Effects of Pharmacologic and Nonpharmacologic Interventions for the Management of Sleep Problems in People With Fibromyalgia: Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

Abstract

Objective: Fibromyalgia is a chronic condition characterized by widespread musculoskeletal pain and fatigue. Almost everyone with fibromyalgia has sleep problems. We aimed to evaluate the effectiveness and safety of current interventions for the management of fibromyalgia-related sleep problems.

Methods: Major electronic databases were searched in November 2021. We focused on randomized controlled trials assessing pharmacologic and/or nonpharmacologic interventions in adults and children and identified 168 studies for inclusion. We assessed the methodologic quality of included studies using the Cochrane Risk-of-Bias tool. Our primary outcome of interest was sleep quality assessed using validated patient-reported outcome measures.

Results: Results from primary studies were analyzed using network meta-analyses (NMA). The NMA for sleep quality included 65 studies evaluating 35 treatment categories (8,247 participants). Most studies were at high overall risk of bias. Compared with placebo or sham treatments, there was some evidence that exercise (specifically land-based aerobic exercise training in combination with flexibility training [standardized mean difference (SMD) -4.69, 95% credible interval (Crl) -8.14 to -1.28] and aquatic-based aerobic exercise training [SMD -2.63, 95% Crl -4.74 to -0.58]) may improve sleep. There was also a suggestion that land-based strengthening exercise, psychological and behavioral therapy with a focus on sleep, electrotherapy, weight loss, dental splints, antipsychotics, and tricyclics may have a modest effect on sleep.

Conclusion: There is a low level of certainty surrounding the effectiveness of interventions for the management of sleep problems in people with fibromyalgia, but some forms of exercise training appear more likely to provide an improvement in sleep quality.

Figure 1

PRISMA flow diagram for identification of the quantitative studies. For more information, visit: http://www.prisma‐statement.org/. Source: Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. AMED, Allied and Complementary Medicine Database; CENTRAL, Cochrane Central Register of Controlled Trials; CINAHL, Cumulative Index to Nursing and Allied Health Literature; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta‐Analyses; PROM, patient‐reported outcome measure; RCT, randomized controlled trial.

Figure 2

Summary of RoB assessment of the included studies. RoB, risk of bias.

Figure 3

Network diagram for sleep outcome. 1, placebo or sham; 2, education and LD flexibility exercise; 3, LD mind‐body exercise; 4, LD aerobic exercise; 5, education; 6, usual care; 7, AQ aerobic exercise; 8, nutrition; 9, balneotherapy; 10, generic PT/BT; 11, manual therapy; 12, relaxation; 13, electrotherapy; 14, LD flexibility exercise; 15, PT/BT targeted to sleep; 16, AQ mind‐body exercise; 17, AQ mixed exercise; 18, weight loss; 19, neuromodulation; 20, nonmainstream practice; 21, dental splint; 22, hyperbaric oxygen therapy; 23, LD aerobic exercise and LD flexibility exercise; 24, multidisciplinary; 25, LD flexibility exercise and manual therapy; 26, balneotherapy and AQ mixed exercise; 27, tricyclics; 28, antipsychotics; 29, endogenous hormones; 30, antioxidant; 31, SRIs; 32, gabapentinoid; 33, analgesic; 34, CNS depressants; and 35, LD strengthening exercise. Circle size represents the number of randomized participants; line width represents the number of direct comparisons. AQ, aquatic; CNS, central nervous system; LD, land‐based; PT/BT, psychological or behavioral therapy; SRI, serotonin reuptake inhibitor. Color figure can be viewed in the online issue, which is available at http://onlinelibrary.wiley.com/doi/10.1002/acr.25505/abstract.