EULAR(European League Against Rheumatism) revised recommendations for the management of fibromyalgia
Acupuncture
Eight reviews included up to 16 trials and 1081 participants. One high-quality review included nine trials, with 395 patients, and demonstrated that acupuncture, added to standard therapy, resulted in a 30% (21%, 39%) improvement in pain.70 Electric acupuncture was also associated with improvements in pain (22%; 4% to 41%) and fatigue (11%; 2% to 20%). Some adverse events were reported, but these were commonly mild and transient. There is little understanding of the active component of acupuncture, and the evidence supporting the use of real versus sham acupuncture was less consistent. Acupuncture evaluation: weak for (93% agreement).
Biofeedback
Two reviews included up to seven trials and 307 participants. Glombiewski et al92 reviewed seven studies, comprising 321 participants. Treatment sessions varied from 6 to 22; with control therapy comprising sham biofeedback, attention control, medication and treatment as usual. Biofeedback was effective in reducing pain intensity (Hedges' g=0.79; 0.22 to 1.36), although all trials were poor quality. There was no evidence of effectiveness in terms of fatigue or sleep and subgroup analysis suggested that any effect was limited to electromyographic (0.86; 0.11 to 1.62) rather than electroencephalographic biofeedback (0.71; −0.37 to 1.8). Biofeedback evaluation: weak against (100% agreement).
Tramadol, a weak opioid with mild serotonin-noradrenalin reuptake inhibitor (SNRI) activity was considered by two reviews. Roskell et al22 identified a single study of tramadol with paracetamol. Those in the active arm were more likely to have 30% improvement in pain (RR 1.77, 95% CI 1.26 to 2.48). Tramadol evaluation: weak for (100% agreement).
The literature search did not identify any reviews on corticosteroids, strong opioids, cannabinoids and antipsychotics. The committee made a ‘strong against’ evaluation (100% agreement) regarding the use of strong opioids and corticosteroids in patients with fibromyalgia on the basis of lack of evidence of efficacy and high risk of side effects/addiction reported in individual trials.
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