Journal of Clinical and Experimental Neuropsychology

ISSN: 1380-3395 (Print) 1744-411X (Online) Journal homepage: http://www.tandfonline.com/loi/ncen20

Meta-analysis of cognitive performance in

fibromyalgia

Tyler Bell, Zina Trost, Melissa T. Buelow, Olivio Clay, Jarred Younger, David
Moore & Michael Crowe

To cite this article: Tyler Bell, Zina Trost, Melissa T. Buelow, Olivio Clay, Jarred Younger, David
Moore & Michael Crowe (2018): Meta-analysis of cognitive performance in fibromyalgia, Journal of
Clinical and Experimental Neuropsychology, DOI: 10.1080/13803395.2017.1422699

To link to this article: https://doi.org/10.1080/13803395.2017.1422699

Published online: 01 Feb 2018.

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JOURNAL OF CLINICAL AND EXPERIMENTAL NEUROPSYCHOLOGY, 2018
https://doi.org/10.1080/13803395.2017.1422699

Meta-analysis of cognitive performance in fibromyalgia

a
Tyler Bell , Zina Trosta, Melissa T. Buelowb, Olivio Claya, Jarred Youngerc, David Moored and Michael Crowea
a
Psychology Department, University of Alabama at Birmingham, Birmingham, AL, USA; bDepartment of Psychology, The Ohio State
University Newark, Newark, OH, USA; cDepartment of Psychology and Department of Anesthesiology, University of Alabama at Birmingham,
Birmingham, AL, USA; dSchool of Natural Sciences and Psychology, Liverpool John Moores University, Liverpool, UK

ABSTRACT ARTICLE HISTORY

Introduction: Fibromyalgia is a condition with symptoms of pain, physical function difficulties, Received 14 August 2017
and emotional problems, but is also characterized by complaints of poor cognition (often called Accepted 18 December 2017
“FibroFog”). Over the last two decades, a number of studies have examined cognitive differences KEYWORDS
between individuals with and without fibromyalgia. The purpose of the current study was to Chronic pain; cognition;
conduct a quantitative synthesis of these differences across multiple cognitive domains. executive function;
Method: Following Cochrane guidelines, we identified 37 eligible studies for analysis where fibromyalgia; memory;
persons with fibromyalgia (total n = 964) were compared to participants from age-matched meta-analysis
control groups without fibromyalgia (total n = 1025) on a range of neuropsychological measures.
Group differences between persons with fibromyalgia and healthy controls were examined for
cognitive domains including processing speed, long- and short-term memory, and executive
functions (inhibitory control, set shifting, updating, and accessing). Random-effect meta-analyses
were conducted to determine effect sizes for these differences in cognitive performance.
Results: Fibromyalgia was significantly and negatively associated with performance on all
domains of cognitive function. The largest effect size was found for inhibitory control
(g = 0.61), followed by memory (g = 0.51 for short-term, 0.50 for long-term memory). The smallest
cognitive difference between those with fibromyalgia and controls was for set shifting (g = 0.30).
Conclusion: These findings support the hypothesis that the self-reported cognitive impact of
fibromyalgia is also found in objective neuropsychological measures. Routine screening for
cognitive dysfunction in those with fibromyalgia may be warranted in addition to assessment
of the traditional fibromyalgia symptoms.

Fibromyalgia is a condition affecting 2% of the general difficulties known as “FibroFog.” To better understand
population at any given time (Lawrence et al., 2008), this emerging symptom cluster, the current study
with most being female (>90%; Schaefer et al., 2016). examined objective difficulties with cognitive perfor-
Common symptoms of fibromyalgia include pain, stiff- mance in those with fibromyalgia.
ness, fatigue, sleep dysfunction, and headaches Approximately 75% of fibromyalgia patients report
(Bennett, 2009; Mease, 2005; Schmidt-Wilcke & significant problems with concentration, memory, and
Clauw, 2011). Previously, fibromyalgia diagnosis multitasking (Donaldson, Sella, & Mueller, 1998;
involved pain lasting at least 3 months across five Leavitt, Katz, Mills, & Heard, 2002). In addition, self-
body quadrants (axial, left, right, upper, and lower reported cognitive difficulty is associated with higher
segment pain) and the presence of 11 out of 18 tender levels of pain, stiffness, poor sleep, and elevated depres-
points, places of high sensitivity to pressure pain sion and anxiety symptoms in fibromyalgia (Leavitt
(Wolfe et al., 1990). Criteria were later revised to et al., 2002; Wolfe et al., 2010). Cognitive difficulties
include presence of pain in seven out of 19 regions, have been reported in focus groups (Arnold et al.,
and ratings greater than 5 out of 12 on a newly created 2008), surveys (Bennett, Jones, Turk, Russell, &
scale rating symptoms of fatigue, sleep, and cognition Matallana, 2007), and observer reports of cognitive
on difficulty from 0 (no problem) to 3 (severe), and impairment from medical professionals (Zachrisson,
general symptom severity from 0 (no symptoms) to 3 Regland, Jahreskog, Kron, & Gottfries, 2002). While
(a great deal; Wolfe et al., 2010). With addition of this cognitive difficulties are thought to be relevant to clin-
symptom scale, one of the most common fibromyalgia ical care in fibromyalgia, it remains unclear whether
symptoms was included: self-reported cognitive these subjective reports correspond to objective

CONTACT Tyler Bell [email protected] Department of Psychology, University of Alabama at Birmingham, Birmingham, AL 36688, USA
© 2018 Informa UK Limited, trading as Taylor & Francis Group
2 T. BELL ET AL.

cognitive difficulties in fibromyalgia, which can impact resources, however, are limited, and cognitive goals
quality of life, treatment adherence, and negative health must be selected by their degree of saliency. Due to
outcomes (Skoog et al., 2005; Tesio et al., 2015; Zinn the evolutionary mechanism of pain (i.e., escape and
et al., 2004). Better understanding of the impact of this survival), pain processing is prioritized at the cost of
pain condition on objective cognitive difficulties may attentional resources for other goal-related behavior.
help provide a more comprehensive view of FibroFog Consequently, Eccleston and Crombez (1999) theo-
and its impact on daily living and health. Moreover, rized that constant goal disruption by pain may cause
prior research shows that the association between pain cognitive difficulties throughout the different stages of
and cognitive performance is not universal across the information processing model. Applying this the-
domains, but more specific to complex task completion ory, the current study tested for cognitive difficulties in
(such as tasks involving executive functions) than sim- fibromyalgia throughout information processing
ple processing tasks (Moore, Keogh, & Eccleston, domains using a model incorporating long-standing
2012). Thus, by understanding the objective impact of theories of working memory (Atkinson & Shiffrin,
fibromyalgia on specific cognitive domains, clinicians 1968; Baddeley & Hitch, 1974) and executive function-
may be able to predict and improve treatment out- ing (Miyake et al., 2000).
comes for this population more accurately. The cognitive model guiding the current study
To date, a large body of research has assessed task- describes the mechanics of information processing,
based neuropsychological performance in fibromyalgia. which begins at sensory perception and ends with a
Overall, research has documented cognitive difficulties behavioral response. In this model, attended informa-
in several domains including processing speed (Reyes tion is initially processed through sensory registries,
del Paso, Montoro, & Duschek, 2015), short-term and low-priority or task-irrelevant information is fil-
memory (Park, Glass, Minear, & Crofford, 2001), tered out. Relevant information is then stored into
long-term memory (Cánovas, León, Roldán, Astur, & short-term memory, which is limited and held very
Cimadevilla, 2009), inhibitory control (Walitt, briefly in systems specific to auditory–verbal and
Roebuck-Spencer, Bleiberg, Foster, & Weinstein, visuospatial information. Rehearsal and elaboration
2008), and working memory (Coppieters et al., 2015). can then move information into long-term memory
However, some mixed results regarding specific cogni- to be stored and recalled for an unlimited amount of
tive domains have also been reported. In a review of time. The storage of relevant information, however, is
literature by Glass (2009), people with fibromyalgia not sufficient to achieve goal-related behavior. Instead,
show consistent difficulties in episodic/semantic mem- a central executive cognitively controls information to
ory and working memory (Cánovas et al., 2009), but produce an appropriate response; such control is pos-
there are other studies showing no signficant differ- sible through specific, though related, sets of executive
ences in other cognitive domains (Cánovas et al., 2009; functions within the central executive.
Di Tella et al., 2015; Walitt et al., 2008; Walteros et al., Executive functions are higher level cognitive pro-
2011), making generalizations from previous research cesses implemented in goal creation, planning, and
more difficult. In order to clarify the objective nature of response execution (Lezak, 2004; Lezak, Howieson, &
cognitive problems in those with fibromyalgia, a meta- Loring, 1983). Miyake et al. (2000) provided evidence
analysis is needed to quantitatively synthesize results for separate but nonorthogonal components of the
across multiple studies and guide futher investigation. central executive, falling into the subcategories of inhi-
bition, set shifting, and updating, which are moderately
interrelated. Inhibiting involves purposive prevention
Theoretical foundations for the current meta-
of interference from prepotent responses (responses
analysis
previously reinforced and associated with stimuli;
Studies examining the cognitive difficulties in fibro- Barkley, 2013); shifting involves changing mental sets
myalgia and other chronic pain conditions have to provide an appropriate response; and updating
hypothesized compromised attention systems due to involves adding and deleting representations in work-
shared networks with pain (Cánovas et al., 2009; ing memory by goal relevance. Recently, Fisk and
Correa, Miro, Martinez, Sanchez, & Lupianez, 2011; Sharp (2004) have expanded on the work of Miyake
Glass et al., 2011). Eccleston and Crombez (1999) pro- et al. (2000) with the addition of a new executive
posed that pain is an obstacle for efficient cognitive function known as accessing (often measured as verbal
processing. In this model, attention leads to selection of fluency), which involves executive action to retrieve
information salient to cognitive goals, which are trig- information from long-term memory. Assessing indi-
gered by internal and external stimuli. Attentional vidual executive functions may add additional insight
 JOURNAL OF CLINICAL AND EXPERIMENTAL NEUROPSYCHOLOGY 3

into the integrity of the central executive in (“fibromyalgia” AND “cognitive”); (“fibromyalgia”
fibromyalgia. AND “executive”); (“fibromyalgia” AND “memory”);
The current study examines differences between (“fibromyalgia” AND neuropsychological”). Identified
persons with fibromyalgia and healthy adults on cog- articles were then indexed by database and key terms.
nitive function including processing speed, short-term
memory, long-term memory, and executive functions.
The potential moderating role of age is also examined Study selection and inclusion
as older adults with fibromyalgia may show greater
Two steps were involved in study article selection (see
cognitive difficulties due to age-related declines.
Figure 1). The first step involved two independent
reviewers (T.B., M.B.) screening all possible citations
Method to filter out articles that did not relate to fibromyalgia
and cognition based on information from titles and
Data sources
abstracts. The key terms searched in the databases
The current study employed a systematic search of the provided 2355 citations, and after removing duplicates
literature using the Cochrane Collaborations (Higgins (n = 882), there were 1472 articles to be screened. After
& Green, 2011) and the Preferred Reporting Items for review, 1367 articles were excluded based on irrele-
Systematic Reviews and Meta-Analyses (PRISMA) vance to the meta-analysis focus (fibromyalgia and
guidelines (Moher, Liberati, Tetzlaff, & Altman, task-measured cognitive performance). For example,
2009). Pubmed, PsychInfo, and OVID databases were 28.9% (n = 396) involved diagnosis and treatment/
searched (from January 1950 to July 2015) using interventions for fibromyalgia, 28.9% (n = 396) did
Boolean terms including “fibromyalgia” and words not pertain to objective task-measured cognition,
describing cognition: (“fibromyalgia” AND “atten- 19.2% (n = 263) were not peer-reviewed empirical
tion”); (“fibromyalgia” AND “cognition”); articles (e.g., reviews, commentaries), 12.5% (n = 171)

Records identified through database

Identification

searching
(n = 2355)

Records after duplicates removed

(n = 1472)
Screening

Records screened Records excluded

(n = 1472) (n = 1367)

Did not include a healthy age-matched

control group (n = 25)
Full-text articles assessed Not available in English (n = 4)
for eligibility
Eligibility

(n = 105) Did not look specifically at cognitive

performance (n = 16)

Not full-text research articles (n =10)

Not specific to fibromyalgia (n = 6)

Not peer-reviewed (n = 3)
Studies included in
quantitative synthesis Used emotional stimuli (n = 1)
Included

(meta-analysis) Used mental status exam/ screening

(n = 37) measure (n = 3)

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guided meta-analysis process.
4 T. BELL ET AL.

did not specifically pertain to fibromyalgia, and 8.2% mental status exam or other screening measure. This
(n = 112) related to neurophysiological aspects of fibro- process left 37 eligible studies for data extraction and
myalgia with no cognitive performance measures. subsequent analyses. It is important to note that these
Other reasons for exclusion included the use of ani- numbers reflect primary reasons for exclusion, as many
mals, no control group, or the article was only available of the excluded articles failed to meet multiple inclu-
as an abstract (less than 1% for each). A total of 105 sion criteria. For this step of selecting the 37 of 105
studies were deemed eligible for inclusion in the next potential articles, there was a high interrater reliability
step of screening, with high interrater reliability above (kappa = .96, p < .001). All included studies with
chance agreement (kappa = .78, p < .001). descriptive information can be seen in Table 1.
The second step involved applying the following
inclusion criteria to each study: (a) The study was not
Data extraction
characterized by comorbid conditions that included
any neurological condition with cognitive effects Data were extracted by two independent reviewers (T.B.,
(including all forms of dementia; neural degeneration M.B.) using a standardized form (Berryman et al., 2013)
or demyelinating disorders; epilepsy; sleep disorders; tailored to current needs. Data extraction included key-
attention-deficit/hyperactivity disorder, ADHD) in the words and the location of the study (Europe, North
control group or in the patient group (other than a America, etc.). Next, data regarding sample size, partici-
primary diagnosis of fibromyalgia); (b) the study pant gender, participant age, and other demographic
looked at objective task-measured cognitive perfor- information were examined. Data were collected for
mance; (c) the study did not assess cognition with each cognitive task, including the name of the test, the
solely a mental status exam or other screening measure; cognitive domain assessed, and the means and standard
(d) the study was peer reviewed; (e) the study included deviations of scores in the fibromyalgia and the healthy
a healthy age-matched control group; (f) the data were control group. Moreover, score means, standard devia-
not related to the effects of a drug or treatment inter- tions, sample sizes, sample mean age, t-statistics, and
vention (baseline comparisons only); (g) the paper was p-values were recorded to compute effect sizes. For each
not a review or conference abstract; (h) the study measure, the domain that the measure most directly
included human participants and did not investigate assessed was determined by study description and initial
animals; (i) the study did not make use of emotion- review (e.g., Stroop–inhibition), scoring type (response
inducing stimuli (i.e., did not use negative or pain- time, accuracy, or errors), and primary stimuli type (ver-
related stimuli) during cognitive tasks, which includes bal auditory versus visuospatial).
the use of non-neutral (positive or negative) stimuli; (j)
the article was available in English; and (k) the study
Data synthesis
pertained to fibromyalgia specifically (not aggregated
with other pain conditions). Outcome measures from each study were synthesized
Of the 105 articles included in this step of eligibility, into cognitive domains of interest guided by estab-
39 studies were initially found to meet the criteria lished theoretical cognitive models (Atkinson &
while 66 articles were excluded (98% reviewer agree- Shiffrin, 1968; Baddeley & Hitch, 1974; Miyake et al.,
ment). Disagreements were settled by discussion 2000). These included processing speed, short-term
between M.B. and T.B. as well as consulting co-authors. and long-term memory, and executive functions of
Further inspection led to the exclusion of two addi- selective attention/response inhibition, set shifting,
tional articles, one that was not fully available in working memory/updating, and accessing. Because
English, and one that did not have an age-matched cognitive tasks can be measured by accuracy (higher
control group (total excluded = 68). The primary rea- scores indicating better performance), errors (more
sons for article exclusion were as follows: Of the 68 errors indicating worse performance), or response
studies excluded, 25 (36.76%) did not include a healthy time (higher scores indicating worse performance),
(age-matched) control group, 16 (23.53%) did not look effect sizes were transformed so that higher effect
specifically at cognitive performance, 10 (14.71%) were sizes indicated worse performance (expected direction).
not full-text research studies (e.g., review, commentary,
conference abstract), six (8.82%) did not pertain to
Data pooling
fibromyalgia specifically, three (4.41%) were not peer
reviewed, four (5.88%) were not available in English, For each group comparison, effect sizes were converted
one (1.47%) included emotional stimuli (induced pain), into standardized mean differences using Hedges’s g,
and three (4.41%) only assessed cognition using a calculated from group means and pooled standard
 JOURNAL OF CLINICAL AND EXPERIMENTAL NEUROPSYCHOLOGY 5

Table 1. Description of studies included and cognitive domains assessed.

Fibromyalgia group Healthy control group Cognitive domains assessed
Authors (Year) n Mage SD F/M n Mage SD F/M PS LTM STM IC SS UP A
Akdoğan, Ayhan, Yıldırım, and Borman (2013) 40 36.2 7.3 40/0 30 33.7 8 30/0 X
Cánovas et al. (2009) 15 53.33 6.29 15/0 15 53.67 6.71 15/0 X X X
Cherry et al. (2014) 43 63 7.2 43/0 44 64.8 7.3 44/0 X X X X X X X
Coppieters et al. (2015) 21 44.52 9.47 16/5 22 38 13.9 14/8 X X X
Correa et al. (2011) 18 48 6.5 18/0 19 42 8.9 19/0 X
Dailey, Keffala, and Sluka (2015) 24 52.41 2.28 23/1 33 45.09 2.5 32/1 X
Di Tella et al. (2015) 40 51.75 7.76 40/0 41 51.83 7.78 41/0 X X X X X X
Dick, Verrier, and Harker (2008) 30 49.6 12.54 30/0 30 46.56 10 30/0 X X
Duschek, Werner, Winkelmann, and Wankner, (2013) 18 59.4 11.7 18/0 24 57.3 8.9 24/0
Duschek, Werner, Limbert, Winkelmann, and Montoya (2014) 27 52.7 9.2 27/0 34 53.9 8.4 34/0 X
Glass, Park, Minear, and Crofford (2005) 23 47.83 NR 23/0 23 47.83 NR 23/0 X
Glass et al. (2011) 18 43.6 9.79 18/0 14 41.13 11.91 14/0 X
González et al. (2010) 25 50.56 8.66 25/0 25 48.04 7.55 25/0 X
Grace, Nielson, Hopkins, and Berg (1999) 30 45.87 9.79 29/1 30 44.73 9.35 29/1 X X X X
Grisart, Linden, and Masquelier (2002) 16 44.8 5.5 12/4 20 39.4 7.8 10/10
Harker, Klein, Dick, Verrier, and Rashiq (2011) 16 47.56 12.77 16/0 16 47.44 13.49 16/0
Kim et al. (2012) 23 37.4 7.1 23/0 24 37.4 8.3 24/0 X X X
Landro et al. (1997)a 25 46.4 10.4 25/0 18 40.1 9.6 14/4 X X X X X
Martinsen et al. (2014) 23 49.8 25–64 23/0 32 46.3 20–63 32/0 X
Mercado et al. (2013) 25 47.8 8.24 25/0 25 48 7.48 25/0 X
Miró et al. (2011) 33 46.56 7.72 33/0 28 42.9 7.38 28/0 X
Miró, Martínez, Sánchez, Prados, and Lupiáñez (2014) 77 45.88 7.06 58/19 48 44.73 8.96 21/27 X
Montoro et al. (2015)a 45 49.48 8.23 45/0 32 47.03 9.26 32/0 X X X
Park et al. (2001) 22 47.83 NR 23/0 23 47.83 NR 23/0 X X X X
Peters, Vlaeyen, and van Drunen (2000) 30 47.1 24–60 30/0 30 46.9 23–58 30/0 X
Reyes del Paso et al. (2015)a 46 49.48 8.23 46/0 32 47.03 9.26 32/0 X
Reyes del Paso, Pulgar, Duschek, and Garrido (2012) 35 50.5 6.7 32/3 29 49.4 9.4 27/2 X
Roldán-Tapia, Cánovas-López, Cimadevilla, and Valverde (2007) 15 48.5 7.49 15/0 15 44.33 5.99 15/0 X X X
Seo et al. (2012) 19 38.73 7.65 19/0 22 38.27 8.48 22/0 X
Shmygalev et al. (2014) 43 55 9 43/0 138 55 10 139/0
Sletvold, Stiles, and Landrø (1995)a 25 46.4 10.4 25/0 18 40.1 9.6 18/0 X X X X
Suhr (2003) 23 48.1 10.9 21/2 21 45.9 12.7 17/4 X X X X X
Tesio et al. (2015) 30 52.8 9.6 30/0 30 53.8 12.4 30/0 X X X X X X
Veldhuijzen, Sondaal, and Oosterman (2012) 35 30.4 8.6 35/0 35 29.3 9.2 35/0 X
Verdejo-García, López-Torrecillas, Calandre, Delgado-Rodríguez, 36 45.86 6.78 36/0 36 44.97 6.7 36/0 X X
and Bechara (2009)
Walitt et al. (2008) 27 45.2 NR 27/0 27 45.2 NR 27/0 X X X X X X
Walteros et al. (2011) 15 50.4 4.6 15/0 15 49 6.7 15/0 X X
Note. k = 37. A = accessing; F = females; IC = inhibitory control; LTM = long-term memory; M = males; NR = not reported; PS = processing speed; SS = set
shifting; STM = short-term memory; UP = updating. Range is included in places where standard deviation was not reported.
a
Part of the same study.

deviations for each cognitive task or directly from Data were collected from independent samples to
Cohen’s d. Hedges’s g statistic was calculated using meet the assumption of independence in our statis-
OpenMeta software (Wallace et al., 2012). In cases tical analyses, allowing only one effect size for a
where standard errors were reported, standard devia- cognitive domain to be collected from each study.
tions were calculated by multiplying the standard error Thus, reviewers decided on which measures of a
by the square root of the sample size for each group. certain domain were most valid for inclusion (had
Hedges’s g is similar to Cohen’s d and can be inter- high construct validity) based on current neuropsy-
preted as how many standard deviations the fibromyal- chological assessment texts and research (Lezak,
gia group is performing above or below the healthy 2004; Strauss, Sherman, & Spreen, 2006) and discus-
control group. Unlike Cohen’s d, Hedges’s g removes sion with co-authors. In many cases, studies used
the bias of small and unequal sample sizes, which may multiple measures of the same domains, for which
overestimate group differences. Effect sizes for composite Hedges’s gs were calculated to provide an
Hedges’s g are equivalent to that of Cohen’s d, where optimal estimate. For example, a study using two
small, medium, and large effects correspond to values measures of processing speed would provide two
of 0.20, 0.50, and 0.80 (Cohen, 1988). An estimate of corresponding effect sizes for that domain, which
Hedges’s g is considered significant if 0 is not included were then averaged to make a composite effect size
in the 95% confidence interval (Nakagawa & Cuthill, for processing to meet the assumption of indepen-
2007). dence. In the current study, random-effects meta-
6 T. BELL ET AL.

analysis (Borenstein, Hedges, Higgins, & Rothstein, healthy control groups. Either years of education or
2010) was then used to provide pooled Hedges’s gs highest education level was recorded from each study.
for each cognitive domain, along with 95% confi- Using studies with available data on years of education
dence intervals and a measure of between-study het- (15 studies), the average education for participants with
erogeneity (I2). fibromyalgia was 12.93 years (SD = 3.61), and
13.34 years (SD = 2.68) for participants in the healthy
control groups. A total of 964 participants with fibro-
Risk of bias assessment myalgia and 1,025 age-matched participants without
Risk of bias was assessed using guidelines provided by fibromyalgia were included from these studies.
the Cochrane Collaboration (Higgins & Green, 2011). Characteristics of all studies can be seen in Table 1.
Each article was strictly assessed on the criteria pro- Regarding bias, five studies showed unclear selection
vided, including domains of selection bias (biased from bias due to a lack of information on recruitment, two
nonrandom generation of groups, noncomparable had unclear selection bias due to attrition bias (unclear
recruitment), attrition bias (bias due to amount, nat- handling of missing data), and three had unclear
ure, or handling of missing data), reporting bias (bias reporting biases due to incomplete output reporting.
due to selective outcome reporting), and other bias Because none of the studies showed a high risk of bias,
(bias due to other sources identified by author all studies were used for subsequent analyses. Meta-
reviewers). Other important concerns derived from analytical results described by cognitive domain below
reviews were noted, such as study limitations and are also summarized in Table 2.
accurate use and interpretation of neuropsychological
measures. To handle bias, any studies that were at high Processing speed
risk were not included in analyses.
Information processing speed, typically defined as the
average time elapsed from stimuli presentation to a
Statistical analysis task-appropriate response, was measured in 10 studies
Analysis was conducted using OpenMeta software using diverse measures. The main measures involved
(Wallace et al., 2012) using the random-effects model the speed at which one completed a simple task or the
with the DerSimonian method (DerSimonian & Laird, number of accurately completed problems within an
1986). Random-effects analysis was used following the allotted time. These measures included the Digit
logic that each study might have its own true effect size Symbol Substitution task (Wechsler, 1997), Pattern/
due to study-specific characteristics with the goal of the Letter/Number Comparison (Salthouse & Babcock,
current study to provide an estimate for the average of 1991), and Trail Making Task Part A (Reitan, 1958),
these true standard mean differences and not one true as well as congruent conditions during the Attention
value for these differences. Furthermore, random effect Network Task–Interactions (ANT–I; Callejas,
models were used to obtain measures of heterogeneity Lupiánez, & Tudela, 2004) and Stroop task (Stroop,
known as I2, which specifies the percentage of varia- 1935). Measures also included reaction times on a
bility in the effect size across studies. In addition to the lab-developed mental arithmetic task (Montoro,
pooled standard mean differences (Hedges’s g), 95% Duschek, Muñoz Ladrón de Guevara, Fernández-
confidence intervals, I2 estimates, and forest plots for Serrano, & Reyes del Paso, 2015), a cued reaction
each cognitive domain were produced. time task (Montoro et al., 2015), and reaction time on

Table 2. Standard mean differences for cognitive domains

Results between persons with fibromyalgia and without fibromyalgia.
Estimate
Characteristics of included studies Domain (g) 95% CI I2 (%) p*
Of the 37 studies analyzed, 26 were based in Europe Processing speed 0.46 [0.25, 0.67] 39.08 .097
Memory storage
(71.1%), nine in North America (23.7%), and two Short-term memory 0.51 [0.29, 0.74] 46.99 .036
(5.3%) in Asia. Regarding participant characteristics, Long-term memory 0.50 [0.28, 0.72] 39.76 .084
Executive functions
the mean age for participants with fibromyalgia across Inhibitory control 0.61 [0.38, 0.83] 65.66 <.001
these studies was 47.85 years (SD = 8.23), and the mean Set shifting 0.30 [0.11, 0.49] 0.0 .490
Updating 0.51 [0.33, 0.69] 44.14 .026
age for the healthy control samples was 45.99 years Accessing 0.38 [0.03, 0.73] 62.88 .019
(SD = 8.83). The average percentage of females in the Note. CI = confidence interval.
fibromyalgia samples was 96.4%, and 94.5% in the *p-value for I2.
 JOURNAL OF CLINICAL AND EXPERIMENTAL NEUROPSYCHOLOGY 7

Figure 2. Forest plot of the standard mean difference on measures of processing speed between people with fibromyalgia and
healthy controls. CI = confidence interval.

the Psychomotor Vigilance Task (Dinges & Powell, (Wechsler, 2004). Additional short-term memory mea-
1985). Looking at measures of response speed (14 out- sures included lab-developed tasks, such as a virtual
come measures), there was a larger effect size (average reality version of the Hole Board Test (Oades &
g = 0.59 than for measures of accuracy (4 outcome Isaacson, 1978), known as the Boxes Room task
measures; average g = 0.49). However, as seen in (Cánovas et al., 2009), as well as classic free recall and
Figure 2, the random-effects model for processing recognition tasks. Looking at tasks using auditory/ver-
speed showed a significant and medium-sized differ- bal stimuli, there was a moderate-sized difference
ence between those with fibromyalgia and healthy con- between those with fibromyalgia and healthy controls
trol groups using both measures of response time and (17 outcome measures; average g = 0.36). The effect
accuracy (g = 0.46, 95% confidence interval, CI [0.25, size for this difference was larger for visuospatial tasks
0.67]), with no significant between-study heterogeneity (14 outcome measures; average g = 1.07).
(I2 = 39.08%, p = .097). Composite effect sizes were made for each study. For
example, the average effect size on measures of short-
term memory was calculated for Cánovas et al. (2009),
Memory which included mean differences on Digit Span
Forward, Corsi Block Forward, and the 10/36 Spatial
Short-term memory
Recall Test. Using composite effect sizes for 12 studies,
We identified 12 studies that assessed short-term mem-
random effects analysis confirmed a moderate difference
ory, defined as the ability to retain information over a
in short-term memory ability in fibromyalgia compared
very brief period of time. These tasks were mainly
to that in healthy adults (g = 0.51, 95% CI [0.29, 0.74]),
composed of immediate recall and recognition of ver-
seen in Figure 3. There was also a significant amount of
bal and visuospatial stimuli. Measures included out-
between-study heterogeneity (I2 = 46.99, p = .036), sug-
comes from the Automated Neuropsychological
gesting substantial differences in short-term memory
Assessment Metrics (ANAM) Code Substitution–
measurement and study characteristics.
Immediate Recall (Kane & Reeves, 1997), Attentional
Blink (McLaughlin, Shore, & Klein, 2001), Benton
Forms and Lines (Benton, 1994), CERAD Long-term memory
(Consortium to Establish a Registry for Alzheimer’s Many of the studies examining short-term memory
Disease)–Immediate Recall (Morris et al., 1989), Corsi also included delayed recall conditions that measured
Block Test Forward (Kessels, Van Zandvoort, Postma, a person’s ability to retrieve information after a pre-
Kappelle, & De Haan, 2000), Digit Span Forward specified delay of time. These measures included
(English and Korean; Orsini et al., 1987; Yeom, Park, delayed recall and recognition subtests of the 10/36
Oh, Kim, & Lee, 1992), Kimura Recurring Figures Spatial Recall Task (Achiron et al., 2005), 15-item Rey
Recognition Test (Kimura, 1963), 10/36 Spatial Recall Memory Test (Rey, 1964), ANAM Code Substitution
Task (Achiron et al., 2005), Rey Auditory Verbal delayed (Kane & Reeves, 1997), CERAD–Delayed
Learning Task–Immediate Recall (English and Korean Recall and Recognition (Morris et al., 1989), Code
versions; Rey, 1964), Rey Complex Figures Task– Memory Test Part 1 (Levander & Elithorn, 1987),
Immediate Recall (Rey, 1941), Spatial Span Forward Complex Figure Test–Delayed Recall (Osterrieth,
(Ha et al., 2002), and Wechsler’s Verbal Memory test 1944); Rey Auditory Verbal Learning Task (English
8 T. BELL ET AL.

Figure 3. Forest plot of the standard mean difference on measures of short-term memory between people with fibromyalgia and
healthy controls. CI = confidence interval.

and Korean versions; Rey, 1964), Randt Memory Task inhibitory control was the interference score from the
(Randt, Brown, & Osborne, 1983), Rey Figure (15-min classic Stroop task (Stroop, 1935) but also included
and 5-min delay recall; Rey et al., 1941), Wechsler interference calculated from the go/no-go paradigm
Memory Test–Delayed Recall (Wechsler, 2004), and (Fillmore & Rush, 2002), Coding Memory Test Part 2
paradigm free recall task. Of the eligible studies, 11 (a measure of inhibition to task-irrelevant verbal sti-
studies assessed long-term memory. The average effect muli, i.e., proactive interference; Levander & Elithorn,
size for tasks using auditory/verbal stimuli was 0.49 (11 1987), and the Test of Everyday Attention (TEA)–
outcome measures), and was 0.53 for visual–spatial Selective Attention subscale (Robertson, Ward,
stimuli (5 outcome measures). Ridgeway, & Nimmo-Smith, 1994).
As seen in Figure 4, random-effects modeling showed Across these instruments, moderate difficulties were
a significant small to moderate difference in long-term found for the Stroop task (12 outcome measures;
memory ability in fibromyalgia compared to that in g = 0.61), and the TEA–Selective Attention (1 outcome
healthy adults (g = 0.50, 95% CI [0.28, 0.72]). There measure; g = 0.54), whereas differences on the go/no-go
was not a significant amount of between-study hetero- paradigm were small (2 outcome measures; g = 0.34). As
geneity for long-term memory (I2 = 39.76, p = .084). seen in Figure 5, results from the random effects meta-
analysis showed a moderate-to-large difficulty in inhibi-
tory control across these measures that was statistically
Executive functions significant comparing those with fibromyalgia to healthy
Inhibitory control controls (g = 0.61, 95% CI [0.38, 0.83]). There was a large
Eighteen studies assessed inhibitory control, involving amount of heterogeneity in effect sizes (I2 = 65.66,
the prevention of inappropriate responses (response p < .001), greater than the amount expected by chance.
inhibition) and ability to ignore goal-irrelevant stimuli Sensitivity analyses revealed that removing the measure
(selective attention). The primary measure of of selective attention did not reduce heterogeneity

Figure 4. Forest plot of the standard mean difference on measures of long-term memory between people with fibromyalgia and
healthy controls. CI = confidence interval.
 JOURNAL OF CLINICAL AND EXPERIMENTAL NEUROPSYCHOLOGY 9

Figure 5. Forest plot of the standard mean difference on measures of inhibitory control between people with fibromyalgia and
healthy controls. CI = confidence interval.

(I2 = 67.53%, p < .001) or significantly change the average flexibility). Measures included the Trail Making Task
of the standard mean differences (g = 0.61, 95% CI [0.37, Part B (TMT–B; Reitan, 1958) and the number of
0.85]). This indicates that pooling estimates of selective perseveration errors on the Wisconsin Card Sorting
attention and response inhibition did not confound the Task (WCST; Rao, Hammeke, & Speech, 1987).
standard mean difference. To test whether the small The average difference between those with fibromyalgia
differences found on the go/no-go paradigm were driving and controls for TMT–B was moderate (5 outcome mea-
heterogeneity in the true effect size, the model was rea- sures; g = 0.44) and larger than that shown for performance
nalyzed without this measure. After removing the go/no- on the WCST (2 outcome measures; g = 0.06). As shown in
go paradigm from the model, there was still a significant Figure 6, a random-effects model showed that the average
amount of between-study heterogeneity (I2 = 68.17%, of standard mean differences was statistically significant,
p = .001), though the standard mean effect size increased with worse set shifting abilities in fibromyalgia than in
(g = 0.63, 95% CI [0.39, 0.88]). Thus, the differences in healthy adults, but this effect was small (g = 0.30; 95%
inhibitory control appear to vary significantly between CI [0.11, 0.49]). There was not significant heterogeneity
studies, and this was not accounted for by inclusion of between studies (I2 = 0.00, p = .490).
both selective attention and response inhibition tasks or
inclusion of the go/no-go paradigm.
Updating
Seventeen studies measured updating, defined as adding
Set shifting goal-relevant information and omitting goal-irrelevant
For the total eligible studies, seven assessed set shifting information from active memory. Commonly used mea-
in fibromyalgia, which is the ability to swtich between sures that involve numerical–verbal information included
tasks, operations, and mental sets (i.e., cognitive Digit Span Backward (Orsini et al., 1987), n-back task

Figure 6. Forest plot of the standard mean difference on measures of set shifting between people with fibromyalgia and healthy
controls. CI = confidence interval.
10 T. BELL ET AL.

(Kirchner, 1958), accuracy on lab-developed mental heterogeneity in the standard mean difference
arithmetic tasks (Montoro et al., 2015), Math and (I2 = 44.14%, p = .026).
Letter–Number Sequencing subtests of the Automated
Neuropsychological Assessment Metrics (ANAM; Accessing
Bleiberg, Kane, Reeves, Garmoe, & Halpern, 2000) and Six studies evaluated accessing, the purposeful retrieval
Wechsler Adult Intelligence Scale (WAIS–III; Wechsler, of information from remote memory. Accessing was
1997), and complex span tasks including Operational measured with tasks of verbal fluency, where partici-
Span Task (OSPAN; Turner & Engle, 1989) and pants name as many words as possible in a semantic
Reading Span tasks (Daneman & Carpenter, 1980). category within a limited amount of time. These
Along with tasks based on numerical–verbal information included the Animal Fluency Task (Morris et al.,
are tasks based on other forms of primary stimuli. The 1989) and Controlled Oral Word Association Test
Auditory Consonant Trigrams paradigm (Stuss, Stethem, (COWAT)–FAS task (Benton & Hamsher, 1976).
& Pelchat, 1988), the Paced Auditory Serial Addition On the FAS task, there was an average moderate
Task (PASAT; Gronwall, 1977), and the TEA–Working difficulty (5 outcome measures; g = 0.53). On the
Memory subscale (Robertson et al., 1994) were used to Animal Fluency Task, participants with fibromyalgia
measure updating of auditory information; the Corsi had better performance than healthy controls (1 outcome
Block Test Backward (Kessels et al., 2000) and failure to measure; g = –0.22), though this was nonsignificant (95%
maintain set during the WCST (indicative of difficulties CI [–0.65, 0.20]). As shown in Figure 8, the random-
with updating; Rao et al., 1987) were used to measure effects model showed a modest difference in accessing
updating ability for visuospatial information. in fibromyalgia (g = 0.38, 95% CI [0.03, 0.73]), though
On average, the largest differences were found on com- there was significant heterogeneity (I2 = 62.88%,
plex span tasks (3 outcome measures including OSPAN p = .019). After removing the Animal Fluency Task, the
and Reading Span, g = 0.93), followed by the PASAT (4 standard mean difference increased (g = 0.52, 95%
outcome measures; g = 0.88) and the Digit Span Backward CI [0.25, 0.78]), and heterogeneity was no longer present
(8 outcome measures; g = 0.45). The smallest differences (I2 = 18.55%, p = .297). The sample using the Animal
were found on arithmetic tasks (5 outcome measures; Fluency Task involved older adults with fibromyalgia,
g = 0.36), n-back (3 outcome measures; g = 0.33), and which may have led to increased heterogeneity in effect
failures to maintain set on WCST (2 outcome measures; size.
g = 0.25). Moreover, tests that primarily used auditory/
verbal information showed larger differences (29 outcome
measures; g = 0.55) than those using visuospatial stimuli (4 Effects of sample age
outcome measures; g = 0.34). As seen in Figure 7, random To test the possibility that higher sample age may lead to
effects modeling confirmed a significant small to moderate greater group differences, standard mean differences
difficulty in updating ability in fibromyalgia (g = 0.51; 95% were metaregressed on sample age for all cognitive
CI [0.33, 0.69]), and there was significant between-study domains with at least 10 or more studies. Sample age

Figure 7. Forest plot of the standard mean difference on measures of updating between people with fibromyalgia and healthy
controls. CI = confidence interval.
 JOURNAL OF CLINICAL AND EXPERIMENTAL NEUROPSYCHOLOGY 11

Figure 8. Forest plot of the standard mean difference on measures of accessing between people with fibromyalgia and healthy
controls. CI = confidence interval.

was significantly associated with differences in long- Our results showed some selective difficulties in
term memory (b = –0.03, 95% CI [–0.05, –0.002]). No subdomains of executive function and memory, as
significant associations were seen for short-term mem- defined by Miyake et al. (2000) and Baddeley and
ory (b = 0.02, 95% CI [–0.040, 0.002], p = .071), inhibi- Hitch (1974). For example, there appeared to be more
tory control (p = .767), updating (p = .662), or difficulties in inhibitory control and updating than in
processing speed (p = .521). Approximately 70% of set shifting or accessing. In addition, memory differ-
differences in long-term memory and 57% of differences ences were larger for short-term than for long-term
in short-term memory were accounted for by the fibro- memory; and visuospatial memory differences were
myalgia sample age. Overall, studies with higher sample larger than verbal memory differences. While some
ages showed smaller differences between the fibromyal- cognitive domains appeared to show larger differences
gia and healthy control participants on measures of than others, the finding of statistically significant dif-
long-term memory (i.e., delayed recall/recognition). ferences across all measured domains may argue for
impairment in the central executive, which would lead
to memory problems and slower processing speed.
Discussion Thus, incorporating measures tapping into overall
The current study found significantly worse perfor- executive control and attention may be worthwhile in
mance on neuropsychological testing for those with clinical and research settings for this population
fibromyalgia than for healthy controls for all investi- (Unsworth, Heitz, Schrock, & Engle, 2005).
gated domains, ranging from small to moderate mag- We also found that greater sample age was asso-
nitude. This supports the idea that FibroFog involves ciated with smaller differences between individuals
both self-reported and objective problems in cognition. with fibromyalgia and age-matched control partici-
Comparing effect sizes, the largest difference between pants on measures of long-term memory (and just
fibromyalgia participants and healthy controls was for beyond statistical significance on measures of short-
the domain of inhibitory control (g = 0.61), which term memory), contrary to the idea that differences
includes measures of selective attention and response would increase with sample age. One explanation is
inhibition. Effect sizes for processing speed, short-term that normal cognitive aging may reduce the discre-
and long-term memory, and updating were medium, pancy between persons with fibromyalgia and healthy
ranging from 0.46 to 0.51. Small differences were found peers on measures of memory encoding and retrieval.
for set shifting and accessing, ranging from 0.30 to However, there was generally a lack of older adults
0.38. Greater problems with inhibitory control parallel included in the samples from previous research, and
research showing substantial overlap in neural net- all studies were cross-sectional, preventing true mea-
works of inhibition and pain perception, and are in surement of cognitive trajectories. This highlights the
line with the hypothesis that consumption of atten- need for research looking at cognitive aging in
tional resources for constant pain perception can fibromyalgia.
impair activation of inhibitory systems in fibromyalgia It is important to note that although pain has been
(Glass et al., 2011). Findings also provide objective hypothesized to cause cognitive disruption, it is also
evidence for the self-reported difficulties of mental possible that cognitive difficulties may contribute to
slowing, memory loss, information overload, and diffi- maintenance or exacerbation of pain difficulties in
culties multitasking in those with fibromyalgia (Leavitt fibromyalgia. For example, the attentional disengage-
& Katz, 2011; Leavitt et al., 2002). ment theory purports that difficulties shifting between
12 T. BELL ET AL.

mental sets and inhibiting other mental sets lead to years of education (i.e., lower cognitive reserve) may
greater rumination on negative self-referent material lead to overestimation of cognitive difficulties in fibro-
(Koster, De Lissnyder, Derakshan, & De Raedt, 2011). myalgia. Additionally, many studies recruited persons
Among persons with fibromyalgia, difficulties in set with fibromyalgia in a different manner than healthy
shifting and inhibitory control, highlighted in the cur- control participants. Almost all the studies used physi-
rent meta-analysis, may lead to intrusions of catastro- cian referral or recruitment of fibromyalgia patients
phizing mental sets and greater rumination about pain. from healthcare clinics, while healthy control partici-
Among healthy adults, poor inhibition has been asso- pants were recruited by community/campus advertise-
ciated with lower tolerance of pain and greater atten- ment, or through word-of-mouth. Though not tested
tion to pain (Oosterman, Dijkerman, Kessels, & in this study, differences in recruitment methods may
Scherder, 2010; Verhoeven et al., 2011), and poor set lead to sample biases as persons recruited from clinical
shifting is associated with more persistent pain (Attal settings may differ from those recruited in commu-
et al., 2014). Therefore, difficulties may explain the lack nities (i.e., more health problems). Differences in cog-
of top-down pain modulation in fibromyalgia. nition may also be affected by other control group
Findings from the current meta-analysis should be characteristics. For example, most of the control
interpreted considering limitations. Primarily, the groups volunteered without financial compensation,
meta-analysis was unable to control for many possible which may have led to a self-selection bias of partici-
confounds, including psychological disorders and med- pants who are internally motivated and show higher
ication use. A theoretical understanding of the impact cognitive function due to greater cognitive effort. In
of chronic pain on cognitive performance is limited addition, a few studies did not screen for issues of pain
without better understanding of depression and anxiety (not related to fibromyalgia), medication use, or his-
that is often found in these patient populations (Bair, tory of psychiatric disorders in the control group. All
Robinson, Katon, & Kroenke, 2003). In general, included studies were cross-sectional and do not allow
depression severity has been negatively related to cog- researchers to determine whether fibromyalgia leads to
nitive performance, especially on measures of proces- cognitive decline. Another limitation to be considered
sing speed, executive function, and episodic memory is that most study participants were middle-aged
(McDermott & Ebmeier, 2009), and this association (range = 36.20 to 59.40 years), limiting the general-
has also been found for measures of memory perfor- izability of findings to other age groups.
mance in fibromyalgia (Suhr, 2003). Therefore, future We also note statistical considerations. First, there
research should control for depressive symptoms in were differences in the number of included studies
statistical analyses or provide comparisons between within each cognitive domain. For instance, seven stu-
subsamples with and without depression diagnosis, dies measured set shifting, and 17 studies measured
though several of the studies included in the current inhibitory control. Unequal numbers of included stu-
meta-analysis did this (Landro, Stiles, & Sletvold, 1997; dies should be considered when making comparisons
Tesio et al., 2015; Walteros et al., 2011). Finally, med- across domains on between-study heterogeneity as
ication use may lead to worse cognitive performance in fewer included studies leads to less valid tests, and
fibromyalgia than in participants in the healthy control nonsignificance should not be interpreted as homoge-
groups. Current recommended treatments for fibro- neity (Higgins, Thompson, Deeks, & Altman, 2003).
myalgia include antidepressant drugs and pregabalin Lastly, the large sample sizes accumulated from
as well as pain relief from various opioid therapies. included studies could result in Type 1 error. For this
Cognitive side effects are possible for these drugs reason, effect sizes rather than significance alone are
(Zaccara, Gangemi, Perucca, & Specchio, 2011). To important to consider.
date, it is not clear how recommended drugs impact
cognitive performance of these patients.
Conclusion
In addition to unmeasured variables that may affect
cognitive performance in those with fibromyalgia, The current meta-analysis strongly supports cognitive
methodological differences may have contributed to difficulty as a significant symptom cluster in fibromyal-
the heterogeneous effect sizes found for several cogni- gia. A remaining question is whether we can improve
tive domains. Foremost, many studies did not match cognitive difficulties in fibromyalgia. Improving pain
controls on measures of estimated premorbid intelli- and sleep, for example, may help reduce FibroFog
gence, and three did not match on education. Matching (Suhr, 2003). There is also some evidence for more
control samples on these individual differences is direct interventions to improve cognitive performance.
important, as lower premorbid intelligence and lower For example, transcranial direct current stimulation
 JOURNAL OF CLINICAL AND EXPERIMENTAL NEUROPSYCHOLOGY 13

has been found in some studies to improve processing Arnold, L. M., Crofford, L. J., Mease, P. J., Burgess, S. M.,
speed, inhibition, memory, and accessing in fibromyal- Palmer, S. C., Abetz, L., & Martin, S. A. (2008). Patient
gia (Baudic et al., 2013; Curatolo et al., 2017). perspectives on the impact of fibromyalgia. Patient
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Cognitive-behavioral therapy may also lead to pec.2008.06.005
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et al., 2011), possibly by rerouting attentional resources proposed system and its control processes. Psychology of
away from pain toward more adaptive behaviors (i.e., Learning and Motivation, 2, 89–195.
behavioral activation). Lastly, physical activity has been Attal, N., Masselin-Dubois, A., Martinez, V., Jayr, C., Albi,
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are needed to determine the clinical utility of neuro- Baddeley, A., & Hitch, G. J. (1974). Working memory. The
cognitive interventions, symptoms of FibroFog could Psychology of Learning and Motivation, 8, 47–89.
be modifiable. Helping physicians and patients see Bair, M. J., Robinson, R. L., Katon, W., & Kroenke, K. (2003).
Depression and pain comorbidity: A literature review.
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Disclosure statement Baudic, S., Attal, N., Mhalla, A., de Andrade, D. C., Perrot, S., &
Bouhassira, D. (2013). Unilateral repetitive transcranial mag-
No potential conflict of interest was reported by the authors. netic stimulation of the motor cortex does not affect cogni-
tion in patients with fibromyalgia. Journal of Psychiatric
Research, 47(1), 72–77. doi:10.1016/j.jpsychires.2012.09.003
Ethical approval Bennett, R., Jones, J., Turk, D., Russell, I. J., & Matallana, L.
All procedures performed in studies involving human parti- (2007). An internet survey of 2,596 people with fibromyal-
cipants were in accordance with the ethical standards of the gia. BMC Musculoskeletal Disorders, 8(1), 27. doi:10.1186/
institutional and/or national research committee and with 1471-2474-8-27
the 1964 Helsinki declaration and its later amendments or Bennett, R. M. (2009). Clinical manifestations and diagnosis
comparable ethical standards. Informed consent was of fibromyalgia. Rheumatic Disease Clinics of North
obtained by all participants in studies used for the meta- America, 35(2), 215–232. doi:10.1016/j.rdc.2009.05.009
analysis. Benton, A., & Hamsher, K. (1976). Multilingual aphasia
examination. Iowa City, IA: University of Iowa.
Benton, A. L. (1994). Contributions to neuropsychological
Funding assessment: A clinical manual. New York, NY: Oxford
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This work was supported, in part, by the Edward R. Roybal Berryman, C., Stanton, T. R., Jane Bowering, K., Tabor, A.,
Center for Translational Research on Aging and Mobility, McFarlane, A., & Lorimer Moseley, G. (2013). Evidence
Institute on Aging at the National Institutes of Health [grant for working memory difficulties in chronic pain: A sys-
number 2 P30 AG022838]. tematic review and meta-analysis. Pain, 154(8), 1181–
1196. doi:10.1016/j.pain.2013.03.002
Bleiberg, J., Kane, R. L., Reeves, D. L., Garmoe, W. S., &
ORCID Halpern, E. (2000). Factor analysis of computerized and
traditional tests used in mild brain injury research. The
Tyler Bell http://orcid.org/0000-0001-5702-5995 Clinical Neuropsychologist, 14(3), 287–294. doi:10.1076/
1385-4046(200008)14:3;1-P;FT287
Borenstein, M., Hedges, L. V., Higgins, J., & Rothstein, H. R.
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