Newly revised fibromyalgia recommendations advise exercise

By John Murphy, MDLinx
Published July 19, 2016

Key Takeaways

For the first time since 2005, the European League Against Rheumatism (EULAR) has released recommendations on the management of fibromyalgia—and its strongest recommendation is for exercise.

The league published its recommendations July 4, 2016 in Annals of the Rheumatic Diseases.

“We were unanimous in providing a ‘strong for’ recommendation for the use of exercise, particularly given its effect on pain, physical function and well-being, availability, relatively low cost, and lack of safety concerns,” the authors wrote. “The available evidence did not allow us to distinguish between the benefits of aerobic or strengthening.”

Management of fibromyalgia should take a graduated approach with the aim of improving health-related quality of life, EULAR recommended. Initial management should focus on nonpharmacological therapies and involve patient education.

If these fail to provide sufficient response, further therapies should be tailored to the individual patient’s specific needs. These include psychological therapies (for mood disorders and unhelpful coping strategies), pharmacotherapy (for severe pain or sleep disturbance), and/or a multimodal rehabilitation program (for severe disability). Despite this recommendation, EULAR evaluated these therapies as “weak” based on meta-analyses.

The group also noted that the evidence was weak for meditative movement therapies (which improved sleep, fatigue, and quality of life), mindfulness-based stress reduction (which improved pain and quality of life), acupuncture (which improved pain and fatigue), and hydrotherapy (which improved pain and quality of life).

EULAR advised against other non-pharmacological therapies due to lack of effectiveness and/or low study quality, such as biofeedback, capsaicin, hypnotherapy, massage, SAMe (S-adenosyl methionine), and other complementary and alternative therapies.

“We provided a ‘strong against’ evaluation for chiropractic based on safety concerns,” the authors added.

For patients with severe pain, the group recommended considering pharmacological therapies (duloxetine, pregabalin, tramadol), although the evidence for these was weak.

“We did not recommend several pharmacological therapies including NSAIDs, MAOIs, and SSRIs because of lack of efficacy, and specifically gave a ‘strong against’ evaluation to growth hormone, sodium oxybate, strong opioids, and corticosteroids based on lack of efficacy and high risk of side effects,” the authors wrote.

The previous EULAR recommendations in 2005 were a “milestone” in the management of fibromyalgia, the group noted. However, most of its 9 recommendations came from expert opinion, and only 3 were based on strong evidence from scientific literature.

For these revised recommendations, a multidisciplinary group (that included members from 12 countries) identified a total of 2,979 articles, from which they selected 275 full papers and 106 reviews and/or meta-analyses. They reviewed these articles using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for making their recommendations.

In reviewing the evidence, the EULAR authors identified several “research gaps” that left lingering questions, such as: “Which type of exercise is most effective: strength and/or aerobic training?” and “Are combined pharmacological and non-pharmacological approaches to management more effective than single modality management?”. These and other questions require further investigation, the group noted.

EULAR plans to revise these guidelines in 5 years in the hopes of collecting more forthcoming evidence-based studies and potentially new therapies for the management of fibromyalgia.

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