Evidenced-Based Guidelines on the Treatment of Fibromyalgia Patients: Are They Consistent and If Not, Why Not? Have Effective Psychological Treatments Been Overlooked?

updated Dec 5, 2018

Tags: treatment, mind, fibromyalgia, exercise, medications, chronic pain, pain problems, self-treatment

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This paper is an extremely technical analysis of four sets of treatment guidelines for fibromyalgia produced by four different organizations. Although extremely technical, it all boiled down to a really simple conclusion: they don’t agree with each other!

Four different organizations looked a great deal of research with impressively little overlap: not a single study was referenced by all four, for instance, and 35% was the highest citation overlap reached between any two of them. While “there were a number of similarities” in their recommendations, there were also many inconsistencies, which “can be attributed to the criteria used for study inclusion, the studies themselves, weighting systems, and composition of the panels.”

Exercise, cognitive behavioural therapy, and the old-school anti-depressant drug amitryptiline were about the only treatments with strong agreement. Opioids were the only treatment all four recommended against. And they were collectively equivocal or blatantly contradictory on dozens of others. For instance, one group strongly recommends against massage therapy, another recommends it (moderately), a third is weakly against it, and the fourth had no comment.

Happily, there was just a single example of a treatment with a “strong” contradictory recommendations — the drug milnacipran — so at least there’s that.

original abstract†Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

We compared the recommendations and methodology of several recent evidence-based guidelines for the management of patients with fibromyalgia published by professional organizations: 1) American Pain Society (APS; 2005), 2) Association of the Scientific Medical Societies in Germany (AWMF; 2012), 3) Canadian Pain Society (CPS; 2013; also used in the United Kingdom), and 4) European League Against Rheumatism (EULAR; 2016). Each guideline used systematic reviews and meta-analyses as highest level of evidence; APS, CPS, and AWMF also included individual randomized clinical trials. The APS, CPS, and AWMF assigned the highest ranking of recommendation to aerobic exercise, cognitive-behavioral therapy, amitriptyline, and multicomponent treatment. In contrast, the most recent EULAR guidelines assign the highest level of recommendation to exercise, contrary to the 2008 EULAR guidelines, which recommended pharmacotherapy. Although there was some consistency for pharmacological treatment recommendations among the 4 guidelines, APS, CPS, and AWMF guidelines gave the higher ranking to cognitive-behavioral therapy and multicomponent treatments. The inconsistencies across guidelines can be attributed to the criteria used for study inclusion, outcome measures used, weighting systems, and composition of the review panels. A guideline consensus is needed to harmonize the discrepancies.

PERSPECTIVE: This article presents an overview and highlights the inconsistencies of 4 recent clinical practice guidelines for treatment of fibromyalgia patients related to study inclusion criteria, outcome measures used, ranking system used, and composition of the review panels. The discrepancies suggest a need to create a guideline consensus to synthesize guidelines.

original abstract†Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

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