Carville, S. F. et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann. Rheum. Dis. 67, 536-541

Academic Rheumatology Unit, King's College London, Weston Education Centre, Cutcombe Road, London SE5 9RJ, UK.
Annals of the rheumatic diseases (Impact Factor: 10.38). 05/2008; 67(4):536-41. DOI: 10.1136/ard.2007.071522
Source: PubMed


To develop evidence-based recommendations for the management of fibromyalgia syndrome.
A multidisciplinary task force was formed representing 11 European countries. The design of the study, including search strategy, participants, interventions, outcome measures, data collection and analytical method, was defined at the outset. A systematic review was undertaken with the keywords "fibromyalgia", "treatment or management" and "trial". Studies were excluded if they did not utilise the American College of Rheumatology classification criteria, were not clinical trials, or included patients with chronic fatigue syndrome or myalgic encephalomyelitis. Primary outcome measures were change in pain assessed by visual analogue scale and fibromyalgia impact questionnaire. The quality of the studies was categorised based on randomisation, blinding and allocation concealment. Only the highest quality studies were used to base recommendations on. When there was insufficient evidence from the literature, a Delphi process was used to provide basis for recommendation.
146 studies were eligible for the review. 39 pharmacological intervention studies and 59 non-pharmacological were included in the final recommendation summary tables once those of a lower quality or with insufficient data were separated. The categories of treatment identified were antidepressants, analgesics, and "other pharmacological" and exercise, cognitive behavioural therapy, education, dietary interventions and "other non-pharmacological". In many studies sample size was small and the quality of the study was insufficient for strong recommendations to be made.
Nine recommendations for the management of fibromyalgia syndrome were developed using a systematic review and expert consensus.

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    • "The polysymptomatic nature of FM leads to great suffering for FM patients and high costs for society. Unfortunately, current treatments are not very efficient (Carville et al., 2008). Although much remains to be understood regarding the neuronal mechanisms that are involved in FM, the combination of multimodal increase in pain sensitivity (Kosek et al., 1996) and dysfunction of descending pain inhibition (Kosek and Hansson, 1997; Lannersten and Kosek, 2010) suggest the importance of central nervous system mechanisms in the pathophysiology of FM. "
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    ABSTRACT: Fibromyalgia (FM) is a syndrome characterized by chronic pain without known peripheral causes. Previously we have reported dysfunctional pain inhibitory mechanisms for FM patients during pain administration. In the current study we employed a seed correlation analysis (SCA), independent component analysis (ICA), and an analysis of fractional amplitude of low frequency fluctuations (fALFF) to study differences between a cohort of female fibromyalgia patients and an age- and sex matched healthy control group during a resting state condition. FM patients showed decreased connectivity between thalamus and premotor areas, between the right insula and primary sensorimotor areas, as well as between supramarginal and prefrontal areas. Individual sensitivity to painful pressure was associated with increased connectivity between pain related regions (e.g. insula and thalamus) and midline regions of the default mode network (including posterior cingulate cortex and medial prefrontal cortex) among patients and controls. However, neither ICA nor fALFF revealed any group differences. Our findings suggest that abnormal connectivity patterns between pain related regions and the remaining brain during rest reflect an impaired central mechanism of pain modulation in FM. Weaker coupling between pain regions and prefrontal- and sensorimotor areas might indicate a less efficient system level control of pain circuits. Moreover, our results show that multiple, complementary analytical approaches are valuable for obtaining a more comprehensive characterization of deviant resting state activity. In conclusion, our findings show that FM primarily is associated with decreased connectivity, e.g. between several pain related areas and sensorimotor regions, which could reflect a deficiency in pain regulation.
    Full-text · Article · Jul 2014 · Brain Connectivity
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    • "Some pain-relieving procedures are founded on the competition between nociceptive and nonnociceptive (touch, proprioception, and vibration) sensory modalities, whereas other strategies aim at normalizing higher-order sensory representations [31] [49] [61]. Procedures tested to treat fibromyalgia with a range of success include peripheral nerve stimulation [19], vibrotactile stimulation [66], whole-body vibration therapy [54], heated water body stimulation, aerobic exercise [10], body awareness therapy [38], and cognitive behavioral therapy [10]. Therefore, a variety of tested treatments are primarily focused on increasing the tone of nonnociceptive sensory activity. "
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    ABSTRACT: Fibromyalgia typically presents with spontaneous body pain with no apparent cause and is considered pathophysiologically to be a functional disorder of somatosensory processing. We have investigated potential associations between the degree of self-reported clinical pain and resting-state brain functional connectivity at different levels of putative somatosensory integration. Resting-state functional MRI was obtained in 40 women with fibromyalgia and 36 control subjects. A combination of functional connectivity-based measurements were used to assess (i) the basic pain signal modulation system at the level of the periaqueductal gray (PAG), (ii) the sensory cortex with an emphasis on the parietal operculum/secondary somatosensory cortex (SII) and (iii) the connectivity of these regions with the self-referential "default mode" network. Compared with control subjects, a reduction of functional connectivity was identified across the three levels of neural processing, each showing a significant and complementary correlation with the degree of clinical pain. Specifically, self-reported pain in fibromyalgia patients correlated with (i) reduced connectivity between PAG and anterior insula, (ii) reduced connectivity between SII and primary somatosensory, visual and auditory cortices, and (iii) increased connectivity between SII and the default mode network. The results confirm previous research demonstrating abnormal functional connectivity in fibromyalgia and show that alterations at different levels of sensory processing may contribute to account for clinical pain. Importantly, reduced functional connectivity extended beyond the somatosensory domain and implicated visual and auditory sensory modalities. Overall this study suggests that a general weakening of sensory integration underlies clinical pain in fibromyalgia.
    Full-text · Article · May 2014 · Pain
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    • "Treatment for fibromyalgia includes pharmacological treatment, behavioral intervention, physical therapy, exercises, and alternative medicine.40–48 Although fibromyalgia patients often use analgesics, antidepressants, anticonvulsants, opioids, dopamine agonists, and other medications to alleviate their symptoms, the only pharmacologic treatments approved by the US Food and Drug Administration (FDA) for fibromyalgia are pregabalin (approved in 2007),49–53 duloxetine (approved in 2008),53–56 and milnacipran (approved in 2009).57–59 "
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    ABSTRACT: To compare health care utilization of duloxetine initiators and pregabalin initiators among fibromyalgia patients in a real-world setting. A retrospective cohort study was conducted based on a US national commercial health claims database (2006-2009). Fibromyalgia patients who initiated duloxetine or pregabalin in 2008, aged 18-64 years, and who maintained continuous health insurance coverage 1 year before and 1 year after initiation were assigned to duloxetine or pregabalin cohorts on the basis of their initiated agent. Patients who had pill coverage of the agents over the course of 90 days preceding the initiation were excluded. The two comparative cohorts were constructed using propensity score greedy match methods. Descriptive analysis and paired t-test were performed to compare health care utilization rates in the postinitiation year and the changes of these rates from the preinitiation year to the postinitiation year. Both matched cohorts (n=1,265 pairs) had a similar mean initiation age (49-50 years), percentage of women (87%-88%), and prevalence of baseline comorbid conditions (neuropathic pain other than diabetic peripheral neuropathic pain, low back pain, cardiovascular disease, hypertension, headache or migraine, and osteoarthritis). In the preinitiation year, both cohorts had similar inpatient, outpatient, and medication utilization rates (inpatient, 15.7%-16.1%; outpatient, 100.0%; medication, 97.9%-98.7%). The utilization rates diverged in the postinitiation year, with the pregabalin cohort using more fibromyalgia-related inpatient care (3.2% versus 2.2%; P<0.05), any inpatient care (19.3% versus 16.8%; P<0.05), and fibromyalgia-related outpatient care (62.1% versus 51.8%; P<0.05). From the preinitiation period to the postinitiation period, the duloxetine cohort experienced decreases in certain utilization rates, whereas the pregabalin cohort had increases (percentage of patients with a fibromyalgia-related admission, -1.2% versus 0.4% [P<0.01]; number of fibromyalgia-related outpatient claims, -1.7 versus 4.7 [P<0.01]). Fibromyalgia patients initiating pregabalin tended to consume more fibromyalgia-related inpatient and outpatient care in the first postinitiation year, whereas fibromyalgia patients initiating duloxetine tended to have lower utilization rates of fibromyalgia-related inpatient care in the postinitiation year than in the preinitiation year.
    Full-text · Article · Jan 2014 · Journal of Pain Research
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