title: Repetitive Transcranial Magnetic Stimulation for Fibromyalgia: Systematic Review and Meta-Analysis.
abstract: BACKGROUND
  Fibromyalgia (FM) is a prevalent chronic pain syndrome with few effective therapeutic options available. Repetitive transcranial magnetic stimulation (rTMS) is an emerging therapeutic alternative for this condition; however, results have been mixed.
  
  
  OBJECTIVE
  To evaluate the efficacy of rTMS on FM, a comprehensive systematic review and meta-analysis were performed.
  
  
  METHODS
  Relevant published, English and Portuguese language, randomized clinical trials (RCT) comparing rTMS (irrespective of the stimulation protocol) to sham stimulation for treating FM pain intensity, depression, and/or quality of life (QoL) were identified, considering only those with low risk for bias. Trials available until April 2014 were searched through MEDLINE, EMBASE, the Cochrane Library Databases, and other 26 relevant medical databases covering from every continent. The outcomes for pain, depression, and QoL assessed closest to the 30th day after rTMS treatment were extracted, and changes from baseline were calculated to compare the effects of rTMS vs. placebo.
  
  
  RESULTS
  One hundred and sixty-three articles were screened, and five with moderate to high quality were included. rTMS improved QoL with a moderate effect size (Pooled SMD = -0.472 95%CI = -0.80 to -0.14); it showed a trend toward reducing pain intensity (SMD = -0.64 95%CI = -0.31 to 0.017), but did not change depressive symptoms.
  
  
  CONCLUSIONS
  In comparison with sham stimulation, rTMS demonstrated superior effect on the QoL of patients with FM 1 month after starting therapy. However, further studies are needed to determine optimal treatment protocols and to elucidate the mechanisms involved with this effect, which does not seem to be mediated by changes in depression, but that may involve pain modulation. Level of evidence 1b.
authors.affiliation: Laboratory of Pain and Neuromodulation, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil.|School of Medicine, Rio Grande do Sul Federal University (UFRGS), Porto Alegre, Brazil.
authors.forename: Leonardo M
authors.initials: LM
authors.lastname: Knijnik
authors.affiliation: Laboratory of Pain and Neuromodulation, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil.|Post-Graduate Program in Medical Sciences, School of Medicine, UFRGS, Porto Alegre, Brazil.|Pain and Palliative Care Service at HCPA, UFRGS, Porto Alegre, Brazil.
authors.forename: Jairo A
authors.initials: JA
authors.lastname: Dussán-Sarria
authors.affiliation: Laboratory of Pain and Neuromodulation, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil.
authors.forename: Joanna R
authors.initials: JR
authors.lastname: Rozisky
authors.affiliation: Post-Graduate Program in Medical Sciences, School of Medicine, UFRGS, Porto Alegre, Brazil.|Pharmacology Department, Institute of Basic Health Sciences, UFRGS, Porto Alegre, Brazil.
authors.forename: Iraci L S
authors.initials: IL
authors.lastname: Torres
authors.affiliation: Service of Interdisciplinary Neuromodulation, Department and Institute of Psychiatry, University of São Paulo, São Paulo, Brazil.
authors.forename: Andre R
authors.initials: AR
authors.lastname: Brunoni
authors.affiliation: Spaulding Center of Neuromodulation, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, U.S.A.
authors.forename: Felipe
authors.initials: F
authors.lastname: Fregni
authors.affiliation: Laboratory of Pain and Neuromodulation, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil.|Pain and Palliative Care Service at HCPA, UFRGS, Porto Alegre, Brazil.|Department of Surgery, HCPA, UFRGS, Porto Alegre, Brazil.
authors.forename: Wolnei
authors.initials: W
authors.lastname: Caumo
mesh_terms: D005356:Fibromyalgia / Q000523:psychology / Q000628:therapy*; D006801:Humans; D010146:Pain / Q000209:etiology; D059408:Pain Management / Q000379:methods*; D010147:Pain Measurement; D016032:Randomized Controlled Trials as Topic; D050781:Transcranial Magnetic Stimulation / Q000379:methods*; D016896:Treatment Outcome
keywords: depression; fibromyalgia; meta-analysis; neuromodulation; pain; quality of life; repetitive transcranial magnetic stimulation