Efficacy of nonpharmacological interventions for individual features of fibromyalgia: a systematic review and meta-analysis of randomised controlled trials

Effects of manual lymphatic drainage on pain intensity, impact of disease and quality of life in women with fibromyalgia syndrome: a double-blind randomized sham-controlled trial

PURPOSE

This study aimed to investigate the effectiveness of Manual Lymphatic Drainage (MLD) on the pain intensity, impact of the disease, and health-related quality of life among women diagnosed with Fibromyalgia syndrome (FMS).

METHODS

The study was designed as a single-center, double-blind, randomized, and sham-controlled trial. Twenty women with FMS were included and randomized into intervention (n = 11) and sham control (n = 9) groups. In the intervention group, MLD was applied in addition to medical treatment, whereas the sham control group received sham MLD along with medical care over a period of 3 weeks. The Visual Analog Scale (VAS), Fibromyalgia Impact Questionnaire (FIQ-R), and 12-item Short Form Survey (SF-12) were used to measure outcomes. Participants were assessed baseline, immediately after the treatment, at 12 weeks, and at 24 weeks.

RESULTS

The VAS score, the FIQ-R symptom and FIQ-R overall scores, and SF-12 score showed a statistically significant time effect (p < 0.05) in intervention group. No significant main effects in any parameters for any time interval were observed in the sham group (p > 0.05).

CONCLUSION

MLD added to medical treatment may be an effective alternative method that could be used in the treatment of FMS to reduce pain intensity and improve impact of disease.

Effectiveness of transcutaneous electrical nerve stimulation improves pain intensity, disability and quality of life in patients with fibromyalgia syndrome: a systematic review with meta-analysis

PURPOSE

The transcutaneous electrical nerve stimulation (TENS) is one of the most frequently electrophysical agents employed in reducing the impact of FMS. This meta-analysis intended to determine the effectiveness of TENS on pain, disability, and quality of life (QoL) in patients with FMS.

METHODS

According to PRISMA, we performed a meta-analysis (CRD42023456439), searching in PubMed Medline, PEDro, CINAHL Complete, Web of Science, and Scopus, since inception up to October 2023. This review focused on controlled clinical trials evaluating the effect of TENS on pain, disability, and QoL in patients with FMS. The pooled effect was estimated using Cohen's standardized mean difference (SMD) and its 95% confidence interval (95%CI).

RESULTS

Twelve studies, providing data from 944 patients, were included (PEDro score of 5.6 points). Meta-analyses showed that TENS interventions are effective in improving pain (SMD = -0.61; 95%CI -1 to -0.16); disability (SMD = -0.27; 95%CI -0.41 to -0.12); and physical dimension of QoL (SMD = 0.26; 95%CI 0.08 to 0.44). Additionally, when TENS is used as a unique therapy, it represents the best therapeutic option for improving pain, disability, and QoL.

CONCLUSIONS

This meta-analysis, including the largest number of studies, showed that TENS intervention is an effective therapy to reduce pain and disability and increase QoL in FMS patients.

Do patients with fibromyalgia syndrome receive updated management strategies? A web-based survey among Italian physiotherapists

INTRODUCTION

Fibromyalgia syndrome (FMS) causes significant pain, disability, and costs among patients. It is paramount that healthcare professionals have an updated knowledge of its characteristics and Clinical Practice Guidelines (CPGs).

OBJECTIVES

To determine the knowledge, adherence to CPGs, and confidence of Italian physiotherapists in managing patients with FMS, explore barriers to the implementation of CPG' recommendations, compare groups' adherence to CPGs, and determine which variables explained most of the participants' knowledge.

METHODS

The survey was administered via social media and newsletter (i.e., Italian Association of Physiotherapists, AIFI) to Italian practicing physiotherapists. The protocol of this work was prospectively registered in the Open Science Framework.

RESULTS

Total replies were 398. Italian physiotherapists showed a good knowledge of FMS and adherence to CPGs. Ninety-one percent reported a medium or lower confidence in managing patients with FMS. Sixty-seven percent judged their knowledge of CPGs as poor or very poor. The remaining 33% mentioned patients' psychosocial aspects, multidisciplinary relationships, and lack of training on communication strategies as the main barriers to the implementation of CPGs. Being an Orthopaedic Manipulative Physical Therapist (OMPT) resulted in a better adherence to CPGs on 11/14 items. Knowledge scores were correlated (r = 0.244) with being an OMPT (Stand β = 0.123) and years of professional activity (Stand β = -0.126).

CONCLUSIONS

Although Italian physiotherapists demonstrated a good knowledge of FMS and reported a good adherence to CPGs' recommendations, they may still experience barriers to the implementation of evidence-based management strategies.

Impact of spa therapy on physical activity, sleep and heart rate variability among individuals with fibromyalgia: Results of an ancillary study

Spa therapy is recommended to manage symptoms of fibromyalgia, but the physiological mechanisms underlying this improvement have been poorly studied. In an original study, we explored the effect of a 3-week rheumatology spa treatment for fibromyalgia patients on quality of life and with a symptom severity questionnaire. We present here the results of an ancillary study which explored three secondary criteria using objective measurement methods: diurnal actimetry for physical activity analysis, nocturnal actimetry for sleep analysis and heart rate variability. Eighty-three fibromyalgia patients were randomized to participate in an immediate 3-week rheumatological spa therapy, either a start within 6 weeks after inclusion (interventional group, n = 39) or a delayed, start 6 months after inclusion (control group, n = 44). Patients were asked to wear an actimeter (n = 56) to assess diurnal physical activity and sleep quality and a 24-h Holter ECG (n = 60) to assess nocturnal heart rate variability at baseline, 3 months and 6 months after inclusion. Time spent in sedentary and light physical activity was reduced to ∼30 min at 6 months in the interventional group (P = 0.027). Sleep quality and heart rate variability were not improved. Spa therapy made it possible to reduce sedentary activities in patients' daily life for up to 6 months afterwards, concomitant with the improvement in quality of life, pain and fatigue as highlighted in the original Thermalgi study.

Association between Drug Use and Perception of Mental Health in Women Diagnosed with Fibromyalgia: An Observational Study

BACKGROUND/OBJECTIVES

Fibromyalgia (FM) is a chronic syndrome characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and mental health issues. It affects approximately 1.78% of the general population; an estimated 4:1 ratio between women and men is observed. It significantly impacts quality of life and carries both clinical and social stigma. This study aims to evaluate the relationship between drug use and mental health in female patients with fibromyalgia.

METHODS

This study is prospective, observational, and cross-sectional. A questionnaire was administered to 544 subjects, achieving a representative sample size from a population of 800,000 subjects by using an algorithm for proportion estimation with a known sampling frame. The selection was non-random, making the sampling non-probabilistic. Logistic regression models were applied to assess the effect of drug use on perception of mental health; presence of symptoms such as comprehension and memory problems, insomnia, depression, and anxiety; and severity of cognitive symptoms and non-restorative sleep. To quantify the impact, odds ratios and confidence intervals have been observed.

RESULTS

The findings indicate the non-recommended use of medications and reveal the ineffectiveness and adverse effects of drug interactions on mental health. The use of benzodiazepines and sedative-hypnotics is significantly associated with a negative perception of mental health. Benzodiazepines do not improve symptoms or significantly reduce their severity. SSRI antidepressants do not enhance mental health perception; however, when used exclusively, they are effective in reducing the severity, but not the prevalence, of cognitive symptoms.

CONCLUSIONS

The results highlight the complexity of pharmacological management in FM and raise concerns about the inappropriate use of ineffective or counterproductive drug interactions affecting patients' mental health. They underscore the need for multidisciplinary and personalized strategies that include close and careful monitoring, as well as the simultaneous use of non-pharmacological treatments that have demonstrated evidence in improving quality of life without negatively affecting mental health, such as patient education, psychological therapy, physiotherapy, and mindfulness.

Relationship of Pain, Depression, Fatigue, and Sleep Problems with Functional Capacity, Balance, and Fear of Falling in Women with Fibromyalgia: Cross-Sectional Study

(1) Background: Fibromyalgia (FM) is a syndrome marked by chronic widespread pain, fatigue, sleep issues, and other symptoms. Interventions like physical exercise can potentially enhance physical function in individuals with FM. This study aimed to assess physical function, perceived physical fitness, balance confidence, and fear of falling in women with FM based on their levels of pain, depression, fatigue, and sleep problems. (2) Methods: Participants underwent a series of tests and questionnaires to evaluate physical and perceptual aspects. These included the Time Up and Go, Four Step Square Test, 6-Minute Walking Test, Maximum Handgrip Strength, Back Scratch, International Fitness Scale, Activities-Specific Balance Confidence Scale, and Fall Efficacy Scale-International. Participants were categorised by the severity of their pain, depression, fatigue, and sleep problems (mild, moderate, severe). A Kruskal-Wallis test assessed intergroup differences, while Spearman's rho evaluated correlations between the study variables and symptom levels. (3) Results: Perceived physical condition varied significantly with symptom severity. Symptoms and sleep problems were notably linked to fear of falling, though no significant differences emerged in the physical tests. (4) Conclusions: In women with fibromyalgia, symptom severity was primarily related to perceptual and subjective aspects of physical condition and fall safety.

The effectiveness and safety of non-pharmacological intervention for pain management in Parkinson's disease: A systematic review

Chronic pain is a non-motor symptom affecting from 60 to 80% of patients with Parkinson's disease (PD). PD patients can suffer from different types of pain, either specific or not specific of the disease, and depending on various pathophysiological mechanisms (nociceptive, nociplastic or neuropathic), which can be present at any stage of the disease. Non-pharmacological interventions (NPIs) are essential to complement routine care interventions in PD pain management. Moreover, in the literature, it has been shown that 42% of PD patients are already using complementary therapies. Hence, our aim was to investigate the effectiveness and safety of NPIs for pain management in PD. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Eighteen published randomized control trials (RCTs) were included between 2004 and 2021 leading to a total of 976 PD patients. From them, we reported fifteen different NPIs classified in seven categories: physical exercises, balneotherapy, manual therapy, acupuncture, botanical preparation, body-psychological practice and multiprotection care. Our results have shown that NPIs for PD pain management had a low-to-moderate level of evidence showing mainly favourable results, even if some NPIs presented inconclusive results. Moreover, our review highlighted the clinical relevance of some specific NPIs in PD pain management: NPIs consisting of active physical activities, opposed to passive activities. The safety of NPIs was also confirmed since only few minor transient adverse events were reported. Nevertheless, even if some interesting results were found, the methodology of future studies needs to be more robust and to include comprehensive descriptions in order to offer reliable and sound recommendations to clinicians.

Understanding the Associations between Executive Function and Psychological Variables in Fibromyalgia Syndrome: A Network Analysis Approach

The aim of this study was to quantify the multivariate relationships between clinical, cognitive performance, executive functioning, and psychological outcomes in women with fibromyalgia (FMS) using network analyses. Demographic (age, height, weight), clinical (pain history, pain intensity, and related disability), neurocognitive (D2 Attention test, Rey-Osterrieth Complex Figure for visual perception, "Digits D/R/I" tests of the WAIS-IV battery for working memory, the 5-Digit Test for mental inhibition, the Symbol Search for processing speed and the Zoo Test for planning/decision making) and psychological (depressive symptoms, anxiety levels, sleep quality, pain hypervigilance) variables were collected in 129 women with FMS and 111 healthy women. Network analyses were conducted separately for each group to quantify the adjusted correlations between the modeled variables and to assess their centrality indices (i.e., connectivity with other symptoms in the network and their importance in the network). The network identified 74 associations in FMS women and 46 associations in controls with small differences. The strongest correlations in both groups were found between different attention variables: d2_CON with d2_C, d2_O with d_2TR, and d2_CON with d2_TA. The most central variables were d2_TA, d2_C, and d2_CON (highest strength centrality in both groups) and anxiety levels and pain hypervigilance (highest harmonic centrality in FMS women). The strength centrality of the network was stable for women with FMS (CScor0.7: 0.68) but not for healthy women (CScor0.7: 0.28). This study found that attention variables are most relevant within a neurocognitive network and that psychological variables are most important for the treatment of women with FMS. The clinical implications of the current findings, such as the development of treatments targeting these variables, are discussed.

Effectiveness of craniosacral therapy, Bowen therapy, static touch and standard exercise program on sleep quality in fibromyalgia syndrome: A randomized controlled trial

BACKGROUND

Sleep disturbance is commonly seen in fibromyalgia syndrome (FMS); however, high quality studies involving manual therapies that target FMS-linked poor sleep quality are lacking for the Indian population.

OBJECTIVE

Craniosacral therapy (CST), Bowen therapy and exercises have been found to influence the autonomic nervous system, which plays a crucial role in sleep physiology. Given the paucity of evidence concerning these effects in individuals with FMS, our study tests the effectiveness of CST, Bowen therapy and a standard exercise program against static touch (the manual placebo group) on sleep quality in FMS.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTION

A placebo-controlled randomized trial was conducted on 132 FMS participants with poor sleep at a hospital in Bangalore. The participants were randomly allocated to one of the four study groups, including CST, Bowen therapy, standard exercise program, and a manual placebo control group that received static touch. CST, Bowen therapy and static touch treatments were administered in once-weekly 45-minute sessions for 12 weeks; the standard exercise group received weekly supervised exercises for 6 weeks with home exercises until 12 weeks. After 12 weeks, all study participants performed the standard exercises at home for another 12 weeks.

MAIN OUTCOME MEASURES

Sleep quality, pressure pain threshold (PPT), quality of life and fibromyalgia impact, physical function, fatigue, pain catastrophizing, kinesiophobia, and positive-negative affect were recorded at baseline, and at weeks 12 and 24 of the intervention.

RESULTS

At the end of 12 weeks, the sleep quality improved significantly in the CST group (P = 0.037) and Bowen therapy group (P = 0.023), and the PPT improved significantly in the Bowen therapy group (P = 0.002) and the standard exercise group (P < 0.001), compared to the static touch group. These improvements were maintained at 24 weeks. No between-group differences were observed for other secondary outcomes.

CONCLUSION

CST and Bowen therapy improved sleep quality, and Bowen therapy and standard exercises improved pain threshold in the short term. These improvements were retained within the groups in the long term by adding exercises. CST and Bowen therapy are treatment options to improve sleep and reduce pain in FMS.

TRIAL REGISTRATION NUMBER

Registered at Clinical Trials Registry of India with the number of CTRI/2020/04/024551. Please cite this article as: Ughreja RA, Venkatesan P, Gopalakrishna DB, Singh YP, Lakshmi VR. Effectiveness of craniosacral therapy, Bowen therapy, static touch and standard exercise program on sleep quality in fibromyalgia syndrome: a randomized controlled trial. J Integr Med. 2024; 22(4): 474-484.

Functional neurological disorder, physical activity and exercise: What we know and what we can learn from comorbid disorders

Functional neurological disorder (FND) is a common neurologic disorder associated with many comorbid symptoms including fatigue, pain, headache, and orthostasis. These concurrent symptoms lead patients to accumulate multiple diagnoses comorbid with FND, including fibromyalgia, chronic fatigue syndrome, postural orthostatic tachycardia syndrome, persistent post-concussive symptoms, and chronic pain. The role of physical activity and exercise has not been evaluated in FND populations, though has been studied in certain comorbid conditions. In this traditional narrative literature review, we highlight some existing literature on physical activity in FND, then look to comorbid disorders to highlight the therapeutic potential of physical activity. We then consider abnormalities in the autonomic nervous system (ANS) as a potential pathophysiological explanation for symptoms in FND and comorbid disorders and postulate how physical activity and exercise may provide benefit via autonomic regulation.

Effect of physical activity education on shoulder girdle pain and muscle strength in participants with fibromyalgia: a pilot experimental study

Background

In patients with fibromyalgia, exercise and education are recommended to decrease pain level and improve pain management. The latest scientific evidence recommends to focus interventions on the upper limb. The aim of this pilot study was to compare the immediate effect of physical activity education vs. a control group on pain and muscle capacity in fibromyalgia patients.

Method

Fifty-six participants with fibromyalgia were randomized into an experimental group and a control group. The intervention consisted in watching a five-minute video that provided information about fibromyalgia, pain, kinesiophobia and physical activity. The control group watched a neutral five-minute video about beavers in Quebec. Following the video, participants performed a muscular fatigue task consisting of a repeated unilateral shoulder abduction task. At baseline and following the muscular fatigue task, maximal voluntary contraction (MVC) in shoulder abduction was assessed as well as pain level and pressure pain threshold (PPT) in the upper limb. Electromyographic activity was also assessed for upper trapezius and middle deltoid muscles. Two-way repeated measures analysis of variance was used to compare the MVC, PPT, and pain level before and after the muscular fatigue task between groups.

Results

The experimental group showed a significantly lower increase in pain than the control group in the middle deltoid muscle (p = 0.002) when assessed by verbal pain rating scale. No significant interaction or main effect of Group and Time were observed for the pain level at the upper trapezius and elbow extensor muscles nor for any of the PPT measures. According to electromyographic data, the median frequency values indicate that neither group experienced muscle fatigue during the repeated contraction task.

Conclusions

The preliminary results suggest that a short physical activity education video positively influenced middle deltoid pain following repeated abduction in participants with fibromyalgia. Electromyographic analysis showed no evidence of objective muscle fatigue, suggesting that there might be a partial disconnection between the perception of muscle fatigue and the physiological biomarkers associated with muscle fatigue.

Effects of Prolonged Medical Fasting during an Inpatient, Multimodal, Nature-Based Treatment on Pain, Physical Function, and Psychometric Parameters in Patients with Fibromyalgia: An Observational Study

Fibromyalgia syndrome (FMS) is a common chronic pain disorder and often occurs as a concomitant disease in rheumatological diseases. Managing FMS takes a complex approach and often involves various non-pharmacological therapies. Fasting interventions have not been in the focus of research until recently, but preliminary data have shown effects on short- and medium-term pain as well as on physical and psychosomatic outcomes in different chronic pain disorders. This single-arm observational study investigated the effects of prolonged fasting (3-12 days, <600 kcal/d) embedded in a multimodal treatment setting on inpatients with FMS. Patients who were treated at the Department of Internal Medicine and Nature-Based Therapies of the Immanuel Hospital Berlin, Germany, between 02/2018 and 12/2020 answered questionnaires at hospital admission (V0) and discharge (V1), and then again three (V2), six (V3), and 12 (V4) months later. Selected routine blood and anthropometric parameters were also assessed during the inpatient stay. A total of 176 patients with FMS were included in the study. The Fibromyalgia Impact Questionnaire (FIQ) total score dropped by 13.7 ± 13.9 (p < 0.001) by V1, suggesting an improvement in subjective disease impact. Pain (NRS: reduction by 1.1 ± 2.5 in V1, p < 0.001) and quality of life (WHO-5: +4.9 ± 12.3 in V1, p < 0.001) improved, with a sustainable effect across follow-up visits. In contrast, mindfulness (MAAS: +0.3 ± 0.7 in V1, p < 0.001), anxiety (HADS-A: reduction by 2.9 ± 3.5 in V1, p < 0.0001), and depression (HADS-D: reduction by 2.7 ± 3.0 in V1, p < 0.0001) improved during inpatient treatment, without longer-lasting effects thereafter. During the study period, no serious adverse events were reported. The results suggest that patients with FMS can profit from a prolonged therapeutic fasting intervention integrated into a complex multimodal inpatient treatment in terms of quality of life, pain, and disease-specific functional parameters. ClinicalTrials.gov Identifier: NCT03785197.

Effects of exercise-based interventions on inflammatory markers in patients with fibromyalgia: A systematic review and meta-analysis

OBJECTIVES

The aim of the present review was (1) to determine the effects of exercise based-interventions (EBIs) on pro-inflammatory and anti-inflammatory biomarkers in patients with fibromyalgia (FM), and (2) to determine the most effective type (acute or maintained) and modality (aerobic, resistance, etc.).

METHODS

A systematic search was conducted in various electronic databases to identify all the relevant studies: Medline (PubMed), PEDro, EBSCO and Google Scholar. Clinical trials assessing the effects of EBIs in patients with FM were selected. Methodological quality was evaluated by two independent investigators using the Cochrane Risk of Bias Tool. Qualitative analysis was based on the classification of the results into levels of evidence according to GRADE.

RESULTS

Eleven studies were included. The meta-analysis showed a statistically significant decrease in proinflammatory biomarkers by EBIs with a large clinical effect in 19 comparisons (SMD: 1.74; 95 % CI: 0.85-2.62; p < 0.05), especially for IL8. The certainty of the evidence was low. The meta-analysis showed no statistically significant increase in anti-inflammatory biomarkers (IL10) by EBIs in 6 comparisons and very low certainty of evidence. Evidence was found for acute and maintained effects of exercise, with aerobic and aquatic exercise modalities showing better improvements than resistance exercise.

CONCLUSIONS

EBIs are effective in inducing an immunomodulatory response in FM, characterized by decreased pro-inflammatory signaling. However, there was no evidence of an increase in anti-inflammatory biomarkers. These results should be interpreted with caution due to low certainty of evidence.

"Fibromyalgia - are there any new approaches?"

INTRODUCTION

Approaching patients with fibromyalgia (FM) is challenging due to the limited availability of scientifically proven effective therapies.

OBJECTIVE

Review the treatments in use for FM and present new knowledge that could benefit these patients. Non-pharmacological interventions are recommended as the first line of treatment: aerobic exercise, cognitive behavioral therapy and patient education, all aimed at improving pain and other symptoms. Additional approaches have been studied, such as, digital health interventions, combined treatments, noninvasive neuromodulation, and others. Concerning pharmacological therapy, the mechanism of action of the medications currently used is to promote pain modulation. Medications approved by Food and Drug Administration are duloxetine, milnacipran and pregabalin. Amitriptyline, cyclobenzaprine, gabapentin and naltrexone are considered for off-label use. Cannabinoids, vitamin D supplementation are still controversial and further research is needed.

CONCLUSION

The combination of therapies, whether old, recent or reformulated, are the most effective strategy for managing symptoms in patients with fibromyalgia.

KEY WORDS

fibromyalgia, treatment, nonpharmacological interventions, pharmacological treatment.

Comparative effectiveness of non-pharmacological interventions on sleep in individuals with chronic musculoskeletal pain: A systematic review with network meta-analysis

This network meta-analysis aimed to estimate the comparative effectiveness of non-pharmacological interventions on sleep in individuals with chronic musculoskeletal pain. Seven databases were systematically searched up to February 2023. A random-effects network meta-analysis in a frequentist framework was performed to synthesize continuous data as standardized mean differences (SMD) along with a 95% confidence interval (95% CI). A total of 15,641 records were identified, and 107 randomized controlled trials involving 8,121 participants were included. Of 14 identified interventions, eight were significantly more effective than passive control in improving sleep quality at immediate post-intervention (SMDs = 0.67-0.74), with cognitive behavioral therapy (CBT) being the most effective treatment (SMD = 0.74, 95% CI: 0.45-1.03). Only CBT demonstrated sustained effects at short-term (SMD = 1.56; 95% CI: 0.62-2.49) and mid-term (SMD = 1.23; 95% CI: 0.44-2.03) follow-ups. Furthermore, CBT significantly improved subjective (SMD = 0.64; 95% CI: 0.25-1.03) and objective (SMD = 0.30; 95% CI: 0.01-0.59) sleep efficiency compared with passive control at immediate post-intervention. Our findings support CBT as the first-line treatment for improving sleep in individuals with chronic musculoskeletal pain, given its superior effectiveness across multiple sleep outcomes and its sustainable effects until mid-term follow-up. However, the certainty of evidence for these interventions in improving sleep quality was very low to low.

Tonic cuff pressure pain sensitivity in chronic pain patients and its relation to self-reported physical activity

OBJECTIVES

Physical inactivity is a global health concern and a significant problem among chronic pain patients. They often experience pain flare-ups when they try to increase their physical activity level. Most research on the relationship between pain sensitivity and physical activity has been on healthy participants. Data on chronic pain patients are lacking. Using cuff pressure algometry, this study investigated tonic cuff pressure pain sensitivity and its associations to self-reported physical activity and other patient-reported outcomes in chronic pain patients.

METHODS

Chronic pain patients (n=78) were compared to healthy controls (n=98). Multivariate data analysis was used to investigate the associations between tonic cuff pressure pain sensitivity, physical activity, and other patient-reported outcome measures.

RESULTS

The three most important variables for group discrimination were perceived health status (EQVAS: p(corr)=-0.85, i.e., lower in patients), depression (HADS-D: p(corr)=0.81, i.e., higher in patients), and the tonic cuff pressure pain sensitivity variable maximum pain intensity (VAS-peak-arm: p(corr)=0.75, i.e., higher in patients). In patients, the most important predictors for high VAS-peak-arm were female sex (p(corr)=-0.75), higher number of painful regions (p(corr)=0.72), higher pain intensity (p(corr)=0.55), followed by lower level of self-reported physical activity (p(corr)=-0.39). VAS-peak-arm in patients correlated negatively with self-reported physical activity (rho=-0.28, p=0.018).

CONCLUSIONS

Physical activity may be the most important patient-changeable variable correlating to pain sensitivity. This study highlights the importance of more research to further understand how increased physical activity may decrease pain sensitivity in chronic pain patients.

Naltrexone 6 mg once daily versus placebo in women with fibromyalgia: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Low-dose naltrexone is used to treat fibromyalgia despite minimal evidence for its efficacy. This trial aimed to investigate whether 12-week treatment with 6 mg low-dose naltrexone was superior to placebo for reducing pain in women with fibromyalgia.

METHODS

We did a single-centre, randomised, double-blind, placebo-controlled trial in Denmark. We enrolled women aged 18-64 years who were diagnosed with fibromyalgia. Participants were randomly assigned 1:1 to receive low-dose naltrexone (6 mg) or an identical-appearing placebo, using a computerised algorithm with no stratifications applied. Participants, investigators, outcome assessors, and statistical analysts were all masked to treatment allocation. The primary outcome was change in pain intensity on an 11-point numeric rating scale from baseline to week 12, in the intention-to-treat population. Safety was assessed in participants in the intention-to-treat population who received at least one dose of their allocated intervention. This trial was registered with ClincalTrials.gov (NCT04270877) and EudraCT (2019-000702-30).

FINDINGS

We screened 158 participants for eligibility from Jan 6, 2021, to Dec 27, 2022, and 99 patients were randomly assigned to low-dose naltrexone (n=49) or placebo (n=50). The mean age was 50·6 years (SD 8·8), one (1%) of 99 participants was Arctic Asian and 98 (99%) were White. No participants were lost to follow-up. The mean change in pain intensity was -1·3 points (95% CI -1·7 to -0·8) in the low-dose naltrexone group and -0·9 (-1·4 to -0·5) in the placebo group, corresponding to a between-group difference of -0·34 (-0·95 to 0·27; p=0·27, Cohen's d 0·23). Discontinuations due to adverse events were four (8%) of 49 in the low-dose naltrexone group and three (6%) of 50 in the placebo group. 41 (84%) of 49 patients in the low-dose naltrexone group had an adverse event versus 43 (86%) of 50 in the placebo group. One serious adverse event occurred in the placebo group and no deaths occurred.

INTERPRETATION

This study did not show that treatment with low-dose naltrexone was superior to placebo in relieving pain. Our results indicate that low-dose naltrexone might improve memory problems associated with fibromyalgia, and we suggest that future trials investigate this further.

FUNDING

The Danish Rheumatism Association, Odense University Hospital, Danielsen's Foundation, and the Oak Foundation.

Exercise Training for Chronic Pain: Available Evidence, Current Recommendations, and Potential Mechanisms

Chronic pain conditions pose a significant global burden of disability, with epidemiological data indicating a rising incidence. Exercise training is commonly recommended as a standalone or complementary approach for managing various chronic pain conditions like low back pain, osteoarthritis, rheumatoid arthritis, fibromyalgia syndrome, and neuropathic pain. Regardless of the specific condition or underlying cause (e.g., autoimmune disease, chronic inflammation), exercise training consistently leads to moderate to large reductions in pain. Moreover, exercise yields numerous benefits beyond pain alleviation, including small-to-moderate improvements in disability, quality of life, and physical function. Despite its efficacy, there is a lack of comprehensive research delineating the optimal intensity, duration, and type of exercise for maximal benefits; however, evidence suggests that sustained engagement in regular exercise or physical activity is necessary to achieve and maintain reductions in both clinical pain intensity ratings and the level that pain interferes with activities of daily living. Additionally, the precise mechanisms through which exercise mitigates pain remain poorly understood and likely vary based on the pathophysiological mechanisms underlying each condition.

Effectiveness of non-pharmacological interventions for fibromyalgia and quality of review methods: an overview of Cochrane Reviews

BACKGROUND

Fibromyalgia syndrome (FMS) is defined as chronic widespread pain associated with sleep disorders, cognitive dysfunction, and somatic symptoms present for at least three months and cannot be better explained by another diagnosis.

OBJECTIVES

To examine efficacy and safety of non-pharmacological interventions for FMS in adults reported in Cochrane Reviews, and reporting quality of reviews.

METHODS

Systematic reviews of randomised controlled trials (RCTs) of non-pharmacological interventions for FMS were identified from the Cochrane Database of Systematic Reviews (CDSR 2022, Issue 3 and CDSR 2023 Issue 6). Methodological quality was assessed using the AMSTAR-2 tool and a set of methodological criteria critical for analgesic effects. The primary efficacy outcomes of interest were clinically relevant pain relief, improvement in health-related quality of life (HRQoL), acceptability, safety, and reduction of mobility difficulties as reported by study participants. No pooled analyses were planned. We assumed a clinically relevant improvement was a minimal clinically important difference (MCID) between interventions and controls of 15%, or a SMD of more than 0.2, or a MD of more than 0.5, on a 0 to 10 scale.

RESULTS

Ten Cochrane reviews were eligible, reporting 181 randomized or quasi- randomized trials (11,917 participants, average trial size 66 participants). The reviews examined exercise training, acupuncture, transcutaneous electrical nerve stimulation, and psychological therapies. One review was rated moderate according to AMSTAR 2, seven were rated low and two were rated critically low. All reviews met most of the additional methodological quality criteria. All reviews included studies with patient-reported outcomes for pain. We found low certainty evidence of clinically relevant positive effects of aerobic and mixed exercise training and for cognitive behavioural therapies (CBTs) at reducing mobility difficulties and for mixed exercise training and CBTs for improving HRQoL at the end of the intervention. Number needed to treat for an additional beneficial outcome (NNTB) values for a MCID of 15% ranged between 4 and 9. We found low certainty evidence that was clinically relevant for mixed exercise and CBTs for reducing mobility difficulties at an average follow up of 24 weeks. We found low certainty evidence of clinically relevant positive effects of mixed exercise on HRQoL at an average follow up of 24 weeks. NNTB values for a MCID of 15% ranged from 5 to 11. The certainty of evidence of the acceptability (measured by dropouts) of the different non-pharmacological interventions ranged from very low to moderate and the dropout rate for any reason did not differ across the interventions or the controls, except for biofeedback and movement therapies. All the systematic reviews stated that the reporting of adverse events was inconsistent in the studies analysed (very low certainty evidence).

AUTHORS' CONCLUSIONS

There is low certainty evidence of clinically relevant reduction of mobility difficulties and of improvement of HRQoL among individuals with FMS by aerobic and mixed exercise training and by CBTs at the end of the intervention. There is low certainty evidence that CBTs and mixed exercise training reduces mobility difficulties post-treatment and that mixed exercise training improves HRQoL at follow-up by clinically meaningful scores.

Effectiveness of Land- and Water-based Exercise on Fatigue and Sleep Quality in Women With Fibromyalgia: The al-Ándalus Quasi-Experimental Study

OBJECTIVE

To assess the effectiveness of 24 weeks of land- and water-based exercise on fatigue and sleep quality in women with fibromyalgia, and the persistence of changes 12 weeks after exercise cessation.

DESIGN

Quasi-experimental study.

SETTING

University facilities and fibromyalgia associations.

PARTICIPANTS

Women with fibromyalgia (N=250; 50.8±7.6 years old).

INTERVENTIONS

Participants were assigned to land-based exercise (n=83), water-based exercise (n=85), or no exercise control (n=82) groups. The intervention groups engaged in a similar multicomponent exercise program for 24 weeks.

MAIN OUTCOME MEASURES

The Multidimensional Fatigue Inventory and Pittsburgh Sleep Quality Index were used.

RESULTS

Intention-to-treat analyses revealed that, compared with the control group, at week 24: (i) the land-based exercise group improved physical fatigue (mean difference -0.9 units; 95% confidence interval -1.7 to -0.1; Cohen's d=0.4) and (ii) the water-based exercise group improved general fatigue (-0.8; -1.4 to -0.1, d=0.4), and global sleep quality (-1.6; -2.7 to -0.6, d=0.6). Additionally, compared with the land-based exercise group, the water-based exercise group improved global sleep quality (-1.2; -2.2 to -0.1, d=0.4). Changes were generally not sustained at week 36.

CONCLUSION

Land-based multicomponent exercise improved physical fatigue, whereas water-based exercise improved general fatigue and sleep quality. The magnitude of the changes was small-to-medium, and no benefits were maintained after exercise cessation.

Effects of progressive intensity resistance training on the impact of fibromyalgia: protocol for a blinded randomized controlled trial

BACKGROUND

Fibromyalgia guidelines indicate that exercise is critical in the management of fibromyalgia, and there is evidence that patients with fibromyalgia can perform resistance training at moderate and high intensities. However, despite the biological plausibility that progression of intensity provides greater benefit to individuals, no studies have compared different intensities (progressive versus constant intensities) of the same exercise in this population.

OBJECTIVE

To compare the effect of 24 sessions of resistance training (progressive vs. constant intensity) on impact of fibromyalgia, sleep quality, anxiety, depression, pain, walking ability, and musculoskeletal capacity.

METHODS

A protocol for a blinded randomized controlled trial. The sample will be randomized into three groups: group 1 (progressive intensity, experimental), group 2 (constant intensity, control A), and group 3 (walking, control B). Group 1 will perform resistance training at moderate intensity (50% of maximum dynamic strength), previously determined by the 1 repetition maximum (1-RM) test in the proposed exercises. The strength of each individual will be reassessed every 4 weeks (by 1-RM) and the intensity of each exercise will be positively adjusted by 20% of the value observed in kg (i.e., first month 50%; second month 70%; third month 90% of the maximum dynamic strength). Group 2 will perform the same procedure, but the intensity will be maintained at 50% of the maximum dynamic strength throughout the treatment (i.e., constant intensity from the first to the third month). Group 3 will perform a 40-minute treadmill walk at low intensity, defined by a walking speed corresponding to 60-70% of the maximum heart rate, which we will control with a heart rate monitor. All groups will receive a 45-minute pain education session prior to the exercise program, covering the pathophysiologic mechanisms of chronic pain, strategies for coping with pain, avoiding hypervigilance, and deconstructing beliefs and myths about chronic pain.

DISCUSSION

The results of the present study may help health care professionals adjust the intensity of resistance training and thus plan the most effective intervention (progressive or constant intensity) to reduce the impact of fibromyalgia on patients' lives.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials (ReBEC) ID: RBR-9pbq9fg, date of registration: October 06, 2022.

The Challenge of Fibromyalgia Efficacy of Hypnosis in Alleviating the Invisible Pain: A Narrative Review

Fibromyalgia syndrome (FMS) is a multifaceted and incapacitating functional pain syndrome characterized by continuous, severe, widespread musculoskeletal pain. FMS is associated with other symptoms such as fatigue, nonrestorative sleep, cognitive/emotional dysfunction, and diminished health-related quality of life. The pathogenesis of FMS is still not fully understood, but an increasing amount of evidence supports the link between childhood/adulthood emotional, physical, sexual abuse or neglect and the development of FMS. Managing and treating FMS patients can be challenging because the syndrome is refractory to most treatments. However, psychological interventions, particularly hypnotherapy, have been shown to be effective in the cognitive modulation of fibromyalgic pain. FMS patients may benefit from hypnotherapy alone or in combination with standard medical therapy. Symptom-oriented hypnosis aims to reduce pain, fatigue, sleep problems, anxiety, and depression, while hypnotherapy focuses on resolving emotional conflicts and unresolved traumas associated with FMS. In conclusion, hypnosis may be a useful and safe adjunct tool for managing chronic pain and dysfunctional symptoms in challenging fibromyalgic patients.

Sedentary time is associated with depressive symptoms and state anxiety in women with fibromyalgia. Could physical activity and fitness modify this association? The al-Ándalus project

PURPOSE

To analyze the associations of total and prolonged sedentary time (ST) with depressive symptoms and state anxiety in women with fibromyalgia and whether these associations are modified by moderate-to-vigorous physical activity (MVPA) and physical fitness.

METHODS

This cross-sectional exploratory study included 386 women with fibromyalgia aged 51.2 ± 7.6 years. Total ST, time in prolonged bouts of ST (≥30- and ≥60-min) and MVPA were measured with triaxial accelerometry. Depressive symptoms were assessed with the "Beck Depression Inventory-second edition," state anxiety with the "State-Trait Anxiety Inventory," and physical fitness with the "Senior Fitness Test Battery."

RESULTS

Total and prolonged ST were directly associated with depressive symptoms (total: β = 0.19, ≥30-min bout: β = 0.15, and ≥60-min bout: β = 0.12) and odds of severe depressive symptoms (all, p < 0.001). These associations generally remained significant after adjustments for MVPA and physical fitness (all, p < 0.05). Total and prolonged ST were directly associated with state anxiety (total: β = 0.11, ≥30-min bout: β = 0.12, and ≥60-min bout: β = 0.07; all, p < 0.001). These associations were generally independent of MVPA (p < 0.05) but vanished when considering physical fitness (p > 0.05).

CONCLUSIONS

Higher levels of total and prolonged ST are associated with greater depressive symptoms and state anxiety in women with fibromyalgia. MVPA did not modify these associations, although physical fitness could play a protective role specially for state anxiety.IMPLICATIONS FOR REHABILITATIONReducing sedentary time and avoiding its accumulation in prolonged periods could potentially reduce depressive symptoms and state anxiety in fibromyalgia.Higher sedentary time is associated with more severe depressive symptoms even in patients who engage in moderate-to-vigorous physical activity.Higher levels of physical fitness could attenuate the negative associations of sedentary time with depressive symptoms and, specially, state anxiety."Sit less, move more and exercise to increase your fitness" could be a positive message for people with fibromyalgia in clinical settings.

Personalized pain management: Is it time for process-based therapy for particular people with chronic pain?

BACKGROUND AND OBJECTIVE

Psychological treatments for chronic pain have helped many people around the world. They are among the most researched and best evidenced treatments a person can receive when they have persistent, disabling and distressing pain. At the same time, improvements in the effectiveness of these treatments appear to be at a standstill. This may be due to an inherent lack of generalizability from aggregated group data to the individual, limited utility of our current schemes for categorizing people with pain conditions, faced with their inherent heterogeneity, our relatively coarse categories of treatment types and focus on treatment packages rather than individual methods, and our current failures to find adequate predictors of outcome, or to assign people their best-suited treatment methods, based on group data. In this review, it is argued that the development and examination of truly personalized treatment is a next logical step to create progress and improve the results people achieve.

METHODS

Key research studies pertaining to psychological treatments, treatment outcome, heterogeneity in chronic pain, prediction of treatment outcome, subtyping and treatment tailoring are reviewed.

RESULTS AND CONCLUSION

It is suggested that development of future treatments for chronic pain ought to incorporate an idiographic, process-based approach, focused on evidence-based mechanisms of change, individually and dynamically addressed, based on contextually sensitive ongoing assessment. Knowledge and practical solutions needed to make process-based therapy for chronic pain happen are discussed.

SIGNIFICANCE

Psychological approaches to chronic pain have been highly successful in the past but improvement in the effectiveness of these over time is slow to nonexistent. It is argued here that this has happened due to a failure to adequately consider the individual. Future psychological treatments for chronic pain ought to incorporate an idiographic, process-based approach, focused on evidence-based mechanisms of change, individually and dynamically addressed, grounded in ongoing contextually sensitive assessment.

The Effects of Non-Pharmacological Interventions in Fibromyalgia: A Systematic Review and Metanalysis of Predominants Outcomes

(1) Fibromyalgia (FM) is a chronic musculoskeletal condition with multiple symptoms primarily affecting women. An imbalance in cytokine levels has been observed, suggesting a chronic low-grade inflammation. The main aim of the meta-analysis was to examine the effect of multimodal rehabilitation on cytokine levels and other predominant variables in patients with FM. Furthermore, to examine which non-pharmacological tools have been used to investigate the effects that these can have on cytokines in FM patients. (2) Methods: Searches were conducted in PubMed, Scopus, Web of Science, Cochrane, and ScienceDirect databases. This systematic review and metanalysis followed the PRISMA statement protocol. The methodological quality of the studies was assessed using the PEDro scale, the risk of bias followed the Cochrane Manual 5.0.1, and the GRADE system was used for rating the certainty of evidence. (3) Results: Of 318 studies found, eight were finally selected, with a sample size of 320 women with a mean age of 57 ± 20. The proinflammatory cytokines IL-1β, IL-6, IL-8 and TNF-α were the most studied. Resistance exercise, aquatic exercise, dynamic contractions, cycling, treadmill, and infrared therapy were the main non-pharmacological tools used. (4) Conclusions: The systematic review with meta-analysis found evidence of elevated cytokine levels in patients with FM, suggesting low chronic inflammation and a possible contribution to central sensitization and chronic pain. However, the effects of physiotherapeutic interventions on cytokine levels are variable, highlighting the importance of considering different factors and the need for further research.

Exercise-based interventions on sleep quality in patients with fibromyalgia syndrome: An umbrella and mapping review with meta-analysis

The main aim of this umbrella review was to assess the impact of exercise-based interventions (EBIs) on sleep quality in patients with fibromyalgia syndrome (FMS). We searched systematically in PubMed, PEDro, EMBASE, CINAHL, SPORTDiscus and Google Scholar. Methodological quality was analyzed using AMSTAR and ROBIS scale, and the strength of evidence was established according to GRADE. Nine systematic reviews were included. Meta-analysis (MA) of primary studies (n = 42) were performed with a random-effects model. The MA revealed a moderate statistically significant effect of EBIs (SMD=-0.46 [-0.69 to -0.23]). Subgroup analyses by type of exercise showed significant effect of body-mind exercises (SMD=-0.55 [-0.86 to -0.23]) and combined exercises (SMD=-1.11 [-2.12 to -0.11]) but not for aerobic (SMD=-0.04 [-0.15 to 0.07]) or strength (SMD=-0.52 [-1.14 to 0.1]) exercises in isolation. The results obtained showed that EBIs were effective in improving sleep quality compared to minimal intervention, no intervention or usual care, with a low certainty of evidence. Subgroup analyses showed that mind-body and combined exercises elicited the strongest effect, while aerobic and strength exercise in isolation did not show significant effects.

Effectiveness of rehabilitation strategies in primary fibromyalgia syndrome: A systematic review and meta-analysis

Objectives

The aim of this review was to (1) summarize evidence on the effectiveness of rehabilitation strategies in fibromyalgia syndrome (FMS) and (2) determine the most effective rehabilitation strategy for reducing pain and depression in people with FMS.

Data Sources

PubMed, Ovid (Sp), and Cochrane search engines were used for identifying relevant studies done up to 1st of July 2022.

Study Selection

Randomized control trials (RCTs) that have a passive control group and an active control group were included in this review for primary and secondary aim, respectively. The primary outcome measures were pain and depression. Secondary outcome was one from the sleep or fatigue or healthy related quality of life (HRQOL).

Data Extraction

Two researchers independently selected the studies and extracted the key information.

Data Synthesis

A total of 25 RCTs were included. Studies with passive control group showed moderate to large positive effects on pain (standard mean difference -0.65, 95% confidence interval -0.93 to -0.38; I2 = 72%) and HRQOL (MD -5.40, 95% CI -10.17 to -0.62; I2 = 74%) but were not statistically significant for sleep, fatigue, and depression. Furthermore, on subgroup analysis studies with a short term protocol showed significant effects on pain only, whereas studies with long term protocols showed positive effects on pain and HRQOL only, but no statistical significance at the time of post-trial follow-up. Studies with active control groups gave non-significant results except where there was mixed exercises, which showed a positive effect (mean difference -4.78, 95% CI -7.98 to -1.57; I2 = 0%) for HRQOL.

Conclusion

All rehabilitation strategies were effective for pain and HRQOL, and had a marginal effect on depression, sleep, and fatigue but efficacy was not maintained at the time of post-trial follow-up. However, in this review, we could not differentiate any rehabilitation strategies for the best among those used in the included studies.

The Potential Role of Spa Therapy in Managing Frailty in Rheumatic Patients: A Scoping Review

Frailty is not limited to the elderly, as patients with rheumatic diseases can also experience this condition. The present scoping review aimed to investigate the possibility of using the health resort setting as an alternative location for managing rheumatic patients with frailty. The research resulted in finding several in vitro, in vivo, and clinical studies, resulting in evidence supporting the effectiveness of spa treatments in reducing pain, improving function, and managing comorbidity in rheumatic diseases. Additionally, spa treatments were demonstrated to modulate the MAPK/ERK pathway and the NF-kB pathway's activation and to reduce proinflammatory molecules' secretion in rheumatic diseases, thus suggesting their potential effective role in the regulation of inflammaging in frailty. Moreover, the health resort setting may offer potential resources to reduce risk factors, such as drug consumption, inactivity, and disease severity, and may serve as a setting for developing prevention protocols for frailty. Future research should explore innovative approaches, such as exercise training and early diagnostics, for the overall management of frailty in rheumatic patients in the spa setting.

Do the instruments used to assess fibromyalgia symptoms according to American College of Rheumatology criteria generate similar scores in other chronic musculoskeletal pain?

BACKGROUND

As with fibromyalgia, several musculoskeletal disorders are characterized by chronic pain, raising a clinical question - do the instruments used to assess fibromyalgia symptoms according to ACR criteria (ACR criteria) generate similar scores in other chronic musculoskeletal pain?

OBJECTIVE

To compare the symptoms among fibromyalgia and other chronic musculoskeletal pain. Additionally, we also compared the most researched outcomes in fibromyalgia (i.e., present pain at rest and after movement; fatigue; pain severity and impact; function, global impact, and fibromyalgia symptom).

METHODS

A cross-sectional study. Participants over 18 years old were included if they presented report of chronic musculoskeletal pain (≥ 3 months) and after that, they were divided into two groups (fibromyalgia and chronic pain). They answered the Fibromyalgia Impact Questionnaire-Revised (FIQ-R), Brief Pain Inventory (BPI), Numerical Pain Rating Scale (NPRS) for pain and fatigue, WPI, and SSS.

RESULTS

A total of 166 participants were included in this study into two independent groups (chronic pain, n = 83; fibromyalgia, n = 83). We observed significant differences (p < 0.05) and large effect sizes (Cohen's d, ≥ 0.7) in clinical outcomes comparisons between groups (i.e., widespread pain; symptom severity; present pain at rest and after movement; fatigue; pain severity and impact; function, global impact, and fibromyalgia symptoms).

CONCLUSION

Fibromyalgia patients (2016 ACR criteria) compared to other chronic musculoskeletal pain patients have higher levels of pain (at rest or after movement) and fatigue, greater impairment in both functionality and global impact, and worse symptoms. Therefore, the WPI and SSS instruments should be used exclusively to assess fibromyalgia symptoms.

Effectiveness of Vestibular Rehabilitation in Improving Health Status and Balance in Patients with Fibromyalgia Syndrome: A Single-Blind Randomized Controlled Trial

BACKGROUND

Fibromyalgia Syndrome (FMS) is a highly prevalent health problem whose main symptom is widespread pain, although it presents as other manifestations, such as loss of balance, that seem to mainly affect visuo-vestibular information.

OBJECTIVE

to compare the effects of a Vestibular Rehabilitation (VR) program versus those of a Conventional Physical Exercise (CPE) program on the health status of patients with FMS.

METHODS

A single-blind randomized controlled trial was performed. Patients with FMS were randomly assigned to VR or CPE programs. The protocols were performed in 40 min group sessions, twice weekly, for 16 sessions. Perceived health status, static and dynamic balance, verticality perception, confidence in balance, sensitization and kinesiophobia were measured at baseline, post-treatment and at the three-month follow-up and analyzed using an intention-to-treat approach.

RESULTS

Forty-eight subjects were randomly assigned, of whom thirty-five completed the planned VR (n = 19) or CPE (n = 16) program. At the three-month follow-up, there were differences in physical health status measured with the SF-12 (mean = -4.36, SE = 1.88, p = 0.027), balance during walking (mean = 1.90, SE = 0.57, p = 0.002), the perception of verticality in degrees (mean = 3.61, SE = 1.51, p = 0.024) and the anteroposterior position of the center of pressure (mean = -7.88, SE = 2.80, p = 0.009), as well as a decrease in the number of falls (mean = 0.98, SE = 0.44, p = 0.033), favoring the VR group.

CONCLUSIONS

Vestibular Rehabilitation can be as beneficial as conventional exercise in improving the state of health in patients with Fibromyalgia Syndrome, providing additional improvements in physical health status, body balance, the perception of verticality and the number of falls.

The Efficacy and Safety of Telerehabilitation for Fibromyalgia: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Fibromyalgia is a chronic pain syndrome characterized by persistent and widespread musculoskeletal pain. Telerehabilitation is a promising treatment for patients with fibromyalgia through long-term monitoring, intervention, supervision, consultation, and education.

OBJECTIVE

This study aimed to perform a comprehensive systematic review and meta-analysis of the efficacy and safety of telerehabilitation in patients with fibromyalgia.

METHODS

Randomized controlled trials (RCTs) related to fibromyalgia and telerehabilitation were systematically searched in the PubMed, PEDro, Cochrane Library, ScienceDirect, Ovid MEDLINE, Embase, and Web of Science databases from inception to November 13, 2022. Two independent researchers screened the literatures and evaluated the methodological quality using the Cochrane Risk of Bias Tool. The outcome measures included the Fibromyalgia Impact Questionnaire scale, pain intensity, depression, pain catastrophizing, quality of life (QoL), and adverse events. Pooled effect sizes were calculated by Stata SE 15.1; a fixed effects model was used when I²<50%, whereas a random effects model was used when I²≥50%.

RESULTS

A total of 14 RCTs with 1242 participants were included in this meta-analysis. The pooled results indicated that the telerehabilitation improved the Fibromyalgia Impact Questionnaire score (weighted mean difference -8.32, 95% CI -11.72 to -4.91; P<.001), pain intensity (standardized mean difference [SMD] -0.62, 95% CI -0.76 to -0.47; P<.001), depression levels (SMD -0.42, 95% CI -0.62 to -0.22; P<.001), pain catastrophizing (weighted mean difference -5.81, 95% CI -9.40 to -2.23; P=.001), and QoL (SMD 0.32, 95% CI 0.18 to 0.47; P<.001) in patients with fibromyalgia compared to control interventions. Only 1 RCT reported a mild adverse event of telerehabilitation; the other 13 RCTs did not mention this.

CONCLUSIONS

Telerehabilitation can improve the symptoms and QoL of fibromyalgia. However, the safety of telerehabilitation remains uncertain due to the lack of sufficient evidence for the management of fibromyalgia. More rigorously designed trials are needed in the future to verify the safety and efficacy of telerehabilitation in fibromyalgia.

TRIAL REGISTRATION

PROSPERO CRD42022338200; https://tinyurl.com/322keukv.

Fibromyalgia, Pain, and Physical Activity: A Bibliometric Analysis

Fibromyalgia (FM) is a rheumatic disease characterized by pain, fatigue, low-quality sleep, depression, anxiety, stiffness, fall risk, mood disturbance, cognitive impairment, poor physical condition, and other symptoms leading to a worse quality of life. Physical activity (PA) and exercise are effective methods to reduce FM symptoms, including pain. This study presents the first bibliometric study on FM, pain, and PA. An advanced search of the Web of Science (WoS) Core Collection database performed on this topic using was carried out traditional bibliometric laws. A total of 737 documents were found. Annual publications presented an exponentially growing trend (R2 = 85.3%). Rheumatology International, Kaisa Mannerkorpi, and the USA were the journal, co-author, and country most productive, respectively. The exponential growth of annual publications on FM, PA, and pain shows the high interest of researchers and publishers in this topic. The document "Fibromyalgia A Clinical Review" was the most cited. Moreover, Kaisa Mannerkorpi was the most prolific co-author, Rheumatology International was the most prolific journal, "Fibromyalgia: a clinical review" was the most highly cited document, and Daniel Clauw was the most cited co-author.

Effect of Exercise Interventions on Health-Related Quality of Life in Patients with Fibromyalgia Syndrome: A Systematic Review and Network Meta-Analysis

OBJECTIVE

Several guidelines highlight the beneficial impact of exercise on the management of symptoms and health-related quality of life (HRQOL) in patients with fibromyalgia syndrome (FMS). However, few analyses have compared different types of exercise. We, therefore, intent to compare the effects of different exercise types on improving the overall HRQOL and typical symptoms in patients with FMS.

METHODS

Medline, Embase, the Cochrane Register of Clinical Trials, and NIH ClinicalTrials.gov were searched from inception to April 21, 2022. Randomized clinical trials (RCTs) were included to assess the impact of exercise intervention on health parameters in adult FMS patients. Data were extracted independently and a frequentist network meta-analyses (NMA) was performed to rank the effects of interventions according to P-scores. The NMA evidence certainty was assessed using the method recommended by Grading of Recommendations Assessment, Development, and Evaluation Working Group.

RESULTS

A total of 57 RCTs were identified, including 3319 participants, involving 9 interventions (7 types of exercise, 2 controls). Of all treatments compared with usual care in efficacy outcomes, Mind-body exercise was associated with the best HRQOL (SMD, -12.12; 95% CI, -15.79 to -8.45). On the other characteristic symptom dimensions, based on moderate quality evidence, sensorimotor training was associated with minimal pain scores compared with usual care (SMD, -1.81; 95% CI, -2.81 to -0.82), whole body vibration therapy was most promising for improving sleep quality (SMD, -6.95; 95% CI, -10.03 to -3.87), pool-based aerobic exercise was most likely to ease anxiety (SMD, -4.83; 95% CI, -7.47 to -2.19), and whole body vibration was most likely to improve depression (SMD, -10.44; 95% CI, -22.00 to 1.12).

CONCLUSION

Mind-body exercise seems to be the most effective exercise to improve the overall HRQOL of patients with FMS. But at the same time, clinicians still need to develop individualized exercise plans for patients according to their symptoms and accessibility.

Online Questionnaire with Fibromyalgia Patients Reveals Correlations among Type of Pain, Psychological Alterations, and Effectiveness of Non-Pharmacological Therapies

Fibromyalgia (FM) is a chronic pain syndrome with an unclear etiology. In addition to pain, FM patients suffer from a diverse array of symptoms and comorbidities, encompassing fatigue, cognitive dysfunction, mood disorders, sleep deprivation, and dizziness. Due to the complexity of FM, the diagnosis and treatment of it are highly challenging. The aim of the present work was to investigate some clinical and psychological characteristics of FM patients, and to uncover possible correlations with pharmacological and non-pharmacological therapies. We conducted a cross-sectional, questionnaire-based study aimed at evaluating pain, psychological traits, and the self-perceived effectiveness of pharmacological and non-pharmacological treatments in an Italian population of FM patients. Descriptive statistics, correlation, and inference analyses were performed. We found a prevalence of a neuropathic/nociplastic type of pain, which correlated with psychological traits such as anxiety, low mood, psychophysical discomfort, and the inability to relax. The pain type and psychological traits proved to play a role in determining the self-perceived effectiveness of therapeutic interventions. Patients revealed a better response to non-pharmacological therapies, particularly dietary interventions, relaxation techniques, and psychotherapy rather than pharmacological interventions. The sum of our data indicates that for better outcomes, the type of pain and psychological traits should be considered for tailor-made treatments considering non-pharmacological protocols as a complement to the use of drugs.

The role of physiotherapy in fibromyalgia: Current and future perspectives

Fibromyalgia is a chronic pain condition characterized by generalized musculoskeletal pain, hyperalgesia and allodynia, commonly associated with other symptoms such as fatigue, poor sleep quality, anxiety and depression. The clinical manifestations of this rheumatic disease have significant psychosocial and economic repercussions, with a substantial impact on health status, quality of life and social activities. Currently, recommendations for the management of fibromyalgia include patient education and non-pharmacological interventions, and among the indicated treatments, clinical guidelines include several physiotherapeutic resources, essential for individuals affected by this syndrome. Research in the physiotherapy field has demonstrated its effectiveness, but there is a need to update the literature. This study aims to identify the effectiveness of physiotherapy in the treatment of individuals with fibromyalgia. We performed a literature review looking for articles dated from March 2012 to March 2022 using the terms “fibromyalgia”, “physiotherapy”, “physical therapy”, “rehabilitation” in different languages in various databases and their main information was read and collected and presented in a descriptive way. The effects of physiotherapy interventions are summarized in order to provide a reference for future research and clinical application. Research on non-pharmacological physiotherapy-oriented treatments has grown in recent years as an alternative for fibromyalgia treatment. This review allows fibromyalgia patients to receive appropriate physical therapy interventions to promote their health.

Distress and Sensitization as Main Mediators of Severity in Women with Fibromyalgia: A Structural Equation Model

We aimed to explore a path model identified using a structural equation model (SEM) which best explains the multivariate contributions of sensitization, sensitivity, and emotional variables to clinical severity in women with FMS. Pain features, the Central Sensitization Inventory (CSI), painDETECT, S-LANSS, the Hospital Anxiety and Depression Scale (HADS), the Pittsburgh Sleep Quality Index (PSQI), the Pain Catastrophizing Scale (PCS), the Pain Vigilance and Awareness Questionnaire (PVAQ), the 11-item Tampa Scale for Kinesiophobia (TSK-11), and pressure pain thresholds (PPTs) were collected from 113 women with FMS. Four latent variables were created: severity (clinical pain features), sensitivity (PPTs), sensitization (S-LANSS, CSI, painDETECT), and distress (HADS-A, HADS-D, PCS, PVAQ, TSK-11). Data fit for the measurement model were considered excellent (RMSEA = 0.043, CFI = 0.966, SRMR = 0.067, and NNFI = 0.960). Distress had a significant relationship with the mediators of sleep (β = 0.452, p = 0.031) and sensitization (β = 0.618, p = 0.001). The only mediator with a significant effect (β = 1.113, p < 0.001) on severity was sensitization. A significant indirect effect of sensitization (β = 0.687, p = 0.001) that explained the relationship between distress and severity was also identified. The proposed model suggests that distress and sensitization, together with poor sleep, have a complex mediating effect on severity in women with FMS. The identified path model can be leveraged in clinical trials investigating treatment approaches for FMS.

Bayesian Linear Regressions Applied to Fibromyalgia Syndrome for Understanding the Complexity of This Disorder

A better understanding of the connection between factors associated with pain sensitivity and related disability in people with fibromyalgia syndrome may assist therapists in optimizing therapeutic programs. The current study applied mathematical modeling to analyze relationships between pain-related, psychological, psychophysical, health-related, and cognitive variables with sensitization symptom and related disability by using Bayesian Linear Regressions (BLR) in women with fibromyalgia syndrome (FMS). The novelty of the present work was to transfer a mathematical background to a complex pain condition with widespread symptoms. Demographic, clinical, psychological, psychophysical, health-related, cognitive, sensory-related, and related-disability variables were collected in 126 women with FMS. The first BLR model revealed that age, pain intensity at rest (mean-worst pain), years with pain (history of pain), and anxiety levels have significant correlations with the presence of sensitization-associated symptoms. The second BLR showed that lower health-related quality of life and higher pain intensity at rest (mean-worst pain) and pain intensity with daily activities were significantly correlated with related disability. These results support an application of mathematical modeling for identifying different interactions between a sensory (i.e., Central Sensitization Score) and a functional (i.e., Fibromyalgia Impact Questionnaire) aspect in women with FMS.

Therapeutic Approaches to Nociplastic Pain Based on Findings in the Reserpine-Induced Fibromyalgia-Like Animal Model

Nociplastic pain, the third category of chronic pain, has emerged as a serious medical issue. Due to its significant negative influences on patients and society, high prevalence, and lack of sufficiently effective treatments, more efficacious therapies are required. This review highlights the potential therapeutic approaches identified in studies that used reserpine-induced myalgia (RIM) animal model that exhibits nociplastic pain-associated phenotypes. These studies have revealed that biological processes including the chronic reduction of monoamines, increase of oxidative/nitrosative stresses and inflammatory mediators, upregulation of pronociceptive neurotransmitters and their receptors, increase of trophic factors, enhancement of the apoptotic pathway, sensory nerve sensitization, and activation of immune cells in central and/or peripheral regions, underly the nociplastic pain-associated phenotypes in RIM animal model. Potential therapeutic approaches to nociplastic pain, i.e., 1) functional modification of specific molecules which expression is distinctly altered following monoamine reduction, 2) targeting the molecules which are responsible for other major categories of chronic pain (i.e., chronic inflammatory pain and neuropathic pain), 3) supplementation of nutrition to correct the disrupted nutritional balance, 4) improvement of physical constitution by natural substances, and 5) nonpharmacological interventions, have been identified. Significance Statement Studies in RIM animal model have revealed the pathologies that occur after the chronic reduction of monoamines and identified potential therapeutic approaches to nociplastic pain. Translation of their analgesic efficacy from RIM animal model to patients remains an issue to be addressed. Successful translation would lead to better therapies for nociplastic pain.