EULAR revised recommendations for the management of fibromyalgia
Open accessAbstract
Objective The original European League Against Rheumatism recommendations for managing fibromyalgia assessed evidence up to 2005. The paucity of studies meant that most recommendations were 'expert opinion'.Methods A multidisciplinary group from 12 countries assessed evidence with a focus on systematic reviews and meta-analyses concerned with pharmacological/non-pharmacological management for fibromyalgia. A review, in May 2015, identified eligible publications and key outcomes assessed were pain, fatigue, sleep and daily functioning. The Grading of Recommendations Assessment, Development and Evaluation system was used for making recommendations.Results 2979 titles were identified: from these 275 full papers were selected for review and 107 reviews (and/or meta-analyses) evaluated as eligible. Based on meta-analyses, the only 'strong for' therapy-based recommendation in the guidelines was exercise. Based on expert opinion, a graduated approach, the following four main stages are suggested underpinned by shared decision-making with patients. Initial management should involve patient education and focus on non-pharmacological therapies. In case of non-response, further therapies (all of which were evaluated as 'weak for' based on meta-analyses) should be tailored to the specific needs of the individual and may involve psychological therapies (for mood disorders and unhelpful coping strategies), pharmacotherapy (for severe pain or sleep disturbance) and/or a multimodal rehabilitation programme (for severe disability).Conclusions These recommendations are underpinned by high-quality reviews and meta-analyses. The size of effect for most treatments is relatively modest. We propose research priorities clarifying who will benefit from specific interventions, their effect in combination and organisation of healthcare systems to optimise outcome.
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Current clinical guidelines recommend multimodal conservative treatments to improve pain-related symptoms, physical function, and quality of life in fibromyalgia patients.
“Current clinical guidelines for the management of patients with FM recommended multimodal conservative treatments to improve the pain-related symptoms, the physical function and the quality of life [9,10].”
From Effectiveness of non-pharmacological conservative therapies in adults with fibromyalgia: A systematic review of high-quality clinical trials (2022) · cites this paper as [9]
The EULAR revised recommendations section (page not provided) recommends starting with non-pharmacological care and aims to improve health-related quality of life. It also recommends multimodal rehabilitation, but only weakly and for patients with severe disability after earlier approaches have not worked; the claim presents multimodal conservative treatment as a general recommendation for fibromyalgia patients. (LLM, conf=0.86)
Experimental — accuracy not yet measuredGuidelines list non-pharmacological therapies such as exercise therapy, mind-body therapies, patient education, manual therapy, needling therapies, balneotherapy, and multimodal therapies as conservative treatments.
“Among the conservative treatments, clinical guidelines include non-pharmacological therapies such as Exercise Therapy (ET), mind-body therapies, Patient Education (PE), Manual Therapy (MT), Needling Therapies (NT), balneotherapy and multimodal therapies [9,10].”
From Effectiveness of non-pharmacological conservative therapies in adults with fibromyalgia: A systematic review of high-quality clinical trials (2022) · cites this paper as [9]
The EULAR revised recommendations section supports exercise, meditative movement and mindfulness therapies, acupuncture, and hydrotherapy; it also calls for patient information and considers multimodal rehabilitation. The Hydrotherapy/spa therapy section discusses balneotherapy. However, the guideline does not recommend the manual therapies it evaluates: massage receives a weak-against evaluation and chiropractic a strong-against evaluation, so the list overstates their inclusion as recommended treatments. No page numbers are available in our copy. (LLM, conf=0.88)
Experimental — accuracy not yet measuredThe findings of this review are concordant with previous guidelines that recommend multimodal non-pharmacological therapies as first-line intervention.
“These findings are in concordance with previous guidelines that recommend multimodal non-pharmacological therapies as first-line intervention [9,66].”
From Effectiveness of non-pharmacological conservative therapies in adults with fibromyalgia: A systematic review of high-quality clinical trials (2022) · cites this paper as [9]
The Abstract and ‘Comparison with 2007 EULAR recommendations’ say initial management should focus on non-pharmacological therapies and that these should be first-line. But ‘EULAR revised recommendations’ reserves multimodal rehabilitation for patients with severe disability after earlier approaches have lacked effect; it does not recommend multimodal therapy as the first-line intervention. (LLM, conf=0.88)
Experimental — accuracy not yet measuredThe results of this review are concordant with previous studies showing limited evidence of benefits of patient education on pain-related variables.
“The results are in accordance with previous studies that showed limited evidence of the benefits of PE on pain-related variables, but the inclusion in multimodal therapies is recommended [9,81].”
From Effectiveness of non-pharmacological conservative therapies in adults with fibromyalgia: A systematic review of high-quality clinical trials (2022) · cites this paper as [9]
The Multicomponent therapy section (page unavailable) describes interventions combining education or psychological therapy with exercise and gives multicomponent therapy a ‘weak for’ evaluation. The EULAR revised recommendations section also recommends providing patients with information. Neither passage establishes limited evidence for the benefits of patient education alone on pain-related variables. (LLM, conf=0.84)
Experimental — accuracy not yet measuredDespite existing research and guidelines, several major questions about the importance of cognitive behavioural therapies in fibromyalgia syndrome remain unresolved.
“Despite a large amount of research and recommendations for the management of FMS by recent evidence-based guidelines (K€ ollner et al.,2017;MacFarlane et al., 2017) some major questions on the importance of CBTs in FMS are not definitely answered:”
From Efficacy, acceptability and safety of cognitive behavioural therapies in fibromyalgia syndrome – A systematic review and meta-analysis of randomized controlled trials (2018) · cites this paper as MacFarlane et al., 2017
The Cognitive behavioural therapies section reviews multiple trials, and the EULAR revised recommendations section gives CBT a weak recommendation. The Research priorities section identifies unresolved questions about treatment combinations and who responds to specific therapies, but does not identify the importance of CBT itself as an unanswered major question. No page numbers are available in our copy. (LLM, conf=0.83)
Experimental — accuracy not yet measured
Health professionals endorsed by WHO frequently recommend walking for 30 minutes or more at least five days a week due to its low musculoskeletal impact and benefits on pain management, mood or fatigue.
“Health professionals endorsed by the World Health Organization (WHO) frequently recommend walking for 30 minutes or more at least five days a week [3] due to its low musculoskeletal impact and the benefits it has on pain management, mood or fatigue [4].”
From Do Cognitive Abilities Influence Physical and Mental Fatigue in Patients with Chronic Pain after Walking According to a Clinical Guideline for Physical Exercise? (2021) · cites this paper as [3]
The Exercise section reports improved pain with aerobic exercise, and the EULAR revised recommendations section recommends exercise for its effects on pain and well-being. Neither passage specifically establishes walking’s low musculoskeletal impact or benefits for mood or fatigue; the paper attributes fatigue improvements to other therapies. The 30-minute, five-day schedule is attached to citation [3], not this source. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThe European Union recommends a stepped multidisciplinary approach in treating fibromyalgia focusing on patient education, lifestyle counseling, and nonpharmacological interventions before medication.
“اتحادیه اروپا در برابر بیماریهای روماتیسمی رویکرد گامبهگام چندرشتهای را در درمان فیبرومیالژیا با تمرکز بر آموزش بیمار، مشاوره در زمینه سبک زندگی و مداخلات غیردارویی قبل از مصرف دارو توصیه کرده است ] 7 ، 6 [ .”
From The Effect of Acceptance and Commitment Therapy on the Psychological Consequences of Anxiety, Pain Intensity, and Fatigue in Women with Fibromyalgia: Study with the Effect of Waiting (2022) · cites this paper as [7]
The Abstract and EULAR revised recommendations section describe a graduated approach that begins with patient education and non-pharmacological therapies; medication may be considered later according to individual need. The recommendations also say management often requires a multidisciplinary approach. Our copy does not specifically recommend lifestyle counseling, so that element of the claim is unsupported. (LLM, conf=0.87)
Experimental — accuracy not yet measuredFatigue and sleep disturbances are common in FM, and can lower the pain threshold, trigger musculoskeletal pain and increase emotional distress.
“Fatigue and sleep disturbances are common in FM [1], and can lower the pain threshold, trigger musculoskeletal pain and increase emotional distress [46].”
From Mindfulness- And acceptance-based interventions for patients with fibromyalgia - A systematic review and meta-analyses (2019) · cites this paper as [1]
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- Authors
- Macfarlane, G. J., Kronisch, C., Dean, L. E., Atzeni, F., Häuser, W., Fluß, E., Choy, E., Kosek, E., Amris, K., Branco, J., Dincer, F., Leino-Arjas, P., Longley, K., McCarthy, G. M., Makri, S., Perrot, S., Sarzi-Puttini, P., Taylor, A., & Jones, G. T.
- Affiliations
- University of Aberdeen (GB)
- IRCCS Ospedale Galeazzi - Sant'Ambrogio (IT)
- Klinikum Saarbrücken (DE)
- Cardiff University (GB)
- Karolinska Institutet (SE)
- Frederiksberg Hospital (DK)
- Hospital de Egas Moniz (PT)
- Mater Misericordiae University Hospital (IE)
- Hôpital Cochin (FR)
- Corresponding author
- Macfarlane, G J
- ORCID
- Venue
- Annals of the Rheumatic Diseases
- Publisher
- Elsevier BV
- Published
- 2017-02
- Volume
- 76
- Issue
- 2
- Pages
- 318-328
- ISSN
- 0003-4967 (ISSN-L)
- OpenAlex
- W2473039652
- Cited by
- 1,566
- References
- 113
- Citations by year
- 2026: 175 · 2025: 171 · 2024: 201 · 2023: 201 · 2022: 223 · 2021: 193 · 2020: 152 · 2019: 90 · 2018: 73 · 2017: 73 · 2016: 12 · 2014: 1
- FWCI
- 72.51
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Annals of the Rheumatic Diseases (publishedVersion)
- PubMed (publishedVersion)
- ORCA Online Research @Cardiff (Cardiff University) (acceptedVersion)
- Aberdeen University Research Archive (Aberdeen University) (submittedVersion)
- Archivio Istituzionale della Ricerca (Universita Degli Studi Di Milano) (submittedVersion, other-oa)
- ORCA Online Research @Cardiff (Cardiff University) (submittedVersion)
- mediaTUM (Technical University of Munich) (submittedVersion)
- HighWire Press Open Archive (submittedVersion)
- Hacettepe University Institutional Repository (hacettepe.edu.tr) (submittedVersion, other-oa)
- Funders
- Eli Lilly and Company
- Pfizer
- Les Laboratories Pierre Fabre
- H. Lundbeck A/S
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Fibromyalgia and Chronic Fatigue Syndrome Research
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Cell Biology › Myofascial pain diagnosis and treatment
- Keywords
- fibromyalgia, fibromyalgia management, exercise therapy, non-pharmacological treatment, pharmacotherapy, psychotherapy, multimodal rehabilitation, patient education, shared decision-making, pain, fatigue, sleep disorders, daily functioning, treatment guidelines
- MeSH terms
- Serotonin and Noradrenaline Reuptake Inhibitors, Activities of Daily Living, Amitriptyline, Anti-Inflammatory Agents, Non-Steroidal, Anticonvulsants, Antidepressive Agents, Tricyclic, Biofeedback, Psychology, Capsaicin, Europe, Exercise Therapy, Fatigue, Fibromyalgia, Humans, Hydrotherapy, Hypnosis, Massage, Monoamine Oxidase Inhibitors, Pain, S-Adenosylmethionine, Sleep, Societies, Medical, Sodium Oxybate, Acupuncture Therapy, Cognitive Behavioral Therapy, Treatment Outcome, Selective Serotonin Reuptake Inhibitors, Practice Guidelines as Topic, Sensory System Agents, Evidence-Based Medicine, Human Growth Hormone, Mind-Body Therapies, Manipulation, Chiropractic, Mindfulness
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