Received: 3 December 2022 | Accepted: 22 December 2022
DOI: 10.1111/1756-185X.14571
COMMENT
Comment on: Efficacy of adding pain neuroscience education
to a multimodal treatment in fibromyalgia: A systematic review
and meta-­analysis
We read with interest the systematic review and meta-­analysis (SR/
MA) by Saracoglu et al regarding the efficacy of adding pain neuro-
science 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 effi-
cacy 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 search-
ing 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 fibro-
myalgia 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 for-
mer 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 inter-
vention group should be treated with a multimodal approach added
with PNE. However, the second study in table 1 of the paper does
Chia-­Chin Wu contributed equally to the manuscript as first author.
© 2023 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd.
Int J Rheum Dis. 2023;26:1003–1004. 
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 treat-
ment still lacks sufficient studies to demonstrate the optimum dos-
age 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.
K E Y WO R D S
fibromyalgia, pain neuroscience education
C O N FL I C T O F I N T E R E S T
None to declare.
Ya-­Yu Lee
Chia-­Chin Wu
Yih-­Jyh Lee
School of Medicine, Chung Shan Medical University, Taichung,
Taiwan
wileyonlinelibrary.com/journal/apl | 1003
 |
1004
Correspondence
Yih-­Jyh Lee, School of Medicine, Chung Shan Medical
University, Taichung, Taiwan, Address: No. 22, Fude St., Xinyi
District, Taipei City 110035, Taiwan.
Email: terry8707021@gmail.com
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1756185x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1756-185X.14571 by Readcube (Labtiva Inc.), Wiley Online Library on [03/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
COMMENT
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