An overview of systematic reviews of complementary and alternative therapies for fibromyalgia using both AMSTAR and ROBIS as quality assessment tools

Fibromyalgia pain management effectiveness from the patient perspective: a qualitative evidence synthesis

PURPOSE

This qualitative evidence synthesis aimed to identify and integrate findings where adults with fibromyalgia discussed how they managed their pain, and their perceptions of prescribed treatments from healthcare professionals.

MATERIALS AND METHODS

A comprehensive search strategy was implemented in PubMed, Scopus, ISI Web of Science, and Cinahl Plus databases. The GRADE-CERQual framework was used to evaluate the findings confidence. The findings were analyzed using an inductive thematic analysis approach.

RESULTS

A total of 35 studies (N = 728) were included. The confidence in the findings ranged from high to low confidence. Patients with fibromyalgia often do not benefit from seeking medical attention due to provider stigma, and have varying views on medication effectiveness commonly reporting feeling like "walking chemists." They find mixed effects from exercise, and consider psychological support essential, although the benefits of cognitive-behavioral therapy were controversial. Combining cognitive-behavioral therapy with physical exercise appears more effective, while natural and complementary therapies have short-term benefits and high costs.

CONCLUSIONS

Pain management is a source for frustration and an unmet need for patients with fibromyalgia. The current findings provide crucial insight for providers and researchers; and support the need for fibromyalgia phenotyping and precision medicine approaches to pain management.Implications for RehabilitationChronic widespread pain is the defining feature of fibromyalgia, yet pain reduction is often an unmet need for these individuals.The lack of effective treatments resulting in long-term relief proves frustrating for patients and healthcare providers.Rehabilitation professional should consider the unique insight into this complex, heterogeneous condition that this qualitative synthesis provides to better understand their patient's perspective on pain management.Given the differing perspectives on pain treatment approaches individuals with fibromyalgia report, providers should discuss with each patient their current strategies and take a patient-centered, individualized approach to form an effective treatment plan.

Determining the Completeness of Registration and Reporting in Systematic Reviews of Yoga for Health

Introduction: Yoga is a mind-body practice often used to improve health. Systematic reviews (SRs) of randomized controlled trials on yoga for health are foundational to evidence-based yoga interventions and require rigorous and transparent methods, including preparation of a protocol (e.g., PROSPERO) and following SR reporting guidelines (e.g., Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA]). Objective: To evaluate the availability of protocols and the completeness of reporting for SRs on yoga for health. Methods: We used a previously assembled database of SRs focused on the use of yoga for health. The authors independently extracted data on protocol availability, PROSPERO registration, and reporting for each PRISMA 2009 checklist item. Discrepancies were discussed or referred to a third author. We used Stata 10 software to produce descriptive statistics and tests for relationships between registration, reporting, and publication year, country, and journal type. Results: We included 147 reviews published between 2005 and 2019. The most common first author country was the United States or Germany (total 67/147; 46%), and the most common journal type was specialty journals (71/147; 48%). Most reviews (116/147; 79%) made no mention of a protocol or registration, and only 15/147 (10%) reviews were linked to an accessible protocol or registration. Most SRs published in 2010 or later mentioned or cited PRISMA (97/139; 70%), and individual PRISMA items were addressed between 10% and 100% of the time. PRISMA reporting improved; over time, but there was no relationship with country or journal type. Discussion: This study identifies a need for increased SR registration for yoga research. The assessment of PRISMA reporting did not evaluate the comprehensiveness with which each item was reported, and while trends are encouraging, there is likely room for improvement. We recommend registering all yoga SRs and following updated PRISMA and recent yoga-specific guidelines for reporting. This may increase transparency, minimize bias, and produce high-quality data to inform evidence-based yoga practices.

Umbrella review of musculoskeletal injury burden in dancers: implication for practice and research

BACKGROUND

Dancers are susceptible to injury. Nevertheless, injury epidemiology research in dancers is inconsistent. Furthermore, ballet dancing has dominated the huge body of reviews analyzing the epidemiology of musculoskeletal injuries in a variety of artistic dance forms, making it challenging to acquire a thorough, comprehensive, and understandable reporting of the available data.

PURPOSE

The overview and reanalysis of dancers' musculoskeletal pain and injury load across artistic dance forms.

STUDY DESIGN

Systematic review of systematic reviews and meta-analysis.

METHODS

A search was conducted online for literature written in English using PubMed and Google Scholar (2012-2021). The data gathered was then analyzed using predetermined qualifying criteria.

RESULTS

12 reviews were determined to be qualified, the majority of which had moderate to low confidence and raised concerns about bias based on JBI-URARI and ROBIS. The prevalence of dance-related musculoskeletal injuries ranged from 26% to 84% in any artistic dancers and 42% to 343% in ballet dancers. The incidence was less than 5 per 1000 dance hours in both groups, with lower extremities and back being the commonly reported sites. Reviews themselves stated that the quality of the reviews was often poor. Due to the study's heterogeneity and methodological inconsistency, data pooling and meta-analysis were not possible.

CONCLUSION

The current review emphasizes the gaps and restrictions in the dance epidemiology literature that make it challenging to quantify and report a single overall injury rate for dancers. These results underline the need for better primary investigations and evidence synthesis. As injury epidemiology is a critical component of the overall injury-prevention puzzle, there is a need for standardization in future research, particularly with active and prospective injury surveillance, injury classification, injury evaluation, and injury reporting.

LEVEL OF EVIDENCE

Systematic Review, Level III.

[Recommendations of the committee on complementary medicine and nutrition in ayurvedic medicine, homeopathy, nutrition and Mediterranean diet]

Methods of complementary and alternative medicine (CAM) are appealing for many patients with rheumatic diseases. The scientific data are currently characterized by a large number of publications that stand in contrast to a remarkable shortage of valid clinical studies. The applications of CAM procedures are situated in an area of conflict between efforts for an evidence-based medicine and high-quality therapeutic concepts on the one hand and ill-founded or even dubious offers on the other hand. In 2021 the German Society of Rheumatology (DGRh) launched a committee for CAM and nutrition, which aims to collect and to evaluate the current evidence for CAM applications and nutritional medical interventions in rheumatology, in order to elaborate recommendations for the clinical practice. The current article presents recommendations for nutritional interventions in the rheumatological routine for four areas: nutrition, Mediterranean diet, ayurvedic medicine and homeopathy.

Are systematic reviews addressing nutrition for cancer prevention trustworthy? A systematic survey of quality and risk of bias

CONTEXT

The last 30 years have yielded a vast number of systematic reviews and/or meta-analyses addressing the link between nutrition and cancer risk.

OBJECTIVE

The aim of this survey was to assess overall quality and potential for risk of bias in systematic reviews and meta-analyses (SRMAs) that examined the role of nutrition in cancer prevention.

DATA SOURCES

MEDLINE, Embase, and the Cochrane Library databases were searched (last search performed November 2018).

STUDY SELECTION

Studies identified as SRMAs that investigated a nutritional or dietary intervention or exposure for cancer prevention in the general population or in people at risk of cancer and in which primary studies had a comparison group were eligible for inclusion. Screening, data extraction, and quality assessment were conducted independently by 2 reviewers.

DATA EXTRACTION

Altogether, 101 studies were randomly selected for analysis. The methodological quality and risk of bias were evaluated using the AMSTAR-2 and ROBIS tools, respectively.

RESULTS

Most SRMAs included observational studies. Less than 10% of SRMAs reported a study protocol, and only 51% of SRMAs assessed the risk of bias in primary studies. Most studies conducted subgroup analyses, but only a few reported tests of interaction or specified subgroups of interest a priori. Overall, according to AMSTAR-2, only 1% of SRMAs were of high quality, while 97% were of critically low quality. Only 3% had a low risk of bias, according to ROBIS.

CONCLUSIONS

This systematic survey revealed substantial limitations with respect to quality and risk of bias of SRMAs. SRMAs examining nutrition and cancer prevention cannot be considered trustworthy, and results should be interpreted with caution. Peer reviewers as well as users of SRMAs should be advised to use the AMSTAR-2 and/or ROBIS instruments to help to determine the overall quality and risk of bias of SRMAs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42019121116.

Fibromyalgia: A clinical update

ABSTRACT

Fibromyalgia (FM) is a chronic pain disorder commonly encountered by advanced practice registered nurses in primary and specialty care. Knowing how to recognize FM and its multiple pain and nonpain symptoms facilitates diagnosis. We propose a four-step approach to diagnosis that can reduce costly referrals and treatment delays, and describe evidence-based interventions.

Disentangling Diagnosis and Management of Fibromyalgia

Fibromyalgia (FM) is a chronic pain condition characterized by widespread pain accompanied by symptoms such as fatigue, sleep disturbance, cognitive dysfunction, and mood disorder. The pathophysiology of FM has been unclear, leading to inconsistent diagnosis and ineffective management. Several diagnostic criteria for FM have been proposed in recent years, including the revised 2016 American College of Rheumatology (ACR) criteria, the criteria of the ACTTION-American Pain Society Pain Taxonomy (AAPT) group, and the modified 2019 Fibromyalgia Assessment Status (FAS) criteria. Despite the appearance of newer criteria for FM diagnosis, the 2016 ACR criteria demonstrate the best performance. Many randomized controlled studies and systematic reviews have shown the therapeutic efficacies of pharmacological and non-pharmacological treatments of FM. Nevertheless, further research is needed to develop better treatment options.

Effect of Crocus sativus (Saffron) Intake on Top of Standard Treatment, on Disease Outcomes and Comorbidities in Patients with Rheumatic Diseases: Synthesis without Meta-Analysis (SWiM) and Level of Adherence to the CONSORT Statement for Randomized Controlled Trials Delivering Herbal Medicine Interventions

Rheumatic diseases (RDs) are often complicated by chronic symptoms and frequent side-effects associated with their treatment. Saffron, a spice derived from the Crocus sativus L. flower, is a popular complementary and alternative medicine among patients with RDs. The present systematic review aimed to summarize the available evidence regarding the efficacy of supplementation with saffron on disease outcomes and comorbidities in patients with RD diagnoses. PubMed, CENTRAL, clinicaltrials.gov and the grey literature were searched until October 2021, and relevant randomized controlled trials (RCTs) were screened for eligibility using Rayyan. Risk of bias was assessed using the Cochrane’s Risk of Bias-2.0 (RoB) tool. A synthesis without meta-analysis (SWiM) was performed by vote counting and an effect direction plot was created. Out of 125 reports, seven fulfilled the eligibility criteria belonging to five RCTs and were included in the SWiM. The RCTs involved patients with rheumatoid arthritis, osteoarthritis and fibromyalgia, and evaluated outcomes related to pain, disease activity, depression, immune response, inflammation, oxidative stress, health, fatigue and functional ability. The majority of trials demonstrated some concerns regarding overall bias. Moreover, the majority of trialists failed to adhere to the formula elaborations suggested by the CONSORT statement for RCTs incorporating herbal medicine interventions. Standardization of herbal medicine confirms its identity, purity and quality; however, the majority of trials failed to adhere to these guidelines. Due to the great heterogeneity and the lack of important information regarding the standardization and content of herbal interventions, it appears that the evidence is not enough to secure a direction of effect for any of the examined outcomes.

Efficacy of acupuncture in the treatment of fibromyalgia

Purpose of Review

Fibromyalgia is a highly prevalent chronic pain syndrome that affects up to 4% of the population and causes significant morbidity and disability, with an increasing associated cost. Though many approaches for treatment have been tested, therapy regimens are still elusive, and efficacy is limited. This review summarizes the background of fibromyalgia and acupuncture and reviews the latest and seminal literature discussing the application of acupuncture in fibromyalgia.

Recent Findings

Fibromyalgia is hard to treat, owing both to its chronicity and poorly understood pathophysiology and etiology. Current treatments target symptoms primarily, and few attempt to address the source. Efficacious treatment requires long-term treatment by a multidisciplinary team. Though several treatments exist, they still fall short with a substantial number of patients. Acupuncture, a form of integrative medicine, has been a part of traditional Chinese medication for generations. Evidence shows that it effectively treats different kinds of pain conditions, including migraines and chronic musculoskeletal pain. Recent studies showed evidence to support its use in fibromyalgia. Clinical trials studying acupuncture in fibromyalgia have shown improvement in pain, quality of sleep, and quality of life, though the quality of evidence is mainly low to medium. Several studies were not able to provide evidence to support real over sham acupuncture. Weighing the overall evidence paints a picture of mixed results between equivocal results to positive. In analyzing these results, one must also consider publication bias supporting the dissemination of positive results.

Summary

An increasing number of studies support the utilization of acupuncture for the treatment of fibromyalgia. Though no head-to-head comparison was able to show the superiority of acupuncture to other therapies, mounting evidence supports its use as part of multimodal approaches to treatment with additive efficacy to traditional therapy. Further research will likely provide data on effective regimens and combination therapies.

Quality appraisal of systematic reviews of interventions for children with cerebral palsy reveals critically low confidence

AIM

To evaluate the methodological quality of recent systematic reviews of interventions for children with cerebral palsy in order to determine the level of confidence in the reviews' conclusions.

METHOD

A comprehensive search of 22 databases identified eligible systematic reviews with and without meta-analysis published worldwide from 2015 to 2019. We independently extracted data and used A Measurement Tool to Assess Systematic Reviews-2 (AMSTAR-2) to appraise methodological quality.

RESULTS

Eighty-three systematic reviews met strict eligibility criteria. Most were from Europe and Latin America and reported on rehabilitative interventions. AMSTAR-2 appraisal found critically low confidence in 88% (n=73) because of multiple and varied deficiencies. Only 7% (n=6) had no AMSTAR-2 critical domain deficiency. The number of systematic reviews increased fivefold from 2015 to 2019; however, quality did not improve over time.

INTERPRETATION

Most of these systematic reviews are considered unreliable according to AMSTAR-2. Current recommendations for treating children with CP based on these flawed systematic reviews need re-evaluation. Findings are comparable to reports from other areas of medicine, despite the general perception that systematic reviews are high-level evidence. The required use of current widely accepted guidance for conducting and reporting systematic reviews by authors, peer reviewers, and editors is critical to ensure reliable, unbiased, and transparent systematic reviews. What this paper adds Confidence was critically low in the conclusions of 88% of systematic reviews about interventions for children with cerebral palsy (CP). Quality issues in the sample were not limited to systematic reviews of non-randomized trials, or to those about certain populations of CP or interventions. The inclusion of meta-analysis did not improve the level of confidence in these systematic reviews. Numbers of systematic reviews on this topic increased over the 5 search years but their methodological quality did not improve.

A comparison of two assessment tools used in overviews of systematic reviews: ROBIS versus AMSTAR-2

BACKGROUND

AMSTAR-2 is a 16-item assessment tool to check the quality of a systematic review and establish whether the most important elements are reported. ROBIS is another assessment tool which was designed to evaluate the level of bias present within a systematic review. Our objective was to compare, contrast and establish both inter-rater reliability and usability of both tools as part of two overviews of systematic reviews. Strictly speaking, one tool assesses methodological quality (AMSTAR-2) and the other assesses risk of bias (ROBIS), but there is considerable overlap between the tools in terms of the signalling questions.

METHODS

Three reviewers independently assessed 31 systematic reviews using both tools. The inter-rater reliability of all sub-sections using each instrument (AMSTAR-2 and ROBIS) was calculated using Gwet's agreement coefficient (AC1 for unweighted analysis and AC2 for weighted analysis).

RESULTS

Thirty-one systematic reviews were included. For AMSTAR-2, the median agreement for all questions was 0.61. Eight of the 16 AMSTAR-2 questions had substantial agreement or higher (> 0.61). For ROBIS, the median agreement for all questions was also 0.61. Eleven of the 24 ROBIS questions had substantial agreement or higher.

CONCLUSION

ROBIS is an effective tool for assessing risk of bias in systematic reviews and AMSTAR-2 is an effective tool at assessing quality. The median agreement between raters for both tools was identical (0.61). Reviews that included a meta-analysis were easier to rate with ROBIS; however, further developmental work could improve its use in reviews without a formal synthesis. AMSTAR-2 was more straightforward to use; however, more response options would be beneficial.

Recommendations by the Spanish Society of Rheumatology on Fibromyalgia. Part 1: Diagnosis and treatment

OBJECTIVE

To prevent the impairment of fibromyalgia patients due to harmful actions in daily clinical practice that are potentially avoidable.

METHODS

A multidisciplinary team identified the main areas of interest and carried out an analysis of scientific evidence and established recommendations based on the evidence and "formal evaluation" or "reasoned judgment" qualitative analysis techniques.

RESULTS

A total of 39 recommendations address diagnosis, unsafe or ineffective treatment interventions and patient and healthcare workers' education. This part I shows the first 27 recommendations on the first 2 areas.

CONCLUSIONS

Establishing a diagnosis improves the patient's coping with the disease and reduces healthcare costs. NSAIDs, strong opioids and benzodiazepines should be avoided due to side effects. There is no good evidence to justify the association of several drugs. There is also no good evidence to recommend any complementary medicine. Surgeries show a greater number of complications and a lower degree of patient satisfaction and therefore should be avoided if the surgical indication is not clearly established.

Recommendations by the Spanish Society of Rheumatology on Fibromyalgia. Part 1: Diagnosis and Treatment

OBJECTIVE

To prevent the impairment of fibromyalgia patients due to harmful actions in daily clinical practice that are potentially avoidable.

METHODS

A multidisciplinary team identified the main areas of interest and carried out an analysis of scientific evidence and established recommendations based on the evidence and "formal evaluation" or "reasoned judgment" qualitative analysis techniques.

RESULTS

A total of 39 recommendations address diagnosis, unsafe or ineffective treatment interventions and patient and healthcare workers' education. This part I shows the first 27 recommendations on the first 2 areas.

CONCLUSIONS

Establishing a diagnosis improves the patient's coping with the disease and reduces healthcare costs. NSAIDs, strong opioids and benzodiazepines should be avoided due to side effects. There is no good evidence to justify the association of several drugs. There is also no good evidence to recommend any complementary medicine. Surgeries show a greater number of complications and a lower degree of patient satisfaction and therefore should be avoided if the surgical indication is not clearly established.

Osteopathic medicine for fibromyalgia: a sham-controlled randomized clinical trial

Background:

Patients with fibromyalgia (FM) frequently resort to osteopathic or chiropractic treatment, despite very weak supporting evidence. We aimed to assess the efficacy of osteopathic manipulation in FM in a properly controlled and powered randomized clinical trial.

Methods:

Patients were randomized to osteopathic or sham treatment. Treatment was administered by experienced physical medicine physicians, and consisted of six sessions per patient, over 6 weeks. Treatment credibility and expectancy were repeatedly evaluated. Patients completed standardized questionnaires at baseline, during treatment, and at 6, 12, 24, and 52 weeks after randomization. The primary outcome was pain intensity (100-mm visual analog scale) during the treatment period. Secondary outcomes included fatigue, functioning, and health-related quality of life. We performed primarily intention-to-treat analyses adjusted for credibility, using multiple imputation for missing data.

Results:

In total, 101 patients (94% women) were included. Osteopathic treatment did not significantly decrease pain relative to sham treatment (mean difference during treatment: −2.2 mm; 95% confidence interval, −9.1 to 4.6 mm). No significant differences were observed for secondary outcomes. No serious adverse events were observed, despite a likely rebound in pain and altered functioning at week 12 in patients treated by osteopathy. Patient expectancy was predictive of pain during treatment, with a decrease of 12.9 mm (4.4–21.5 mm) per 10 points on the 0–30 scale. Treatment credibility and expectancy were also predictive of several secondary outcomes.

Conclusion:

Osteopathy conferred no benefit over sham treatment for pain, fatigue, functioning, and quality of life in patients with FM. These findings do not support the use of osteopathy to treat these patients. More attention should be paid to the expectancy of patients in FM management.

Methodological quality and risk of bias in orthodontic systematic reviews using AMSTAR and ROBIS

BACKGROUND

This study aimed to compare the methodological quality and risk bias of orthodontic systematic reviews (SRs) using the AMSTAR (Assessing the Methodological Quality of Systematic Reviews) and ROBIS (Risk of Bias in Systematic Review) tools.

MATERIALS AND METHODS

A search of electronic databases (OVID and Medline) was undertaken to identify orthodontic SRs published in five primary orthodontic journals (January 2015 to December 2018) and the Cochrane Library of Systematic Reviews (January 2000 to January 2018). Full articles were reviewed by two assessors against the eligibility criteria. Methodological quality of each SR was gauged using the AMSTAR tool with a score of 0 or 1 given for each of the 11 items. Cumulative totals were calculated and scores between 4 and 8 represented poor to fair methodological quality and 9 or greater deemed to be good. As per the ROBIS tool, the risk of bias (ROB) for each domain was assessed and the overall ROB was classified as low, high, or unclear.

RESULTS

A total of 91 SRs were included. The median AMSTAR score was 8 (IQR = 3). The methodological quality of 47.3% SRs was rated good. SRs without protocol registration (Coef: -3.00, 95% CI: -3.72, -2.28, P < 0.001) and American continent SRs (Coef: -1.00, 95% CI: -1.72, -0.21, P = 0.007) were associated with lower AMSTAR scores. A total of 56.0% SRs were rated a low ROB, with a lower ROB apparent in multicentre SRs (OR: 0.27, 95% CI: 0.11, 0.64, P = 0.003) and a higher ROB evident in SRs without a registered protocol (OR: 111.81, 95% CI: 22.34, 559.62, P < 0.001). When adjusted for the effect of AMSTAR score on ROB, a higher ROB was associated with SRs without protocol registration (OR: 32.24, 95% CI: 6.03, 172.44, P ≤ 0.001). As the AMSTAR score (per unit) increased, the odds of having a high ROB rating decreased (OR: 0.31, 95% CI: 0.21, 0.45, P ≤ 0.001).

CONCLUSIONS

As the methodological quality rating of orthodontic SRs increases, a reduction in the ROB is evident.

What is the best long-term treatment modality for immature permanent teeth with pulp necrosis and apical periodontitis?

PURPOSE

To evaluate and assess the current knowledge about apexification and regenerative techniques as a meaningful treatment modality and to map the scientific evidence for the efficacy of both methods for the management of traumatised immature teeth with pulp necrosis and apical periodontitis.

METHODS

This systematic review searched five databases: PubMed, Web of Science, Cochrane Library, Ovid (Medline), and Embase. Published articles written in English were considered for inclusion. The following keywords were used: Regenerative endodontic treatment OR regenerat* OR revital* OR endodontic regeneration OR regenerative endodontics OR pulp revascularization OR revasculari* OR 'traumatized immature teeth'. Only peer-reviewed studies with a study size of at least 20 cases followed up for 24 months were included. Eligibility assessment was performed independently in a blinded manner by three reviewers and disagreements were resolved by consensus. Subgroup analyses were performed on three clinical outcomes: survival, success, and continued root development.

RESULTS

Seven full texts out of 1359 citations were included and conventional content analysis was performed. Most of the identified citations were case reports and case series.

CONCLUSIONS

In the present systematic review, the qualitative analysis revealed that both regenerative and apexification techniques had equal rates of success and survival and proved to be effective in the treatment of immature necrotic permanent teeth. Endodontic regenerative techniques appear to be superior to apexification techniques in terms of stimulation of root maturation, i.e. root wall thickening and root lengthening. Knowledge gaps were identified regarding the treatment and follow-up protocols for both techniques.

Which Physical Exercise Interventions Increase HDL-Cholesterol Levels? A Systematic Review of Meta-analyses of Randomized Controlled Trials

BACKGROUND

Meta-analyses of randomized controlled trials (RCTs) have shown the beneficial effect of exercise on HDL-cholesterol (HDL-C) levels. However, systematic reviews are not free of bias, and this could call into question their results.

OBJECTIVES

The aim of this work was to conduct a critical assessment of meta-analyses of RCTs that analyze the association between exercise and HDL-C levels, evaluating their results and the risk of bias (RoB).

METHODS

This systematic review of MEDLINE and EMBASE included meta-analyses of RCTs that studied the effects of exercise on HDL-C levels in healthy adults or patients at cardiovascular risk. The RoB was determined using AMSTAR-2, and information was obtained on exercise and the variation in HDL-C levels.

RESULTS

Twenty-three meta-analyses were included. Great variability was found in exercise (different types, frequencies or intensities in the studied interventions). All the analyses found an improvement in HDL-C levels, ranging from 0.27 to 5.41 mg/dl, in comparison with the control group (no exercise). The RoB was very high, with 18 reviews obtaining a critically low confidence level and the remaining works obtaining the highest confidence level.

CONCLUSIONS

Only one meta-analysis showed good quality, in which HDL-C levels increased by 3.09 mg/dl in healthy adults and patients at high cardiovascular risk who practiced yoga. The rest had high RoB. Therefore, new systematic reviews with low RoB are needed to apply the results to clinical practice. Register: CRD42020158471 (PROSPERO).

Use of Complementary and Alternative Medicine in Fibromyalgia: Results of an Online Survey

BACKGROUND

Fibromyalgia is a chronic condition which may negatively impact various aspects of patients' lives. Many people with fibromyalgia look to complementary and alternative medicine treatments for symptom relief.

AIMS

The three main objectives of this study were to examine self-reported complementary and alternative medicine use in patients with fibromyalgia, to determine associations between the use of complementary and alternative medicine treatments and patients' self-reported quality of live and self-reported pain levels.

DESIGN

Cross-sectional survey.

SETTING

Web-based.

PARTICIPANTS/SUBJECTS

Adults over the age of 18 years who had been diagnosed with fibromyalgia.

METHODS

Patients with fibromyalgia responded to an online questionnaire regarding the following: treatments (complementary and alternative medicine, prescription and over-the-counter medications), quality of life (Quality of Life Scale-16), assessment of current pain (visual analog scale), and demographic information.

RESULTS

Approximately 66% of the respondents used complementary and alternative treatments. Vitamins, massage therapy, and meditation were the most commonly used complementary and alternative therapies. Results indicated respondents using a combination of complementary and alternative medicine and pharmacologic treatments (prescription or over-the-counter) had significantly higher quality of life versus those using pharmacologic treatments alone, p = .011. Similarly, respondents using only complementary and alternative medicine treatment reported significantly lower pain levels versus those using pharmacologic treatment alone, p = .046.

CONCLUSIONS

The study suggests that a large proportion of fibromyalgia patients use complementary and alternative medicine, and these treatments may offer beneficial effects to these patients. Integration of complementary and alternative medicine into conventional treatment regimens may provide opportunities for a holistic treatment approach and greater symptom relief for fibromyalgia patients. This approach is timely, as controlled substances are increasingly difficult for patients with fibromyalgia to access.

Subcutaneous hydration and medications infusions (effectiveness, safety, acceptability): A systematic review of systematic reviews

OBJECTIVE

To synthesize the current evidence for subcutaneous hydration and medication infusions from systematic reviews and to assess their methodological quality.

INTRODUCTION

Peripheral intravascular cannula/catheter insertion is a common invasive procedure for administering fluids and medications. Venous depletion is a growing concern for several patient populations. Subcutaneous access for the administration of isotonic solutions and medications is an alternative; however, vascular access assessment and planning guidelines rarely consider this route.

METHODS

Systematic review of systematic reviews (PROSPERO CRD42018046504). We searched 6 databases published in English language from 1990 to June 2020, identifying subcutaneous infusions an alternate route for fluids or medication. Methodological quality was evaluated using AMSTAR 2 criteria and data for mechanisms of infusion and outcomes related to effectiveness, safety, efficiency and acceptability extracted. The Johanna Briggs Institute's grades of recommendation informed the strength of recommendation.

RESULTS

The search yielded 1042 potential systematic reviews; 922 were excluded through abstract and duplicate screen. Of the remaining articles, 94 were excluded, and 26 were included. Overall, evidence is strong for recommending subcutaneous hydration infusions for older adults, weak for pediatric patients and inconclusive for palliative patients. There is strong evidence for 10 medications; weak evidence supporting 28 medications; however, there are eight medications with inconclusive evidence to make a recommendation and four medications not appropriate for subcutaneous delivery.

CONCLUSION

Subcutaneous access should be considered alongside intravenous therapy for hydration in older adults, and several medications. There are additional benefits in terms of ease of use and cost-effectiveness of this mode. Inclusion of subcutaneous access in clinical guidelines may promote uptake of this route to help preserve vessel health of vulnerable patients. Further high-quality research is needed to inform subcutaneous infusion therapy in a variety of populations (including pediatrics and palliative care) and medications and clarifying the mechanism of delivery.

Quality Assessment and Risk of Bias of Systematic Reviews of Prophylactic Mesh for Parastomal Hernia Prevention Using AMSTAR and ROBIS Tools

BACKGROUND

Systematic reviews play a crucial role in clinical decision making and resource allocation and are expected to be unbiased and consistent. The aim of this study is a review of systematic reviews on the use of prophylactic mesh to prevent parastomal hernia (PH) formation using ROBIS and AMSTAR tools to assess the risk of bias and methodological quality.

METHODS

We included systematic reviews with or without meta-analysis of which the objective was to assess the use of a prophylactic mesh to prevent PH. A systematic search of the literature in five databases from inception until December 2017 was conducted. For each systematic review, methodologic quality and risk of bias were assessed using the AMSTAR and ROBIS tools, respectively. We estimated the inter-rater reliability for individual domains and for the overall methodological quality and risk of bias using Fleiss' k.

RESULTS

We identified 14 systematic reviews that met the inclusion criteria. Using the AMSTAR scale with a cutoff value, six reviews showed high methodologic quality and eight were of low quality. Using the ROBIS tool, the overall risk of bias was low in 50% of the reviews analyzed. In the remaining studies, the risk of bias was unclear.

CONCLUSIONS

The global evidence in favor of the use of a prophylactic mesh for preventing PH is not uniform regarding quality and risk of bias. Surgeons cannot be equally confident in the results of all systematic reviews published on this topic.

Comparison between Acupuncture and Nutraceutical Treatment with Migratens® in Patients with Fibromyalgia Syndrome: A Prospective Randomized Clinical Trial

OBJECTIVES

Fibromyalgia syndrome (FMS) is a chronic clinical condition characterized by pain, fatigue, altered sleep, and cognitive disturbances. The purpose of this study was to compare two alternative treatments (nutraceutical and acupuncture) in FMS patients through a randomized clinical trial.

RESEARCH METHODS

A total of 60 FMS female patients were randomized for treatment with a nutritional combination containing coenzyme Q10, vitamin D, alpha-lipoic acid, magnesium, and tryptophan (Migratens® Group) or acupuncture treatment (Acupuncture Group) performed according the principles of traditional Chinese medicine (TCM), both for 3 months. Changes in pain and in quality of life (QoL) measured with a Fibromyalgia Impact Questionnaire Score-Revised (FIQ-R) and the Fibromyalgia Severity Scale (FSS) were performed at 1, 3, and 6 months after the start of treatments.

RESULTS

A total of 55 patient completed the study (21 in the Migratens® Group and 34 in the Acupuncture Group). Migratens® treatment shows a statistically significant reduction of pain 1 month after the start of therapy (T1, p = 0.025), strengthened after 3 months with maintenance of treatment (p = 0.012). The efficacy in reducing pain was apparent in the Acupuncture Group at all post-treatment determinations and at follow-up (T1 and T2 p = <0.001). Regarding QoL, improvement in FIQ-R and FSS values was revealed in both groups.

CONCLUSION

The nutraceutical approach with Migratens® seems to be an effective option to for patients with FMS. Our experience confirmed also the validity of acupuncture in these patients. Considering the complexity of the management of FMS patients, our results suggest a cyclical and sequential, or even concurrent treatment with different approaches, to improve the efficacy and the compliance of patients to long-term treatment.

Pain symptomology, functional impact, and treatment of people with Neurofibromatosis type 1

Introduction

Neurofibromatosis type 1 (NF1) is a neurogenetic disorder affecting 1 in 3000 people worldwide, where individuals are prone to develop benign and malignant tumors. In addition, many people with NF1 complain of pain that limits their daily functioning. Due to the complexity of the disorder, there are few options for treating pain symptoms besides surgery and medications. Moreover, the spectrum of pain symptomatology and treatment, as well as the mechanisms underlying NF1-associated pain, has been understudied.

Methodology

To address this knowledge gap, we conducted a survey of 255 adults with NF1, leveraging the Washington University NF1 Patient Registry Initiative (NPRI) database. Demographic and pain data were collected using a Qualtrics survey.

Results

All participants had at least one surgical procedure, with 55% reporting having at least one surgery within the last year and 17% being currently prescribed opioid medication. A positive relationship was shown (p<0.001) between those prescribed prescription pain medication, and their pain severity and interference. Moreover, there was a significant relationship (p=0.049) between the usage of complementary treatments and pain severity and interference.

Conclusion

The current study demonstrates that individuals with NF1 report a higher incidence of pain severity and interference than observed in NF1 previous studies, with pain symptoms not localized to any specific region of the body. The consideration for alternative treatments and careful monitoring of current treatments that are more conservative or have less potential adverse side effects may improve pain management and reduce the risk of developing medication dependence.

Processed meat intake and chronic disease morbidity and mortality: An overview of systematic reviews and meta-analyses

Despite the nutritional value of meat, a large volume of reviews and meta-analyses suggests that processed meat intake is associated with an increased risk of chronic diseases. However, assessments of the quality of these published reviews internal validity are generally lacking. We systematically reviewed and assessed the quality alongside summarizing the results of previously published systematic reviews and meta-analyses that examined the association between processed meat intake and cancers, type II diabetes (T2D), and cardiovascular diseases (CVD). Reviews and meta-analyses published until May 2018 were identified through a systematic literature search in the databases MEDLINE and EMBASE, and reference lists of included reviews. The quality of the systematic reviews and meta-analyses was assessed using A Measurement Tool to Assess Systematic Reviews (AMSTAR). All eligible reviews had to comply with two quality requirements: providing sufficient information on quality assessment of the primary studies and a comprehensive search. The results were summarized for T2D, CVD, and each of the different cancer types. The certainty in the estimates of the individual outcomes was rated using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) method. In total, 22 systematic reviews were eligible and thus included in this review. More than 100 reviews were excluded because quality assessment of the primary studies had not been performed. The AMSTAR score of the included reviews ranged from 5 to 8 indicating moderate quality. Overall, the quality assessments of primary studies of the reviews are generally lacking; the scientific quality of the systematic reviews reporting positive associations between processed meat intake and risk of various cancers, T2D and CVD is moderate, and the results from case-control studies suggest more often a positive association than the results from cohort studies. The overall certainty in the evidence was very low across all individual outcomes, due to serious risk of bias and imprecision.

Use of Complementary and Integrative Therapies by Fibromyalgia Patients: A 14-Year Follow-up Study

Objective

To reevaluate the frequency and pattern of complementary and integrative medicine (CIM) use in patients with fibromyalgia (FM).

Patients and Methods

Consecutive patients with FM who were referred to the Mayo Clinic fibromyalgia treatment program from January 5 through July 27, 2017, were invited to complete a survey about their use of CIM therapies in the preceding 6 months. The survey asked about 3 primary CIM domains: treatments and techniques, vitamins and minerals, and herbs and other dietary supplements. For direct comparative purposes, we reused the survey instrument from our prior analogous study of CIM use, performed in 2003.

Results

Of the 310 patients who completed the survey, 304 (98.1%) reported using some form of CIM, similar to the percentage reported in our 2003 study (98%). The most frequently used CIM therapies in the current cohort were spiritual healing (54.0% [163 of 302]), massage therapy (50.0% [152 of 304]), chiropractic treatments (39.3% [118 of 300]), aromatherapy (39.0% [117 of 300]), exercise for a specific medical problem (38.6% [117 of 303]), melatonin (37.9% [77 of 203]), magnesium (36.3% [107 of 295]), green tea (36.1% [73 of 202]), and fish oil (34.5% [68 of 197]). We noted numerous substantial differences from the 2003 data in terms of the pattern of CIM use.

Conclusion

The use of CIM therapies among patients with FM continues to be extremely common for adult patients of all ages. Given the continued high prevalence of CIM use, health care professionals must have awareness and knowledge of these various modalities and their potential incorporation into a multifaceted FM treatment regimen.

Interventions to Treat Erectile Dysfunction and Premature Ejaculation: An Overview of Systematic Reviews

INTRODUCTION

Sexual dysfunction in men is common, and optimal treatment is complex. Although several systematic reviews concerning treatment approaches exist, a comprehensive overview without limitations concerning the population, interventions, or outcomes is lacking.

AIM

To conduct a "review of reviews" to compare the effectiveness of pharmacologic, non-pharmacologic, and combined interventions.

METHODS

9 electronic databases, relevant journals, and reference lists up to July 2018 were searched. For each intervention, only the most recent and comprehensive meta-analysis or systematic review was included. The methodologic quality of the reviews was appraised using the Assessment of Multiple Systematic Reviews-2 tool.

MAIN OUTCOME MEASURE

Sexual functioning (via intravaginal ejaculatory latency time and international index of erectile function), sexual satisfaction, and adverse effects.

RESULTS

30 systematic reviews were included. For premature ejaculation, several treatments, including oral pharmacotherapy (selective serotonin inhibitors, phosphodiesterase type 5 [PDE5] inhibitors, tricyclic antidepressants, and opioid analgesics), topical anesthetics, and combined drug and behavioral therapies demonstrated significant improvements of 1-5 minutes in the intravaginal ejaculatory latency time. Pharmacologic interventions (PDE5 inhibitors, penile injection, and testosterone), shockwave therapy, lifestyle modifications, and combined therapies (PDE5 inhibitors and psychological intervention) were effective in treating erectile dysfunction. Most pharmacologic therapies were associated with adverse effects.

CONCLUSIONS

There is suggestive evidence that pharmacologic interventions or combined therapies are more effective than non-pharmacologic interventions for treating sexual dysfunction in men; however, a range of treatment options should be presented to individual patients so they may consider the risks and benefits of treatments differently. Evidence related to behavioral and psychological interventions is insufficient compared with that related to drug trials, highlighting the necessity for larger and better randomized controlled trials. Ciocanel O, Power K, Eriksen A. Interventions to Treat Erectile Dysfunction and Premature Ejaculation: An Overview of Systematic Reviews. Sex Med 2019;7:251-269.

A psychometric study found AMSTAR 2 to be a valid and moderately reliable appraisal tool

OBJECTIVES

The objectives of this study were to determine the interrater reliability (IRR) of assessment of multiple systematic reviews (AMSTAR) 2 for reviews of pharmacological or psychological interventions for the treatment of major depression, to compare it to that of AMSTAR and risk of bias in systematic reviews (ROBIS), and to assess the convergent validity between the appraisal tools.

STUDY DESIGN AND SETTING

Two groups of four raters were each assigned one of two samples of 30 systematic reviews. All eight raters applied AMSTAR 2 to their sample. Each group also applied either AMSTAR or ROBIS. Fleiss' kappa and Gwet's AC₁ were calculated, and agreement between the tools was assessed.

RESULTS

The median kappa values as a measure of IRR indicated a moderate agreement for AMSTAR 2 (median = 0.51), a substantial agreement for AMSTAR (median = 0.62), and a fair agreement for ROBIS (median = 0.27). Validity results showed a positive association for AMSTAR and AMSTAR 2 (r = 0.91) as well as ROBIS and AMSTAR 2 (r = 0.84). For the overall rating, AMSTAR 2 showed a high concordance with ROBIS and a lower concordance with AMSTAR.

CONCLUSION

The IRR of AMSTAR 2 was found to be slightly lower than the IRR of AMSTAR and higher than the IRR of ROBIS. Validity measurements indicate that AMSTAR 2 is closely related to both ROBIS and AMSTAR.

Postural counseling represents a novel option in pain management of fibromyalgia patients

Background

Chronic pain is a key symptom in fibromyalgia (FM), and its management is still challenging for rheumatologists in daily practice. FM patients show psychological and psychiatric manifestations, going from mood and emotional disorders to depression and alexithymia that negatively impact their quality of life, limiting their daily activities. Since pharmacological strategies have a limited efficacy in FM pain, alternative or complementary non-pharmacological approaches have been introduced in the clinical management of FM.

Patients and methods

This is a retrospective study on FM patients (n=52) treated with a novel integrated postural counseling (PC) rehabilitation program carried out by a counselor physiotherapist. The clinical impact of PC was evaluated by 1) a semi-structured interview using an ad hoc modified questionnaire McGill Illness Narrative Interview (MINI) 1 to obtain data on pain management by highlighting everyday experience of living with pain and 2) an FM impact questionnaire (FIQ) total score.

Results

Two main structures of narrative emplotment of FM illness were recognized: 1) the cumulative life narrative structure (46.15%) and 2) the broken life (53.85%) narrative structure. Baseline FIQ score was 77.38±7.77, and it was significantly reduced after PC to 39.12±13.27 (P<0.0001). Although well-being still requires further definition as outcome in pain management, it is important for FM patients, dealing with pain-related sensations, thoughts and feelings and limiting their daily activities. In our study, 87.5% of interviewed FM patients reported an improvement in their well-being after PC.

Conclusion

Our data suggest that an integrated PC program positively impacts chronic pain and fatigue based on self-management strategies. PC allows FM patients to resume their own life and regenerate their own image. Finally, we propose the introduction of the evaluation of the ability to resume daily activities as the target of rehabilitation programs in FM.

Quality assessment of systematic reviews on vertical bone regeneration

The aim of this study was to evaluate and compare the quality of systematic reviews of vertical bone regeneration techniques, using two quality-assessment tools (AMSTAR and ROBIS). An electronic literature search was conducted to identify systematic reviews or meta-analyses that would evaluate at least one of the following outcomes: implant survival, success rates, complications or bone gain after vertical ridge augmentation. Methodological quality assessment was performed by two independent evaluators. Results were compared between reviewers, and reliability measures were calculated using the Holsti's method^® and Cohen's kappa. Seventeen systematic reviews were included, of which seven presented meta-analysis. Mean ±95% confidence interval AMSTAR score was 6.35 [4.74;7.97], with higher scores being correlated with a smaller risk of bias (Pearson's correlation coefficient=-0.84; P<0.01). Cohen's inter-examiner kappa showed substantial agreement for both checklists. From the available evidence, we ascertained that, regardless of the technique used, it is possible to obtain vertical bone gains. Implant success in regenerated areas was similar to implants placed in pristine bone with results equating between 61.5% and 100% with guided bone regeneration being considered the most predictable technique regarding bone stability, while distraction osteogenesis achieved the biggest bone gains with the highest risk of possible complications.

Evaluation of the reliability, usability, and applicability of AMSTAR, AMSTAR 2, and ROBIS: protocol for a descriptive analytic study

BACKGROUND

Systematic reviews (SRs) of randomised controlled trials (RCTs) can provide the best evidence to inform decision-making, but their methodological and reporting quality varies. Tools exist to guide the critical appraisal of quality and risk of bias in SRs, but evaluations of their measurement properties are limited. We will investigate the interrater reliability (IRR), usability, and applicability of A MeaSurement Tool to Assess systematic Reviews (AMSTAR), AMSTAR 2, and Risk Of Bias In Systematic reviews (ROBIS) for SRs in the fields of biomedicine and public health.

METHODS

An international team of researchers at three collaborating centres will undertake the study. We will use a random sample of 30 SRs of RCTs investigating therapeutic interventions indexed in MEDLINE in February 2014. Two reviewers at each centre will appraise the quality and risk of bias in each SR using AMSTAR, AMSTAR 2, and ROBIS. We will record the time to complete each assessment and for the two reviewers to reach consensus for each SR. We will extract the descriptive characteristics of each SR, the included studies, participants, interventions, and comparators. We will also extract the direction and strength of the results and conclusions for the primary outcome. We will summarise the descriptive characteristics of the SRs using means and standard deviations, or frequencies and proportions. To test for interrater reliability between reviewers and between the consensus agreements of reviewer pairs, we will use Gwet's AC₁ statistic. For comparability to previous evaluations, we will also calculate weighted Cohen's kappa and Fleiss' kappa statistics. To estimate usability, we will calculate the mean time to complete the appraisal and to reach consensus for each tool. To inform applications of the tools, we will test for statistical associations between quality scores and risk of bias judgments, and the results and conclusions of the SRs.

DISCUSSION

Appraising the methodological and reporting quality of SRs is necessary to determine the trustworthiness of their conclusions. Which tool may be most reliably applied and how the appraisals should be used is uncertain; the usability of newly developed tools is unknown. This investigation of common (AMSTAR) and newly developed (AMSTAR 2, ROBIS) tools will provide empiric data to inform their application, interpretation, and refinement.

Prescribable mHealth apps identified from an overview of systematic reviews

Mobile health apps aimed towards patients are an emerging field of mHealth. Their potential for improving self-management of chronic conditions is significant. Here, we propose a concept of "prescribable" mHealth apps, defined as apps that are currently available, proven effective, and preferably stand-alone, i.e., that do not require dedicated central servers and continuous monitoring by medical professionals. Our objectives were to conduct an overview of systematic reviews to identify such apps, assess the evidence of their effectiveness, and to determine the gaps and limitations in mHealth app research. We searched four databases from 2008 onwards and the Journal of Medical Internet Research for systematic reviews of randomized controlled trials (RCTs) of stand-alone health apps. We identified 6 systematic reviews including 23 RCTs evaluating 22 available apps that mostly addressed diabetes, mental health and obesity. Most trials were pilots with small sample size and of short duration. Risk of bias of the included reviews and trials was high. Eleven of the 23 trials showed a meaningful effect on health or surrogate outcomes attributable to apps. In conclusion, we identified only a small number of currently available stand-alone apps that have been evaluated in RCTs. The overall low quality of the evidence of effectiveness greatly limits the prescribability of health apps. mHealth apps need to be evaluated by more robust RCTs that report between-group differences before becoming prescribable. Systematic reviews should incorporate sensitivity analysis of trials with high risk of bias to better summarize the evidence, and should adhere to the relevant reporting guideline.

Evidence-Based Non-Pharmacological Therapies for Fibromyalgia

PURPOSE OF REVIEW

Fibromyalgia (FM) is the second most common rheumatologic pain disorder after osteoarthritis with a multisystem presentation. While the treatment of FM in a clinical setting incorporates both pharmacologic and non-pharmacologic modalities, the present investigation reviews evolving literature on cognitive behavioral and complementary medical therapies. The recent medical literature on FM was reviewed between 2012 and 2017 via MEDLINE and the Cochrane Central Registry of Controlled Trials, with an emphasis on randomized controlled trials, meta-analyses, and evidence-based treatment guidelines.

RECENT FINDINGS

Cognitive behavioral therapy continues to play a significant role in the non-medical therapy of FM. It is especially helpful in high catastrophizing patients as evidenced by recent studies that note changes in the brain on functional magnetic resonance imaging. Mindfulness meditation can be helpful in improving pain symptoms and pain perception. No particular diet is found to have a meaningful impact in FM; however, various diets including low fermentable oligo- di -monosaccharides and polyols diet, gluten free, and hypocaloric may be helpful in ameliorating gastrointestinal distress in select patient populations. Current literature does not support the routine use of acupuncture for improving pain or quality of life in FM; however, given its benign side effect profile, it should not be discouraged. Goals for symptom management and pain control should be set early, and patient engagement remains critical in the management of this complex pain presentation. While low quality evidence exists for most non-pharmacologic treatment modalities for FM, CBT and mindfulness meditation show promise for future investigation.

Quality assessment versus risk of bias in systematic reviews: AMSTAR and ROBIS had similar reliability but differed in their construct and applicability

OBJECTIVES

The objective of the study was to assess the inter-rater reliability (IRR) of AMSTAR and ROBIS in judging individual domains and overall methodological quality/risk of bias of systematic reviews, the concurrent validity of the tools, and the time required to apply them.

STUDY DESIGN AND SETTING

This is a cross-sectional study. Five raters independently read 31 systematic reviews and applied AMSTAR and ROBIS. Fleiss' k for multiple raters for individual domains and overall methodological quality/risk of bias was calculated. Similar domains assessed by both tools and final scores were matched to explore the concurrent validity, using the Kendall tau correlation.

RESULTS

IRR ranged from fair to perfect for AMSTAR and from moderate to substantial for ROBIS. Kappa for overall quality/risk of bias was 0.73 (95% confidence interval [CI] 0.65-0.81) for AMSTAR and 0.64 (95% CI 0.54-0.74) for ROBIS. We judged most of the reviews at intermediate quality with AMSTAR (53%), while judgments were split in high (53%) and low (47%) risk of bias with ROBIS. The correlation between judgments on similar domains ranged from moderate to high, while it was fair on the overall judgment (K = 0.35, 95% CI 0.21-0.49). The mean time to complete ROBIS was about double that for AMSTAR.

CONCLUSION

AMSTAR and ROBIS offer similar IRR but differ in their construct and applicability.