Comment on: Efficacy of adding pain neuroscience education to a multimodal treatment in fibromyalgia: A systematic review and meta-analysis.

Abstract

We read with interest the systematic review and meta-analysis (SR/MA) by Saracoglu et al regarding the efficacy of adding pain neuroscience education (PNE) to a multimodal treatment in fibromyalgia.1 Fibromyalgia can cause widespread musculoskeletal pain, fatigue, sleep disturbance, cognitive dysfunction, and psychiatric symptoms. Moreover, a lack of consensus on etiopathogenesis, classification criteria, and diagnostic criteria leads to inconsistency of treatment.2 PNE is a cognitive therapy among the various fibromyalgia treatment options, and the authors made a great effort to analyze the related randomized controlled trials (RCTs) in order to demonstrate the efficacy of PNE. We recognize the authors' contribution to validate the effectiveness of PNE; however, there are a few points we would like to further discuss. First, the authors selected only 4 studies in their SR/MA, which they admitted as a limitation; nevertheless, we found an SR/MA with a similar topic which includes 8 studies.3 After comparing the searching strategies, Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagrams, and the selected RCTs of the 2 SR/MAs, we consider that the authors of the former SR/MA excluded some RCTs not because their selection was rather strict, but because their searching strategy did not include enough synonyms for fibromyalgia and PNE. For example, 2 RCTs selected in the latter SR/MA titled “How Much Is Needed? Comparison of the Effectiveness of Different Pain Education Dosages in Patients with Fibromyalgia” and “Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: a double-blind randomized controlled trial” respectively,4, 5 might have been excluded by the former SR/MA because the titles do not include the keywords in the searching strategy of the authors. Although the searching strategy of the former SR/MA is reasonable and well-defined, we suppose that adding a few more synonyms in the searching strategy might be beneficial for collecting more RCTs concerning the topic. Second, the title “Efficacy of adding pain neuroscience education to a multimodal treatment in fibromyalgia: A systematic review and meta-analysis” of this SR/MA implies that the control group should be treated with a multimodal approach; on the other hand, the intervention group should be treated with a multimodal approach added with PNE. However, the second study in table 1 of the paper does not match the inference mentioned above,6 since its control group was treated with therapeutic exercise alone, which seems different from multimodal treatment. We suggest that the word “multimodal treatment” should be clearly defined in the context, and the RCTs should be strictly selected according to the meaning of the title. An alternative solution is to broaden the scope of the SR/MA, that is, to contain studies which can demonstrate PNE's efficacy without restricting the type of control group. In that way, the SR/MA could include more studies, and the results would be more universal. Third, we suggest that the authors could analyze the follow-up results of PNE on fibromyalgia patients. The SR/MA by Suso-Martí et al extracted the follow-up results from 8 RCTs and discovered a noteworthy phenomenon.3 Although the patients with fibromyalgia showed a short-term improvement on some aspects of the Fibromyalgia Impact Questionnaire, some of the results manifest no improvement after a follow-up assessment a few months later. In other words, PNE might benefit fibromyalgia patients in the short term, but not in the long term. The outcome mentioned above is still open to discussion; therefore, the addition of a follow-up analysis could be valuable. Above all, the authors made a great attempt on validating the efficacy of PNE. The study also shows that the promising PNE treatment still lacks sufficient studies to demonstrate the optimum dosage and duration. Further discussions and analyses of PNE could take a place in revealing the whole picture of fibromyalgia treatment and contribute to helping patients. None to declare.