Efficacy of Extracorporeal Shockwave Therapy on Pain and Function in Myofascial Pain Syndrome: A Systematic Review and Meta-analysis of Randomized Clinical Trials.

OBJECTIVE: The aim of the study is to examine the effectiveness of extracorporeal shockwave therapy in reducing pain, improving functionality, joint range of motion, quality of life, fatigue, and health status self-perception in people with myofascial pain syndrome. METHODS: PubMed, the Cochrane Library, CINAHL, the Physiotherapy Evidence Database, and SPORTDiscus were systematically searched for only randomized clinical trials published up to June 2, 2022. The main outcome variables were pain, as reported on the visual analog scale and pressure pain threshold, and functionality. A quantitative analysis was conducted using the inverse variance method and the random effects model. RESULTS: Twenty-seven studies were included ( N = 595 participants in the extracorporeal shockwave therapy group). The effectiveness of extracorporeal shockwave therapy for relieving pain was superior for the extracorporeal shockwave therapy group compared with the control group on the visual analog scale (MD = -1.7 cm; 95% confidence interval = -2.2 to -1.1) and pressure pain threshold (mean difference = 1.1 kg/cm 2 ; 95% confidence interval = 0.4 to 1.7) and functionality (standardized mean difference = -0.8; 95% confidence interval = -1.6 to -0.04) with high heterogeneity. However, no differences were found between extracorporeal shockwave therapy and other interventions as dry needling, exercises, infiltrations, and lasers interventions. CONCLUSIONS: Extracorporeal shockwave therapy is effective in relieving pain and improving functionality in patients with myofascial pain syndrome compared with control and ultrasound therapy. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Determine the effectiveness of radial and focal extracorporeal shockwaves on pain perception, the pressure pain threshold, and functionality in people with myofascial pain syndrome; (2) Describe the intervention protocol of extracorporeal shockwave therapy to improve pain perception in people with myofascial pain syndrome; and (3) Describe the advantages and disadvantages of extracorporeal shockwave therapy versus other intervention such as dry needling. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Assessing the relevance of mental health factors in fibromyalgia severity: A data-driven case study using explainable AI.

BACKGROUND AND OBJECTIVE: Fibromyalgia is a chronic disease that causes pain and affects patients' quality of life. Current treatments focus on pharmacological therapies for pain reduction. However, patients' psychological well-being is also affected, with depression and pain catastrophizing being common. This research addresses the clinicians' need to assess the influence of mental health factors on FM severity compared to pain factors. METHODS: A co-development study between FM clinicians and data scientists analyzed data from 166 FM-diagnosed patients to assess the influence of mental health factors on FM severity in comparison to pain factors. The study used the Polysymptomatic Distress Scale (PDS) and Fibromyalgia Impact Questionnaire (FIQ) as FM severity indicators and collected 15 variables including regarding demographics, pain intensity perceived, and mental health factors. The team used an author's developed framework to identify the optimal FM severity classifier and explainability by selecting a number of features that lead to obtaining the best classification result. Machine learning classifiers employed in the framework were: decision trees, logistic regression, support vector machines, random forests, AdaBoost, extra trees, and RUSBoost. Explainability analyses were conducted using the following explainable AI techniques: SHapley Additive exPlanations (SHAP), Partial Dependence Plot (PDP), and Mean Decrease Impurity (MDI). RESULTS: A balanced random forest with 6 features achieved the best performance with PDS (AUC_ROC, mean = 0.81, std = 0.07). Being FIQ the target variable, due to the imbalance in FM severity levels, a binary and a multiclass classification approaches were considered achieving the optimal performance, respectively, a logistic regression classifier (AUC_ROC, mean = 0.83, std = 0.08) with 6 selected features, and a random forest (AUC_ROC, mean = 0.91, std = 0.04) with 8 selected features. Next, the explainability analysis determined mental health factors were found to be more relevant than pain perceived factors for FM severity. CONCLUSIONS: This study's findings, validated by clinicians, are potentially aligned with FM international guidelines that promote non-pharmacological interventions such as promoting mental well-being of FM patients.

Effectiveness of Transcranial Direct Current Stimulation Combined With Exercising in People With Fibromyalgia: A Randomized Sham-Controlled Clinical Trial.

OBJECTIVE: To evaluate the effectiveness of transcranial direct current stimulation (tDCS) combined with exercising in people with fibromyalgia. DESIGN: Randomized, triple-blind, sham-controlled, clinical trial. SETTING: Primary health care center. PARTICIPANTS: A total of 120 volunteer participants (N=120) between 18 and 65 years old and diagnosed with fibromyalgia. Four participants dropped out of the study for causes unrelated to the intervention. INTERVENTION: Participants were randomized into 3 groups (active tDCS+exercising, sham tDCS+exercising, no-intervention control). The intervention was delivered in 5 sessions over 2 weeks. MAIN OUTCOME MEASURES: Pain intensity and referred pain area after suprathreshold pressure stimulation. RESULTS: Pain intensity further decreased in the active tDCS group vs control (mean, -14.43; 95% confidence interval, -25.27 to -3.58) at post intervention, unlike the sham tDCS group. Both tDCS groups did not achieve greater reductions in referred pain vs control. In the active tDCS group, health status (mean, -14.80; 95% confidence interval, -23.10 to -6.50) and pain catastrophizing (mean, -6.68, 95% confidence interval, -11.62 to -1.73) improved at post intervention, and so did health status (mean, -8.81; 95% confidence interval, -17.11 to -0.51), pain catastrophizing (mean, -7.00; 95% confidence interval, -12.13 to -1.87), and depression (mean, -3.52; 95% confidence interval, -6.86 to -0.19) after 1 month. In the sham tDCS group, improvements were recorded in health status (mean, -13.21; 95% confidence interval, -21.52 to -4.91) and depression (mean, -3.35; 95% confidence interval, -6.35 to -0.35) at post intervention and in health status (mean, -8.77; 95% confidence interval, -17.06 to -0.47), pain catastrophizing (mean, -5.68; 95% confidence interval, -10.80 to -0.55), and depression (mean, -3.98; 95% confidence interval, -7.31 to -0.64) after 1 month. No intergroup differences were observed between active and sham tDCS. CONCLUSIONS: Active and sham tDCS improved health status, pain catastrophizing, and depression vs control, but pain intensity decreased only in the active tDCS group.

A New Approach to Assess Blinding for Transcranial Direct Current Stimulation Treatment in Patients with Fibromyalgia. A Randomized Clinical Trial.

Correct blinding is essential for preventing potential biases. The aim of this study was to assess the blinding of participants and a therapist following treatment with transcranial direct current stimulation in subjects with fibromyalgia using James' and Bang's blinding indexes. Eighty subjects were randomly allocated either active or sham stimulation groups in an intervention of five sessions lasting 20 min each. A questionnaire was delivered to both the therapist and patients after the last session to record their guess of which treatment had been applied. No differences between the groups were noted at baseline in terms of demographic or clinical data. James' BI was 0.83 (CI 95%: 0.76-0.90) for the patients and 0.55 (CI 95%: 0.45-0.64) for the therapist. Bang's BI for subjects was -0.08 (CI 95%: -0.24-0.09) and -0.8 (CI 95%: -0.26-0.1) for the active and sham transcranial direct current stimulation groups, respectively. Bang's BI for the therapist was 0.21 (CI 95%: -0.02-0.43) and 0.13 (CI 95%: -0.09-0.35) for the active and sham transcranial direct current stimulation groups, respectively. Protocols of active and sham transcranial direct current stimulation applied in this study have shown satisfactory blinding of the therapist and subjects with fibromyalgia.

Pressure-Induced Referred Pain as a Biomarker of Pain Sensitivity in Fibromyalgia.

BACKGROUND: Fibromyalgia (FM) syndrome is characterized by widespread pain, fatigue, and generalized increased pain sensitivity. Appropriate and simple pain models are methods employed to assess pain mechanisms that can potentially lead to improved treatments. Pressure pain thresholds (PPTs) or mapping the referred pain area produced by pressure stimulation at suprathreshold intensities are used to assess pain mechanisms. The optimal suprathreshold stimulation intensity to elicit referred pain with minimal discomfort for patients with FM has yet to be determined. OBJECTIVES: The aim of this study was to compare the area and intensity of pressure-induced referred pain in patients with FM as elicited by systematic increases in PPTs, compared with controls. STUDY DESIGN: Observational, crossed-section study. SETTING: Research laboratory. METHODS: Twenty-six patients with FM and 26 healthy controls, age- and gender-matched, were included. Suprathreshold stimulation was applied to the infraspinatus muscle of the dominant side at 4 different intensities (PPT +20%, +30%, +40%, and +50%), after which referred pain was evaluated by measuring the area of pain in pixels using a digital body chart and its intensity on a Visual Analog Scale. Factors related to anxiety condition, pain catastrophizing, depression, and quality of life were recorded. RESULTS: The referred pain areas were larger in the FM group compared with healthy individuals at 120% (P = 0.024), 130% (P = 0.001), 140% (P = 0.001), and 150% (P = 0.001) PPT, however, within the FM group no differences were found between the intensity of suprathreshold stimulation and the size of the referred pain areas (P = 0.135) or pain intensity (P > 0.05). There was a positive correlation between the size of referred pain areas and pain catastrophizing in the FM group (r = 0.457, P = 0.032). LIMITATIONS: This study presents some limitations, among which is the variability found in the referred pain areas. CONCLUSIONS: These findings show that referred pain induced by applying a suprathreshold pressure of 120% PPT can be a useful biomarker to assess sensitized pain mechanisms in patients suffering from FM. KEY WORDS: Referred pain, pain sensitivity, fibromyalgia, central sensitization, suprathreshold, pressure pain threshold, biomarker, facilitated pain mechanisms.