Association of Therapies With Reduced Pain and Improved Quality of Life in Patients With Fibromyalgia: A Systematic Review and Meta-analysis

updated
Tags: treatment, fibromyalgia, chronic pain, pain problems

Two articles on PainSci cite Mascarenhas 2020: 1. A Rational Guide to Fibromyalgia2. Cognitive Behavioural Therapy for Chronic Pain

PainSci summary of Mascarenhas 2020: ?This page is one of thousands in the PainScience.com bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.

This meta-analysis of fibromyalgia treatments is partly “garbage in, garbage out,” and partly continuing confirmation that no popular treatment works well for these patients, and most don’t work at all.

The researchers identified “high-quality evidence” that CBT just barely works: good evidence of a minor effect. To an even more modest extent, two classes of drugs — antidepressants and central nervous system depressants — were confirmed to have minor benefits.

But literally none of those seemingly good-news results actually rose to the level of clinical significance. And confirmation of a benefit that is barely noticeable at best is really just one step away from confirming that it doesn’t work, a classic damned-with-faint-praise situation.

And then there’s the rest of the data: the “garbage.” Over 220 trials with almost 30,000 subjects, and most of it was just worthless — which is more of a repudiation of fibromyalgia science itself than fibromyalgia treatments. Lots and lots of data that mostly just tells us that most of the studies are worthless. The researchers concluded: “Clinicians should be aware that current evidence for most of the available therapies for the management of fibromyalgia is limited to small trials of low methodological quality.”

~ Paul Ingraham

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

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.

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