Non-Pharmacological Therapies may Provide Alternative Treatment Options in Fibromyalgia

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The 3-stage Delphi exercise used the expertise of medical and health care professionals with experience in treating patients with fibromyalgia. Treatment recommendations included exercise, education, cognitive behavioral therapy, mindfulness, and mind-body exercises.

Based on evidence-backed expert consensus, investigators created recommendations on non-pharmacological treatments for patients with fibromyalgia to individualize treatments for a variety of symptoms including pain, depression, fatigue, and sleep problems, according to a study published in Science Direct.1

“Non-pharmacological interventions are often recommended as first-line treatment for fibromyalgia,” investigators stated. “However, there are currently no recommendations on which non-pharmacological intervention(s) to offer for the initial management of the different symptoms associated with fibromyalgia and which of these to prioritize as core treatments.”

An international 3-stage Delphi exercise was performed using the expertise of members of the American Pain Society, authors of European Alliance of Associations for Rheumatology (EULAR) and the Canadian Fibromyalgia Guidelines Group, and any medical or health care professional with experience in treating patients with fibromyalgia. Participants selected non-pharmacological interventions that could be helpful for the treatment of specific fibromyalgia symptoms and were asked to further categorize them as either core or adjunctive treatments. Investigators urged professionals to consider efficacy, cost, patient preferences, acceptability, availability, and personal experience when making their recommendations. Evidence summaries were provided to help the decision-making process. All items that received 70% or more of the votes were accepted and those achieving 30-70% of the votes were recirculated for up to 2 additional rounds.

Of the 17 experts included in the exercise, 10 resided in Europe, 6 were from North America, and 1 was from Israel. Of the respondents, there were 7 rheumatologists, 2 physiotherapists, 1 psychologist, 1 nurse, 1 pain specialist, and 5 other health care professionals.

Core treatments for all symptoms included aerobic exercise, sleep hygiene, education, and cognitive behavioral therapy (CBT). The core intervention recommendations for pain, fatigue, and sleep issues were mind-body exercises, such as tai chi and yoga, which focus on breathing, mental focus, and body movement. Mindfulness was a core treatment for symptoms of depression and an adjunctive treatment for all other symptoms. Other adjunctive treatments, which varied between symptoms, included music, relaxation, local heat, and a hot bath.

Including a multidisciplinary and international group of academics and clinicians strengthened the study. Further, a comprehensive list of interventions was provided, allowing for participants to suggest other interventions, and all respondents completed 3 rounds of the exercise.

However, there may have been a biased perspective towards certain interventions as most panel members were physicians. Another limitation was that some of the interventions were grouped together, such as music intervention referred to as listening to music for pleasure or therapeutically. Effect sizes of interventions were provided based on the research findings of investigators, which may have impacted social desirability bias. Lastly, although depression was included, anxiety, another common symptom of patients with fibromyalgia, was omitted from the survey.

“Personalizing treatment for fibromyalgia using a targeted symptom approach has been suggested as a way to improve outcomes for patients,” investigators concluded. “This Delphi exercise has reached agreement on a set of core and adjunctive non-pharmacological interventions for the 4 different major symptoms of fibromyalgia, specifically pain, fatigue, sleep, and depression. Clinicians may find this useful as an aid to shared decision-making and treatment choices with patients as part of an individualized management plan.”


Kundakci B, Hall M, Atzeni F, et al. International, multidisciplinary Delphi consensus recommendations on non-pharmacological interventions for fibromyalgia, Seminars in Arthritis and Rheumatism, Volume 57, 2022, 152101, ISSN 0049-0172,