Pain neuroscience education for fibromyalgia
The study concluded that adding PNE to a multimodal treatment will be effective for the management of fibromyalgia, and recommended that other medications or comorbidities could be compared and elaborated on in the discussion.
Abstract
Dear Editor, We read with great interest the article by Saracoglu et al.,1 which discussed the effect of adding pain neuroscience education (PNE) for patients with fibromyalgia. The study concluded that adding PNE to a multimodal treatment will be effective for the management of fibromyalgia. Fibromyalgia is characterized by central sensitization due to widespread musculoskeletal pain, as attributable to alterations in the sensory processing in the central nervous system.2 As the etiology of fibromyalgia is multifactorial, with triggering factors including not only infection, surgery, and physical trauma, but also immunological and hormonal imbalance,2,3 it is highly plausible that PNE should be incorporated into the multimodal management of fibromyalgia. We strongly agree with and appreciate Saracoglu et al. for their article. However, some points deserve further discussion. First, the contents of educational modules, the number of sessions, and the duration of PNE vary across studies. It is always difficult to measure the effectiveness of educational modules in metaanalyses.4 Consequently, a multimodal approach with details of lifestyle factors such as exercise and PNE sessions and exact content for pain control should be covered to determine the efficacy of patient education incorporating PNE for fibromyalgia. Second, PNE when used as an educational strategy by physicians focused on teaching patients and their families how to cope with pain in the neurobiological and neurophysiological aspects, has been shown to be effective not only in fibromyalgia but also in low back pain in previous studies.5 Further results of PNE in other articles can be discussed further. Noteworthy positive improvements in gait speed, pain disability, and fear of movement have been demonstrated in patients with low back pain who received PNE.5,6 Benefits of PNE were similarly achieved for chronic fatigue syndrome, when patients with chronic fatigue syndrome reported a significant reduction in the Pain Catastrophizing Scale after receiving PNE, compared with control individuals.7 In contrast, in patients with lumbar surgery for radiculopathy, patients receiving PNE were more likely to view their surgical experience favorably and underwent 45% fewer medical tests and treatments; that said, there was no evidence for significant changes in the pain scale between patients who received PNE versus those who did not.8 In addition, we would also recommend that other medications or comorbidities could be compared and elaborated on in the discussion. Besides disease pathogenesis and recommended lifestyle and movement modifications, medicines also play an essential role in pain control for fibromyalgia. Opioids are commonly used for pain control and the treatment of fibromyalgia; nonetheless, the opioid crisis has been largely discussed in recent studies, and the longterm use of opioids in patients has therefore been discouraged because of safety concerns.9 Moreover, serotoninnorepinephrine reuptake inhibitors (SNRIs) were also reported to have no clinical benefit in reducing fatigue or improving healthrelated quality of life over placebo in patients with fibromyalgia.10 As rising studies have provided the efficacy of pharmacological interventions for pain control in fibromyalgia, future studies emphasizing the safety and potential adverse drug reactions11 of pain medications including opioids, SNRIs, and nonsteroidal antiinflammatory drugs12 in educational modules for patients using overthecounter medicines were warranted to augment more aspects of pain control in fibromyalgia. Likewise, as underlying inflammatory processes may trigger or exacerbate fibromyalgia and its comorbidities,13 educational modules that cover antiinflammatory lifestyle and medications may largely benefit patients with fibromyalgia or chronic widespread pain who have concomitant inflammatory rheumatic diseases, including rheumatic arthritis or ankylosing spondylitis.14 These lifestyle determinants include diet, smoking, drinking, sleep,1518 and other habits that serve as risk factors for fibromyalgia,19 for which lifestyle modifications may promote symptom alleviation and improve the quality of life of patients with fibromyalgia. In conclusion, the clinical relevance of PNE for fibromyalgia has been highlighted. For the multifactorial etiology and complex comorbidities of fibromyalgia, the detailed content of patient PNE, lifestyle modifications, and drug safety are of paramount importance to managing fibromyalgia.