285 Non-pharmacological interventions for people with fibromyalgia: a systematic review

Abstract

Background: Fibromyalgia (FM) affects approximately 2% of the population and characterised by chronic widespread pain, fatigue, sleep and cognitive problems. The revised European League Against Rheumatism (EULAR) recommendations for the management of FM advise that initial management should focus on patient education and non-pharmacological interventions. This systematic review aimed to evaluate the evidence-base for non-pharmacological interventions to improve the health related quality of life of people with FM. Methods: Database search included Medline (OVID), Allied and Complementary Medicine Database (AMED), CINAHL, Health Management Information Consortium (HMIC) and PsychINFO up to July 2017. The 27-item PRISMA statement checklist and a four-phase flow diagram were used to guide the review process. Randomised controlled trials (RCT) were assessed for methodological quality using the 11-item Critical Appraisal Skills Programme (CASP) checklist for RCTs by two researchers. Results: Fourteen studies published between 2003 and 2017 were included in the full review following the systematic elimination process. Interventional approaches included multi-disciplinary (MDT) rehabilitation, patient education, cognitive behavioural therapy (CBT), aquatic or aerobic-based exercise, an internet based pain course, mindfulness meditation, movement therapy and acceptance & commitment therapy (ACT). Most common outcome measure used was Fibromyalgia Impact Questionnaire (FIQ) (11 out of 14 studies) which has three domains to measure function, overall impact and symptoms of FM. Evidence to support non-pharmacological interventions for management of FM ranged from low to moderate quality rated by CASP. Majority of studies (n = 13) reported statistically significant changes in participant’s psychological status, pain, anxiety and depression, functional capacity, motivation and sleep scores post-intervention. The evidence to support the positive impact of patient education and combined exercise on quality of life of people with FM was consistent across the studies. However, there was no evidence to support the effectiveness of mindfulness meditation and Qigong movement therapy over and above patient education. MDT rehabilitation improved functional status and physical activity level, as well as significant changes in health outcomes up to 15 months post-intervention. In terms of ACT, less pain and better overall functionality was reported nine months post-intervention, when compared to control. CBT resulted in some improvements in FM symptoms, but only in the short-term. Limitations included small sample sizes, high attrition rates, short follow-ups and lack of patient partner involvement in design and development of studies. Although statistically significant findings were reported, clinical importance of these scores was only touched upon by nine studies. Also, mixed-methods trial design was only adopted by one study. Conclusion: The RCT evidence to support non-pharmacological interventions for FM range from low to moderate quality and main recommendations encompasses patient education and combined exercise therapy. There is a need for large-scale, mixed-methods, longer term RCTs designed with patient research partner involvement to investigate wide range of treatment modalities.