Schulze NB, Salemi MM, de Alencar GG, et al. Efficacy of Manual Therapy on Pain, Impact of Disease, and Quality of Life in the Treatment of Fibromyalgia: A Systematic Review. Pain Physician. 2020 Sep;23(5):461-476. (Systematic review)

BACKGROUND: Myofascial mobilization has been used as an intervention for patients with fibromyalgia (FM) for acting on ascending nociceptive pathways possibly involved in the central sensitization process, modulating the pain experience. However, there is still a gap in its efficacy compared with another hands-on approach because manual therapy has nonspecific effects, such as placebo.

OBJECTIVES: This systematic review aims to review the scientific literature for an overview of the efficacy of manual therapy in pain, disease impact, and quality of life in patients with FM compared with control or other treatments through randomized clinical trials.

STUDY DESIGN: This study involved systematic review of published randomized controlled trials (RCTs).

SETTING: This study examined all RCTs evaluating the effect of manual therapy on pain, impact of disease, and quality of life for patients with FM.

METHODS: Systematic review. The research was performed in 9 databases: MEDLINE/PubMed, CINAHL, Web of Science, Scopus, ScienceDirect, Lilacs, SciELO, PEDro, and Cochrane. Searches were carried out from the end of the project until September 2019, with no language and year restrictions. Randomized controlled clinical trials that used the following outcome measures were included: Visual Analog Scale, Fibromyalgia Impact Questionnaire, and SF-36 Quality of Life Questionnaire. The risk of bias and quality of studies was assessed using the PEDro scale; the Cochrane risk-of-bias tool; and Grading of Recommendations Assessment, Development, and Evaluation System.

RESULTS: Seven studies were included (368 patients). The quantitative analysis was performed on 4 studies because of the lack of data in the others. Myofascial release was the most used modality. The level of evidence ranged from very low to moderate, mainly because of the inconsistency and inaccuracy of results.

LIMITATIONS: The present systematic review presented limitations because of the heterogeneity of the included studies and only a short-term analysis of the intervention results. It was observed that other information, such as pressure, repetition, and/or sustaining manual therapy techniques, could be better described in future protocols, aiming at a better comparison between the techniques and their subsequent reproducibility.

CONCLUSIONS: Current evidence of manual therapy in patients with FM, based on a very low to moderate quality of evidence, was inconclusive and insufficient to support and recommend the use of manual therapy in this population. To date, only general osteopathic treatment has achieved clinically relevant pain improvement when compared with control.

Discipline Area Score
Rehab Clinician (OT/PT) 5 / 7
Physician 5 / 7
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Comments from MORE raters

Physician rater

No conclusion could be mentioned with respect to myofascial release, or myofascial release combined with exercise. The clinical benefit with osteopathic treatment was based only in one study.

Physician rater

The importance of this review is that it shows that manual therapy has no clinically relevant effect on fibromyalgia.

Physician rater

This is a systematic review of published trials looking at the efficacy of manual therapies, mainly Myofascial release, on pain, disease impact and quality of life in patients with Fibromyalgia. Like most systematic reviews, the usefulness of the review is mainly determined by the quality of the published studies included and, unfortunately, like most systematic reviews the published studies that could be included in this review were few, of low to moderate quality with considerable heterogeneity which results in very uncertain conclusions from this systematic review. At this stage, there is little evidence to support a role for such manual therapies in the treatment of Fibromyalgia and such treatments are often poorly tolerated by this group of patients.

Physician rater

This is an interesting systematic review of 7 studies and 368 patients which aims to evaluate the effect of manual therapy on pain, the impact of the disease, and quality of life for patients with fibromyalgia. The review followed PRISMA guidelines and was prospectively registered at PROSPERO. The methodology is described in sufficient detail; although, the number of patients is too small to derive any meaningful conclusion. Overall, this is an interesting and relevant manuscript.

Rehab Clinician (OT/PT) rater

It should be no surprise to clinicians that a passive treatment (manual therapy) is unlikely to have any long term benefit this population. Active treatments with patient education (pain science), coaching, sometimes psychological or cognitive behavioral intervention, and definitely active exercise programs should be the comparison groups in future RCTs for fibromyalgia.
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