Mishel’s Model of Uncertainty Describing Categories and Subcategories in Fibromyalgia Patients, a Scoping Review

The aim of this review was to demonstrate the presence of categories and subcategories of Mishel’s model in the experiences of patients with fibromyalgia by reviewing qualitative studies. Uncertainty is defined as the inability to determine the meaning of disease-related events. A scoping review of qualitative studies was carried out. Twenty articles were included, with sample sizes ranging from 3 to 58 patients. Articles from different countries and continents were included. Three categories of the model and eight subcategories could be shown to be present in the experiences of fibromyalgia patients through the scoping review. The first category, concerning antecedents of uncertainty in patients with fibromyalgia, is constituted by the difficulty in coping with symptoms, uncertainty about the diagnosis and uncertainty about the complexity of the treatment. The second concerns the cognitive process of anxiety, stress, emotional disorder and social stigma. The third category refers to coping with the disease, through the management of social and family support and the relationship with health care professionals.

Table S2.Analysis of the studies included in the review with the most relevant results of each one of them.Four categories detected: -Difficulties in meeting labor demands.
-The need for social support in the work environment -The strategies adopted to continue working -The resistance to leave the labor market.Cedraschi et al., 2013 [22] Primary care Interpretative 33-76 56 / 56 W Semi-structured interview Individual Participants expressed decreases in self-esteem and feelings such as self-esteem or despair.Global perceptions of persistent pain and lasting problems.
The perceived low control over their lives, as well as the beliefs that nothing can be done, increases a feeling of guilt and vulnerability.Community Descriptive-exploratory 5 / 5 M Life story interviews Individual Two narrative models found: "Adjust life to match the disease" and "Be imprisoned for pain."Adjusting one's activities can help control symptoms and support the ability to work in many cases, but for some patients, the experience of feeling healthy or painless may be nothing more than a faded memory.

Hermeneutic analysis 12-19 In-depth interviews Individual
Three main themes: -A life with pain and unpleasant body expressions.
-An altered emotional well-being.
-The struggle to keep up with everyday life.
The teenagers described how they fought for normalcy and for not becoming strangers.However, these young people seem to have a strong motivation to fight for normalcy.The impact of FM on the work and personal life of patients, the impact on their future and aspects of social interaction.Almost all participants had stopped working, leading to feelings of worthlessness and loss of identity.The diagnosis was seen as a relief, marking the end of a period of uncertainty. Participants value the comprehensive care offered by health professionals who can identify their strengths and weaknesses. This in turn can help build a shared work space and avoid disappointment and helplessness related to chronic refractory pain. Women with FM said they felt good when they could do things at their own pace and avoid stressful situations. Through the years they had reached an agreement with the pattern of the disease that allowed them to feel good despite the periods of greatest pain. Women with FM felt good when they were heard and understood.

Matarín et al., 2017 [33]
 Difficulty coping with symptoms ✓ Importance of partner support, the disease affects affective level, affects sexual life with the partner Patients manifest in relation to this factor:  Need more support from professionals  Increase information about  In their battle to preserve their sexual health, women require support and understanding from their partner, their socio-family environment and health ✓ The greater the social support perceived by the person, the greater their ability to cope and their self-esteem.

CATEGORIES AND SUBCATEGORIES TO THE MODEL OF UNCERTAINTY AGAINST MARIE MISHEL'S DISEASE
✓ The lack of trust of people in professionals increases uncertainty.Demand credibility from the first momento. Patient associations and peer support can be an element to contribute to harmonious adaptation.
✓ The knowledge and management of the uncertainty theory of M. Mishel by health professionals favors that it can be applied to the assessment and design of interventions that favor adaptation and improve the quality of life.

Authors, Publication Date and Setting Context Design/Model Age Range N/Sample Characteristic Method of Data Collection Type of Interview Results to Highlight
-Feeling of fatigue not proportional to the effort made associated with a feeling of weakness that interferes with motivation and desired activities.-Thisfatigueprolongstasks and makes it difficult to concentrate, think clearly or remember things.-Mostpeoplewith FM who participated in this study experience fatigue and describe it as more severe fatigue than normal.-Facinga new sex life "and" resist the loss of sexuality of the couple ".Improving intimacy, skin-to-skin contact (during acute FMS outbreaks), finding new positions, non-coital sex and the use of sex toys can increase female desire and help cope with it.Sallimen et al.,  2019 [39]

Table S3 .
Categories and subcategories of Mishel´s Model of Uncertainty in Fibromyalgia Syndrome, identified in the experiences of patients from different qualitative studies.