Clinical Rheumatology

, Volume 31, Issue 1, pp 55–66 | Cite as

An overview of systematic reviews of complementary and alternative medicine for fibromyalgia

Original Article

Abstract

Fibromyalgia (FM) is a chronic pain condition which is difficult to diagnose and to treat. Most individuals suffering from FM use a variety of complementary or alternative medicine (CAM) interventions to treat and manage their symptoms. The aim of this overview was to critically evaluate all systematic reviews of single CAM interventions for the treatment of FM. Five systematic reviews met the inclusion criteria, evaluating the effectiveness of homoeopathy, chiropractic, acupuncture, hydrotherapy and massage. The reviews found some evidence of beneficial effects arising from acupuncture, homoeopathy, hydrotherapy and massage, whilst no evidence for therapeutic effects from chiropractic interventions for the treatment of FM symptoms was found. The implications of these findings and future directions for the application of CAM in chronic pain conditions, as well as for CAM research, are discussed.

Keywords

Complementary/alternative medicine (CAM) Fibromyalgia Systematic review 

Introduction

Fibromyalgia (FM) is a chronic pain disorder characterised by widespread pain and often accompanied by other symptoms including sleep disruption and chronic fatigue. Affecting between 1% and 4% of the population [1], it is also associated with other syndromes such as irritable bowel syndrome and depression. As the pathophysiology of FM remains unclear, neither diagnosis nor treatment is straightforward [2, 3, 4, 5, 6, 7, 8]. Integrated, multidisciplinary care programmes are generally offered conventionally to manage FM symptoms, which take into account the complex interactions between physical, psychological and social factors that shape responses to the pain and other symptoms of FM [4, 5, 6]. Recent evidence-based guidelines for the management of FM [7, 8, 9] have proposed multidisciplinary, tailored approaches to the management of FM symptoms, recommending non-pharmacological and pharmacological interventions. However, clear evidence of the benefits of these remains elusive; reports of symptom reduction are mixed, and adverse effects of medication are frequently experienced [7, 8, 9, 10, 11]. Moreover, a recent review of these guidelines highlighted a number of inconsistencies between the guidelines’ recommendations which may be attributable to the study inclusion criteria, weighting systems and composition of the panels [10].

Prior research has found that around 90% of individuals suffering from FM use or have used at least one form of complementary or alternative medicine (CAM) to manage their symptoms [12, 13, 14, 15]. CAM has been defined as “a group of diverse medical and health care systems, practices and products that are not generally considered part of conventional medicine” [16]. That which may be considered to be CAM is influenced by political, social and cultural issues and the dominant health care system. The definition of CAM is therefore fluid, evolving and often contested, and the boundaries between CAM and conventional medicine are often not clear-cut. The prevalence of CAM use in the general population is generally much lower than amongst FM sufferers, currently around 30–40% in the UK. A growing literature has indicated a variety of ‘push’ and ‘pull’ factors influencing patients’ decision to consult CAM instead of conventional health care providers [17]. An example of a ‘pull’ factor would be ‘holding beliefs that are congruent with the CAM’, whereas a ‘push’ factor would be ‘dissatisfaction with orthodox medicine’. It has been suggested that the perceived failure of conventional medicine (as is often the case for FM sufferers) may be one of the strongest motives for seeking CAM [17].

Considerable amounts of data have accumulated in recent years relating to the efficacy and effectiveness of CAM options to treat FM. These data have emerged from numerous trials which vary in terms of objective, methodology and design, as well as through systematic review and meta-analyses of these trials [see e.g. 18, 19]. Systematic reviews are often considered to be the least biased source of evidence to evaluate the value of a particular intervention. The aim of this article is to provide an overview of the evidence of efficacy and effectiveness from all systematic reviews of single CAM options for the treatment of FM.

Methods

Medline, PsychInfo, Embase, CINAHL, BNI, AMED via the EBSCO interface and CENTRAL via the Cochrane library were searched until March 2010 using two concepts—fibromyalgia and systematic reviews/meta-analyses:
  • Fibromyalgia concept (in Pubmed):

  • Fibromyalgia.af.

  • Fibromyal$.af.

  • Fibrositis.af.

  • Fibromyositis.af.

  • Chronic ADJ widespread ADJ pain.af.

  • Fibromyalgia/.

  • Systematic review filter (Pubmed):

  • Systematic review.ti,ab.

  • Meta-analysis.pt.

  • Meta-analysis.ti,ab.

  • Systematic literature review.ti,ab.

  • Review.pt.

  • Evidence synthesis.ti,ab.

No restrictions regarding the language of the article were imposed. Reference lists of all full-text articles retrieved were hand-searched for additional reviews. Completed systematic reviews of any trial data (e.g. randomised controlled trials or controlled clinical trials) evaluating any type of CAM therapy for the treatment of FM against any comparator were included. The reviews must have reported a systematic search strategy, to have searched more than one database and reviewed a single CAM treatment for FM. Interventions frequently recommended by mainstream healthcare practitioners to treat FM (exercise, patient education, cognitive/behavioural therapies and other widely employed psychological therapies) were excluded. Interventions relating to diet and nutritional advice were also excluded, as were reviews of complex systems consisting of a combination of a wide range of therapeutic modalities such as Traditional Chinese Medicine (TCM).

For inclusion, the systematic reviews must have provided data relating to at least one of the following outcomes
  • Pain (tender point count, tender point count on palpation, pain intensity, affect etc., assessed using a standardised pain measure such as VAS, McGill Pain Questionnaire; Chronic Pain Scale)

  • Global status or overall improvement

  • Specific functional status change

  • Generic functional status of QoL

  • Work-related measures

  • Health care consumption and costs

  • Patient satisfaction

  • Adverse effects/events of treatment

  • Emotional, mood or depression outcomes

Data were independently extracted from the included reviews by two of the authors (RT and RP) and entered on to data extraction sheets. In addition, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, which include a 27-item checklist, were used to evaluate the included reviews [20].

Results

The search strategy produced 1,622 hits. Two of the authors (RT and RP) screened the titles and abstracts of those identified for further discussion by the first author regarding whether or not full-text versions should be retrieved (n = 131). In total, 28 full-text articles were retrieved and examined independently by two authors (RT and RP) in order to determine whether the inclusion criteria were met. Five publications were found to be appropriate for inclusion into the overview and are summarised in Table 1. The remainder of the retrieved texts were excluded because they were not reviews of a single CAM intervention for FM, because they were reviews of combined interventions, because more complete and methodologically robust reviews were available, or a combination of these reasons. The five reviews—of acupuncture [21], chiropractic [22], homoeopathy [23], hydrotherapy [24] and massage [25]—had met or addressed many of the checklist items contained in the PRIMSA guidelines. None of the reviews met all of the PRISMA items. Table 2 summarises whether or not a robust search strategy was employed when executing the systematic reviews, the type and number of studies included, whether or not a meta-analysis was carried out, details of risk of bias (for example, sample size and power issues, whether or not group allocation was concealed, whether or not participants were appropriately randomised and blinding procedures) and heterogeneity, quality assessments of the primary studies and participant numbers and a summary of PRISMA checklist items. The outcome measures reported in each review are detailed in Table 3. A flowchart detailed in Fig. 1 illustrates the process for including or excluding potential systematic reviews.
Table 1

Summary of included reviews

First author (year) and type of CAM intervention

Type of intervention

Type of control

Treatment duration

Side effects

Main results

Authors’ conclusions

Comments

Langhorst et al. (2009) [21] Acupuncture

Traditional Chinese acupuncture points (seven studies), standardised acupuncture points (two studies), individualised points (five studies), electroacupuncture (two studies), manual acupuncture (five studies)

Two control arms with different types of sham acupuncture (one study), three control arms, two sham and one simulated) (one study) simulated vs. no treatment (one study). Four studies had one control arm: simulated acupuncture (three studies) sham acupuncture (one study)

12–15 weeks: median, 8 weeks and nine sessions of acupuncture (range, 6–15)

Three/seven studies reported adverse events (3–70%) including discomfort at needle site, nausea, soreness and worsening of FM. One study reported dropout due to side effects, 17% in verum and 15% in control group

Reduction in pain reported (SMD −0.25; 95% CI −0.49, −0.02 p = 0.04, seven studies) at posttreatment. Significant reduction of pain was only present in studies with risk of bias. No significant reduction in fatigue, sleep disturbance or physical function. No evidence for the reduction of pain or improved physical function at latest follow-up

Small analgesic effect, not distinguishable from bias. Acupuncture cannot be recommended for the management of FM

One high-quality multi-centred study favoured sham acupuncture condition over acupuncture treatment intervention for pain reduction.

Ernst (2009) [22] Chiropractic

‘chiropractic care’ (one study), chiropractic treatment plus cranial electrotherapy stimulation plus prescribed drugs (one study), chiropractic spinal adjustments plus soft tissue therapy (one study), resistance training plus chiropractic twice weekly (one study)

Wait list (one study), CES plus prescribed drugs (one study), ultrasound treatment or no treatment (one study), resistance training (one study)

3 weeks (one study), 4 weeks (one study), 16 weeks, (one study), duration not reported (one study)

Not reported

No significant differences in any outcome between groups in either of the two studies with a Jadad score of 2

“Insufficient evidence to conclude that chiropractic is an effective treatment for fibromyalgia”

Results available for three studies. In one study, no results or participant numbers were reported.

Perry et al. (2009) [23] homoeopathy

Individualised homoeopathy (two studies) standardised or semi standardised (‘best fit’) (two studies)

Placebo (three studies), treatment as usual (one study)

4–22 weeks

Not reported

Significant between-group differences for pain and sleep when remedy ‘well indicated’ (p < 0.05) (one study), significant difference in TPC (two studies), greater TPC in one study (p < 0.05). Significant difference between groups for sleep (two studies)

“All four trials favoured homeopathy over control conditions. Paucity and at times disappointing quality of the available RCTs render firm conclusions problematic”

Notablemethodological flaws make interpretation of the results difficult. However, the highest quality study using individualized remedies in a double-blind RCT showed significant improvements in FM and global health ratings in homoeopathy groups.

Langhorst et al. (2009) [24] Hydrotherapy

Hydrotherapy: medicinal bath (valerian or pine) (one study), hydrogalvanic (Stanger) baths (two studies), mud baths (two studies), spa therapy (five studies)

Therapy as usual (four studies), plain water (one study), relaxation training (two studies), no therapy (one study), amitriptyline (one study), multicomponent treatment plus 222cryocabin (one study)

10 days–5 weeks

Few side effects reported; ‘slight flushing’ in two participants

Reduction in pain (SMD −0.78; 95% CI −1.42 −0.13 p < 0.0001; nine study arms) Improved HR QOL (SMD −1.67 95% CI −2.91, −0.43 p = 0.008 (four studies). Reduction of pain and improvement in HRQOL at latest follow-up (median, 14 weeks; p = 0.0005) High levels of heterogeneity (I2>75)

Moderate evidence that hydrotherapy has short-term beneficial effects of pain and HRQOL in FM patients

Only three had ‘moderate’ van Tulder scores (5–7/11), the rest were lower (<5/11). Largest effect in studies with low van Tulder score

Kalichman (2010) [25] Massage

Massage: manual lymphatic drainage (one study), mechanical (one study), Swedish (three studies), Swedish and shiatsu (one study), connective tissue vs. MLD (one study), connective tissue massage (one study)

TENS/sham TENS Progressive muscle relaxation, no treatment, standard care, or standard care plus phone call

10–15 procedures ranging from 3–24 weeks

No side effects reported

Five studies reported improvements in pain in five of six studies reporting pain measures (p < 0.05), seven studies reported improvements in other measures of well-being or sleep

Evidence supports the assumption that MT is beneficial for FM, but rigorous research needed to confirm and ascertain that MT is safe and effective.

Included studies were of low quality. Review lacked methodological detail. Future research needs to ascertain the most appropriate type of massage, intensity and frequency

Table 2

Summary of search strategy, intervention, design and quality of studies reviewed

 

Robust search?

Type and no. of studies

PRISMA checklist (27 items) addressed or reported

Meta-analysis

Risk of bias/heterogeneity assessment

Quality assessment

Participant no. and no. of participants who completed

Langhorst et al. (2009) [21] Acupuncture

Yes

Randomised, quasi-randomised, seven studies

24 items reported/addressed, 2 not reported/addressed (items 5, 27) 1 partially reported (item 11)

Yes

Yes: type of acupuncture, type of needling, type of stimulation, intensity of acupuncture, type of control acupuncture, adequate vs. inadequate sequence generation, concealment, patient and outcome blinding funnel plots to assess publication bias

van Tulder (scores ranging from 3–8/11

p = 385 acupuncture groups, 92% (76–100%); control groups, 92% (80–100%)

Ernst (2009) [22] Chiropractic

Yes

Randomised, quasi randomised, three studies

20 items reported/addressed, 6 not reported (items 5, 16, 21, 22, 23, 27) 1 discussed (item 15)

No

Jadad (scores ranging from 1–2/5)

p = 108, 19/21 (91%) (one study), 21/27 (78%) (one study), dropoutates not reported in two studies

Perry et al. (2009) [23] homoeopathy

Yes

Randomised, quasi randomised, four studies

21 items reported/addressed, 5 items not reported (5, 16, 17, 21, 23) 1 discussed (item 15)

No

Jadad (scores ranging from 2–4/5)

p = 163 (randomised). Completed, 27/30 (one study); 36/47 (one study); 24/24 (one study), dropout rates unclear in one study

Langhorst et al. (2009) [24] Hydrotherapy

Yes

Randomised, quasi randomised, ten studies

24 items reported, 1 item partially addressed (item 11), 2 not reported/addressed (5, 27)

Yes

Removal of studies with inadequate randomization, allocation concealment and dropout rate, quality score and mean substitution

van Tulder (scores ranging from 1–6/11)

p = 446 (numbers randomised not reported by all studies) Completed, 152 (hydrotherapy) intervention; 131 (control)

Kalichman (2010) [25]

No

Trials of ‘any methodological quality’ with ‘an emphasis on RCTs’

13 items addressed, 14 not reported/addressed (items 1, 5, 10, 11, 12, 13, 15, 16, 17, 19, 21, 22, 23, 27)

No

No quality assessment reported

118 (treatment groups; eight studies/treatment arms), 117 (six studies/eight control arms)

Table 3

FM-related outcomes reported in the included studies

Type of FM outcome measure

Acupuncture [21] (seven studies)

Chiropractic [22] (four studies; three reporting results)

Homoeopathy [23] (four studies plus one reanalysis)

Hydrotherapy [24] (ten studies)

Massage [25]

Pain intensity

VAS 0–10/100 (six studies)

VAS (at least one study)

VAS (two studies), FIQ pain (one study)

VAS 0–10/100 (nine studies)

VAS (at least two studies), other ‘pain’ rating (six studies)

Pain quality/affect/other

MPQ (total; sensory affect., eval.)

MPQ (two studies)

Dolorimeter value (one study)

Tender point count/TP on palpation

No. of tender points (four studies)

TPC (one study)

Fibromyalgia symptoms

No. of FM symptoms (one study)

HR QOL/global health rating/FIQ/other quality of life or well-being scale

HRQOL (1 study)

Global health (one study), EuroQuol (one study), number of days felt good (one study)

HRQOL/FIQ Total score (five studies)

FIQ (two studies), well-being VAS (one study), Disability rating index (one study), Rheumatology attitudes index (RAI) (one study), Quality of well-being scale (QWB) (one study), Arthritis impact measurement scale (AIMS) (one study)

Anxiety/depression/mood (POMS/HADS)

SF 36 (one study), VAS 0–10 (one study)

POMS (one study), HADS (one study)

BDI (three studies)

STAI, POMS (one study), CES-D (two studies)

Anger/hostility

POMS 1 study

Fatigue

VAS (two studies), MFI (one study)

Tiredness on waking (one study), fatigue (one study), POMS fatigue (one study)

VAS (one study)

Self-rated fatigue (two studies)

Sleep-related measures

0–10 VAS (one study), 0–100 VAS (one study)

VAS

VAS 0–10 (one study)

Various sleep measures (four studies)

Other FM outcome measures

Physical impairment (one study)

28 outcome measures (one study)

NHP emotional reaction (one study), corticotrophin releasing factor-like immunoreactivity (CRF-LI) (one study), stiffness (three studies), physical activity (one study)

Fig. 1

Flow chart of systematic review selection process

Acupuncture

Several systematic reviews of acupuncture have been carried out, and these were retrieved for further assessment [21, 26, 27]. The most recent of these reviews [21] was judged to be the most comprehensive and therefore selected for inclusion. It addressed methodological issues faced by prior reviews, included more recent trials (data searched included publications up to July 2009) and carried out subgroup and sensitivity analyses. The methodological quality of the studies included in this review of acupuncture was assessed using the van Tulder scale [28], which comprises a list of items relating to the internal validity of a trial, including blinding, allocation concealment and outcome assessments. All trials included had at least one control arm, which consisted of either sham or simulated acupuncture. Five of the seven randomised controlled trials (RCTs) included in the review reported greater levels of pain amelioration after the acupuncture intervention compared to control (sham acupuncture either on acupuncture points on non-acupuncture points). However, subsequent sensitivity analyses suggested that these effects were only significant in studies with risk of bias (inadequate randomisation or concealment of allocation procedures or inadequate blinding of the patient and/or outcome assessor to the intervention), whereas in studies lower risk of bias, these effects on pain were not significant. No evidence was found for fatigue reduction, sleep disturbances or improvement of physical function. At the last follow-up, levels of pain reduction were no longer significantly different between the two groups, and no improvement of physical function was found (p > 0.71 and 0.83, respectively). These findings led Langhorst et al. [21] to conclude that acupuncture could not be recommended for the treatment of FM. Three of the studies included in the review report adverse effects, stemming from all types of acupuncture, which affected between 3% and 70% of the study population. Many of the events reported were mild such as unpleasant sensation upon needle insertion.

Hydrotherapy

The recent systematic review and meta-analysis conducted by Longhorst and colleagues [24] included ten trials of hydrotherapy. Hydrotherapy interventions were described as 36–37°C thermal pool baths (five studies), 36°C whirl bath infused with pine or valerian extracts (one study), mud bath therapy (two studies), hot air therapy following 42°C mud bath (one study) and hydrogalvanic (Stanger) baths (two studies). All hydrotherapy interventions were compared to either no therapy or therapy as usual (the continuation of medication was permitted in two of five studies) and thus should be considered to be pragmatic trials, providing information on the effectiveness of the hydrotherapy intervention, rather than efficacy. Meta-analyses were carried out for pain at end of treatment (measured by VAS; nine treatment arms) and at last follow-up. Four of the ten studies were included in a meta-analysis of treatment effect on health-related quality of life at the end of therapy (p < 0.001). Langhorst et al. concluded that there is ‘moderate’ evidence that hydrotherapy has short-term positive effects on pain and health-related quality of life in FM patients. However, Langhorst et al. also highlighted the possibility that the effects of hydrotherapy may be overestimated due to the methodological design of the included studies and the small number of trials that could be included into the meta-analysis. Sample sizes were generally small, with only three studies having >25 participants in each intervention group, (previously identified as an adequate sample size to detect clinically important differences between active treatments). Most of the primary studies included in this review scored 5 or less on the van Tulder scale, with only three studies scoring between 5 and 7 out of a possible score of 11 on the van Tulder scale. Although these low scores are partly due to the pragmatic nature of the included trials, only two studies reported adequate randomisation procedures, and none appeared to adequately conceal treatment allocation or carry out intention-to-treat analyses. Only one study reported adverse effects experienced in the hydrotherapy intervention groups; 2 of the 24 participants reported ‘slight flushing’.

In a number of respects, the included reviews of acupuncture and hydrotherapy were methodologically superior to previous reviews of these topics, meeting most of the quality guidelines set out by the PRISMA statement relating to the execution of systematic reviews (Table 2) and including meta-analyses and sensitivity analyses. However, the reported search strategy for both of these was unconventional in that ‘fibromyalgia’ search terms and the acronym ‘RCT’ appeared to be combined into one search concept.

Homoeopathy

The review of homoeopathy [23] included four RCTs, two of which were described as feasibility studies. All of these reported some positive effects of the homoeopathic remedy or package of care when compared to a placebo, wait-list control condition or treatment as usual. Two studies tested the efficacy of a range of specific homoeopathic remedies [29, 30], and one tested the effectiveness of a package of care by a homoeopath [31]. One recently conducted double-blind RCT of individualised homoeopathic remedies [32], which was of a high methodological quality (appropriately powered, controlled and blinded), found some statistically significant differences between active homoeopathic remedies and placebo controls, in terms of tender point count and tender point pain on palpation. In addition, appraisals of FM symptoms and global health improved significantly after receiving homoeopathic treatment compared to placebo. The authors concluded that even though the results of the included studies favoured homoeopathy, the degree of efficacy of the homoeopathic remedy for the symptomatic treatment for FM remains ambiguous. No adverse effects of homoeopathy were reported.

Chiropractic

Only three of the four trials included in the review of chiropractic management of FM [22] reported meaningful outcome data. Control interventions included waiting list/no treatment, cranial electrotherapy stimulation and prescribed medication, ultrasound and a resistance training programme. One of the included trials was an open pilot study; one was quasi-randomised to receive either chiropractic treatments or cranial electrotherapy, with no details of each intervention provided. A third study, described as an RCT, failed to report any findings, referring only to protocol and recruitment. The authors of this review concluded that the methodological quality of the included studies was generally poor. The data suggest few differences between the groups of participants undergoing various chiropractic interventions and the control groups, and this review concluded that there was no evidence to indicate that chiropractic may be effectively used to treat the symptoms of FM. Adverse effects were not reported in this review.

Massage therapy

Massage therapy is widely used by patients with FM [14, 15], and data from pragmatic trials relating to the efficacy of connective tissue, manual lymphatic drainage, Swedish and Shiatsu massage have recently been reviewed [25]. Six included studies were described as RCTs (although in one study, no direct comparisons between study groups were made), and two were reported as single-arm studies. Control treatment included transcutaneous electrical nerve stimulation (TENS), sham TENS, progressive muscle relaxation, no treatment, standard care and standard care plus phone call. A wide range of outcomes were assessed by the primary studies (see Table 3). Whilst all studies included in the review reported improvements in FM measures (pain, sleep, well-being, etc.), these tended to be short-lived. No data on adverse effects were reported. The authors concluded that the existing literature provides modest support for the use of massage therapy in FM but highlighted the need for additional rigorous research to establish its safety and efficacy of the particular massage interventions and the appropriateness of different types, intensity and frequency of the massage intervention.

Discussion

Five reviews of single CAM interventions for FM met the present inclusion criteria. None of the included reviews generated conclusively positive evidence for a CAM intervention for the effective management or treatment of FM. However, some significant reductions in pain ratings and improvements in quality of life measures compared to the control intervention were reported by a notable proportion of the trials included in the homoeopathy, hydrotherapy, massage and acupuncture reviews.

Acupuncture is widely used to manage a broad spectrum of chronic pain conditions, and the data obtained from the systematic review and meta-analysis indicate some short-term analgesic effect for FM pain compared to the control conditions. This is a clinically interesting finding particularly if, as Langhorst et al. noted [21], the control conditions (including sham or simulated acupuncture) may influence pain perception to some extent through a number of theoretical physiological mechanisms (e.g. spinal and supraspinal endorphin release, diffuse noxious inhibitory control). Possible underlying physiological actions of some forms of acupuncture for individuals suffering FM-related pain have been identified, and a variety of hypotheses have been generated which may provide some explanation for the apparently conflicting results of the trial data included in the published systematic reviews of acupuncture [33]. One large and well-executed study included in Langhort et al’s review appeared to favour control conditions (sham and simulated acupuncture) over the verum acupuncture in terms of pain amelioration. However, whilst this in an important finding, there may be notable statistical and methodological aspects of this particular study which may need to be considered when evaluating these findings. The effect of acupuncture on posttreatment pain was significant only in studies of medium methodological quality, not in those studies with high or low methodological quality.

Weighing up the available evidence, there may be grounds for trying acupuncture as a clinically relevant intervention for FM pain. However, pain is only one symptom of FM and any positive effects have been generally found to be short-lived. The observed trends in favour of acupuncture need to be investigated further to ascertain the extent to which these benefits arise from the acupuncture treatment and the extent to which other nonspecific therapeutic effects are involved. A recent systematic review of TCM for fibromyalgia [34] (which included trials of acupuncture, cupping and Chinese herbal medicine but excluded from our overview because it reviewed combinations of TCM rather than single interventions) similarly concluded that larger and appropriately designed trials are warranted.

For other FM symptoms (e.g. fatigue, sleep and physical function), evidence to indicate the efficacy of acupuncture is lacking. Measures relating to quality of life, fatigue and sleep satisfaction were only reported in two of the seven studies included in the review. No significant reductions in fatigue, sleep disturbance or improvement in physical function was found (<0.05). The current evidence therefore suggests that future research efforts may be more productive with a narrower focus on the use of acupuncture for FM pain per se rather than the broader range of FM symptoms.

The review of hydrotherapy interventions concluded that there was ‘moderate’ evidence for the effectiveness of hydrotherapy to manage the symptoms of FM on the basis of meta-analyses and subsequent sensitivity analyses. Whilst these findings appear to be promising, it is necessary to examine the specific and mechanistic effects underlying this type of therapeutic intervention, which essentially involves bathing in water heated to temperatures around 40°C, with or without the addition of various herbal infusions. If these effects are found to be replicable in more methodologically robust investigations, thermal baths with or without the addition of herbs—or mud—may provide a cost-effective, low risk and simple form of pain relief which could be used to self-manage pain, one of the most prevalent and debilitating aspects of FM, in at-home settings.

The evidence relating to the efficacy or effectiveness of chiropractic interventions tends to be negative as the reviewed data provide no indication of any specific therapeutic benefits to be gained for FM sufferers when compared to various control interventions. Because of the heterogeneity inherent in FM populations and the high prevalence of comorbidities, it is plausible that some individuals may find certain aspects of chiropractic intervention to be of some value. However, the summary of trial data currently available provides little evidence that chiropractic practices should be adopted by FM sufferers or recommended by health professionals.

Current data relating to the efficacy of homoeopathy for FM are limited, and the published literature relating to homoeopathic interventions continues to present a conundrum for many CAM researchers. Whilst some argue that the basic principles of homoeopathy are biologically implausible and that any observed effects arise from some form of placebo response, others have argued that some homoeopathy trials do seem to indicate benefits for patients, in spite of the fact that a clear scientific explanation of the action of homoeopathic preparations is elusive [35]. Clarifying the relative efficacy of the homoeopathic remedy per se and the effectiveness of the homoeopathic intervention (which includes many other facets of care as well as the homoeopathic remedy) is essential if any headway is to be made towards identifying which aspects of the homoeopathic interventions are responsible for any observed effects [36].

Massage is widely used to relieve the symptoms of FM and, although the primary studies and the review of massage are not methodologically robust, the data relating to massage therapy for the treatment of FM symptoms may provide preliminary indications that some types of massage may help to ease FM-related pain and improve sleep quality and other QOL measures in the short term. In support of this assertion, massage has been shown to have positive effects on autonomic responses, assist general body relaxation, muscle spasm and tissue tenderness and increase plasma b-endorphins [37]. Other types of massage aimed at stimulating lymphatic drainage may be effective in relieving other symptoms such as anxiety and fatigue [38].

Certain methodological issues currently limit recommendations or conclusions relating to the efficacy or effectiveness of massage for FM from being made. The quality of the primary massage trials included in the review appears to be generally quite low, and the number of participants is small. No quality assessment of the primary studies was included, and details relating to intervention blinding and allocation concealment were lacking. In addition, the search strategy of the review was not fully reported, and only keywords that were included in the database search were provided. The review of massage for FM was apparently carried out by only one author, which theoretically may compromise the systematic review process. Although the review of chiropractic interventions also only had one author, two other individuals were acknowledged for their assistance with data extraction, quality assessment and literature searching.

The currently available reviews of CAM therapies suggest that acupuncture, massage, homoeopathy and hydrotherapy may be helpful in the treatment of FM. But there remains a deficit in the evidence base, and the nonspecific effects of CAM treatments are generally poorly understood. Nonspecific effects may be considered under the umbrella term of ‘placebo’, whilst others may result from other needs being met, such as improving feelings of being in control of one’s health, positive patient–practitioner interaction and addressing other lifestyle and psychological factors.

It is perhaps encouraging to note that all of the included systematic reviews have been published very recently. This may indicate that CAM research may be moving further up the agenda for research funders and institutions, and if this continues, there may come a time when it is possible to collate data from trials of a reasonably high quality to provide a clearer indication of efficacy and how these findings may translate into effectiveness of the intervention in ‘real world’ settings. However, trial data for many nutritional, herbal and hormonal supplements, Ayurvedic medicine, hypnosis, various forms of relaxation and other mind–body interventions and energy therapies which may be useful in the treatment of FM remain to be systematically reviewed. Qualitative research investigating how and why various forms of CAM are found to be beneficial for FM sufferers, in combination with ‘N of 1’ methodology [39], may provide insights in addition to those gained from high-quality controlled trials and subsequent systematic reviews of such trials.

Limitations and future directions

The current overview of the included review literature has important limitations. Even though we went to great lengths to find all relevant publications, we cannot be entirely sure that all have been retrieved; for example, publication bias might have led to negative reviews remaining undiscovered by our search strategy. The included systematic reviews reported that most interventions were only assessed as adjunct therapies. Details on blinding, allocation concealment, potential biases in outcome reporting and other threats to internal validity such as power and sample size calculations and sampling strategy were sparse. On the other hand, it is important to note that these difficulties are not unique to CAM research, and previous investigators have noted the high proportion of systematic reviews of biomedical interventions which have concluded that there is insufficient evidence to indicate efficacy [40]. The value of future systematic reviews and meta-analyses would be further enhanced by closely adhering to the recently developed PRISMA guidelines for the reporting of systematic reviews. In addition, the wide variety of symptoms inherent in FM potentially hinders the assessment of the value of therapeutic CAM interventions. The choice of outcome measures and the necessity for improving the methodological quality of future trials and subsequent systematic reviews of those trials must therefore be a foremost consideration in the design of future investigations of CAM treatments for FM.

Conclusion

The five systematic reviews included in this overview were all published recently, which suggests a current keen scientific interest in this area. Although none of the reviews were without flaws, and whilst certainty regarding the efficacy of treatment remains elusive, encouraging evidence exists for hydrotherapy and massage interventions. The use of homoeopathy and acupuncture to treat the pain of FM also appears promising, but the specific therapeutic value of the interventions remains uncertain. Therefore, further rigorous and well-designed investigations appear to be warranted to ensure that a thorough assessment of the value of the intervention can be made, both in terms of efficacy and in terms of how this translates into ‘real world’ practice.

Notes

Acknowledgements

We would like to express our gratitude to Leala Watson for her assistance with the search strategy and to Igho Onakpoya for his advice and help in the preparation of this manuscript. We would also like to thank an anonymous reviewer for the constructive and valuable comments during the preparation of this work.

Conflict of interests

We would like to point out that Edzard Ernst is the author of Chiropractic treatment for fibromyalgia: a systematic review, and Rachel Perry, Rohini Terry and Edzard Ernst are the authors of A systematic review of homoeopathy for the treatment of fibromyalgia.

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Copyright information

© Clinical Rheumatology 2011

Authors and Affiliations

  1. 1.Complementary Medicine, Peninsula Medical SchoolUniversity of ExeterExeterUK

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