Mascarenhas RO, Souza MB, Oliveira MX, et al. Association of Therapies With Reduced Pain and Improved Quality of Life in Patients With Fibromyalgia: A Systematic Review and Meta-analysis. JAMA Intern Med. 2020 Oct 26. pii: 2772354. doi: 10.1001/jamainternmed.2020.5651. (Systematic review)

Importance: Fibromyalgia is a chronic condition that results in a significant burden to individuals and society.

Objective: To investigate the effectiveness of therapies for reducing pain and improving quality of life (QOL) in people with fibromyalgia.

Data Sources: Searches were performed in the MEDLINE, Cochrane, Embase, AMED, PsycInfo, and PEDro databases without language or date restrictions on December 11, 2018, and updated on July 15, 2020.

Study Selection: All published randomized or quasi-randomized clinical trials that investigated therapies for individuals with fibromyalgia were screened for inclusion.

Data Extraction and Synthesis: Two reviewers independently extracted data and assessed risk of bias using the 0 to 10 PEDro scale. Effect sizes for specific therapies were pooled using random-effects models. The quality of evidence was assessed using the Grading of Recommendations Assessment (GRADE) approach.

Main Outcomes and Measures: Pain intensity measured by the visual analog scale, numerical rating scales, and other valid instruments and QOL measured by the Fibromyalgia Impact Questionnaire.

Results: A total of 224 trials including 29?962 participants were included. High-quality evidence was found in favor of cognitive behavioral therapy (weighted mean difference [WMD], -0.9; 95% CI, -1.4 to -0.3) for pain in the short term and was found in favor of central nervous system depressants (WMD, -1.2 [95% CI, -1.6 to -0.8]) and antidepressants (WMD, -0.5 [95% CI, -0.7 to -0.4]) for pain in the medium term. There was also high-quality evidence in favor of antidepressants (WMD, -6.8 [95% CI, -8.5 to -5.2]) for QOL in the short term and in favor of central nervous system depressants (WMD, -8.7 [95% CI, -11.3 to -6.0]) and antidepressants (WMD, -3.5 [95% CI, -4.5 to -2.5]) in the medium term. However, these associations were small and did not exceed the minimum clinically important change (2 points on an 11-point scale for pain and 14 points on a 101-point scale for QOL). Evidence for long-term outcomes of interventions was lacking.

Conclusions and Relevance: This systematic review and meta-analysis suggests that most of the currently available therapies for the management of fibromyalgia are not supported by high-quality evidence. Some therapies may reduce pain and improve QOL in the short to medium term, although the effect size of the associations might not be clinically important to patients.

Discipline Area Score
Psychologist 7 / 7
Physician 6 / 7
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Comments from MORE raters

Physician rater

Good review.

Physician rater

I see nothing new here.

Physician rater

It is interesting to see that antidepressants have a medium-term effect on pain for patients with fibromyalgia. However, these associations were small and may not be clinically important to patients considering the adverse effects in the longer term. Withdrawal from antidepressants is an emerging health problem in patients with mood disorders, so what about patients with chronic pain?

Physician rater

This is a very important review. Fibromyalgia is a major cause of chronic non-malignant pain and causes significant disability. This systematic review follows the PRISMA guidelines. The comprehensive searching strategy and the accountable process of appraising the evidence were the strengths of this review. It shows that the availability of good evidence is very limited. Most of the treatment approaches were not supported by good evidence.Only cognitive behavioral therapy for pain and antidepressants and central nervous system depressants for pain and quality-of-life were supported by strong evidence, but the associations were small. Further trials are warranted.

Physician rater

This is a well-written article assessing a large number of trials in fibromyalgia treatments. The authors were rigorous in selecting trials for inclusion in their survey and correctly rejected some smaller trials after examining funnel plot analysis of the studies. As in many of the meta-analyses that are carried out in this area, many studies are under-powered and show apparent benefit in the short term but not for longer periods. The results are not really surprising to those working in this field.

Psychologist rater

This is an important study thank you for publishing this...
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