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Re: In favor of multidisciplinary recommendations for fibromyalgia syndrome

Dear Editor,

For complex syndromes, such as fibromyalgia, knowledge about pathophysiology and other maintaining factors is limited and there is still no optimal treatment option on how patients have to be treated. Consequently, it is important to develop guidelines based on empirical evidence or (in the case of lacking evidence) expert opinions from different disciplines. An expert team on fibromyalgia was formed and developed recommendations for the management on fibromyalgia syndrome at the Eular 2007. However, the present expert groups did not come to the same conclusions as several published meta-analyses, namely that non-pharmacological treatments, particularly a combination of cognitive-behavior therapy and exercise therapy, were more effective than pharmacological treatments (1-5). Although possible new evidence may be a reason for this altered conclusion, it may at least partly be ascribed to the way the recommendations and guidelines were developed in the present article. For example, the authors state that the contribution of cognitive behavior therapy was based on expert opinion, because “the only two studies identified for our review with pure cognitive behavioral therapy (CBT) were of poor quality”. However, this conclusion might be mainly ascribed to the type of the selection and quality criteria (in addition to the expert opinions) used for the present recommendations.

With regard to the quality of trials, the recommendations are based on 3 main criteria, including randomization, blinding and allocation concealment. However, with regard to the blinding criteria, it is rather impossible in cognitive-behavioral interventions to include blinding in a (placebo) control condition, since patients have to be aware about the content of the intervention. This largely explains the differences in quality scores between the pharmacological and non-pharmacological trials (1-5). Consequently, different quality criteria for pharmacological and non-pharmacological studies in RCTs have to be used, in line with previous quality criteria developed for non-pharmacological pain treatments (6). Relying on the quality criteria for pharmacological studies results in a selection bias of studies on which the recommendations are based and the exclusion of trials that showed positive effects of non-pharmacological treatments. Also with regard to the selection process, only those studies were selected that used outcome measures of “VAS pain” and “FIQ” as a measure of pain and disability. As a result, several high-quality studies using other (better validated) outcomes measures are now excluded (1-5). Moreover, randomization is usually a prerequisite for a study to be included in meta-analyses instead of being used as a quality criterion. However, non-randomized open trials were included for the recommendations, which may largely interfere with the results of other high-quality studies. As a consequence, the selection and judgments of the analyzed studies from more than 140 studies in this review is not entirely clear.

Finally, high-quality studies of combinations of cognitive-behavior therapy with exercise therapy, which was previously recommended as the highest priority, have not been included (1-5). As an multidisciplinary expert group on fibromyalgia, we consequently suggest to update the published EULAR 2007 recommendations and to re-evaluate the contribution of multidisciplinary treatments for fibromyalgia syndrome, in favor of the well-being of patients with fibromyalgia.

References

1. Rossy LA, Buckelew SP, Dorr N, et al. A meta-analysis of fibromyalgia treatment interventions. Ann Behav Med 1999;21:180-91.

2. Hadhazy VA, Ezzo J, Creamer P, et al. Mind-body therapies for the treatment of fibromyalgia. A systematic review. J Rheumatol 2000;27:2911-8.

3. Sim J, Adams N. Systematic review of randomized controlled trials of nonpharmacological interventions for fibromyalgia. Clin J Pain 2002;18:324-36.

4. Koulil S. van, Effting M, Kraaimaat FW, Lankveld W van, Helmond Tvan, Cats H, Riel PLCM, van, de Jong AJL, Haverman JF, & Evers AWM. A review of cognitive-behaviour therapies and exercise programmes for fibromyalgia patients: State of the art and future directions. Ann Rheum Dis 2007;66:571-581.

5. Scascighini L, Toma V, Dober-Spielmann S, Sprott H. Multidiscplinary treatment for chronic pain: a systematic review of interventions and outcomes. Rheumatol 2008, doi: 10.1093/rheumatology/ken021