Fibromyalgia syndrome module at OMERACT 9: domain construct

Translation, Cross-Cultural Adaptation, and Psychometric Properties of the Revised Fibromyalgia Impact Questionnaire (FIQR) for Use in Arabic-Speaking Patients in Saudi Arabia

Background/Aim

Fibromyalgia (FM) is a complex and debilitating condition that significantly impacts patients' daily lives. The continuous assessment of the impact and severity of FM is essential to manage the condition effectively. Assessment tools in Arabic are lacking for use in Saudi Arabia, which might lead to ineffective management. This study aimed to translate and cross-culturally adapt and validate the Arabic version of the Revised Fibromyalgia Impact Questionnaire (FIQR).

Methods

Following translation guidelines, 2 Arabic translators and 2 English-certified translators performed forward and backward translations of the FIQR. In a cross-sectional study design, the questionnaire was piloted with 5 participants and then subjected to cognitive interviews and psychometric analysis. Participants were FM patients recruited from a University Hospital in Riyadh and FM support groups in Saudi Arabia. The internal consistency, and reliability using the Cronbach α and interclass correlation coefficient (ICC) of 2-week test-retest, and criterion validity were evaluated.

Results

The results included a total of 42 participants with FM. Six minor modifications were made during the stepwise translation of the questionnaire. The Arabic version of the FIQR had good internal consistency and test-retest reliability, with a Cronbach α of 0.855 for the physical functioning domain, 0.663 for overall well-being, 0.803 for symptoms, and 0.895 for the total FIQR, and the Pearson correlation coefficient of the ICC for physical functioning was 0.769 (95% confidence interval (CI), 0.541-0.884) for the overall well-being domain, 0.555 (95% CI, 0.129-0.772) for the symptoms domain, and 0.720 (95% CI, 0.370-0.868) and 0.794 (95% CI, 0.579-0.899) for the total FIQR score (p < 0.001), respectively.

Conclusion

The Arabic version of the FIQR is a valid, reliable, and practical tool for assessing the impact of FM on Arabic-speaking patients and potentially contributing to the improvement of FM outcomes.

Whole-Body Photobiomodulation Therapy Propels the Fibromyalgia Patient into the Recomposition Phase: A Reflexive Thematic Analysis

BACKGROUND

Recent evidence has identified great promise for the novel whole-body photobiomodulation therapy (PBMT) for individuals with fibromyalgia (FM). However, currently no evidence has documented the experiences of participants. The objective of this study was to qualitatively assess treatment experience and response in a group of participants with FM undergoing a course of whole-body PBMT.

METHODS

An interpretive hermeneutic phenomenological study situated within the worldview of pragmatism was undertaken. A convenience sample of individuals with FM were included if they had undertaken a novel 6-week trial of PBMT. Individuals undertook semi-structured interviews exploring treatment experience and multidimensional treatment responses during Week 3 and Week 6.

RESULTS

Sixteen trial participants (47.3 ± 10.9 years) took part in this study. The analysis produced three overarching themes that were previously identified from a baseline study (namely, 'Body Structure & Function', 'Activities & Participation', and 'Environment') with an additional five sub-themes that highlighted the intervention experience. Subsequently, four important processes were observed and identified: increased motivation; feeling proud; improved confidence; feeling like 'old self'. This ultimately culminated in the identification of a positive spiral, which we have termed 'recomposition'.

CONCLUSIONS

We believe our study is the first in the field of chronic pain management to utilise qualitative methodology to directly assess the acceptability and efficacy of a specific medical intervention in a clinical trial, and the first study to qualitatively assess whole-body PBMT experience. The findings are compelling and warrant further work to support the introduction of this device into the National Health Service (NHS).

Validation of the Danish Version of the Fibromyalgia Impact Questionnaire Revised

Purpose

Increasing recognition of chronic pain diseases, including Fibromyalgia, warrants the need for tools to monitor the impact of the disease as well as the efficacy of interventions. The Revised Fibromyalgia Impact Questionnaire (FIQR) has previously proved to be a valuable tool in both clinical and research settings. The study objective was to translate and validate the FIQR in Danish.

Patients and Methods

A forward/backward translation, following the WHO-guidelines, was used to develop the Danish version of FIQR. The Danish translation of FIQR was answered by 101 patients suffering from fibromyalgia. The patients simultaneously answered the Hospital Anxiety and Depression Scale (HADS) and the 36-Item Short-Form Health Survey (SF-36) for validation.

Results

The Danish FIQR showed excellent internal consistency, and reliability with Interclass Correlation Coefficients above 0.9. The correlations to HADS and SF-36 ranged from fair to very good. All results were found to have a p-value <0.05.

Conclusion

The present version of the Danish FIQR presents a valid and reliable tool for monitoring the impact of fibromyalgia.

The Fibromyalgia Pain Experience: A Scoping Review of the Preclinical Evidence for Replication and Treatment of the Affective and Cognitive Pain Dimensions

Fibromyalgia is a chronic, widespread pain disorder that is strongly represented across the affective and cognitive dimensions of pain, given that the underlying pathophysiology of the disorder is yet to be identified. These affective and cognitive deficits are crucial to understanding and treating the fibromyalgia pain experience as a whole but replicating this multidimensionality on a preclinical level is challenging. To understand the underlying mechanisms, animal models are used. In this scoping review, we evaluate the current primary animal models of fibromyalgia regarding their translational relevance within the affective and cognitive pain realms, as well as summarize treatments that have been identified preclinically for attenuating these deficits.

Conditioned pain modulation (CPM) paradigm type affects its sensitivity as a biomarker of fibromyalgia

Fibromyalgia (FM) is a widespread chronic pain syndrome, possibly associated with the presence of central dysfunction in descending pain inhibition pathways. Conditioned Pain Modulation (CPM) has been proposed as a biomarker of FM. Nonetheless, the wide variety of methods used to measure CPM has hampered robust conclusions being reached. To clarify the validity of CPM as a biomarker of FM, we tested two CPM paradigms (parallel and sequential) in a sample of 23 female patients and 23 healthy women by applying test (mechanical) stimuli and conditioning (pressure cuff) stimuli. We evaluated whether CPM indices could correctly classify patients and controls, and we also determined the correlations between the indices and clinical variables such as symptomatology, disease impact, depression, quality of life, pain intensity, pain interference, fatigue and numbness. In addition, we compared the clinical status of CPM responders (efficient pain inhibitory mechanism) and non-responders. We observed that only parallel CPM testing correctly classified about 70% of patients with FM. In addition, more than 80% of healthy participants were found to be responders, while the rate was about 50% in the FM patients. The sequential CPM test was not as sensitive, with a decrease of up to 40% in the response rate for both groups. On the other hand, we did not observe any correlation between CPM measures and clinical symptoms. In summary, our findings demonstrate the influence of the CPM paradigm used and confirm that CPM may be a useful marker to complement FM diagnosis. However, the findings also cast doubts on the sensitivity of CPM as a marker of pain severity in FM.

Feldenkrais awareness though movement intervention for fibromyalgia syndrome: A proof-of-concept study

INTRODUCTION

The Feldenkrais Method® is a form of awareness through movement (ATM) aimed at improving spatial and kinesthetic awareness through verbally guided movements, in order to learn more effective actions.

METHOD

The present study, a proof-of-concept, observational, non-controlled prospective study, aims at exploring the effectiveness of ATM for fibromyalgia syndrome (FM), measuring the effect by means of multi-dimensional questionnaires, administered at baseline and after 4 months of ATM activity.

RESULTS

One hundred twenty-eight FM patients (mean age 54 years old, 2% males) participated in the study. A statistically significant improvement was found in FM-specific measures (Polysymptomatic Distress Scale, PDS) (p = 0.003) and the Pain Catastrophization Scale (PCS) (p = 0.020); coherently, the Revised Fibromyalgia Impact Questionnaire (FIQR) showed a trend in improvement after the intervention, although this improvement was not statistically significant. The logistic regression analysis found a correlation between PDS, fatigue and anxiety measures; PCS, years from diagnosis and anxiety.

CONCLUSION

ATM could improve FM-specific measures and pain-related catastrophizing. Further studies are needed to identify FM subgroups in order to find personalized targets that can be used to guide treatments.

Whole-Body Photobiomodulation Therapy for Fibromyalgia: A Feasibility Trial

Effective treatment for fibromyalgia (FM) is lacking and further treatment options are needed. Photobiomodulation therapy (PBMT) represents one potential treatment option. Whilst favourable findings have been reported using localised PBMT, no investigations have established the value of whole-body PBMT for the complete set of symptom domains in FM. A single-arm feasibility study was conducted in accordance with CONSORT (Consolidated Standards of Reporting Trials) guidelines. A non-probability sampling method was used to access individuals with FM. The primary outcome measure was identified as the Revised Fibromyalgia Impact Questionnaire (FIQR). Forty-nine participants were screened and twenty-one trial participants entered the trial. Nineteen participants completed the intervention (18 whole-body PBMT sessions over approximately six weeks). Descriptive statistics and qualitative analysis was undertaken to represent feasibility outcomes. Acceptability of the trial device and processes were established. Outcome measures towards efficacy data were guided by core and peripheral OMERACT (outcomes measures in rheumatological clinical trials) domains, utilising a combination of participant-reported and performance-based outcome measures. Data for the embedded qualitative component of the trial were captured by participant-reported experience measures and audio-recorded semi-structured interviews. Positive changes were observed for FM-specific quality of life, pain, tenderness, stiffness, fatigue, sleep disturbance, anxiety, depression and cognitive impairment. Patient global assessment revealed improvements at 6 weeks, with continued effect at 24 weeks. FM-specific quality of life at 24 weeks remained improved compared with baseline scores. The findings provided evidence to support a full-scale trial and showed promise regarding potential efficacy of this novel non-invasive treatment in an FM population.

Are OMERACT recommendations followed in clinical trials on fibromyalgia? A systematic review of patient-reported outcomes and their measures

PURPOSE

Patient-Reported Outcomes (PROs) and its measures (PROMs) are key to outcome assessment in Fibromyalgia (FM) trials. The aim of this review was to investigate which domains and instruments were assessed in recent FM trials and to compare them to recommendations by the Outcome Measures in Rheumatology (OMERACT) initiative. In addition, we investigated the overlap with a generic health assessment approach, i.e. eight domains suggested by the Patient-Reported Outcome Measurement Information System® (PROMIS®).

METHODS

In compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic literature search in scientific databases including PubMed, PsycInfo, and Embase was conducted to identify studies that assessed at least two dimensions of health-related quality of life (HRQoL) from 2015 to June 2022. Non-randomized and randomized controlled trials were included in the analysis. We extracted PROs and PROMs used in each study.

RESULTS

From 1845 identified records, 107 records out of 105 studies met the inclusion criteria. Studies investigated 50 PROs using 126 different PROMs. Most frequently assessed domains were pain, depression, fatigue, and anxiety (> 95% of the studies). The disease-specific FIQ was the most frequently applied PROM (82%). Overall, only 9% of the studies covered all domains deemed mandatory by OMERACT. Very few studies covered all eight generic health domains suggested by PROMIS.

CONCLUSION

The majority of trials covered most OMERACT domains or generic PROMIS health domains. There was, however, great variability in the instruments used to assess the domains, which points at a limited degree of standardization in the field.

A systematic literature review on the clinical efficacy of low dose naltrexone and its effect on putative pathophysiological mechanisms among patients diagnosed with fibromyalgia

Background

Low dose naltrexone (LDN) is used off-label by many individuals with fibromyalgia to help manage their pain. There is no current systematic literature review summarising the evidence to support this use of LDN. The objectives of this study were to evaluate if patients with fibromyalgia prescribed LDN have reduced pain scores and greater quality of life compared with those allocated to placebo in randomized controlled trials. Secondly to determine if changes in inflammatory markers and brain structure and function are observed among patients with fibromyalgia taking LDN.

Methods

Systematic literature searches were conducted in MEDLINE, Embase Classic + Embase, APA PsychInfo, and The Cochrane Library from inception to May 2022. Reference lists from the selected papers were cross-checked with database search results.

Results

Three studies met our inclusion criteria for the assessment of efficacy, and two studies on potential LDN mechanisms. Results indicated some evidence to suggest LDN reduces pain and increases quality of life. One study reported baseline erythrocyte sedimentation rate (ESR) predicted LDN response (≥30% reduction in fibromyalgia symptoms) and a second study showed plasma concentrations of inflammatory biomarkers were lower after LDN treatment. To our knowledge, there are no brain imaging studies reporting the effect of LDN in patients with fibromyalgia. All studies were based on small sample sizes, were restricted to women and the risk of bias was assessed to be high. There is also some evidence of publication bias.

Conclusion

The strength of evidence from randomized controlled trials to support the use of LDN among patients with fibromyalgia is low. Two small studies suggest ESR and cytokines may be involved in the mechanism by which LDN exerts its effects. Two trials (INNOVA and FINAL) are currently in progress, but further work is needed among men and different ethnic groups.

Efficacy, safety, and tolerability of antidepressants for pain in adults: overview of systematic reviews

OBJECTIVE

To provide a comprehensive overview of the efficacy, safety, and tolerability of antidepressants for pain according to condition.

DESIGN

Overview of systematic reviews.

DATA SOURCES

PubMed, Embase, PsycINFO, and the Cochrane Central Register of Controlled Trials from inception to 20 June 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Systematic reviews comparing any antidepressant with placebo for any pain condition in adults.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data. The main outcome measure was pain; for headache disorders it was frequency of headaches. Continuous pain outcomes were converted into a scale of 0 (no pain) to 100 (worst pain) and were presented as mean differences (95% confidence intervals). Dichotomous outcomes were presented as risk ratios (95% confidence intervals). Data were extracted from the time point closest to the end of treatment. When end of treatment was too variable across trials in a review, data were extracted from the outcome or time point with the largest number of trials and participants. Secondary outcomes were safety and tolerability (withdrawals because of adverse events). Findings were classified from each comparison as efficacious, not efficacious, or inconclusive. Certainty of evidence was assessed with the grading of recommendations assessment, development, and evaluation framework.

RESULTS

26 reviews (156 unique trials and >25 000 participants) were included. These reviews reported on the efficacy of eight antidepressant classes covering 22 pain conditions (42 distinct comparisons). No review provided high certainty evidence on the efficacy of antidepressants for pain for any condition. 11 comparisons (nine conditions) were found where antidepressants were efficacious, four with moderate certainty evidence: serotonin-norepinephrine reuptake inhibitors (SNRIs) for back pain (mean difference -5.3, 95% confidence interval -7.3 to -3.3), postoperative pain (-7.3, -12.9 to -1.7), neuropathic pain (-6.8, -8.7 to -4.8), and fibromyalgia (risk ratio 1.4, 95% confidence interval 1.3 to 1.6). For the other 31 comparisons, antidepressants were either not efficacious (five comparisons) or the evidence was inconclusive (26 comparisons).

CONCLUSIONS

Evidence of efficacy of antidepressants was found in 11 of the 42 comparisons included in this overview of systematic reviews-seven of the 11 comparisons investigated the efficacy of SNRIs. For the other 31 comparisons, antidepressants were either inefficacious or evidence on efficacy was inconclusive. The findings suggest that a more nuanced approach is needed when prescribing antidepressants for pain conditions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022311073.

Efficacy and safety of hyperbaric oxygen therapy for fibromyalgia: a systematic review and meta-analysis

OBJECTIVE

To investigate the efficacy and safety of hyperbaric oxygen therapy (HBOT) for fibromyalgia (FM).

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

PubMed, EMBASE, Cochrane Library, Web of Science, VIP (China Science and Technology Journal Database), CNKI (China National Knowledge Infrastructure) and WanFang database were searched from from inception to 22 October 2022.

ELIGIBILITY CRITERIA

We included clinical trials (randomised controlled and non-randomised controlled trials) of HBOT for FM.

DATA EXTRACTION AND SYNTHESIS

Two researchers independently screened the literature, extracted data and evaluated the quality of the included studies, with disagreements resolved by a third researcher. The Cochrane Collaboration checklists and the Methodological Index for Non-randomised Studies were used to assess the risk of bias. Meta-analysis was performed by RevMan V.5.4.1 software. Random effect models were used for meta-analysis.

RESULTS

Nine studies were included in this review, with a total of 288 patients. For pain assessment, we combined the results of the Visual Analogue Scale and Widespread Pain Index. The results showed that HBOT could relieve the pain of FM patients compared with the control intervention (standardised mean difference=-1.56, 95% CI (-2.18 to -0.93), p<0.001, I 2=51%). Most included studies reported that HBOT ameliorated tender points, fatigue, multidimensional function, patient global and sleep disturbance in FM. Adverse events occurred in 44 of 185 patients (23.8%). Twelve patients (6.5%) withdrew because of adverse reactions. No serious adverse events or complications were observed.

CONCLUSIONS

HBOT might have a positive effect in improving pain, tender points, fatigue, multidimensional function, patient global and sleep disturbance in FM, with reversible side effects. Low pressure (less than 2.0 atmospheric absolute) may be beneficial to reduce adverse events in FM. Further studies should be carried out to evaluate the optimal protocol of HBOT in FM.

PROSPERO REGISTRATION NUMBER

CRD42021282920.

Efficacy of ozone therapy as an add-on treatment in fibromyalgia: A randomized double-blind placebo-controlled study

BACKGROUND

Fibromyalgia (FM) is a chronic disease that causes widespread pain, fatigue, and sleep disturbance. There is still no effective definitive treatment method; therefore, the search for treatment continues.

OBJECTIVE

The purpose of this study is to investigate the effectiveness of ozone therapy (OT), which has been used in FM treatment in recent years, as an additional treatment.

METHODS

The patients were divided into OT (n= 26) and placebo control (PC) (n= 28) groups. Both groups received OT in the form of major autohemotherapy (MaAHT) and minor autohemotherapy (MiAHT) for two sessions per week for a total of 10 sessions. The fibromyalgia impact questionnaire (FIQ), Pittsburgh sleep quality index (PSQI), and 12-item short-form health survey (SF-12) were used for evaluation pre- and post-intervention.

RESULTS

In the between-group comparison, the OT group showed significant post-treatment improvements in FIQ subscales (feel good, fatigue) and PSQI total score and subscales (subjective sleep quality, sleep latency and sleep disturbances) compared to the PC group (p< 0.05). Although there were improvements in the FIQ total score post-treatment in both groups, there was no significant difference between the groups (p>0.05).

CONCLUSION

OT, which is applied as an additional treatment with the autohemotherapy method, simultaneously improves the subscale scores (feel good and fatigue) of FM and sleep quality in the treatment period. However, changes in the post-treatment FIQ total score were not different in the ozone therapy group from the placebo control group.

Effectiveness, cost-utility and physiological underpinnings of the FIBROWALK multicomponent therapy in online and outdoor format in individuals with fibromyalgia: Study protocol of a randomized, controlled trial (On&Out study)

Introduction: The On&amp;Out study is aimed at assessing the effectiveness, cost-utility and physiological underpinnings of the FIBROWALK multicomponent intervention conducted in two different settings: online (FIBRO-On) or outdoors (FIBRO-Out). Both interventions have proved to be efficacious in the short-term but there is no study assessing their comparative effectiveness nor their long-term effects. For the first time, this study will also evaluate the cost-utility (6-month time-horizon) and the effects on immune-inflammatory biomarkers and Brain-Derived Neurotrophic Factor (BDNF) levels of both interventions. The objectives of this 6-month, randomized, controlled trial (RCT) are 1) to examine the effectiveness and cost-utility of adding FIBRO-On or FIBRO-Out to Treatment-As-Usual (TAU) for individuals with fibromyalgia (FM); 2) to identify pre–post differences in blood biomarker levels in the three study arms and 3) to analyze the role of process variables as mediators of 6-month follow-up clinical outcomes.

Methods and analysis: Participants will be 225 individuals with FM recruited at Vall d’Hebron University Hospital (Barcelona, Spain), randomly allocated to one of the three study arms: TAU vs. TAU + FIBRO-On vs. TAU + FIBRO-Out. A comprehensive assessment to collect functional impairment, pain, fatigue, depressive and anxiety symptoms, perceived stress, central sensitization, physical function, sleep quality, perceived cognitive dysfunction, kinesiophobia, pain catastrophizing, psychological inflexibility in pain and pain knowledge will be conducted pre-intervention, at 6 weeks, post-intervention (12 weeks), and at 6-month follow-up. Changes in immune-inflammatory biomarkers [i.e., IL-6, CXCL8, IL-17A, IL-4, IL-10, and high-sensitivity C-reactive protein (hs-CRP)] and Brain-Derived Neurotrophic Factor will be evaluated in 40 participants in each treatment arm (total n = 120) at pre- and post-treatment. Quality of life and direct and indirect costs will be evaluated at baseline and at 6-month follow-up. Linear mixed-effects regression models using restricted maximum likelihood, mediational models and a full economic evaluation applying bootstrapping techniques, acceptability curves and sensitivity analyses will be computed.

Ethics and dissemination: This study has been approved by the Ethics Committee of the Vall d’Hebron Institute of Research. The results will be actively disseminated through peer-reviewed journals, conference presentations, social media and various community engagement activities. Trial registration number NCT05377567 (clinicaltrials.gov).

Decision Making and Fibromyalgia: A Systematic Review

Decision making (DM) is the ability to choose among multiple options, considering external and internal variables and identifying potential paths of action that need to be assessed. Some brain areas involved in decision making are also implicated in pain processing, such as in fibromyalgia (FM). FM is a syndrome characterized by chronic widespread musculoskeletal pain and cognitive difficulties. We conducted a systematic review with the aim of identifying articles that evaluated DM in people with fibromyalgia, highlighting the main assessment tools. This work was conducted according to the PRISMA statement by consulting six online databases and providing a quality assessment of each search that met the inclusion criteria. In line with the limited interest in this in the scientific landscape to date, we found nine studies that evaluated the performance of DM in patients with FM; furthermore, we discovered that only certain types of DM were tested. The importance of our work lies in shedding light on a cognitive ability that is often undervalued in the scientific landscape but essential in everyday life. This review can serve as a starting point for further studies to clarify the relationship between DM and FM, improving understanding of the topic.

Effectiveness of two video-based multicomponent treatments for fibromyalgia: The added value of cognitive restructuring and mindfulness in a three-arm randomised controlled trial

BACKGROUND/OBJECTIVES

The aim of this study was to examine the effectiveness of two video-based multicomponent programs (FIBROWALK) and the Multicomponent Physiotherapy Program (MPP) for patients with fibromyalgia (FM) compared to treatment-as-usual (TAU) only. We posit that FIBROWALK, due to inclusion of specific psychological ingredients (cognitive restructuring and mindfulness), can produce additional clinical benefits when compared to TAU or MPP alone.

METHODS

A total of 330 patients with FM were recruited and randomly allocated (1:1:1) to TAU only, TAU + FIBROWALK, or TAU + MPP. FIBROWALK and MPP consisted of weekly videos on pain neuroscience education, therapeutic exercise and self-management patient education, but only the FIBROWALK intervention provided cognitive restructuring and mindfulness. Both programs were structurally equivalent. Between-group differences in functional impairment, pain, kinesiophobia, anxious-depressive symptoms and physical functioning were evaluated at post-treatment following Intention-To-Treat and complete-case approaches.

RESULTS

Compared to TAU only, individuals in the FIBROWALK arm showed larger improvements in all clinical outcomes; similarly, participants in the MPP program also showed greater improvements in functional impairment, perceived pain, kinesiophobia, depressive symptoms compared to TAU only. The FIBROWALK intervention showed superior effects in improving pain, anxiety and depressive symptoms and physical functioning compared to MPP.

CONCLUSIONS

This RCT supports the short-term effectiveness of the video-based multicomponent programs FIBROWALK and MPP for FM and provides evidence that cognitive-behavioural and mindfulness-based techniques can be clinically useful in the context of physiotherapeutic multicomponent treatment programs.

TRIAL REGISTRATION NUMBER

NCT04571528.

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

ABSTRACT

Fibromyalgia is a highly heterogeneous condition, but the most common symptoms are widespread pain, fatigue, poor sleep, and low mood. Nonpharmacological interventions are recommended as first-line treatment of fibromyalgia. However which interventions are effective for the different symptoms is not well understood. The objective of this study was to assess the efficacy of nonpharmacological interventions on symptoms and disease-specific quality of life. Seven databases were searched from their inception until June 1, 2020. Randomised controlled trials comparing any nonpharmacological intervention to usual care, waiting list, or placebo in people with fibromyalgia aged >16 years were included without language restriction. Fibromyalgia Impact Questionnaire (FIQ) was the primary outcome measure. Standardised mean difference and 95% confidence interval were calculated using random effects model. The risk of bias was evaluated using the modified Cochrane tool. Of the 16,251 studies identified, 167 randomised controlled trials (n = 11,012) assessing 22 nonpharmacological interventions were included. Exercise, psychological treatments, multidisciplinary modality, balneotherapy, and massage improved FIQ. Subgroup analysis of different exercise interventions found that all forms of exercise improved pain (effect size [ES] -0.72 to -0.96) and depression (ES -0.35 to -1.22) except for flexibility exercise. Mind-body and strengthening exercises improved fatigue (ES -0.77 to -1.00), whereas aerobic and strengthening exercises improved sleep (ES -0.74 to -1.33). Psychological treatments including cognitive behavioural therapy and mindfulness improved FIQ, pain, sleep, and depression (ES -0.35 to -0.55) but not fatigue. The findings of this study suggest that nonpharmacological interventions for fibromyalgia should be individualised according to the predominant symptom.

Managing fibromyalgia with complementary and alternative medical exercise: a systematic review and meta-analysis of clinical trials

Fibromyalgia is a chronic medical condition of unclear etiopathology that diminished patients' quality of life; chronic pain is the main symptom, yet patients with fibromyalgia struggle also with depression, anxiety, and insomnia. For many years, pharmaceutical management of pain was the mainstay of treatment. In the latest decade, conventional low-impact aerobic exercise and complementary and alternative medical (CAM) exercise have become important when structuring a personalized therapeutic plan, since side effects are practically inexistent. Heterogenous studies with different methodological approaches have failed to display a clear clinical effect. We conducted a systematic review with meta-analysis of clinical trials putting emphasis on standardized measurable outcomes (Fibromyalgia Impact Questionnaire, FIQ) in our effort to draw a safe conclusion on CAM exercise's effect. After analyzing 14 studies, including 886 patients, meta analysis showed CAM exercise had a beneficial effect on patients' FIQ score reports: standardized mean difference (SMD) 1.330 (95% CI 0.733-1.928). Among them, dance and Tai chi, had a more profound effect: SMD 1.969 (95% CI 0.575-3.364) and SMD 1.852 (95% CI 0.119-3.584), respectively. However, the risk of bias was overall medium to high and statistical heterogeneity was very high. Our meta-regression analysis failed to identify any variable that could account for high heterogeneity. Even though more experimental studies should be done on this subject, CAM exercise seems beneficial for patients with Fibromyalgia.

The Pain Outcomes Comparing Yoga vs. Structured Exercise (POYSE) Trial in Veterans With Fibromyalgia: Study Design and Methods

Background

Fibromyalgia is a common pain condition that often leads to significant disability. Unfortunately, the effectiveness of most medications for fibromyalgia is limited, and there is a need for alternative, non-pharmacological therapies. Yoga and aerobic exercise are both evidence-based non-pharmacological treatments for fibromyalgia. However, no prior studies have directly compared the effectiveness of yoga vs. exercise.

Objective

This article describes the study design and recruitment outcomes of the Pain Outcomes comparing Yoga vs. Structured Exercise (POYSE) Trial, a two-arm randomized comparative effectiveness trial.

Methods

Veterans with fibromyalgia, defined by the 2010 American College of Rheumatology diagnostic criteria, who also experienced at least moderate pain severity were enrolled. The participants were randomized to a 12-week yoga-based or a structured exercise program (SEP) and will undergo comprehensive outcome assessments at baseline, 1, 3, 6, and 9 months by interviewers blinded to treatment assignment. The primary outcome will be the overall severity of fibromyalgia as measured by the total Fibromyalgia Impact Questionnaire-Revised. Secondary outcomes included depression, anxiety, health-related quality of life, pain beliefs, fatigue, sleep, and self-efficacy.

Results

A total of 2,671 recruitment letters were sent to potential participants with fibromyalgia. Of the potential participants, 623 (23.3%) were able to be contacted by telephone and had their eligibility assessed. Three hundred seventy-one of those interviewed were found to be eligible (59.6%) and 256 (69.0%) agreed to participate and were randomized to the YOGA (n = 129) or the SEP (n = 127) arm of the trial.

Conclusions

Clinicians are faced with numerous challenges in treating patients with fibromyalgia. The interventions being tested in the POYSE trial have the potential to provide primary care and other care settings with new treatment options for clinicians while simultaneously providing a much needed relief for patients suffering from fibromyalgia.

Trial Registration

Funded by VA Rehabilitation Research and Development (D1100-R); Trial registration: ClinicalTrials.gov, NCT01797263.

Whole-body photobiomodulation therapy for chronic pain: a protocol for a feasibility trial

INTRODUCTION

Chronic pain conditions are a leading cause of disease and disability. They are associated with symptoms such as fatigue, sleep and mood disturbances. Minimal evidence is available to support effective treatments and alternatives treatment approaches are called for. Photobiomodulation therapy has been highlighted as one promising option. A whole-body therapy device (NovoTHOR) has recently been developed with a number of potential advantages for people with chronic pain. Research is needed to consider the feasibility of this device.

METHODS AND ANALYSIS

A single-centre single-armed (no placebo group) feasibility study with an embedded qualitative component will be conducted. The intervention will comprise 18 treatments over 6 weeks, with 6-month follow-up, in the whole-body photobiomodulation device. A non-probability sample of 20 adult participants with a clinician diagnosis of chronic axial pain, polyarthralgia, myofascial pain or widespread pain will be recruited (self-referral and clinician referral). Outcome measures will focus on acceptability of trial processes with a view to guiding a definitive randomised controlled trial. Analyses will use descriptive statistics for quantitative aspects. The qualitative element will be assessed by means of a participant-reported experience questionnaire postintervention and semistructured audio-recorded interviews at three stages; preintervention, midintervention and postintervention. The latter will be transcribed verbatim and a reflexive thematic analysis will be used to identify emerging themes. Exploratory outcomes (participant-reported and performance-based measures) will be analysed according to data distribution.

ETHICS AND DISSEMINATION

The study has received ethical approval from the Leicester Central Research and Ethics Committee. Findings will be disseminated via local chronic pain groups, public register update, submission for presentation at scientific meetings and open-access peer-reviewed journals, and via academic social networks.

TRIAL REGISTRATION NUMBER

NCT05069363.

Fibromyalgia Syndrome and Cognitive Decline: The Role of Body Mass Index and Clinical Symptoms

The high prevalence of obesity and overweight in fibromyalgia (FM) may be an important factor in the well-known cognitive deficits seen in the disorder. This study analyzed the influence of body mass index (BMI) and primary clinical symptoms of FM (pain, fatigue, insomnia, anxiety, and depression) on attention, memory, and processing speed in FM. Fifty-two FM patients and thirty-two healthy participants completed cognitive tasks assessing selective, sustained, and divided attention; visuospatial and verbal memory; and information processing speed. Furthermore, they were evaluated in terms of the main clinical symptoms of the disorder. FM patients showed a marked reduction of cognitive performance in terms of selective, sustained, and divided attention; visuospatial memory; and processing speed, but no group differences were observed in verbal memory. BMI negatively affects sustained and selective attention, verbal memory, and processing speed and is the main predictor of performance in these basic cognitive domains. Our findings confirm the presence of cognitive deficits with respect to attention and visual memory, as well as slower processing speed, in FM. Moreover, the results support a role of BMI in the observed cognitive deficits. Interventions increasing physical activity and promoting cognitive stimulation could be useful for strengthening cognitive function in FM patients.

Advances in the management of fibromyalgia: what is the state of the art?

INTRODUCTION

Fibromyalgia (FM) is a chronic pain syndrome associated with fatigue, insomnia, dyscognition, and emotional distress. Critical illness mechanisms include central sensitization to nociceptive and non-nociceptive stimuli often resulting in hypersensitivity to all sensory input.

AREAS COVERED

The clinical presentation of FM can vary widely and therefore requires therapies tailored to each patient's set of symptoms. This manuscript examines currently prescribed therapeutic approaches supported by empirical evidence as well as promising novel treatments. Although pharmacological therapy until now has been only moderately effective for FM symptoms, it represents a critical component of every treatment plan.

EXPERT OPINION

Currently approved pharmacological therapies for FM symptoms have limited but proven effectiveness. Novel therapies with cannabinoids and naltrexone appear promising. Recent functional imaging studies of FM have discovered multiple brain network abnormalities that may provide novel targets for mechanism-based therapies. Future treatment approaches, however, need to improve more than clinical pain but also other FM domains like fatigue, insomnia, and distress.

Characterizing Neurocognitive Impairment in Juvenile Fibromyalgia Syndrome: Subjective and Objective Measures of Dyscognition

OBJECTIVES

Our understanding of brain fog, or dyscognition, among youth with juvenile fibromyalgia syndrome is limited. We aimed to determine the prevalence of subjective (self-reported) and objective dyscognition, as well as factors associated with subjective dyscognition in juvenile fibromyalgia syndrome.

METHODS

A cross-sectional cohort study of patients (n = 31) 12-17 years old diagnosed with primary juvenile fibromyalgia syndrome and one of their parents from 2017 to 2019. Subjects completed a series of survey measures and patients completed a brief neurocognitive battery. Subjective dyscognition was determined based on scores on the Pediatric Quality of Life Inventory (PedsQL) Cognitive Functioning Scale and Behavior Rating Inventory of Executive Function (BRIEF-2) global executive composite (GEC). Objective dyscognition was defined as impairment of more than two standard deviations in any of the neurocognitive domains. We used Fisher's exact test or Wilcoxon rank-sum test, as appropriate, to compare clinical patients based on the presence of dyscognition. Multivariable logistic regression modeling was performed to determine factors associated with subjective dyscognition.

RESULTS

Of the 31 subjects, 65% reported subjective dyscognition and 39% had objective dyscognition, primarily in the domains of psychomotor speed (23%), executive function (23%), and attention (3%). Subjective dyscognition was not indicative of objective dyscognition. Subjective dyscognition was independently associated with functional disability (OR: 1.19 [95% CI: 1.02-1.40]) and anxiety (OR: 1.12 [95% CI: 1.02-1.24]).

DISCUSSION

Adolescents with fibromyalgia predominantly experience subjective dyscognition but more than 1/3 also experience objective dyscognition. Future research should explore the impact of interdisciplinary rehabilitation programs on the treatment of dyscognition in youth with JFMS.

Relationship between pineal gland, sleep and melatonin in fibromyalgia women: a magnetic resonance imaging study

A total of 80% of fibromyalgia (FM) population have reported poor sleep. In this regard, the pineal gland, involved in circadian rhythm processes as a key neuroendocrine organ which mainly synthesises and secretes melatonin, has never been studied before in this population. Therefore, this study aimed to evaluate the parenchyma pineal volume and its relation to sleep hours, sleep quality index and melatonin level at night. A total of 50 participants, 30 women with FM and 20 healthy control women underwent cranial magnetic resonance imaging. The total pineal volume, cyst pineal volume and parenchyma pineal volume were manually calculated in cubic millimetres. Also, the total pineal volume was estimated using Hasehawa method. Parenchyma pineal volume was significantly correlated with sleep hours (p-value = 0.041) and nocturnal melatonin level (p-value = 0.027). Moreover, there was also a non-significant correlation between parenchyma pineal volume and sleep quality index (p-value = 0.055). Furthermore, a mean parenchyma pineal volume of 102.00 (41.46) mm³ was observed, with a prevalence of 29.60% cyst in FM group. This is the first study that has reported pineal gland volumes, cyst prevalence and correlative relationships between parenchyma pineal volume and sleep hours and melatonin levels in women with FM.

The Role of Nutrient Supplementation in the Management of Chronic Pain in Fibromyalgia: A Narrative Review

INTRODUCTION

The multifaceted clinical presentation of fibromyalgia (FM) supports the modern understanding of the disorder as a more global condition than one simply affecting pain sensation. The main pharmacologic therapies used clinically include anti-epileptics and anti-depressants. Conservative treatment options include exercise, myofascial release, psychotherapy, and nutrient supplementation.

METHODS

Narrative review.

RESULTS

Nutrient supplementation is a broadly investigated treatment modality as numerous deficiencies have been linked to FM. Additionally, a proposed link between gut microbiome patterns and chronic pain syndromes has led to studies investigating probiotics as a possible treatment. Despite positive results, much of the current evidence regarding this topic is of poor quality, with variable study designs, limited sample sizes, and lack of control groups.

CONCLUSIONS

The etiology of FM is complex, and has shown to be multi-factorial with genetics and environmental exposures lending influence into its development. Preliminary results are promising, however, much of the existing evidence regarding diet supplementation is of poor quality. Further, more robust studies are needed to fully elucidate the potential of this alternative therapeutic option.

Efficacy of the FIBROWALK Multicomponent Program Moved to a Virtual Setting for Patients with Fibromyalgia during the COVID-19 Pandemic: A Proof-of-Concept RCT Performed Alongside the State of Alarm in Spain

FIBROWALK is a multicomponent program including pain neuroscience education, therapeutic exercise, cognitive behavioral therapy and mindfulness training that has recently been found to be effective in patients with fibromyalgia (FM). This RCT started before the COVID-19 pandemic and was moved to a virtual format (i.e., online videos) when the lockdown was declared in Spain. This study is aimed to evaluate the efficacy of a virtual FIBROWALK compared to Treatment-As-Usual (TAU) in patients with FM during the first state of alarm in Spain. A total of 151 patients with FM were randomized into two study arms: FIBROWALK plus TAU vs. TAU alone. The primary outcome was functional impairment. Secondary outcomes were kinesiophobia, anxiety and depressive symptomatology, and physical functioning. Differences between groups at post-treatment assessment were analyzed using Intention-To-Treat (ITT) and completer approaches. Baseline differences between clinical responders and non-responders were also explored. Statistically significant improvements with small-to-moderate effect sizes were observed in FIBROWALK+TAU vs. TAU regarding functional impairment and most secondary outcomes. In our study, the NNT was 5, which was, albeit modestly, indicative of an efficacious intervention. The results of this proof-of-concept RCT preliminarily support the efficacy of virtual FIBROWALK in patients with FM during the Spanish COVID-19 lockdown.

Clinical Findings in SMR Neurofeedback Protocol Training in Women with Fibromyalgia Syndrome

Fibromyalgia is related to central sensitization syndrome (CSS) and is associated with chronic pain and a decrease in general health. The aim of this study was to explore how changes in brain patterns of female fibromyalgia patients are shaped by neurofeedback therapy and how it affects pain perception and general health. A quasi-experimental study with pre- and post-tests was carried out with 37 female fibromyalgia patients referred by the Pain Unit of the National Health Service of Spain. The method involved applying a sensorimotor rhythm (SMR) protocol to monitor changes in brain waves under different conditions, taking pre-/post-test measurements of perceived pain, general health and the impact on fibromyalgia. Measures included the Fibromyalgia Impact Questionnaire Revised (FIQR), the Visual Analogue Scale (VAS), the General Health Questionnaire (GHQ-28) and EEG (SMR, theta waves). During therapy, the SMR/theta wave ratio increased significantly and after application of therapy, significant results were observed for the FIQR, VAS and GHQ-28. In conclusion, neurofeedback therapy increases the SMR/theta wave ratio in fibromyalgia, helping to maintain a balance between brain functions. This is associated with the activation of inhibitory processes, which is related to the perceived improvement of pain in fibromyalgia patients.

Effects of Wearable Transcutaneous Electrical Nerve Stimulation on Fibromyalgia: A Randomized Controlled Trial

Purpose

Fibromyalgia is a chronic condition characterized by widespread pain and interference with daily activities. The aim of this study is to assess the benefit of transcutaneous electrical nerve stimulation (TENS) for persons diagnosed with fibromyalgia.

Patients and Methods

Adults meeting diagnostic criteria for fibromyalgia were randomized in a double-blind trial to receive either an active (n=62) or sham (n=57) wearable TENS device for 3-months. Subjects were classified as having lower or higher pain sensitivity by Quantitative Sensory Testing (QST). Patient Global Impression of Change (PGIC, primary outcome) and secondary efficacy measures including Fibromyalgia Impact Questionnaire (FIQR), Brief Pain Inventory (BPI) and painDETECT questionnaire (PDQ) were assessed at baseline, 6-weeks and 3-months. Treatment effects were determined by a mixed model for repeated measures (MMRM) analysis of the intention-to-treat (ITT) population (N=119). A pre-specified subgroup analysis of pain sensitivity was conducted using an interaction term in the model.

Results

No differences were found between active and sham treatment on PGIC scores at 3-months (0.34, 95% CI [−0.37, 1.04], p=0.351) in the ITT population. However, in subjects with higher pain sensitivity (n=60), PGIC was significantly greater for active treatment compared to sham (1.19, 95% CI [0.24, 2.13], p=0.014). FIQR total score (−7.47, 95% CI [−12.46, −2.48], p=0.003), FIQR pain item (−0.62, 95% CI [−1.17, −0.06], p=0.029), BPI Interference (−0.70, 95% CI [−1.30, −0.11], p=0.021) and PDQ (−1.69, 95% CI [−3.20, −0.18], p=0.028) exhibited significant improvements for active treatment compared to sham in the ITT population. Analgesics use was stable and comparable in both groups.

Conclusion

This study demonstrated modest treatment effects of reduced disease impact, pain and functional impairment from wearable TENS in individuals with fibromyalgia. Subjects with higher pain sensitivity exhibited larger treatment effects than those with lower pain sensitivity. Wearable TENS may be a safe treatment option for people with fibromyalgia.

Clinicaltrials.gov Registration

NCT03714425.

Self-management for chronic widespread pain including fibromyalgia: A systematic review and meta-analysis

BACKGROUND

Chronic widespread pain (CWP) including fibromyalgia has a prevalence of up to 15% and is associated with substantial morbidity. Supporting psychosocial and behavioural self-management is increasingly important for CWP, as pharmacological interventions show limited benefit. We systematically reviewed the effectiveness of interventions applying self-management principles for CWP including fibromyalgia.

METHODS

MEDLINE, Embase, PsycINFO, The Cochrane Central Register of Controlled Trials and the WHO International Clinical Trials Registry were searched for studies reporting randomised controlled trials of interventions adhering to self-management principles for CWP including fibromyalgia. Primary outcomes included physical function and pain intensity. Where data were sufficient, meta-analysis was conducted using a random effects model. Studies were narratively reviewed where meta-analysis could not be conducted Evidence quality was rated using GRADE (Grading of Recommendations, Assessment, Development and Evaluations) (PROSPERO-CRD42018099212).

RESULTS

Thirty-nine completed studies were included. Despite some variability in studies narratively reviewed, in studies meta-analysed self-management interventions improved physical function in the short-term, post-treatment to 3 months (SMD 0.42, 95% CI 0.20, 0.64) and long-term, post 6 months (SMD 0.36, 95% CI 0.20, 0.53), compared to no treatment/usual care controls. Studies reporting on pain narratively had greater variability, however, those studies meta-analysed showed self-management interventions reduced pain in the short-term (SMD -0.49, 95% CI -0.70, -0.27) and long-term (SMD -0.38, 95% CI -0.58, -0.19) compared to no treatment/usual care. There were few differences in physical function and pain when self-management interventions were compared to active interventions. The quality of the evidence was rated as low.

CONCLUSION

Reviewed studies suggest self-management interventions can be effective in improving physical function and reducing pain in the short and long-term for CWP including fibromyalgia. However, the quality of evidence was low. Future research should address quality issues whilst making greater use of theory and patient involvement to understand reported variability.

Occupational Adaptation of People Living With Fibromyalgia: A Systematic Review and Thematic Synthesis

IMPORTANCE

Fibromyalgia (FM) is a chronic pain disorder that interferes with daily activities. Because occupational adaptation varies among people, there is a need to determine which factors can influence adaptation to FM in order to better intervene with them.

OBJECTIVE

To understand the occupational adaptation process of people living with FM.

DATA SOURCES

A systematic review of the literature was conducted in the AMED, CINAHL, MEDLINE, OTseeker, OTDBASE, and PsycINFO databases. Articles dated before September 2020 were searched using a strategy with the keywords fibromyalgia and occupation. Study Selection and Data Collection: This article follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Qualitative articles were included if they documented occupational aspects of participants with FM. Two independent reviewers screened the articles and performed the quality assessment using the Critical Appraisal Skills Program checklist. A thematic synthesis was conducted.

FINDINGS

Of the 560 articles identified, 347 remained after duplicates were removed. After screening titles and abstracts, 303 articles were rejected, and 44 articles were read in their entirety. Twelve qualitative articles were included in the review. The synthesis highlights that support from relatives is a key to successfully adapting to FM. Identity is crucial to a fulfilled life, and occupational competence is greatly affected by the experience of FM. Occupational adaptation is an issue for some people, but maintaining routines and integrating management strategies would help them to achieve it.

CONCLUSIONS AND RELEVANCE

This review highlights the importance of considering the components of occupational adaptation while caring for people with FM. What This Article Adds: This systematic review identifies the factors influencing the occupational adaptation of people living with FM and emphasizes the importance of addressing those factors.

[Effects of a Cognitive Behavior Therapy Program for Patients with Fibromyalgia Syndrome: A Randomized Controlled Trial]

PURPOSE

This study developed a cognitive behavioral therapy program aimed at altering the physical condition, emotions, and behaviors of fibromyalgia patients, and confirmed the program's clinical applicability. The program was developed by analyzing previous studies conducting in-depth interviews with fibromyalgia patients, drawing on cognitive behavior theory to establish the program contents, recruiting experts to test its validity, and conducting a preliminary survey.

METHODS

To confirm the program's effect, this study used a randomized controlled trial design. The participants were outpatients diagnosed with fibromyalgia in Dong-A University Hospital, Busan. The 30 patients in the experimental group took part in the program, which comprised 8 sessions (90 to 120 minutes) based on cognitive behavior theory, delivered over 8 weeks. Hypothesis testing was carried out using the repeated measures ANOVA.

RESULTS

The analysis revealed significant differences between the experimental and control groups in positive automatic thoughts, pain, fatigue, depression, and interpersonal relationships. However, there was no significant difference between the groups in terms of sleep disorders and negative automatic thoughts.

CONCLUSION

This program is a positive effect on physical condition, emotions, and behaviors. It is thus expected to be used to help fibromyalgia patients improve their disease conditions.

Outcome Measures for Functional Neurological Disorder: A Review of the Theoretical Complexities

The development and selection of optimal outcome measures is increasingly recognized as a key component of evidence-based medicine, particularly the need for the development of a standardized set of measures for use in clinical trials. This process is particularly complex for functional neurological disorder (FND) for several reasons. FND can present with a wide range of symptoms that resemble the full spectrum of other neurological disorders. Additional physical (e.g., pain, fatigue) and psychological (e.g., depression, anxiety) symptoms are commonly associated with FND, which also can be highly disabling with implications for prognosis, and warrant concurrent assessment, despite an unclear etiological relationship with FND. Furthermore, several unique clinical aspects of FND make it likely that the usual prioritization of "objective" (or clinician-rated) over "subjective" (or patient-rated) measures might not be appropriate. Self-report measures may be more clinically meaningful in this patient population. Despite being a common and disabling disorder, there has been little research into outcome measures in FND, and to date trials have largely used measures designed for the assessment of other disorders. An international FND Core Outcome Measure group (FND-COM) has been established to develop a consensus battery of outcomes for FND: a "core outcome set." In this perspective article, the authors reviewed the process of outcome measure development and selection before considering the specific features of FND affecting the development of a core outcome set, as well as a research agenda to optimize outcome measurement in this complex neuropsychiatric disorder.

Acceptance and commitment therapy for people with rheumatic disease: Existing evidence and future directions

INTRODUCTION

Despite advances in the management of rheumatic diseases, many patients experience persistent pain and fatigue. Psychological interventions are useful adjunctive treatments, but improvements tend to be small, and progress in this area is needed. The aim of this review was to evaluate the effectiveness of acceptance and commitment therapy (ACT) for the treatment of chronic pain and fatigue in patients with rheumatic disease.

METHODS

A systematic literature search was conducted in MEDLINE, EMBASE, and PsycINFO for randomised controlled trials (RCTs) of ACT for the treatment of chronic pain and fatigue in patients with rheumatic disease. Ten RCTs that included people with rheumatic disease were identified, rated for risk of bias, and summarised in terms of effects on relevant outcomes (disability, emotional functioning, pain, and quality of life).

RESULTS

Treatment with ACT was associated with improvements in physical and emotional functioning, pain, and quality of life in chronic pain patients. The favourable effects of ACT were evident when compared with those of treatment as usual or active control conditions (e.g., pain education and novel medication). There was consistent evidence to show that ACT is beneficial in improving physical and emotional functioning in patients with fibromyalgia but a lack of evidence pertaining to patients with other forms of rheumatic disease.

CONCLUSION

ACT provides benefit for fibromyalgia patients. Further high-quality research is needed to develop ACT interventions for people with inflammatory rheumatic diseases and to evaluate their effectiveness for managing the pain and fatigue associated with these conditions.

Childhood and adult attention deficit hyperactivity disorder symptoms in fibromyalgia: associations with depression, anxiety and disease impact

Objective: The first aim of this study was to determine the prevalence of childhood and current attention deficit hyperactivity disorder (ADHD) symptoms in patients with fibromyalgia. The second aim is to assess the role of depression and anxiety on the relationship between childhood and adult ADHD symptoms with disease impact in this population.Methods: Sixty-four patients with fibromyalgia were compared to matched 58 healthy controls. All participants completed the Wender Utah Rating Scale (WURS), Adult ADHD Self-Report Scale (ASRS), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI) and Fibromyalgia Impact Questionnaire (FIQ).Results: Patients with fibromyalgia had significantly higher mean scores of depression (BDI), anxiety (BAI), childhood ADHD symptoms (WURS) and adult ADHD symptoms (ASRS total, ASRS hyperactivity/impulsivity subscale and ASRS attention deficit subscale) than the control group. Fibromyalgia impact (FIQ) was significantly correlated with depression (BDI; r = 0.57, p < .001), anxiety (BAI; r = 0.56, p < .001) and childhood ADHD symptoms (WURS; r = 0.41, p < .001) in fibromyalgia group. There was no significant correlation between fibromyalgia impact (FIQ) and adult ADHD symptoms (ASRS total or sub-scale scores). Hierarchical multiple regression indicated that childhood ADHD symptoms (WURS), anxiety (BAI) and depression (BDI) predicted fibromyalgia impact. Both anxiety (BAI) and depression (BDI) mediated the relationship between childhood ADHD symptoms (WURS) and fibromyalgia impact (FIQ).Conclusion: Childhood ADHD symptoms may be a contributory factor to poorer functioning in the patients with fibromyalgia. The relationship was more pronounced in the presence of depression and anxiety symptoms. Evaluation of childhood and adult ADHD symptoms in patients with fibromyalgia is important for recognition and treatment of ADHD comorbidity and also for attenuating the severity of the disease.

Is there a dose response relationship between soft tissue manual therapy and clinical outcomes in fibromyalgia?

BACKGROUND

Current clinical guidelines do not support the use of manual therapy (MT) interventions for Fibromyalgia (FM) patients, despite evidence of positive biochemical, mechanical and psychological effects, and the popularity of hands-on treatments amongst patients. An optimal dose for MT has not been established; this may explain the discrepancies found within the published literature. The aim of this systematic review was to determine whether there is a dose response relationship for MT leading to improvements in core domains of FM symptomology; Pain, Mood, Sleep, Global Measure of Impact (Functional Status & Quality of Life).

METHODS

We searched six databases from 1990 to January 2018; studies were evaluated using the PEDro scale. Within-group (ESd) and between-group (ESg) Effect Sizes were calculated.

RESULTS

We identified and screened 4012 articles, 12 articles were critically appraised. Overall, there is moderate evidence that MT has positive effects on the four clinical outcomes investigated. However, there was no consistent dose response relationship observed across all studies.

CONCLUSIONS

A dose of approximately 45 min MT, three to five times per week, for three to five weeks, totalling 11 h 15 min, should be considered a baseline generic protocol for treatment delivery and research trials. Further research is necessary to confirm domain specific, or patient specific optimal doses. Moderator variables such as treatment time, frequency, duration; and MT type also need to be explored to ensure optimal delivery of MT in future research and clinical care provision.

Translation, validation and cross-cultural adaptation of the Revised Fibromyalgia Impact Questionnaire (FIQR) in Nepali language

OBJECTIVE

To translate, cross-culturally adapt and test the psychometric properties of the Revised Fibromyalgia Impact Questionnaire (FIQR) in Nepali language (Nepali FIQR).

METHODS

The translation was performed following the methodological standards described by Beaton. Comprehensibility testing of the preliminary version was done in 40 fibromyalgia patients, and a pre-final version was prepared after making changes in the original version to maintain the equivalence with the target version. Psychometric testing was done in another group of 130 fibromyalgia patients to test for content validity and reliability. Construct validity was tested with visual analog score (VAS) for pain and Short Form (SF)-36.

RESULTS

Nepali FIQR was comprehensible to 92.5% patients. The internal consistency was also acceptable with Cronbach's alpha of 0.900, 0.714 and 0.863 for function, overall and symptoms domain, respectively. Construct validity was also acceptable with a moderate correlation between Nepali FIQR and VAS and SF-36. Test-retest reliability of the total Nepali FIQR and of each item were acceptable with intraclass correlation coefficient (ICC) of >0.7 in all items except for question 1 of function domain (ICC: 0.65).

CONCLUSIONS

Nepali FIQR is a comprehensible, reliable and valid tool for evaluation of the functional status of Nepalese patients with fibromyalgia and should be implemented in routine clinical care and research settings.

Patient Reported Outcome Measures of Sleep Quality in Fibromyalgia: A COSMIN Systematic Review

Poor sleep quality is a common concern and a troublesome symptom among patients suffering from fibromyalgia. The purpose of this review was to identify and describe the available patient reported outcome measures (PROMs) of sleep quality validated in adult people diagnosed with fibromyalgia. The COSMIN and PRISMA recommendations were followed. An electronic systematized search in the electronic databases PubMed, Scopus, CINAHL Plus, PsycINFO, and ISI Web of Science was carried out. Validation studies of PROMs of sleep quality in fibromyalgia published in English or Spanish were included. The selection of the studies was developed through a peer review process through the online software "COVIDENCE". The quality of the studies was assessed using the COSMIN Risk of Bias checklist. A total of 5 PROMs were found validated in patients with fibromyalgia: (1) Pittsburgh Sleep Quality Index (PSQI), (2) Jenkins Sleep Scale (JSS), (3) Sleep Quality Numeric Rating Scale (SQ-NRS), (4) Medical Outcomes Study-Sleep Scale (MOS-SS), and (5) Fibromyalgia Sleep Diary (FSD). The quality of the evidence was very good and the quality of the results ranged from moderate to high. All the included PROMs, except for the FSD, showed adequate psychometric properties and, therefore, are valid and reliable tools for assessing sleep quality in the context of FM. However, none of the studies analyzed all the psychometric properties of the included PROMs as established in the COSMIN guidelines, highlighting that this is a potential field of research for future investigations.

Diagnosis of fibromyalgia: comparison of the 2011/2016 ACR and AAPT criteria and validation of the modified Fibromyalgia Assessment Status

Objective

To compare the concordance of the three diagnostic criteria, respectively the 2011 ACR criteria (ACR 2011 Cr), the ACR 2016 criteria (ACR 2016 Cr) and the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks (ACTTION)-APS Pain Taxonomy criteria (AAPT Cr), and to explore the performance of an additional set of criteria, the modified Fibromyalgia Assessment Status (FAS 2019 modCr), in the diagnosis of FM syndrome.

Methods

Consecutive patients with chronic widespread pain, referred by the primary care setting, underwent rheumatologic assessment that established the presence or not of FM and were investigated through the four sets of proposed criteria. For the FAS 2019 modCr, discriminant validity to distinguish patients with FM and non-FM was assessed with receiver operating characteristic curve analysis.

Results

A total of 732 (405 with FM and 327 with other common chronic pain problems) patients were evaluated. Against the clinical diagnosis of FM, the sensitivity, specificity and correct classification were, respectively: 79.8, 91.7 and 85.1% for ACR 2011 Cr; 78, 90.5 and 83.6% for the ACR 2016 Cr; and 73.8, 91.7 and 81.8% for the AAPT Cr. The alternative set, proposed on the FAS 2019 modCr, provided a maximal diagnostic accuracy with a score ≥20 (Youden’s index), with a sensitivity of 84.2%, specificity 89.0% and positive likelihood ratio 7.65.

Conclusion

There is a considerable agreement between criteria-based diagnoses of FM, although the AAPT Cr perform least well in terms of percentage of correct classification. The FAS 2019 modCr had comparable characteristics.

Flexibility exercise training for adults with fibromyalgia

BACKGROUND

Exercise training is commonly recommended for adults with fibromyalgia. We defined flexibility exercise training programs as those involving movements of a joint or a series of joints, through complete range of motion, thus targeting major muscle-tendon units. This review is one of a series of reviews updating the first review published in 2002.

OBJECTIVES

To evaluate the benefits and harms of flexibility exercise training in adults with fibromyalgia.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PEDro (Physiotherapy Evidence Database), Thesis and Dissertation Abstracts, AMED (Allied and Complementary Medicine Database), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), and ClinicalTrials.gov up to December 2017, unrestricted by language, and we reviewed the reference lists of retrieved trials to identify potentially relevant trials.

SELECTION CRITERIA

We included randomized trials (RCTs) including adults diagnosed with fibromyalgia based on published criteria. Major outcomes were health-related quality of life (HRQoL), pain intensity, stiffness, fatigue, physical function, trial withdrawals, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected articles for inclusion, extracted data, performed 'Risk of bias' assessments, and assessed the certainty of the body of evidence for major outcomes using the GRADE approach. All discrepancies were rechecked, and consensus was achieved by discussion.

MAIN RESULTS

We included 12 RCTs (743 people). Among these RCTs, flexibility exercise training was compared to an untreated control group, land-based aerobic training, resistance training, or other interventions (i.e. Tai Chi, Pilates, aquatic biodanza, friction massage, medications). Studies were at risk of selection, performance, and detection bias (due to lack of adequate randomization and allocation concealment, lack of participant or personnel blinding, and lack of blinding for self-reported outcomes). With the exception of withdrawals and adverse events, major outcomes were self-reported and were expressed on a 0-to-100 scale (lower values are best, negative mean differences (MDs) indicate improvement). We prioritized the findings of flexibility exercise training compared to land-based aerobic training and present them fully here.Very low-certainty evidence showed that compared with land-based aerobic training, flexibility exercise training (five trials with 266 participants) provides no clinically important benefits with regard to HRQoL, pain intensity, fatigue, stiffness, and physical function. Low-certainty evidence showed no difference between these groups for withdrawals at completion of the intervention (8 to 20 weeks).Mean HRQoL assessed on the Fibromyalgia Impact Questionnaire (FIQ) Total scale (0 to 100, higher scores indicating worse HRQoL) was 46 mm and 42 mm in the flexibility and aerobic groups, respectively (2 studies, 193 participants); absolute change was 4% worse (6% better to 14% worse), and relative change was 7.5% worse (10.5% better to 25.5% worse) in the flexibility group. Mean pain was 57 mm and 52 mm in the flexibility and aerobic groups, respectively (5 studies, 266 participants); absolute change was 5% worse (1% better to 11% worse), and relative change was 6.7% worse (2% better to 15.4% worse). Mean fatigue was 67 mm and 71 mm in the aerobic and flexibility groups, respectively (2 studies, 75 participants); absolute change was 4% better (13% better to 5% worse), and relative change was 6% better (19.4% better to 7.4% worse). Mean physical function was 23 points and 17 points in the flexibility and aerobic groups, respectively (1 study, 60 participants); absolute change was 6% worse (4% better to 16% worse), and relative change was 14% worse (9.1% better to 37.1% worse). We found very low-certainty evidence of an effect for stiffness. Mean stiffness was 49 mm to 79 mm in the flexibility and aerobic groups, respectively (1 study, 15 participants); absolute change was 30% better (8% better to 51% better), and relative change was 39% better (10% better to 68% better). We found no evidence of an effect in all-cause withdrawal between the flexibility and aerobic groups (5 studies, 301 participants). Absolute change was 1% fewer withdrawals in the flexibility group (8% fewer to 21% more), and relative change in the flexibility group compared to the aerobic training intervention group was 3% fewer (39% fewer to 55% more). It is uncertain whether flexibility leads to long-term effects (36 weeks after a 12-week intervention), as the evidence was of low certainty and was derived from a single trial.Very low-certainty evidence indicates uncertainty in the risk of adverse events for flexibility exercise training. One adverse effect was described among the 132 participants allocated to flexibility training. One participant had tendinitis of the Achilles tendon (McCain 1988), but it is unclear if the tendinitis was a pre-existing condition.

AUTHORS' CONCLUSIONS

When compared with aerobic training, it is uncertain whether flexibility improves outcomes such as HRQoL, pain intensity, fatigue, stiffness, and physical function, as the certainty of the evidence is very low. Flexibility exercise training may lead to little or no difference for all-cause withdrawals. It is also uncertain whether flexibility exercise training has long-term effects due to the very low certainty of the evidence. We downgraded the evidence owing to the small number of trials and participants across trials, as well as due to issues related to unclear and high risk of bias (selection, performance, and detection biases). While flexibility exercise training appears to be well tolerated (similar withdrawal rates across groups), evidence on adverse events was scarce, therefore its safety is uncertain.

Stress levels predict substantial improvement in pain intensity after 10 to 12 years in women with fibromyalgia and chronic widespread pain: a cohort study

Background

Previous studies of prognosis for women with Fibromyalgia (FM) or chronic widespread pain (CWP) show contradictory results. However, some women appear to improve in pain and other core symptoms over time. There is limited knowledge about predictors of substantial improvement in pain intensity over a longer period of time. The primary objective of this study was to investigate the natural course of pain intensity and distribution of pain over 10 to 12 years in a cohort of 166 women with FM or CWP. Secondarily we wanted to investigate predictors of substantial improvement (≥50%) in pain intensity after 10 to 12 years.

Methods

The study is a longitudinal prospective cohort study. 166 women with FM or CWP were followed up after 10 to 12 years. 126 women (76%) participated in the follow-up and completed a battery of questionnaires concerning pain intensity, pain distribution and other physical and mental aspects of health. Differences in symptoms within the cohort over 10 to 12 years and predictors of substantial improvement (≥50%) in pain intensity were calculated.

Results

Pain had improved at the 10 to 12 year follow-up (p < 0.001) with a mean change of − 9.2 mm (SD 23.3, 95% CI: − 13.3; − 5.0) for pain intensity and − 2.0 sites (SD 4.2, 95% CI: − 2.7; − 1.2) for pain distribution. Nine percent of the 126 women showed an individual moderate improvement in pain intensity while 16% showed a substantial improvement at the follow-up as compared to baseline. Lower symptoms of stress and higher pain intensity at baseline predicted higher probability of reporting at least 50% less pain intensity after 10 to 12 years as compared to baseline.

Conclusions

A majority of women with FM and CWP appear to have a positive course of pain over time, which should be communicated to these patients in health care. Reducing stress levels might contribute to better chances of improvement over time.

Trial registration

Clinicaltrials.gov NCT02872129, registered 06/30/2016.

The benefit of adding a physiotherapy or occupational therapy intervention programme to a standardized group-based interdisciplinary rehabilitation programme for patients with chronic widespread pain: a randomized active-controlled non-blinded trial

Objective:

To evaluate the benefit of adding occupational therapy or physiotherapy interventions to a standard rehabilitation programme targeted for chronic widespread pain.

Design:

Randomized active-controlled non-blinded trial.

Subjects:

Women with chronic widespread pain recruited in a tertiary outpatient clinic.

Methods:

Participants were randomized to a two-week, group-based standard rehabilitation programme followed by 16 weeks of group-based occupational therapy (Group BOT, n = 43) or 16 weeks of group-based physiotherapy (Group BPT, n = 42). Group A only received the two-week rehabilitation programme acting as comparator ( n = 96).

Outcomes:

Primary outcomes were the Assessment of Motor and Process Skills and Short Form-36 (SF36) Mental Component Summary score.

Results:

Mean changes in motor and process ability measures were clinically and statistically insignificant and without differences across the three groups assessed 88 weeks from baseline. Motor ability measures: −0.006 (95% confidence interval (CI): −0.244 to 0.233) in Group BOT; −0.045 (95% CI: −0.291 to 0.202) in Group BPT; and −0.017 (95% CI: −0.248 to 0.213) in Group A, P = 0.903. Process ability measures: 0.087 (95% CI: −0.056 to 0.231) in Group BOT; 0.075 (95% CI: −0.075 to 0.226) in Group BPT; and 0.072 (95% CI: −0.067 to 0.211) in Group A, P = 0.924. Mean changes in patient-reported outcomes were likewise small; clinically and statistically insignificant; and independent of group allocation, except for the SF36 mental component summary score in the BPTgroup: 8.58 (95% CI: 1.75 to 15.41).

Conclusion:

Participants were on average stable in observation-based measures of functional ability and patient-reported outcomes, except in overall mental well-being, favouring the enhanced intervention. Efficacy of additional interventions on functional ability remains uncertain.

Pain Measurement in Rheumatic and Musculoskeletal Diseases: Where To Go from Here? Report from a Special Interest Group at OMERACT 2018

Objective.

Establishing a research agenda on standardizing pain measurement in clinical trials in rheumatic and musculoskeletal diseases (RMD).

Methods.

Discussion during a meeting at the Outcome Measures in Rheumatology (OMERACT) 2018, prepared by a systematic review of existing core outcome sets and a patient online survey.

Results.

Several key questions were debated: Is pain a symptom or a disease? Are pain core (sub)domains consistent across RMD? How to account for pain mechanistic descriptors (e.g., central sensitization) in pain measurement?

Conclusion.

Characterizing and assessing the spectrum of pain experience across RMD in a standardized fashion is the objective of the OMERACT Pain Working Group.

Therapeutic validity of exercise interventions in the management of fibromyalgia

BACKGROUND

This study aimed to evaluate the therapeutic validity of exercise interventions included in a previous umbrella systematic review of high-quality randomized controlled trials (RCTs) in the management of fibromyalgia and to explore whether exercise interventions with high therapeutic validity and that meet the 2013 American College of Sports Medicine (ACSM) guidelines are positively associated with greater pain relief.

METHODS

Therapeutic validity was evaluated based on the CONsensus on Therapeutic Exercise and Training (CONTENT) Scale, in high methodological quality RCTs found in the nine systematic reviews of a previous umbrella review on exercise interventions in the management of fibromyalgia. Additionally, adherence to the 2013 ACSM exercise recommendations for fibromyalgia was analyzed. The effect size for pain relief after the exercise programs was also considered.

RESULTS

The CONTENT mean total score was 4.42 out of 9, demonstrating generally low therapeutic validity of the 28 included RCTs. There was poor concordance between therapeutic validity and pain relief (Kappa values ranging between -0.6 to 0.57). Kappa statistic results showed poor concordance (k=0.01) between statistically significant (P<0.05) pain relief values and adherence to the 2013 ACSM exercise recommendations.

CONCLUSIONS

The therapeutic validity of exercise intervention programs in fibromyalgia is low. This is mainly due to incomplete descriptions of exercise interventions and adherence. Poor concordance is found between high therapeutic validity and adherence to the ACSM exercise recommendations with pain relief. Improved standardized reporting is recommended to identify optimal exercise prescription for fibromyalgia.