EULAR revised recommendations for the management of fibromyalgia

Efficacy and safety of mirogabalin for the treatment of fibromyalgia: results from three 13-week randomized, double-blind, placebo- and active-controlled, parallel-group studies and a 52-week open-label extension study

Objective: To investigate the efficacy and safety of mirogabalin, an α₂δ ligand, in patients with fibromyalgia (FM). Methods: In three 13-week, multicenter, double-blind, phase 3 studies (studies A, B, and C), patients with FM (n = 1293, 1270, and 1301, respectively) were randomized (1:1:1:1) to placebo, pregabalin 150 mg twice daily, mirogabalin 15 mg once daily or mirogabalin 15 mg twice daily. The primary endpoint was the change in weekly average daily worst pain score (ADPS) at week 13. Key secondary endpoints included Patient Global Impression of Change and change in the Fibromyalgia Impact Questionnaire total score. Long-term safety of mirogabalin was assessed in a 52-week extension study. Results: Neither mirogabalin dose demonstrated a significant ADPS reduction from baseline vs. placebo at week 13 in any of the three studies. Pregabalin significantly reduced ADPS from baseline vs. placebo in studies B and C (p = .0008 and .0001, respectively). The effect of mirogabalin compared with placebo on key secondary endpoints was variable across the studies. Mirogabalin was well tolerated by most patients in the phase 3 studies; no unexpected adverse events occurring during the 52-week extension study. Conclusion: While both mirogabalin doses were well tolerated by most patients and showed potential for reducing pain associated with FM, the primary endpoint of significant pain reduction in patients on mirogabalin compared with placebo was not achieved in any of the three randomized controlled studies. Clinical trial registration: NCT02146430; NCT02187159; NCT02187471; and NCT02234583 (extension study).

Effectiveness, cost-utility, and benefits of a multicomponent therapy to improve the quality of life of patients with fibromyalgia in primary care: A mixed methods study protocol

INTRODUCTION

Fibromyalgia (FM) is a chronic condition characterized by chronic pain, fatigue and loss of function which significantly impairs quality of life. Although treatment of FM remains disputed, some studies point at the efficacy of interdisciplinary therapy. This study aims to analyze the effectiveness, cost-utility and benefits of a multicomponent therapy on quality of life (main variable), functional impact, mood and pain in people suffering from FM that attend primary care centers (PCCs) of the Catalan Institute of Health (ICS).

METHODS AND ANALYSIS

A 2-phase, mixed methods study has been designed following Medical Research Council guidance. Phase 1: Pragmatic randomized clinical trial with patients diagnosed with FM that attend one of the 11 PCCs of the ICS Gerència Territorial Terres de l'Ebre. We estimate a total sample of 336 patients. The control group will receive usual clinical care, while the multicomponent therapy group (MT group) will receive usual clinical care plus group therapy (consisting of health education, exercise and cognitive-behavioural therapy) during 12 weeks in 2-hourly weekly sessions.

ANALYSIS

the standardized mean response and the standardized effect size will be assessed at 3, 9, and 15 months after the beginning of the study using multiple linear regression models. Utility measurements will be used for the economic analysis. Phase 2: Qualitative socio constructivist study to evaluate the intervention according to the results obtained and the opinions and experiences of participants (patients and professionals). We will use theoretical sampling, with 2 discussion groups of participants in the multicomponent therapy and 2 discussion groups of professionals of different PCCs. A thematic content analysis will be carried out.

ETHICS AND DISSEMINATION

This study protocol has been approved by the Clinical Research Ethics Committee of the Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (code P18/068). Articles will be published in international, peer-reviewed scientific journals.

TRIAL REGISTRATION

Clinical-Trials.gov: NCT04049006.

Fibromyalgia and Shoulder Surgery: A Systematic Review and a Critical Appraisal of the Literature

Fibromyalgia is a common musculoskeletal syndrome characterized by chronic widespread pain and other systemic manifestations, which has demonstrated a contribution to higher postoperative analgesic consumption to other surgeries such as hysterectomies and knee and hip replacements. The aim of this review is to search current literature for studies considering the impact of fibromyalgia on clinical outcomes of patients undergoing shoulder surgery. A systematic literature review was conducted in PubMed/Medline, Embase, and ClinicalTrials.gov in February 2019. Studies were selected based on the following participants, interventions, comparisons, outcomes, and study design criteria: adult patients undergoing surgery for shoulder pain (P); diagnosis of fibromyalgia (I); patients without fibromyalgia (C); outcome of surgery in terms of pain or analgesic or non-steroidal anti-inflammatory drugs consumption (O); case series, retrospective studies, observational studies, open-label studies, randomized clinical trials, systematic reviews and meta-analyses were included (S). Authors found 678 articles, of which four were found eligible. One retrospective study showed that patients with fibromyalgia had worse clinical postoperative outcomes; two retrospective studies reported a higher opioid prescription in patients with fibromyalgia and one prospective observational study found that a higher fibromyalgia survey score correlated with lower quality of recovery scores two days after surgery. The scarce and low-quality evidence available does not allow confirming that fibromyalgia has an impact on postoperative outcomes in shoulder surgery. Future studies specifically focusing on shoulder surgery outcomes may help improvement and personalization of the management of patients with fibromyalgia syndrome (PROSPERO 2019, CRD42019121180).

Heart Rate Variability Biofeedback to Treat Fibromyalgia: An Integrative Literature Review

OBJECTIVES

Fibromyalgia (FM) is associated with debilitating pain and a reduced heart rate variability (HRV), reflecting decreased emotional adaptability and resistance to stress. Common pharmacological treatments are ineffective, and opioids are highly addictive and cause an estimated 15,000 overdose deaths per year. Effective recommendations include patient-centered interventions like physical activity, cognitive behavioral therapy, and biofeedback. Heart rate variability biofeedback (HRVB) may be effective in improving HRV, thus increasing stress resistance and emotional adaptability and reducing pain.

DESIGN

This integrative literature review was conducted to examine the relationship between HRVB and FM-related chronic pain using the Theory of Symptom Self-Management and to identify available HRVB technology.

DATA SOURCES

We searched PubMed, EBSCOhost, and Google Scholar electronic databases for relevant publications. Manuscripts were selected using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses strategy, and study quality was assessed using the Critical Appraisal Skills Programme guidelines. The relationship between HRVB and FM was analyzed and evaluated based on the methodological framework proposed by Whittemore and Knafl.

REVIEW/ANALYSIS METHODS

We reviewed 22 articles and included six in this review. Five reported HRVB as a treatment for chronic pain, and one for FM pain.

RESULTS

Overall, the articles in this review support the claim that HRVB is related to decreased pain. The researchers evaluated five HRVB programs, three on handheld devices and two on desktop computers.

CONCLUSIONS

The reviewed studies had methodological flaws. However, HRVB is a promising treatment for chronic pain. Larger, randomized controlled studies are needed to thoroughly evaluate the relationship between HRVB and FM pain.

Mindfulness- and acceptance-based interventions for patients with fibromyalgia - A systematic review and meta-analyses

Objectives

To analyze health effects of mindfulness- and acceptance-based interventions, including mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT) and acceptance and commitment therapy (ACT). Additionally, we aimed to explore content and delivery components in terms of procedure, instructors, mode, length, fidelity and adherence in the included interventions.

Methods

We performed a systematic literature search in the databases MEDLINE, PsychINFO, CINAHL, EMBASE, Cochrane Central and AMED from 1990 to January 2019. We included randomized and quasi-randomized controlled trials analyzing health effects of mindfulness- and acceptance-based interventions for patients with fibromyalgia compared to no intervention, wait-list control, treatment as usual, or active interventions. MBSR combined with other treatments were included. Predefined outcomes were pain, fatigue, sleep quality, psychological distress, depression, anxiety, mindfulness, health-related quality of life and work ability. The Template for Intervention Description and Replication (TIDieR) checklist and guide was used to explore content and delivery components in the interventions. Meta-analyses were performed, and GRADE was used to assess the certainty in the evidence.

Results

The search identified 4430 records, of which nine original trials were included. The vast majority of the participants were women. The analyses showed small to moderate effects in favor of mindfulness- and acceptance-based interventions compared to controls in pain (SMD -0.46 [95% CI -0.75, -0.17]), depression (SMD -0.49 [95% CI -0.85, -0.12]), anxiety (SMD -0.37 [95% CI -0.71, -0.02]), mindfulness (SMD -0.40 [-0.69, -0.11]), sleep quality (SMD -0.33 [-0.70, 0.04]) and health-related quality of life (SMD -0.74 [95% CI -2.02, 0.54]) at end of treatment. The effects are uncertain due to individual study limitations, inconsistent results and imprecision.

Conclusion

Health effects of mindfulness- and acceptance-based interventions for patients with fibromyalgia are promising but uncertain. Future trials should consider investigating whether strategies to improve adherence and fidelity of mindfulness- and acceptance-based interventions can improve health outcomes.

Practical approach to a patient with chronic pain of uncertain etiology in primary care

Chronic pain of uncertain etiology often presents a challenge to both patients and their health care providers. It is a complex condition influenced by structural and physiological changes in the peripheral and central nervous systems, and it directly influences, and is modulated by, psychological well-being and personality style, mood, sleep, activity level and social circumstances. Consequently, in order to effectively treat the pain, all of these need to be evaluated and addressed. An effective management strategy takes a multidisciplinary biopsychosocial approach, with review of all current medications and identification and careful withdrawal of those that may actually be contributing to ongoing pain. The management approach is primarily nonpharmacological, with carefully considered addition of medication, beginning with pain-modulating treatments, if necessary. In this article, we present a primary care approach to the assessment and management of a patient with chronic pain where the cause cannot be identified.

Flexibility exercise training for adults with fibromyalgia

BACKGROUND

Exercise training is commonly recommended for adults with fibromyalgia. We defined flexibility exercise training programs as those involving movements of a joint or a series of joints, through complete range of motion, thus targeting major muscle-tendon units. This review is one of a series of reviews updating the first review published in 2002.

OBJECTIVES

To evaluate the benefits and harms of flexibility exercise training in adults with fibromyalgia.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PEDro (Physiotherapy Evidence Database), Thesis and Dissertation Abstracts, AMED (Allied and Complementary Medicine Database), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), and ClinicalTrials.gov up to December 2017, unrestricted by language, and we reviewed the reference lists of retrieved trials to identify potentially relevant trials.

SELECTION CRITERIA

We included randomized trials (RCTs) including adults diagnosed with fibromyalgia based on published criteria. Major outcomes were health-related quality of life (HRQoL), pain intensity, stiffness, fatigue, physical function, trial withdrawals, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected articles for inclusion, extracted data, performed 'Risk of bias' assessments, and assessed the certainty of the body of evidence for major outcomes using the GRADE approach. All discrepancies were rechecked, and consensus was achieved by discussion.

MAIN RESULTS

We included 12 RCTs (743 people). Among these RCTs, flexibility exercise training was compared to an untreated control group, land-based aerobic training, resistance training, or other interventions (i.e. Tai Chi, Pilates, aquatic biodanza, friction massage, medications). Studies were at risk of selection, performance, and detection bias (due to lack of adequate randomization and allocation concealment, lack of participant or personnel blinding, and lack of blinding for self-reported outcomes). With the exception of withdrawals and adverse events, major outcomes were self-reported and were expressed on a 0-to-100 scale (lower values are best, negative mean differences (MDs) indicate improvement). We prioritized the findings of flexibility exercise training compared to land-based aerobic training and present them fully here.Very low-certainty evidence showed that compared with land-based aerobic training, flexibility exercise training (five trials with 266 participants) provides no clinically important benefits with regard to HRQoL, pain intensity, fatigue, stiffness, and physical function. Low-certainty evidence showed no difference between these groups for withdrawals at completion of the intervention (8 to 20 weeks).Mean HRQoL assessed on the Fibromyalgia Impact Questionnaire (FIQ) Total scale (0 to 100, higher scores indicating worse HRQoL) was 46 mm and 42 mm in the flexibility and aerobic groups, respectively (2 studies, 193 participants); absolute change was 4% worse (6% better to 14% worse), and relative change was 7.5% worse (10.5% better to 25.5% worse) in the flexibility group. Mean pain was 57 mm and 52 mm in the flexibility and aerobic groups, respectively (5 studies, 266 participants); absolute change was 5% worse (1% better to 11% worse), and relative change was 6.7% worse (2% better to 15.4% worse). Mean fatigue was 67 mm and 71 mm in the aerobic and flexibility groups, respectively (2 studies, 75 participants); absolute change was 4% better (13% better to 5% worse), and relative change was 6% better (19.4% better to 7.4% worse). Mean physical function was 23 points and 17 points in the flexibility and aerobic groups, respectively (1 study, 60 participants); absolute change was 6% worse (4% better to 16% worse), and relative change was 14% worse (9.1% better to 37.1% worse). We found very low-certainty evidence of an effect for stiffness. Mean stiffness was 49 mm to 79 mm in the flexibility and aerobic groups, respectively (1 study, 15 participants); absolute change was 30% better (8% better to 51% better), and relative change was 39% better (10% better to 68% better). We found no evidence of an effect in all-cause withdrawal between the flexibility and aerobic groups (5 studies, 301 participants). Absolute change was 1% fewer withdrawals in the flexibility group (8% fewer to 21% more), and relative change in the flexibility group compared to the aerobic training intervention group was 3% fewer (39% fewer to 55% more). It is uncertain whether flexibility leads to long-term effects (36 weeks after a 12-week intervention), as the evidence was of low certainty and was derived from a single trial.Very low-certainty evidence indicates uncertainty in the risk of adverse events for flexibility exercise training. One adverse effect was described among the 132 participants allocated to flexibility training. One participant had tendinitis of the Achilles tendon (McCain 1988), but it is unclear if the tendinitis was a pre-existing condition.

AUTHORS' CONCLUSIONS

When compared with aerobic training, it is uncertain whether flexibility improves outcomes such as HRQoL, pain intensity, fatigue, stiffness, and physical function, as the certainty of the evidence is very low. Flexibility exercise training may lead to little or no difference for all-cause withdrawals. It is also uncertain whether flexibility exercise training has long-term effects due to the very low certainty of the evidence. We downgraded the evidence owing to the small number of trials and participants across trials, as well as due to issues related to unclear and high risk of bias (selection, performance, and detection biases). While flexibility exercise training appears to be well tolerated (similar withdrawal rates across groups), evidence on adverse events was scarce, therefore its safety is uncertain.

Efficacy of baths with mineral-medicinal water in patients with fibromyalgia: a randomized clinical trial

The layout of this study, designed as a randomized crossover clinical trial, is to evaluate the efficacy of an intervention with mineral-medicinal water from As Burgas (Ourense) in patients suffering from fibromyalgia. This sample was randomly divided into two groups: group A and group B. In phase 1, group A had 14 baths in thermal water for a month and standard pharmacological treatment; group B, standard pharmacological treatment. Washout period is 3 months. In phase 2, group A had standard treatment and group B had 14 baths in thermal water for a month plus standard treatment. The Fibromyalgia Impact Questionnaire (FIQ) was used; this grades the impact of the illness from 1 (minimum) to 10 (maximum), which was measured in both phases. Twenty-five patients were included in each group and the study was concluded with 20 patients in group A and 20 in group B. The intervention group obtained, once the baths finished, a mean score of 60.3 (± 11.8) and the control group of 70.8 (± 13.0) (p < 0.001). Three months later, the intervention group presented a mean score of 64.4 (± 10.6) and the control group of 5.0 (± 11.3) (p < 0.001). We can therefore conclude that the simple baths with mineral-medicinal water from As Burgas can make an improvement on the impact caused by fibromyalgia.

Goal Preferences, Affect, Activity Patterns and Health Outcomes in Women With Fibromyalgia

Some motivational models understand health behavior as a result of the interaction between goal preferences and mood. However, this perspective has not been explored in fibromyalgia. Furthermore, in chronic pain, it has only been explored with regard to negative affect. Thus, our aims were: (1) to develop a Spanish version of the Goal Pursuit Questionnaire (GPQ); (2) to explore the relationships between goal preferences and health outcomes, testing the moderator role of affect and the mediating role of chronic pain activity patterns. We conducted two cross-sectional studies. In Study 1, after a double translation/back-translation process, we interviewed 94 women attending the Fibromyalgia Unit of the Community of Valencia in order to identify the cultural feasibility and the content validity of the GPQ. Study 2 comprised 260 women. We explored the GPQ structure and performed path analyses to test conditional mediation relationships. Eight activities from the original GPQ were changed while maintaining the conceptual equivalence. Exploratory factor analysis showed two factors: 'Pain-avoidance goal' and 'Mood-management goal' (37 and 13% of explained variance, respectively). These factors refer to patients' preference for hedonic goals (pain avoidance or mood-management) over achievement goals. Robust RMSEA fit index of the final models ranged from 0.039 for pain to 0.000 for disability and fibromyalgia impact. Pain avoidance goals and negative affect influenced pain mediated by task-contingent persistence. They also affected disability mediated by task and excessive persistence. Pain avoidance goals and positive affect influenced fibromyalgia impact mediated by activity avoidance. We also found a direct effect of negative and positive affect on health outcomes. Preference for pain avoidance goals was always related to pain, disability and fibromyalgia impact through activity patterns. Affect did not moderate these relationships and showed direct and indirect paths on health outcomes, mainly by increasing persistence and showing positive affect as an asset and not a risk factor. Intervention targets should include flexible reinforcement of achievement goals relative to pain avoidance goals and positive affect in order to promote task-persistence adaptive activity patterns and decreased activity avoidance.

Types of pain and their psychosocial impact in women with rheumatoid arthritis

Rheumatoid arthritis (RA) is a systemic inflammatory autoimmune disease predominantly affecting middle-aged women. Very commonly, pain is a manifestation of active disease and because untreated RA can result in joint deformities, the current evaluation of pain has largely focused on inflammation. In addition, treatment has centered on the premise of reducing disease activity with the hopes of halting worsening damage, preventing future deformities, and ultimately providing pain relief for the patient. Yet research shows that all patients with RA, but women in particular, often suffer from increased mechanical pain and fibromyalgia, as well as anxiety, depression, sleep disturbances, sexual dysfunction, and disability, which add to the burden of the illness. Determining and addressing alternative pain triggers as well as understanding the psychosocial burden of RA is key in treating patients, especially in those who may not improve with traditional pharmacotherapy.

The opioid epidemic: helping rheumatologists prevent a crisis

An endemic increase in the number of deaths attributable to prescribed opioids is found in all developed countries. In 2016 in the USA, more than 46 people died each day from overdoses involving prescription opioids. European data show that the number of patients receiving strong opioids is increasing. In addition, there is an upsurge in hospitalisations for opioid intoxication, opioid abuse and deaths in some European countries. This class of analgesic is increasingly used in many rheumatological pathologies. Cohort studies, in various chronic non-cancer pain (CNCP) (osteoarthritis, chronic low back pain, rheumatoid arthritis, etc), show that between 2% and 8% of patients are treated with strong opioids. In order to help rheumatologists prescribe strong opioids under optimal conditions and to prevent the risk of death, abuse and misuse, recommendations have recently been published (in France in 2016, the recommendations of the French Society of Study and Treatment of Pain, in 2017, the European recommendations of the European Federation of IASP Chapters and the American Society of International Pain Physicians). They agree on the same general principles: opioids may be of interest in situations of CNCP, but their prescription must follow essential rules. It is necessary to make an accurate assessment of the pain and its origin, to formulate therapeutic objectives (pain, function and/or quality of life), to evaluate beforehand the risk of abuse and to get a specialised opinion beyond a certain dose or duration of prescription.

Physical and psychological paths toward less severe fibromyalgia: A structural equation model

OBJECTIVES

Previous research suggested isolated associations of physical and psychological factors with fibromyalgia severity. Integration of physical and psychological, experienced and observed, modifiable factors associated with fibromyalgia severity in a single model will reveal therapeutic paths toward less severity of disease. We aimed to examine an encompassing model of determinants of fibromyalgia severity.

METHODS

This observational, population-based cross-sectional study included 569 people with fibromyalgia. An integrative model of fibromyalgia severity was tested by using structural equation modelling. This model included 8 factors: resilience, catastrophizing, active lifestyle, declarative memory, subjective fitness, objective fitness, psychological distress, and physical fatigue.

RESULTS

Two core paths were associated with reduced fibromyalgia severity: 1) a psychological path connecting high resilience and low catastrophizing with low distress and 2) a physical path, connecting a more active lifestyle (directly and via high objective and subjective physical fitness) with low fatigue. Additional interconnecting paths especially suggested a connection from the psychological to physical path. Our model explained 83% of the fibromyalgia severity.

CONCLUSIONS

The present model integrated the complexity of mutually influencing factors of fibromyalgia severity, which may help to better understand the disease. It emphasised the importance of: 1) physical factors and psychological factors and their interconnections, 2) patients' experiences and clinical measurements, and 3) positive and negative signs such as physical fitness and distress. Future longitudinal and experimental research should aim at testing the causal direction of the associations in the model as well as the clinical implications suggested by the model. For instance, to reduce fatigue, exercise should enhance not only objective fitness but also fitness-related perceptions. Reducing distress and fatigue seems crucial for lowering fibromyalgia severity.

Group Psychotherapy With Fibromyalgia Patients: A Systematic Review

Objectives

This review aims to investigate the factors that play a role on the efficacy of group psychotherapy (GP) interventions for fibromyalgia syndrome (FMS).

Materials and methods

We employed a search using keywords group psychotherapy and fibromyalgia in the databases of Scopus, Web of Sciences, CINAHL, BMJ, MEDLINE, ScienceDirect and EBSCOhost.

Results

A total of 30 original studies were identified. These studies, which aimed to improve primary outcomes (POs-pain and fibromyalgia impact) and/or secondary outcomes (SOs-psychosocial), indicated that 15 were conducted in a multidisciplinary (MT) fashion, and the rest were unidimensional as they employed only GPs. Cognitive behavior therapy, which modifies dysfunctional thoughts and accompanying behaviors, was the most utilized psychological intervention. Overall, MTs were only slightly superior to GPs; however, improvements in POs were more frequent than SOs in MTs, and the vice versa in GPs.

Conclusion

Although studies varied in various methodological characteristics, the content of the interventions in MTs should be designed to cover the biopsychosocial nature of FMS.

Demographic, clinical, and treatment characteristics of the juvenile primary fibromyalgia syndrome cohort enrolled in the Childhood Arthritis and Rheumatology Research Alliance Legacy Registry

BACKGROUND

To describe the demographic, clinical, and treatment characteristics of youth diagnosed with juvenile primary fibromyalgia syndrome (JPFS) who are seen in pediatric rheumatology clinics.

METHODS

Information on demographics, symptoms, functioning, and treatments recommended and tried were obtained on patients with JPFS as part of a multi-site patient registry (the Childhood Arthritis and Rheumatology Research Alliance Legacy Registry). Data were summarized using descriptive statistics. In a subset of patients completing registry follow-up visits, changes in symptoms, pain, and functioning were evaluated using growth modeling.

RESULTS

Of the 201 patients with JPFS enrolled in the registry, most were Caucasian/White (85%), non-Hispanic (83%), and female (84%). Ages ranged from 9 to 20 years (M = 15.4 + 2.2). The most common symptoms reported were widespread musculoskeletal pain (91%), fatigue (84%), disordered sleep (82%), and headaches (68%). Pain intensity was rated as moderate to severe (M = 6.3 + 2.4/10). Scores on measures of functioning indicated mild to moderate impairment, with males observed to report significantly greater impairments. For the 37% of the initial cohort having follow-up data available, indicators of function and well-being were found to either worsen over time or remain relatively unchanged.

CONCLUSIONS

The symptoms of JPFS remained persistent and disabling for many patients treated by pediatric rheumatologists. Further study appears warranted to elucidate gender differences in the impact of JPFS symptoms. Work also is needed to identify accessible and effective outpatient treatment options for JPFS that can be routinely recommended or implemented by pediatric rheumatology providers.

Effectiveness of Tai Chi on fibromyalgia patients: A meta-analysis of randomized controlled trials

OBJECTIVE

To identify empirical evidence on the effectiveness of Tai Chi in treating fibromyalgia (FM).

METHOD

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to compare the effectiveness of Tai Chi and standard care or conventional therapeutic exercise in patients with FM. PubMed, Medline, and Physiotherapy Evidence Database were searched for relevant studies published before May 2019. Treatment effectiveness was evaluated using the fibromyalgia impact questionnaire (FIQ), and the total score, pain score, sleep quality index, fatigue, depression, and quality of life were assessing among the patients.

RESULTS

Six RCTs with 657 patients were included. Results of our meta-analysis indicated that Tai Chi exerts significant positive effects on reducing the total FIQ score at 12-16 weeks (standard mean difference [SMD]: -0.61; 95% confidence interval [CI]: -0.90 to -0.31) and pain score (SMD: -0.88; 95% CI: -1.58 to -0.18), improving sleep quality (SMD: -0.57; 95% CI: -0.86 to -0.28), relieving fatigue (SMD: -0.92; 95% CI: -1.81 to -0.04), alleviating depression (SMD: -0.49; 95% CI: -0.97 to -0.01), and enhancing quality of life physically (SMD: 6.21; 95% CI: 3.18-9.24) and psychologically (SMD: 5.15; 95% CI: 1.50-8.81).

CONCLUSION

Tai Chi exerts significantly greater effects on patients with FM than standard care; therefore, we suggest that Tai Chi can be used as an alternative treatment. However, more large-scale, high-quality, and multicenter trials are required to provide stronger evidence on the effectiveness of Tai Chi, as an alternative to aerobic exercise, compared with conventional therapeutic exercise.

Impact of water therapy on pain management in patients with fibromyalgia: current perspectives

Exercise-related interventions have been recommended as one of the main components in the management of fibromyalgia syndrome (FMS). Water therapy, which combines water's physical properties and exercise benefits, has proven effective in improving the clinical symptoms of FMS, especially pain, considered the hallmark of this syndrome. However, to our knowledge, the mechanisms underlying water therapy effects on pain are still scarcely explored in the literature. Therefore, this narrative review aimed to present the current perspectives on water therapy and the physiological basis for the mechanisms supporting its use for pain management in patients with FMS. Furthermore, the effects of water therapy on the musculoskeletal, neuromuscular, cardiovascular, respiratory, and neuroendocrine systems and inflammation are also addressed. Taking into account the aspects reviewed herein, water therapy is recommended as a nonpharmacologic therapeutic approach in the management of FMS patients, improving pain, fatigue, and quality of life. Future studies should focus on clarifying whether mechanisms and long-lasting effects are superior to other types of nonpharmacological interventions, as well as the economic and societal impacts that this intervention may present.

Physiotherapists' accounts of fibromyalgia: role-uncertainty and professional shortcomings

PURPOSE

This article examines accounts of fibromyalgia provided by physiotherapists. This qualitative study asks how physiotherapists define and understand fibromyalgia, what professional resources are available to them for treating patients, and where physiotherapists can turn when facing the scarcity of professional resources.

METHOD

The data were collected by means of semi-structured, in-depth, face-to-face interviews, conducted with 20 practicing physiotherapists. The physiotherapists were recruited using a purposive-sampling strategy and had extensive experience treating fibromyalgia patients (mean value: 6.5 years). The authors analyzed the interviews in accordance with the methods of thematic analysis.

RESULTS

The study findings expose two overarching themes: (a) fibromyalgia as an ambiguous and uncertain diagnosis: physiotherapists devalue the diagnosis, referring to it as a syndrome rooted on psychological factors; (b) role ambiguity and creativity in physiotherapy treatment: by questioning their role, physiotherapists end up focusing on illness management and developing creative treatments.

CONCLUSIONS

The study concludes that treating fibromyalgia patients challenges physiotherapists, mainly because of professional shortcomings. The findings highlight the necessity to train physiotherapists to respond to the needs of their patients with greater competence and less ambivalence.Implications for rehabilitationHealth providers need to acknowledge the difficulty physiotherapists are facing when providing treatment to fibromyalgia patients.Physiotherapists treating fibromyalgia should undergo special training to reduce their uncertainty and role ambiguity.Health providers should improve communication between physiotherapists and the General Practitioners referring fibromyalgia patients, to enable them to set shared evidence-based treatment goals.

Testing the effects of gentle vibrotactile stimulation on symptom relief in fibromyalgia

Background

Sensory disturbances in fibromyalgia extend beyond nociception. It has been proposed that imbalance in the mutual competition between painful input and non-painful sensory activity may, to a significant extent, account for the augmented subjective perception of pain. In this context, non-nociceptive somatosensory stimulation could arguably attenuate fibromyalgia symptoms by restoring the sensory balance. We specifically tested the effect of vibrotactile stimulation on symptom relief in fibromyalgia patients with a randomized, double-blind, sham-controlled, crossover clinical trial.

Methods

Seventy-seven female patients were randomized and data from 63 valid cases were analyzed. Active intervention involved extensive body stimulation with gentle mechanical vibrations administered during 3 h at night for 3 weeks, and the placebo effect was controlled using identical instruments to simulate an alternative treatment option. The primary outcome measure combined pain, fatigue, and complaints of poor cognition.

Results

Vibrotactile stimulation was significantly superior to sham in alleviating fibromyalgia symptoms globally. However, univariate analyses showed that the effect was not universal. Benefits were perceived on unpleasant somatic sensations such as generalized pain and fatigue, but not on poor cognition, anxiety, and depression. Vibrotactile stimulation was notably well tolerated and sleep quality significantly improved despite the fact that vibrations were administered at night.

Conclusions

Results thus provide new evidence that non-nociceptive somatosensory stimulation may favorably act upon altered somatosensory balance in fibromyalgia. From a clinical perspective, both the degree of improvement and the easy application of our proposal would seem to support a potential role for vibrotactile stimulation in the symptomatic treatment of fibromyalgia.

Trial registration

ClinicalTrials.gov registration number NCT03227952. Registered 24 July, 2017.

Safety and Efficacy of Medical Cannabis in Fibromyalgia

BACKGROUND

Chronic pain may be treated by medical cannabis. Yet, there is scarce evidence to support the role of medical cannabis in the treatment of fibromyalgia. The aim of the study was to investigate the characteristics, safety, and effectiveness of medical cannabis therapy for fibromyalgia.

METHODS

A prospective observational study with six months follow-up period based on fibromyalgia patients who were willing to answer questionnaire in a specialized medical cannabis clinic between 2015 and 2017.

RESULTS

Among the 367 fibromyalgia patients, the mean age was 52.9 ± 15.1, of whom 301 (82.0%) were women. Twenty eight patients (7.6%) stopped the treatment prior to the six months follow-up. The six months response rate was 70.8%. Pain intensity (scale 0-10) reduced from a median of 9.0 at baseline to 5.0 (p < 0.001), and 194 patients (81.1%) achieved treatment response. In a multivariate analysis, age above 60 years (odds ratio [OR] 0.34, 95% C.I 0.16-0.72), concerns about cannabis treatment (OR 0.36, 95% C.I 0.16-0.80), spasticity (OR 2.26, 95% C.I 1.08-4.72), and previous use of cannabis (OR 2.46 95% C.I 1.06-5.74) were associated with treatment outcome. The most common adverse effects were mild and included dizziness (7.9%), dry mouth (6.7%), and gastrointestinal symptoms (5.4%).

CONCLUSION

Medical cannabis appears to be a safe and effective alternative for the treatment of fibromyalgia symptoms. Standardization of treatment compounds and regimens are required.

The Turkish Society of Physical Medicine and Rehabilitation (TSPMR) guideline recommendations for the management of fibromyalgia syndrome

In the present study, we aimed to establish a national guideline including recommendations of the Turkish Society of Physical Medicine and Rehabilitation (TSPMR) for the management of Fibromyalgia (FM) syndrome. This guideline was built mainly in accordance with the 2017 revised European League Against Rheumatism (EULAR) guideline recommendations for the management of FM. A total of 46 physical medicine and rehabilitation specialists were included. A systematic literature search was carried out in PubMed, Scopus, Cochrane, and Turkish Medical Index between 2000 and 2018. Evidence levels of the publications were evaluated, and the levels of recommendation were graded on the basis of relevant levels of evidence, The Assessment of Level of Agreement with opinions by task force members was established using the electronic Delphi technique. Recommendations were assessed by two Delphi rounds and 7 of 10 points were deemed necessary for agreement. The treatment recommendations were classified as non-pharmacological therapies (6 main items), pharmacological treatments (10 items), and complementary therapies (5 items). These were recommended in the light of evidence, depending on the clinical and general condition of each patient. This is the first national TSPMR guideline recommendations for the management of FM in Turkey. We believe our effort would be helpful for the physicians who are interested in the treatment of FM.

A PharmD program curricular approach to addressing the opioid crisis

BACKGROUND AND PURPOSE

The opioid crisis in the United States is widespread and requires large scale efforts to reduce the problem. A recent call by the American Association of Colleges of Pharmacy requested commitments by member schools to enact curricular changes in order to prepare pharmacy graduates to be impactful in addressing the opioid crisis.

EDUCATIONAL ACTIVITY

A taskforce reviewed existing pain management and opioid-related curricular content in the North Dakota State University School of Pharmacy (NDSU SOP). As a result, all pre-existing opioid-related content was maintained and six new educational activities were designed and implemented to enhance hands-on experience and application of pain management and opioid-related concepts and skills. Students were surveyed after completing the pre-APPE curriculum regarding their confidence in identifying inappropriate use of opioids and engaging in conversations with patients about safe opioid use.

FINDINGS

The full longitudinal approach to addressing pain management and opioid content in the North Dakota State University School of Pharmacy program is described. Curricular gap analysis, thoughtful coordination, faculty collaboration, and curriculum mapping were required in order to bring the full pain management and opioid curricular plan to fruition. The vast majority of students were confident in their ability to counsel patients on appropriate options for safe use and disposal of opioids (96%) and their ability to determine if a patient is at risk for opioid misuse (92%). A lower percentage (71%) were confident in their ability to converse with patients regarding opioid misuse concerns.

SUMMARY

This is the first report to summarize a longitudinal, curriculum-wide approach taken to address the opioid crisis in the United States and in response to AACP's call to action for pharmacy schools. This description may be valuable to other pharmacy and health professions educational programs in search of means to implement and/or enhance their current curricular offerings related to pain management and opioids.

Chronic pain and central sensitization in immuno-inflammatory rheumatic diseases: pathogenesis, clinical manifestations, the possibility of using targeted disease modifying antirheumatic drugs

Chronic pain is one of the main manifestations of immuno-inflammatory rheumatic diseases (IIRD), such as rheumatoid arthritis (RA) and psoriatic arthritis (PsA), which determines the severity of suffering, reduced quality of life and disability of patients. Unfortunately, the use of synthetic and biological disease modifying antirheumatic drugs, as well as non-steroidal anti-inflammatory drugs does not always provide sufficient control of pain in IIRD, even when it is possible to achieve a significant reduction in inflammatory activity. The reason for this is the complex mechanism of chronic pain. It includes not onlystimulation of pain receptors caused by damage of the elements of the musculoskeletal system, but also a change in the perception of pain associated with the phenomenon of central sensitization (CS). CS is characterized by a significant and persistent increase in the sensitivity of nociceptive neurons to pain and nonpain stimuli. One of the main theories of the CS development consider this phenomenon as an inflammatory reaction of the neuronenvironmentthe activation of astrocytes and microglial cells, local hyperproduction of cytokines, inflammatory mediators and neurotrophic factors. Factors contributing to the development of CS in IIRD are obesity, depression and anxiety, damage of the somatosensory system, insufficient relief of pain in the onset of the disease. Clinical manifestations of CS in IIRD is hyperalgesia, allodinia, «expanded pain» and secondary fibromyalgia. An important role in the development of chronic pain and CS plays the intracellular inflammatory pathway JAK-STAT. Therefore, JAK inhibitors, such as tofacitinib, used in RA and PsA, can also be considered as an effective means of controlling chronic pain in these diseases.

Association of objectively measured physical activity and sedentary time with health-related quality of life in women with fibromyalgia: The al-Ándalus project

PURPOSE

To examine the association of physical activity (PA) intensity levels and sedentary time with health-related quality of life (HRQoL) in women with fibromyalgia and whether patients meeting the current PA guidelines present better HRQoL.

METHODS

This cross-sectional study included 407 women with fibromyalgia aged 51.4 ± 7.6 years. The time spent (min/day) in different PA intensity levels (light, moderate, and moderate-to-vigorous physical activity (MVPA) and sedentary time were measured with triaxial accelerometry. The proportion of women meeting the American PA recommendations (≥150 min/week of MVPA in bouts ≥10 min) was also calculated. HRQoL domains (physical function, physical role, bodily pain, general health, vitality, social functioning, emotional role, and mental health), as well as physical and mental components, were assessed using the 36-item Short-Form Health Survey.

RESULTS

All PA intensity levels were positively correlated with different HRQoL dimensions (r partial between 0.10 and 0.23, all p < 0.05). MVPA was independently associated with social functioning (p < 0.05). Sedentary time was independently associated with physical function, physical role, bodily pain, vitality, social functioning, and both the physical and mental component summary score (all p < 0.05). Patients meeting the PA recommendations presented better scores for bodily pain (mean = 24.2 (95%CI: 21.3-27.2) vs. mean = 20.4 (95%CI: 18.9-21.9), p = 0.023) and better scores for social functioning (mean = 48.7 (95%CI: 43.9-44.8) vs. mean = 42.3 (95%CI: 39.8-44.8), p = 0.024).

CONCLUSION

MVPA (positively) and sedentary time (negatively) are independently associated with HRQoL in women with fibromyalgia. Meeting the current PA recommendations is significantly associated with better scores for bodily pain and social functioning. These results highlight the importance of being physically active and avoiding sedentary behaviors in this population.

Managing fatigue in patients with primary Sjögren's syndrome: challenges and solutions

Primary Sjögren's syndrome (pSS) patients identify fatigue as their most important symptom and the one most difficult to cope with, but there are still many challenges and few solutions to manage this debilitating symptom. Promising pharmacological treatments, such as rituximab, have failed in more stringent tests including randomized controlled trials (RCTs) and meta-analysis. While non-pharmacological interventions may be safer, less costly, and address other common comorbidities, to date only aerobic exercise seems to be effective at reducing fatigue in pSS. All interventions, pharmacological or not, need to be tested in high-quality RCTs. The aim of this review is to provide an overview of fatigue management in pSS and discuss potential opportunities for future research.

Non-supervised breathing exercise regimen in women with fibromyalgia: A quasi-experimental exploratory study

OBJECTIVES

To know the effectiveness and safety of non-supervised breathing exercise regimen by promoting patients' self-management, and to investigate if non-supervised breathing exercise regimen shows similar benefits to supervised regimen in improving pain and fibromyalgia (FM) impact on daily life.

MATERIAL AND METHODS

Fifty-one women with FM were assigned to: supervised breathing exercise regimen group, non-supervised breathing exercise regimen group, and control group. Pain thresholds tolerance on tender points and FM impact on daily life were evaluated.

RESULTS

After 12-weeks of breathing exercises statistical differences were not found between supervised and non-supervised regimen. However, supervised regimen showed additional improvements in pain thresholds tolerance and in pain-FIQ subscale.

CONCLUSION

Our results suggest that performing a non-supervised breathing exercise program could be as safe and effective as the supervised regimen. However, it was observed that there could be a tendency of supervised exercise regimen to show additional benefits in terms of pain.

Exercise-Induced Hypoalgesia in Pain-Free and Chronic Pain Populations: State of the Art and Future Directions

Exercise is considered an important component of effective chronic pain management and it is well-established that long-term exercise training provides pain relief. In healthy, pain-free populations, a single bout of aerobic or resistance exercise typically leads to exercise-induced hypoalgesia (EIH), a generalized reduction in pain and pain sensitivity that occurs during exercise and for some time afterward. In contrast, EIH is more variable in chronic pain populations and is more frequently impaired; with pain and pain sensitivity decreasing, remaining unchanged or, in some cases, even increasing in response to exercise. Pain exacerbation with exercise may be a major barrier to adherence, precipitating a cycle of physical inactivity that can lead to long-term worsening of both pain and disability. To optimize the therapeutic benefits of exercise, it is important to understand how EIH works, why it may be impaired in some people with chronic pain, and how this should be addressed in clinical practice. In this article, we provide an overview of EIH across different chronic pain conditions. We discuss possible biological mechanisms of EIH and the potential influence of sex and psychosocial factors, both in pain-free adults and, where possible, in individuals with chronic pain. The clinical implications of impaired EIH are discussed and recommendations are made for future research, including further exploration of individual differences in EIH, the relationship between exercise dose and EIH, the efficacy of combined treatments and the use of alternative measures to quantify EIH. PERSPECTIVE: This article provides a contemporary review of the acute effects of exercise on pain and pain sensitivity, including in people with chronic pain conditions. Existing findings are critically reviewed, clinical implications are discussed, and recommendations are offered for future research.

Does aerobic exercise associated with tryptophan supplementation attenuates hyperalgesia and inflammation in female rats with experimental fibromyalgia?

The objective of this study was to verify the effects of aerobic exercise associated with tryptophan (TRP) supplementation on hyperalgesia, as well as on cortisol, IL-6 and TNF concentrations in female rats with experimental fibromyalgia (FM). Female Wistar rats (initial body weight: ~ 350 g; age: 12 months) were randomly divided into 5 groups: CON (Control); F (Fibromyalgia induced); FE (Fibromyalgia induced plus exercise); FES (Fibromyalgia induced plus exercise and TRP supplementation) and FS (Fibromyalgia induced plus TRP supplementation). Fibromyalgia was induced with two injections (20 μL) of acidic saline (pH 4.0) into the right gastrocnemius muscle with a 3-day interval. Control animals received the same doses of neutral saline (pH 7.4). The exercised animals underwent progressive low-intensity aerobic exercise (LIAE) on a treadmill (10–12 m/min, 30–45 min/day, 5 days/week) for three weeks. During this period, the supplemented animals received a TRP supplemented diet (210 g/week), while the others received a control diet. Mechanical hyperalgesia was evaluated weekly and serum cortisol and muscle IL-6 and TNF concentrations were assessed after three weeks of interventions. Experimental FM caused bilateral hind paw hyperalgesia and augmented serum cortisol and muscle IL-6 concentrations. After 3 weeks of interventions, LIAE alone reduced hyperalgesia (151%) and reduced serum cortisol concentrations (72%). Tryptophan supplementation itself diminished hyperalgesia (57%) and reduced serum cortisol concentrations (67%). Adding TRP supplementation to LIAE did not further reduce hyperalgesia significantly (11%), which was followed by an important decrease in muscle IL-6 concentrations (68%), though reduction in serum cortisol pulled back to 45%. Muscle TNF concentrations were not affected. In conclusion, the association of TRP supplementation to LIAE does not potentiate significantly the reduction of bilateral mechanical hyperalgesia promoted by LIAE in female rats with experimental FM, however an important decrease in IL-6 is evident.

Analgesic effects of mirogabalin, a novel ligand for α2δ subunit of voltage-gated calcium channels, in experimental animal models of fibromyalgia

Mirogabalin, a novel ligand for the α₂δ subunit of voltage-gated calcium channels, is under the development for the treatment of neuropathic pain. Mirogabalin specifically and potently binds to α₂δ subunits, and it shows analgesic effects in both peripheral and central neuropathic pain models in rats. To expand pharmacological findings on mirogabalin and provide additional information of its potential for chronic pain therapy, we examined the effects of mirogabalin in 2 experimental models of fibromyalgia, namely, the intermittent cold stress model (ICS model) and the unilateral intramuscular acidic saline injection model (Sluka model). To induce chronic mechanical hypersensitivity, mice were placed under ICS conditions for 3 days, whereas rats were injected twice with acidic saline (pH 4) into the gastrocnemius muscle in a 4-day interval. The pain sensitivity was evaluated by the von Frey test. Long-lasting increases in pain response score or decreases in pain threshold to the von Frey stimulation were observed in both the ICS and Sluka models. Mirogabalin (1, 3, or 10 mg/kg, p.o.) dose-dependently alleviated the mechanical hypersensitivity, with significant effects persisting at 6 or 8 h following administration. The standard α₂δ ligand, pregabalin (30 mg/kg, p.o.), also significantly reduced the mechanical hypersensitivity. In summary, mirogabalin showed analgesic effects in the ICS model mice and in the Sluka model rats. Therefore, mirogabalin may have the potential to provide effective pain relief in patients with fibromyalgia.

Role of inflammation in the pathogenesis and treatment of fibromyalgia

Fibromyalgia is a multifaceted disease. The clinical picture of fibromyalgia covers numerous comorbidities. Each comorbidity stands as a distinct condition. However, common pathophysiologic factors are occupied in their background. Along with the genetic, environmental and neuro-hormonal factors, inflammation has been supposed to have role in the pathogenesis of fibromyalgia. The aim of the present article was to review the current literature regarding the potential role of inflammation in the pathogenesis and treatment of fibromyalgia. A literature search was conducted through PubMed/MEDLINE and Web of Science databases using relevant keywords. Recent evidence on this highly studied topic indicates that fibromyalgia has an immunological background. Cytokines/chemokines, lipid mediators, oxidative stress and several plasma-derived factors underlie the inflammatory state in fibromyalgia. There are potential new therapeutic options targeting inflammatory pathways in fibromyalgia patients. In conclusion, there is evidence to support the inflammation-driven pathways in the pathogenesis of fibromyalgia. However, further research is required to fully understand the network of inflammation and its possible role in diagnosis and/or treatment of fibromyalgia.

Mitochondrial Dysfunction in Skeletal Muscle of a Fibromyalgia Model: The Potential Benefits of Melatonin

Fibromyalgia syndrome (FMS) is considered a musculoskeletal disorder associated to other symptoms including chronic pain. Since the hypothesis of FMS etiogenesis is consistent with mitochondrial dysfunction and oxidative stress, we evaluated the pathophysiological correlation among these factors studying some proteins involved in the mitochondrial homeostasis. We focused our attention on the roles of peroxisome proliferator activated receptor gamma coactivator-1alpha (PGC-1α), mitofusin2 (Mfn2), and coenzyme Q10 (CoQ10) in reserpine-induced myalgic (RIM) rats that manifest fibromyalgia-like chronic pain symptoms. First, we underlined that RIM rats are a good model for studying the pathophysiology of FMS and moreover, we found that PGC-1α, Mfn2, and CoQ10 are involved in FMS. In fact, their expressions were reduced in gastrocnemius muscle determining an incorrect mitochondrial homeostasis. Today, none of the currently available drugs are fully effective against the symptoms of this disease and they, often, induce several adverse events; hence, many scientists have taken on the challenge of searching for non-pharmacological treatments. Another goal of this study was therefore the evaluation of the potential benefits of melatonin, an endogenous indoleamine having several functions including its potent capacity to induce antioxidant enzymes and to determine the protective or reparative mechanisms in the cells. We observed that melatonin supplementation significantly preserved all the studied parameters, counteracting oxidative stress in RIM rats and confirming that this indoleamine should be taken in consideration for improving health and/or counteract mitochondrial related diseases.

Health beliefs, attitudes, and health-related quality of life in persons with fibromyalgia: mediating role of treatment adherence

Fibromyalgia is a chronic illness characterized by pain and fatigue. Persons with fibromyalgia experience increased the risk for poor mental and physical health-related quality of life, which may be dependent on multiple factors, including health beliefs, such as confidence in physicians and the health-care system, and health behaviors, such as treatment adherence. Respondents with fibromyalgia (n = 409) were recruited nationally, via support organizations, and completed self-report measures: Multidimensional Health Profile - Health Functioning Index (MHP-H), Short-Form-36 Health Survey (SF-36v2), and Medical Outcomes Study (MOS) Measure of Patient Adherence - General Adherence Items. In mediation models, belief in the healthcare system and health-care personnel, and health efficacy exerted an indirect effect through treatment adherence on mental and physical quality of life. Adaptive health beliefs and attitudes were related to greater treatment adherence and, in turn, to a better quality of life. Maladaptive health beliefs and mistrusting attitudes about physician-level and systemic-level healthcare provision are negatively related to both treatment adherence and consequent physical and mental health-related quality of life in persons with fibromyalgia. Future randomized controlled trials are needed to determine if therapeutic strategies to alter health values might improve adherence and self-rated health.

Acupuncture therapy for fibromyalgia: a systematic review and meta-analysis of randomized controlled trials

Purpose

Fibromyalgia (FM) can cause chronic widespread pain and seriously affect the quality of patient lives. Acupuncture therapy is widely used for pain management. However, the effect of acupuncture on FM is still uncertain. The aim of this review was to determine the effect and safety of acupuncture therapy on the pain intensity and quality of life in patients with FM.

Materials and methods

We searched PubMed, the Cochrane Library, Embase, the China National Knowledge Infrastructure, the Chinese Science and Technology Periodical Database, and the Chinese Biomedical Literature Database to collect randomized controlled trials (RCTs) of acupuncture for FM published before May 2018. A meta-analysis was performed according to the Cochrane systematic review method by using RevMan 5.3 software, and GRADE was used to evaluate the quality of the evidence.

Results

We identified 12 RCTs that compared acupuncture therapy to sham acupuncture or conventional medication. Meta-analysis showed that acupuncture was significantly better than sham acupuncture for relieving pain (MD =−1.04, 95% CI [−1.70, –0.38], P=0.002, I²=78%) and improving the quality of life (MD =−13.39, 95% CI [−21.69, –5.10], P=0.002, I²=82%), with low- to moderate-quality evidence in the short term. At follow-up in the long term, the effect of acupuncture was also superior to that of sham acupuncture. No serious adverse events were found during acupuncture.

Conclusion

Acupuncture therapy is an effective and safe treatment for patients with FM, and this treatment can be recommended for the management of FM.

Patients' perspective of the effectiveness and acceptability of pharmacological and non-pharmacological treatments of fibromyalgia

Background and aims Fibromyalgia is a complex condition characterised by widespread pain, sleep disturbance, fatigue and cognitive impairment, with a global mean prevalence estimated at 2.7%. There are inconsistencies in guidelines on the treatment of fibromyalgia leading to dissatisfaction from patients and healthcare professionals. This study investigated patient-reported outcomes of pharmacological and non-pharmacological treatment usage and effectiveness with an assessment of acceptability. Methods Nine hundred and forty-one participants completed a self-administered anonymous questionnaire giving quantitative data of demographics, treatment usage and treatment outcomes. Participant-reported effectiveness and side effects were compared in the following treatment classes: analgesics, antidepressants, gabapentinoids, gastrointestinal treatments, activity interventions, dietary-based treatments, and psychological, physical and alternative therapies. Participants also reported whether they knew about or had tried different treatments. Results The results from the online survey indicated that the range of mean effectiveness ratings were similar for pharmacological and non-pharmacological treatments, whereas non-pharmacological treatments had lower side effects ratings and higher acceptability relative to pharmacological treatments. Participants were not aware of some treatment options. Conclusions The results show lower side effects ratings and higher acceptability for non-pharmacological treatments compared to pharmacological treatments despite similar effectiveness ratings. Implications This article presents results from a large online survey on fibromyalgia patient perspectives of pharmacological and non-pharmacological treatments. Results will inform healthcare professionals and patients about optimal treatments based on ratings of effectiveness, side effects and acceptability that are tailored to patient symptom profiles. Some participants were unaware of treatment options highlighting the importance of patient education allowing collaboration between patients and healthcare professionals to find optimal treatments.

Pattern of sleep dysfunction in systemic lupus erythematosus: a cluster analysis

OBJECTIVES

To investigate how the different components of sleep dysfunction described in SLE patients combine together in sleep clusters.

METHODS

We conducted a cross-sectional study on a perspective cohort of 79 SLE patients (mean age 8.2 ± 14.3 years). Sleep was evaluated using Pittsburgh Sleep Quality Index (PSQI). Clusters were defined using the single components of PSQI in a hierarchical clustering model. We used Beck Depression Inventory, Hamilton Anxiety Rating Scale, and Medical Outcomes Study Short Form 36 (SF36) to measure depressive symptoms, anxiety, and quality of life, respectively.

RESULTS

Three sleep clusters were identified. The cluster 1 (N = 47) is characterized by the lowest values of PSQI total score. The cluster 2 (N = 21) presents higher values of sleep latency, but sleep duration similar to cluster 1. In cluster 3 (N = 11), we found sleep latency increased as in cluster 2, but the highest values of PSQI total score and reduced sleep duration. Scores of anxiety and sedentary time were higher in clusters 2 and 3 than in cluster 1. Cluster 3 presented the highest scores of depression and reduced mental and physical components of SF36.

CONCLUSIONS

The combination of different sleep components in SLE patients allowed us to identify three patterns of dysfunction: a first cluster with better sleep latency and duration, a second with increased sleep latency but conserved duration, and a third with impairment of both latency and duration. The stratification of sleep disorders in clusters might be useful for the personalization of therapy in relation to sleep cluster membership.

Effectiveness and cost-effectiveness of the modified Pilates method versus aerobic exercise in the treatment of patients with fibromyalgia: protocol for a randomized controlled trial

Background

Fibromyalgia is characterized by chronic generalized pain, fatigue, sleep disorders and other symptoms. Physical exercise is recommended as the first choice of non-pharmacological therapy. Thus, the aim of this study is to evaluate the effectiveness and cost-effectiveness of modified Pilates exercises compared to aerobic exercises in the treatment of patients with fibromyalgia.

Methods

In this randomized controlled trial with blinded assessor, 98 patients who meet the fibromyalgia classification criteria of the American College of Rheumatology 2010, aged between 20 and 75 years, and with pain intensity greater than or equal to 3 points in the Pain Numerical Rating Scale, will be randomly divided into Aerobic Group (aerobic exercises on treadmills or stationary bikes) and Pilates Group (modified Pilates exercises), and treated twice a week for eight weeks on the Center for Excellence in Clinical Research in Physical Therapy at Universidade Cidade de São Paulo, Brazil. The following outcomes will be evaluated by a blinded assessor at baseline, eight weeks, six months, and 12 months after randomization: impact of fibromyalgia assessed by the Fibromyalgia Impact Questionnaire, pain intensity by the Pain Numerical Rating Scale, kinesiophobia by the Tampa Scale of Kinesiophobia, specific disability by the Patient-Specific Functional Scale, functional capacity by the 6-min Walk Test, quality of sleep by the Pittsburgh Sleep Quality Index, and health-related quality of life by EQ-5D-3L and SF-6D questionnaires.

Discussion

It is expected that the Pilates exercises will be more effective than aerobic exercises in improving clinical outcomes and that this improvement will be maintained over the medium to long term. This study aims to clarify whether the Pilates method can be incorporated into the clinical practice of physical therapists treating patients with fibromyalgia. The study will also provide information on which exercise will be most cost-effective, information that can be used by insurers and public health systems.

Trial registration

This study was prospectively registered at the Clinical Trials Registry (NCT03050606) in February 2017.

Exercise-induced hypoalgesia: A meta-analysis of exercise dosing for the treatment of chronic pain

OBJECTIVE

Increasing evidence purports exercise as a first-line therapeutic for the treatment of nearly all forms of chronic pain. However, knowledge of efficacious dosing respective to treatment modality and pain condition is virtually absent in the literature. The purpose of this analysis was to calculate the extent to which exercise treatment shows dose-dependent effects similar to what is seen with pharmacological treatments.

METHODS

A recently published comprehensive review of exercise and physical activity for chronic pain in adults was identified in May 2017. This report reviewed different physical activity and exercise interventions and their effectiveness in reducing pain severity and found overall modest effects of exercise in the treatment of pain. We analyzed this existing data set, focusing specifically on the dose of exercise intervention in these studies. We re-analyzed data from 75 studies looking at benefits of time of exercising per week, frequency of exercise per week, duration of intervention (in weeks), and estimated intensity of exercise.

RESULTS

Analysis revealed a significant positive correlation with exercise duration and analgesic effect on neck pain. Multiple linear regression modeling of these data predicted that increasing the frequency of exercise sessions per week is most likely to have a positive effect on chronic pain patients.

DISCUSSION

Modest effects were observed with one significant correlation between duration and pain effect for neck pain. Overall, these results provide insufficient evidence to conclude the presence of a strong dose effect of exercise in pain, but our modeling data provide tes predictions that can be used to design future studies to explicitly test the question of dose in specific patient populations.

Substituting Sedentary Time With Physical Activity in Fibromyalgia and the Association With Quality of Life and Impact of the Disease: The al-Ándalus Project

OBJECTIVE

There is an overall awareness of the detrimental health effects of sedentary time (ST) in fibromyalgia; however, data are limited on how replacement of ST with physical activity (PA) of different intensity may be related to health in this condition. The aim of this study was to examine how a substitution of ST with light PA (LPA) or moderate-to-vigorous PA (MVPA) is associated with quality of life and disease impact.

METHODS

This study comprised 407 women with fibromyalgia, mean ± SD age 51.4 ± 7.6 years. The time spent in ST and PA was measured with triaxial accelerometry. Quality of life and disease impact were assessed using the Short Form 36 (SF-36) health survey and the Revised Fibromyalgia Impact Questionnaire (FIQR), respectively. The substitution of ST with an equivalent time of LPA or MVPA and the associated outcomes were examined using isotemporal substitution analyses.

RESULTS

Substituting 30 minutes of ST with LPA in the isotemporal model was associated with better scores in bodily pain (B = 0.55), vitality (B = 0.74), and social functioning (B = 1.45) according to the SF-36, and better scores at all of the domains (function, overall impact, symptoms, and total impact) of the FIQR (B ranging from -0.95 to -0.27; all P < 0.05). When ST was replaced with MVPA, better physical role (B = 2.30) and social functioning (B = 4.11) of the SF-36 and function of the FIQR (B = -0.73) were observed (all P < 0.05).

CONCLUSION

In regression models, allocation of time of sedentary behavior to either LPA or MVPA was associated with better quality of life and lower disease impact in women with fibromyalgia.