EULAR Favors Exercise as First Step in Managing Fibromyalgia

EULAR Favors Exercise as First Step in Managing Fibromyalgia

The European League Against Rheumatism (EULAR), in newly revised recommendations, highlights exercise as the strongest evidence-based therapy to manage fibromyalgia. These guidelines favor nonpharmacologic approaches as an initial treatment,  with more personalized therapies in cases of non-response that may include medications. The recommendations, based on 107 reviews scientific, are in the document, “EULAR revised recommendations for the management of fibromyalgia” published in the Annals of the Rheumatic Diseases.

A multidisciplinary group from 12 countries assessed evidence with a focus on systematic reviews and meta-analyses concerned with pharmacological and nonpharmacological management of fibromyalgia. A review identified eligible publications in May 2015, and key outcomes assessed were pain, fatigue, sleep and daily functioning. The system known as Grading of Recommendations Assessment, Development and Evaluation was used for making the recommendations.

“These guidelines and our EULAR recommendations are in agreement on the principles of approach to management, the need for tailored therapy to the individual, and the first-line role of nonpharmacological therapies,” the authors wrote.

The original European League Against Rheumatism recommendations for managing fibromyalgia assessed evidence up to 2005. The paucity of studies at the time meant that most recommendations were “expert opinion.”

Since then, a considerable number of individual trials have examined pharmacological and non-pharmacological interventions, and systematic reviews were conducted for nearly all commonly used management strategies. The recommendations, however, do not represent a major change to the approach of managing patients with fibromyalgia, but rather provides new evidence in support for some additional non-pharmacological therapies.

Exercise was recommended strongly — “particularly given its effect on pain, physical function and well-being, availability, relatively low cost, and lack of safety concerns,” the authors wrote. Existing evidence did not allow the review panel to differentiate between the benefits of aerobic or strengthening exercises.

Weak but positive recommendations were given meditative movement therapies like yoga, mindfulness-based stress reduction, acupuncture or hydrotherapy. Evidence exists that these therapies can help with fatigue, pain, sleep improvement, and quality of life.

Biofeedback, capsaicin, hypnotherapy, massage, and other complementary therapies are not recommended because of the lack of effectiveness found in the studies reviewed. The EULAR review panel gave a “strong against” evaluation for chiropractic care based on safety concerns.

In case of lack of effect of these therapeutic approaches, EULAR recommends personalized treatments according to patient needs.

The panel considers psychological therapies, such as Cognitive Behavioral Therapy, of help to patients with mood disorder or dysfunctional coping strategies. In the case of pharmacological therapies, the new EULAR recommendations consider that duloxetine, pregabalin, and tramadol can be helpful for patients with severe pain, as is amitriptyline at low dose, and that cyclobenzaprine or pregabalin should be considered for patients with sleep disturbance.

EULAR does not recommend several pharmacological therapies with nonsteroidal anti-inflammatory drugs (NSAIDs), monoamine oxidase inhibitors (MAOIs), selective serotonin re-uptake inhibitors (SSRIs), growth hormone, sodium oxybate, strong opioids, and corticosteroids because of lack of efficacy and high risk of side effects.

Patients with severe disability should be considered for multimodal rehabilitation programs rather than individual therapies.

According to the team, research priorities include identifying the most effective type of exercise, evaluating the effectiveness of a combined pharmacologic and non-pharmacologic approach compared with a single modality, as well as identifying predictors of response to specific treatments.

For those patients with incapacitating symptoms, multimodal therapy combining non-pharmacologic and pharmacologic approaches is recommended. In general, the likelihood of a good outcome for patients relies on early diagnosis, patient education, and behavioral changes including regular physical activity.


  1. Jan Robbins says:

    I think this is bull shit, ( excuse my words ) I have had Fibromyalgia for 25years, I’ve tried exercise, hydro pool, had flare up with that, so swimming was out of the question. Acupuncture, didn’t work. Steroid injections every 2wks, didn’t work. Medication doesn’t work. It makes you put on weight, which I ended up having a stroke & mini Stroke I didn’t even know I had taken till I went & had my neck checked. I have brought up 2 kids my eldest is now coming up for 34y old man, who still lives at home with me, he was registered Mentally Handicapped, & was so hyper, I was up all night with him for 9y plus still in nappies + I had a daughter as well. I worked as a kid from the age of 4 picking berries & strawberries for clothes, I worked part time in a chip shop at 10y & never stopped working till a month before my son was born. I had T.B at 11 going on 12y old, I had & have an irritable bowel, ( which makes me think I had Fibromyalgia at 18y old, so more than 25ys,) so I am single & brought my 2 kids up on my own with no help from my family at the hardest times. My son was my full time job. I didn’t treat them differently just got use to being up all night, & wouldn’t change a thing. Physo did nothing for me just brought on flare ups, reflex (messaging your feet) was comforting but again nothing . They pump you with tablets that do nothing but make your health worse & I know a lot of people out there will agree. I have never Been lazy in my life, I was just getting started with my life, then I got struck down with Fibromyalgia, plus 2 strokes, Vascular Surgery, 4 mini strokes, I can go above Migraine as it’s worse than that, I’m tired most of the time, my days I sleep at night I’m awake, I’m on Parkinson tablets to stop my legs from jumping, I have Asthma, Arthritis & over weight. I was always around 7 -8 Stone, since being on medication. I’m in a size 4XL. Now why is this, I don’t get home help, I hardly eat, 3 small meals a day. Someone tell me why we have to put up with it, some .of use are made to go out & be classed as a druggie, we’re already that. But Marijuana seems the best cure for our PAIN. APPETITE & PROPER SLEEP, it would save the NHS for 1 & we’d have more money to put into our NHS. If anyone agrees with this I’d love to here comments. [email protected] all the way far SCOTLAND. Hope this helps your qualifications. You all know nothing what we go through every day.

  2. Shy says:

    Reading articles recomending exercise is enough [mental] gymnastics for me to have had a good work out. :]

    In all seriousness, it is fine if they want to recomend exercise, but they need to be realistic about how helpful it will be and to who and how many. You can’t just blanket offer exercise to everyone with fibro, so I’m glad at least they recognized some patients are so severe as to need more personalized multidisciplinary care. That’s almost miraculous given the current climate of research.

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