EULAR Recommends Exercise First For Fibromyalgia

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EULAR Recommends Exercise First For Fibromyalgia

The European League Against Rheumatism (EULAR) emphasizes on exercise as the strongest evidence-based therapy in the management of fibromyalgia. The revised recommendations consider nonpharmacologic measures as the focus of initial therapy, with an individualized approach in non-responders.

A multidisciplinary panel of 18 members from 12 European countries reviewed the evidence, mostly from systematic reviews and meta-analyses, on the management of fibromyalgia which was headed by Gary Macfarlane. The findings and recommendations, notified by 107 reviews, appear online in Annals of rheumatology.

The recommendations are consistent with other recent guidelines from Canada, Israel, and Germany. The panel wrote that" These guidelines and our EULAR recommendations are in agreement on the principles of approach to management, the need for tailored therapy to the individual, and the first-line role of nonpharmacological therapies".

The panel noted the original EULAR recommendations and recommendations published till 2005. Also, due to the limited evidences, most recommendations included in the document were considered as "expert opinion".

Despite a significcant increase in the trial data since the original recommendations, there are no crucial changes to the approach of managing patients with fibromyalgia, although we furnish new evidence in support for some additional non-pharmacological therapies".

Macfarlane et al explained that the use of exercise was endorsed unanimously, particularly given its effect on pain, physical function and well-being, availability, relatively low cost, and lack of safety concerns. The present evidence did not permit the panel to distinguish between the benefits of aerobic or strengthening exercise.

Weak recommendations were given in favor of meditative movement therapies for their capability to improve sleep, fatigue, and quality of life; mindfulness-based stress reduction as per improvements in pain relief and quality of life acupuncture or hydrotherapy for which evidence exists for better pain/fatigue and pain/quality of life, respectively.

Non-pharmacological therapies were not endorsed due to either lack of effectiveness or the low quality of existing studies were capsaicin, biofeedback, hypnotherapy, massage, the dietary supplement S-adenosylmethionine (SAMe) and other complementary and alternative therapies. Also, a "strong against" recommendation was given for chiropractic manipulation, by reviewing the safety concerns. With the lack of effect of these therapies individualized treatment "according to patient need" is recommended. A weak recommendation favoring psychological therapies was given to help patients with mood disorder or who had not responded to other coping strategies; particularly, cognitive behavioral therapy is assessed effective at generating modest, long-term reductions in pain and disability and in improving mood, as per the panel.

They also wrote that the evidence to support pharmacotherapy is weak. Patients with severe pain may be taken up for duloxetine, pregabalin, or tramadol, and those with sleep disturbance may profit from amitriptyline, cyclobenzaprine, or pregabalin. Although the evidence to support any of these treatments is weak.

Because of lack of efficacy, various pharmacological therapies like nonsteroidal anti-inflammatory drugs (NSAIDs), monoamine oxidase inhibitors, and selective serotonin reuptake inhibitors were not recommended. The panel specifically suggested against growth hormone, sodium oxybate, strong opioids, and corticosteroids, on the basis of lack of efficacy and high risk of side effects.

The patients with acute disability should be regarded for multimodal rehabilitation programs (a "weak" recommendation in favor) rather than individual therapies. The team said that the research priorities encompass identifying the most effective type of exercise, estimating the effectiveness of a combined pharmacologic and non-pharmacologic approach compared with a single modality, and recognizing predictors of response to specific therapies.

Leslie J. Crofford, MD, of Vanderbilt University in Nashville, Tenn commented that in upgrading previous recommendations, the panel was able to assemble a base of evidence from recent published literature that largely support those of other professional societies.

The MD told MedPage today that lesser emphasis on medications "emphasizes a cultural difference between the U.S. and other countries. It is also to be noted that there was a strong recommendation against most opioids and other drugs with high risk of misuse and abuse such as sodium oxybate. The risk-benefit ratio for these agents weighs heavily against their use in fibromyalgia." 

Crofford further added that for patients with debilitating symptoms, multimodal therapy using non-pharmacologic and pharmacologic treatment is recommended. In general, the likelihood of a good outcome for patients relies on early diagnosis, patient education, and behavioral changes including maintaining physical activity.



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Original title of article:

EULAR Recommends Exercise First For Fibromyalgia

Exploratory, European League Against Rheumatism (EULAR), Exercise, Fibromyalgia, Nonpharmacologic, Recommendation
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