model for the set of reasons outlined below.
selectedandcontactedbyphoneinordertoarrangeanew First, the one-factor model met all the pre-established fit
interview to complete the instruments again 1–2 weeks criteria, except for the chi-squaredgoodness-of-fit statis-
later. This subsample included 5 men and 156 women, tic, which was statistically significant (an unsurprising
with a mean age of 50.8 years (SD=7.9; Range=33–68). result,giventhatthisstatisticishighlysensitiveandeven
Data from this subsample showed a test-retest coefficient small differences in model fit are statistically significant).
of0.90(CI=0.89–0.92). Second, with the exception of item 6, all items loaded
strongly onthe latent factor (all factorloadingsexceeded
Constructvalidity 0.40). Third, the underlying construct of the second la-
The convergent and divergent validity of the MAAS was tent factor in the two-factor model is difficult to inter-
calculated using Pearson’s product–moment correlations pret, other than on the basis of the item difficulty of the
with other relevant measures of psychopathology and 4 loaded items. For instance, forgetting another person’s
measures of level of acceptance related to pain (see name almost as soon as one has been introduced for the
Table 2). Overall, with the exception of the EQ-5D, the first time is quite common, even amongst healthy indivi-
measures correlated moderately and significantly with duals; this item had the lowest mean score. The two-
total scoresontheMAAS. factormodelwasproposedonthebasisofapreviousex-
ploratory factor analysis, and it is well known that
Discussion “artifactual difficulty” factors may be generated in unidi-
Themainobjectiveofthisstudywastoexaminethepsy- mensional instruments when using exploratory techni-
chometric properties of the Spanish version of the ques [50]. Fourth, the one-factor structure of the MAAS
MAAS in a sample of patients with fibromyalgia. The gained further support from the internal consistency
MAAS scoring in our sample of patient s with FM (N= analysis, which yielded an excellent Cronbach's α. Fifth,
251; M=3.78; SD=1.68) compared with the community all items showed a corrected item-total correlation that
washigher than conventionalminimum valueof0.20.
Table2Means(M)andstandarddeviations(SD)ofstudy The test-retest reliability analysis yielded good tem-
measuresandassociationwithMAAStotalscorein poral stability in a 1–2 week period. Regarding the cor-
fibromyalgiapatients relation analyses, almost all of the measures included in
M(SD) MAAS thestudy correlatedintheexpected waywith theMAAS
CPAQ 47.6(23.3) 0.37** total scores. These results are consistent with those
found in other studies that demonstrate the importance
PCS 24.3(13.6) −0.47**
of acceptance capacity in the experience of pain [5,6].
FIQ 58.0(15.0) −0.46**
The only exception to this pattern of findings was the
EIQ 30.1(12.1) −0.45** correlations between the MAAS and EQ-5D. However,
PIPS 57.1(18.2) −0.47** these data are not surprising, given the results found by
EQ-5D 47.1(19.8) 0.15* Boomershine [51], who performed a comprehensive
evaluation of standardised assessment tools in the
*p<0.05;**p<0.001.
MAAS=MindfulAttentionAwarenessScale;CPAQ=ChronicPainAcceptance diagnosis of the fibromyalgia syndrome and in the
Questionnaire;PCS=PainCatastrophizingScale;FIQ=FibromyalgiaImpact
assessment of fibromyalgia severity. In this evalu-
Questionnaire;IEQ=InjusticeExperienceQuestionnaire;PIPS=The
PsychologicalInflexibilityinPainScale;EQ-5D=Health-relatedqualityoflife. ation, the EQ-5D was not among the recommended
Cebollaetal.HealthandQualityofLifeOutcomes2013,11:6 Page6of7
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instruments for assessing HRQL or global improve- Authordetails
ment in these patients with FM. 1Departamentodepersonalidad,evaluaciónytratamientospsicológicos,
UniversitatJaumeI,CIBEROBNCiberFisiopatologiadelaobesidadyla
The two-factor structure was best supported by the
nutrición,Castellón,Spain.2ParcSanitariSantJoandeDéuandFundació
data found in this research study, but results are not SantJoandeDéu,SantBoideLlobregat,Barcelona,Spain.3Departmentof
strong enough to conclude that this factorial model is FamilyMedicine,UniversityofSaoPaulo,SaoPaulo,Brazil.4Bitbrain
Technologies,Zaragoza,Spain.5DepartmentofPsychiatry,MiguelServet
best for the reasons already described. In both cases (uni
Hospital&UniversityofZaragoza,InstitutoAragonésdeCienciasdelaSalud,
and bifactorial models), the factor structure exhibited an ReddeActividadesPreventivasydePromocióndelaSalud(REDIAPP),
acceptable fits, although more research is needed to ex- Zaragoza,Spain.
plore the stability of the factor structure in FM and
Received:12September2012Accepted:11January2013
otherchronicpainpatients. Published:14January2013
Thisstudyhasseverallimitations.First,asinanystudy
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