Repetitive Transcranial Magnetic Stimulation for Patients with Fibromyalgia: A Systematic Review with Meta-Analysis

Abstract

Objective Fibromyalgia is a poorly understood pain syndrome. Repetitive transcranial magnetic stimulation is a noninvasive brain stimulation therapy and is commonly applied for the management of fibromyalgia. However, controversy regarding its efficacy remains. Therefore, a meta-analysis was conducted to evaluate the effectiveness of repetitive transcranial magnetic stimulation (rTMS) for fibromyalgia syndrome. Method Four medical databases and one physiotherapy database were screened for randomized controlled trials. A systematic review and meta-analysis was performed. Numerical Pain Rating Scale (NPRS), Beck Depression Inventory (BDI), Hospital Anxiety and Depression Scale (HADS) anxiety score, Pain Catastrophizing Scale (PCS), Fatigue Severity Scale (FSS), Short Form-36 general health survey mental score, and Fibromyalgia Impact Questionnaire (FIQ) were set as outcome measures. Results Analysis of 14 studies and 433 participants indicated that rTMS exerted more favorable effects on the NPRS than sham rTMS after treatment (standardized mean difference = −0.49, 95% confidence interval = −0.86 to − 0.13, P = 0.008, I2 = 68%) and FIQ (standardized mean difference = −0.50, 95% confidence interval = −0.75 to − 0.25, P = 0.0001, I2 = 28%). However, the BDI, FSS, PCS, mood index, and HADS scores showed no significant difference compared with sham rTMS after treatment. The mean methodological quality of included studies was an acceptable score of 8.5 based on the PEDro scale, suggesting the validity of our conclusions. Conclusion This study demonstrated that rTMS relieved pain and enhanced quality of life of patients with fibromyalgia; however, it did not improve anxiety, depression, and other symptoms based on current reports.

Efficacy of Repetitive Transcranial Magnetic Stimulation in Fibromyalgia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

“…The higher statistical power in our review may explain the discrepancies. As for the effect sizes of previous meta-analyses, pain reduction was most surveyed, which had small to medium effect sizes [30][31][32]46]. This corresponds to our study, which also revealed a medium effect size [46].…”

“…Among them, 11 treated fibromyalgia with rTMS, and the pooled effect size revealed significant reductions in pain, depression, fatigue, and the number of tender points as well as general improvements in health and function. Finally, the most recent meta-analysis including 14 RCTs revealed improvements in pain intensity and FIQ score [32]. By enrolling up-to-date RCTs counting 17 in total, our meta-analysis further revealed treatment effects not only in FIQ score and pain but also in depression and anxiety.…”

“…Four articles of meta-analysis [29][30][31] have been published that investigated the efficacy of rTMS in patients with fibromyalgia and detected the sources of between-study heterogeneity [29][30][31][32]. The most recent one, conducted by Sun et al, concluded that rTMS improves pain intensity and FIQ score in patients with fibromyalgia, and the low-frequency rTMS in the dorsolateral prefrontal cortex (DLPFC) region seems to bring an optimal effect regarding the intensity of pain [32]. However, Sun et al did not measure the modulator effect of different diagnostic criteria for fibromyalgia.…”

“…Additionally, in patients with major depressive disorder, the effect size of rTMS was determined to be related to age, sex, episode severity, and total rTMS pulses [34][35][36][37]. However, in patients with fibromyalgia, a previous meta-analysis did not recognize a dose-effect response in pain reduction [32]. Whether a dose-effect response measured with FIQ exists is worthy of further research because the FIQ assesses a wider spectrum of symptoms [38].…”

“…Furthermore, the influence of age on rTMS efficacy in patients with fibromyalgia has not been surveyed. Finally, although Sun et al conducted a thorough and comprehensive review of this topic, they did not survey it longitudinally [32]. The duration of the treatment effect of rTMS and its moderators remain unclear.…”