Con excepcin de la acupunrura, no existen revisiones sistemticas sobre estas modalidades teraputicas y, en general, los EC disponibles son escasos

y de muy baja calidad metodolgica. Los principales problemas metodolgicos que se han detectado son: escaso nmero de pacientes, intervenciones de corta duracin, grandes prdidas de seguimiento, tratamientos heterogneos y diferentes instrumentos de medida(14). En relacin con la quiropraxia, la osteopata, los masajes y la ozonoterapia, no se han encontrado EC, y los estudios piloto que existen son de baja calidad metodolgica, por lo que en la actualidad no hay ninguna evidencia sobre su eficacia en los pacientes con FM La',acupuntura para los pacientes con FM ha sido objeto de varias revisiones narrativas y sistemticas en los ltimos aos(l4). Las conclusiones de todos esos trabajos son similares y ninguno encuentra una buena evidencia de su eficacia. Recientemente se han publicado 2 ECA (18,19); en el primero de ellos, se demuestra una discreta eficacia, pero en el segundo, no se encontraron diferencias respecto a los pacientes del grupo control y, por lo tanto, el grado de evidencia es incongruente.

13. Busch A, Scbacbter CL, Peloso PM, Bombardier C. Exercise fur trf:ating fibromyalgia syndrome [Cocbrane Review]. En: The Cocbrane Library,issue 1. Oxfurd: Update Software; 2003. 14. Nisbisbinya MB, Rivera J, Alegre de Miquel C, Pereda CA. Revisin sistemtica de las intervenciones no farmacolgicas y alternativas en la fibromialgia (pendiente de publicacin) 8. Dcluzc C, Bosia L, Zirbs A, Chantraine A, VIScher TL. Electroacupuncture in fibromyalgia: results of a controlled trial. BMJ. 1992;305:1249-52 19. Assefi NP, Sherman KJ, Jacobsen C, Goldberg J, Smith WR, Bucbwald D. A randomized clinical triaJ of acnpuncture compared with sham acupuncture In fibromyalgia. Ano Intern Me<!. 2005;143:10-9
The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011. MATERIALS AND METHODS: The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy("Deutsche Interdisziplinren Vereinigung fr Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a

total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies. RESULTS AND CONCLUSION: Low-to-moderate intensity aerobic exercise and strength training are strongly recommended. Chiropractic, lasertherapy, magnetic field therapy, massage and transcranial current stimulation are not recommended. The English full-text version of this article is available at SpringerLink (under "Supplemental").

Combined Therapy (Ultrasound and Interferential Current) in Patients with Fibromyalgia: Once or Twice in a Week?
1. 2. 3. 4. 5. 6. Felipe Azevedo Moretti1, Freddy Beretta Marcondes2,3,*, Jos Roberto Provenza4, Thiago Yukio Fukuda5, Rodrigo Antunes de Vasconcelos3, Suely Roizenblatt1 Article first published online: 24 NOV 2011 DOI: 10.1002/pri.525

Keywords:

electrotherapy; fibromyalgia; tender points; widespread pain

Abstract

Background and Purpose

Combined Therapy (CT) composed of ultrasound and Interferential Therapy has been reported as a costeffective, local analgesic intervention on tender points in Fibromyalgia (FM). This study aims to investigate the difference between CT applied once a week and twice a week in patients with FM.

Method
Fifty patients with the diagnosis of FM were randomized into two groups (G1=once a week treatment and G2=twice a week treatment) with each group containing 25 patients. All eighteen tender points were assessed and treated with CT during each session, over a three-month time period. Interferential Therapy was modulated at 4,000Hz of current carrier, 100Hz of amplitude modulated frequency and at a bearable sensorial threshold of intensity. Pulsed ultrasound of 1MHz at 20% of 2.5W/cm was used. For eva luation,

the Visual Analogue Scale, Fibromyalgia Impact Questionnaire, Post Sleep Inventory and the tender point count were utilized, and the examiner was blinded to the group assignments.

Results
G1 and G2 showed a significant improvement in Visual Analogue Scale (p<0.0001 and p<0.0005, respectively), Tender Points (p<0.005 and p<0.001, respectively), Fibromyalgia Impact Questionnaire and Post Sleep Inventory (p<0.005 and p<0.05, respectively). However, there was no significant difference between the two groups in all performed analyses.

Conclusion
There is no advantage in increasing the number of sessions of combined therapy in terms of reducing generalized pain, quality of life and sleep quality for patients with FM. Copyright 2011 John Wiley & Sons, Ltd.

Effects of myofascial release techniques on pain, physical function, and postural stability in patients withfibromyalgia: a randomized controlled trial.
Castro-Snchez AM, Matarn-Pearrocha GA, Arroyo-Morales M, SaavedraHernndez M, Fernndez-Sola C, Moreno-Lorenzo C. Source
Department of Nursing and Physical Therapy, University of Almera (UAL), Spain. adelaid@ual.es

Abstract
OBJECTIVE: To determine the effect of myofascial release techniques on pain symptoms, postural stability and physical function in fibromyalgiasyndrome. DESIGN: A randomized, placebo-controlled trial was undertaken. SUBJECTS: Eighty-six patients with fibromyalgia syndrome were randomly assigned to an experimental group and a placebo group. INTERVENTIONS: Patients received treatments for 20 weeks. The experimental group underwent 10 myofascial release modalities and the placebo group received sham short-wave and ultrasound electrotherapy. MAIN MEASURES: Outcome variables were number of tender points, pain, postural stability, physical function, clinical severity and global clinical assessment of improvement. Outcome measures were assessed before and immediately after, at six months and one year after the last session of the corresponding intervention. RESULTS: After 20 weeks of myofascial therapy, the experimental group showed a significant improvement (P<0.05) in painful tender points, McGill Pain Score (20.66.3, P<0.032), physical function (56.1017.3, P<0.029), and clinical severity (5.081.03, P<0.039). At six months post

intervention, the experimental group had a significantly lower mean number of painful points, pain score (8.251.13, P<0.048), physical function (58.6016.30, P<0.049) and clinical severity (5.280.97, P<0.043). At one year post intervention, the only significant improvements were in painful points at second left rib and left gluteal muscle, affective dimension, number of days feeling good and clinical severity. CONCLUSION: The results suggest that myofascial release techniques can be a complementary therapy for pain symptoms, physical function and clinical severity but do not improve postural stability in patients with fibromyalgia syndrome.

Effectiveness of physical activity in reducing pain in patients with fibromyalgia: a blinded randomized clinical trial.
Kayo AH, Peccin MS, Sanches CM, Trevisani VF. Source
Universidade Federal de So Paulo, So Paulo, SP, Brazil.

Abstract
The purpose of this study was to evaluate and compare the effectiveness of musclestrengthening exercises (MS) and a walking program (WA) in reducing pain in patients with fibromyalgia. Ninety women, 30-55 years of age, diagnosed with fibromyalgia according to the American College of Rheumatology 1990 criteria, were randomized into 3 groups: WA Group, MS Group, and control group. Pain (visual analog scale) was evaluated as the primary outcome. Physical functioning (Fibromyalgia Impact Questionnaire, FIQ), health-related quality of life (Short-Form 36 Health Survey, SF-36), and use of medication were evaluated as secondary outcomes. Assessments were performed at baseline, 8, 16, and 28 weeks. Intentionto-treat and efficacy analyses were conducted. Sixty-eight patients completed the treatment protocol. All 3 groups showed improvement after the 16-week treatment compared to baseline. At the 28-week follow-up, pain reduction was similar for the WA and MS groups (P = 0.39), but different from the control group (P = 0.01). At the end of the treatment, 80% of subjects in the control group took pain medication, but only 46.7% in the WA and 41.4% in the MS groups. Mean FIQ total scores were lower for the WA and MS groups (P = 0.96) compared with the control group (P < 0.01). Patients in the WA and MS groups reported higher scores (better health status) than controls in almost all SF-36 subscales. MS was as effective as WA in reducing pain regarding all study variables; however, symptoms management during the followup period was more efficient in the WA group.

Comment in
Exercise for fibromyalgia: evidence for an integrated modulation of autonomic and nociception neural regulation. [Rheumatol Int. 2012]

A randomized controlled trial investigating the effects of craniosacral therapy on pain and heart rate variability infibromyalgia patients.
Castro-Snchez AM, Matarn-Pearrocha GA, Snchez-Labraca N, Quesada-Rubio JM, Granero-Molina J, Moreno-Lorenzo C.

Source
Department of Nursing and Physical Therapy, University of Almera, Spain. adelaid@ual.es

Abstract
CONTEXT: Fibromyalgia is a prevalent musculoskeletal disorder associated with widespread mechanical tenderness, fatigue, non-refreshing sleep, depressed mood and pervasive dysfunction of the autonomic nervous system: tachycardia, postural intolerance, Raynaud's phenomenon and diarrhoea. OBJECTIVE: To determine the effects of craniosacral therapy on sensitive tender points and heart rate variability in patients with fibromyalgia. DESIGN: A randomized controlled trial. SUBJECTS: Ninety-two patients with fibromyalgia were randomly assigned to an intervention group or placebo group. INTERVENTIONS: Patients received treatments for 20 weeks. The intervention group underwent a craniosacral therapy protocol and the placebo group received sham treatment with disconnected magnetotherapy equipment. MAIN MEASURES: Pain intensity levels were determined by evaluating tender points, and heart rate variability was recorded by 24-hour Holter monitoring. RESULTS: After 20 weeks of treatment, the intervention group showed significant reduction in pain at 13 of the 18 tender points (P<0.05). Significant differences in temporal standard deviation of RR segments, root mean square deviation of temporal standard deviation of RR segments and clinical global impression of improvement versus baseline values were observed in the intervention group but not in the placebo group. At two months and one year post therapy, the intervention group showed significant differences versus baseline in tender points at left occiput, left-side lower cervical, left epicondyle and left greater trochanter and significant differences in temporal standard deviation of RR segments, root mean square deviation of temporal standard deviation of RR segments and clinical global impression of improvement. CONCLUSION: Craniosacral therapy improved medium-term pain symptoms in patients with fibromyalgia.

Effects of reflexology on fibromyalgia symptoms: a multiple case study.

Gunnarsdottir TJ, Peden-McAlpine C. Source
Faculty of Nursing, University of Iceland, Reykjavik, Iceland. stalolaz@logosnet.cy.net

Abstract
PURPOSE: To explore the effects of reflexology on pain and other symptoms in women with fibromyalgia syndrome [FM]. METHODS:

Multiple case study method as developed by Stake was used to investigate the effects of reflexology on six cases of women with FM which were given ten sessions of weekly reflexology. Data were collected with observation, interviews and diary and then analyzed within cases and across cases. RESULTS: Reflexology affected the symptom of pain in multiple areas such as head, neck and arms. Pain started to isolate and decrease. CONCLUSION: Reflexology may be helpful to decrease fibromyalgia symptoms. Qualitative research methods and individually tailored interventions are important when researching complementary and alternative therapies.

Massage therapy for fibromyalgia symptoms.

Kalichman L. Source
Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel. kleonid@bgu.ac.il

Abstract
Massage therapy is widely used by patients with fibromyalgia seeking symptom relief. We performed a review of all available studies with an emphasis on randomized controlled trials to determine whether massage therapy can be a viable treatment of fibromyalgia symptoms. Extensive narrative review. PubMed, PsychInfo, CINAHL, PEDro, ISI Web of Science, and Google Scholar databases (inception-December 2009) were searched for the key words "massage", "massotherapy", "self-massage", "soft tissue manipulation", "soft tissue mobilization", "complementary medicine", "fibromyalgia" "fibrositis", and "myofascial pain". No language restrictions were imposed. The reference lists of all articles retrieved in full were also searched. The effects of massage on fibromyalgia symptoms have been examined in two single-arm studies and six randomized controlled trials. All reviewed studies showed short-term benefits of massage, and only one single-arm study demonstrated long-term benefits. All reviewed studies had methodological problems. The existing literature provides modest support for use of massage therapy in treating fibromyalgia. Additional rigorous research is needed in order to establish massage therapy as a safe and effective intervention for fibromyalgia. In massage therapy of fibromyalgia, we suggest that massage will be painless, its intensity should be increased gradually from session to session, in accordance with patient's symptoms; and the sessions should be performed at least 1-2 times a week.
PMID:

20306046

[PubMed - indexed for MEDLINE]

Effect of pilates training on people with fibromyalgia syndrome: a pilot study.

Altan L, Korkmaz N, Bingol U, Gunay B.

Source
Department of Physical Medicine and Rehabilitation, University of Uludag, Bursa, Turkey. lalealtan@uludag.edu.tr

Abstract
Altan L, Korkmaz N, Bingol U, Gunay B. Effect of Pilates training on people with fibromyalgia syndrome: a pilot study. OBJECTIVE: To investigate the effects of Pilates on pain, functional status, and quality of life in fibromyalgia, which is known to be a chronic musculoskeletal disorder. DESIGN: Randomized, prospective, controlled, and single-blind trial. SETTING: Physical medicine and rehabilitation department. PARTICIPANTS: Women (N=50) who had a diagnosis of fibromyalgia syndrome (FMS) according to the American College of Rheumatology criteria. INTERVENTION: The participants were randomly assigned into 2 groups. In group 1, a Pilates exercise program of 1 hour was given by a certified trainer to 25 participants 3 times a week for 12 weeks. In group 2, which was designed as the control group, 25 participants were given a home exercise (relaxation/stretching) program. In both groups, pre- (week 0) and posttreatment (week 12 and week 24) evaluation was performed by one of the authors, who was blind to the group allocation. MAIN OUTCOME MEASURES: Primary outcome measures were pain (visual analog scale) and Fibromyalgia Impact Questionnaire (FIQ). Exploratory outcome measures were number of tender points, algometric score, chair test, and Nottingham Health Profile. RESULTS: Twenty-five Pilates exercise and 24 relaxation/stretching exercise participants completed the study. In group 1, significant improvement was observed in both pain and FIQ at week 12 but only in FIQ at 24 weeks. In group 2, no significant improvement was obtained in pain and FIQ at week 12 and week 24. Comparison of the 2 groups showed significantly superior improvement in pain and FIQ in group 1 at week 12 but no difference between the 2 groups at week 24. CONCLUSIONS: We suggest Pilates as an effective and safe method for people with FMS. Our study is the first clinical study designed to investigate the role of the Pilates method in FMS treatment. We believe that further research with more participants and longer follow-up periods could help assess the therapeutic value of this popular physical exercise method.

Effect of amitriptyline vs. physiotherapy in management of fibromyalgia syndrome: What predicts a clinical benefit?
MN Joshi, R Joshi, AP Jain
Department of Medicine, MGIMS, Sewagram, Wardha, Maharashtra, India

The results of our study suggest that both amitriptyline and physiotherapy strategies significantly reduced disability due to fibromyalgia, as seen in a rural-based tertiary care hospital in central India. Both the strategies were equally effective in reduction of total FIQ score. Low socioeconomic status and high disability at baseline (as measured by FIQ score)

were the only parameters that could predict benefit. Our study has evaluated the effect of two different therapeutic modalities in the treatment of fibromyalgia. No similar study has been undertaken in the developing world. Our study had a few limitations, firstly a hierarchical screening method was used and this could have perhaps resulted in the small number of participants who were referred to the study investigator. As only clinical history was used for exclusion of patients, it could have potentially resulted in over-inclusion. However, in a resource-limited setting it was not feasible to perform laboratory investigations in all patients who were screened. Secondly, one-thirds of our study population was educated up to primary level only, and this could have limited the understanding of questionnaire-based scores. To overcome this we preferred interviewed questionnaire rather than using a self-administered questionnaire. Thirdly, given the nature of interventions, allocation could not be concealed. Lack of allocation concealment raises a high risk of bias. As fibromyalgia is a chronic illness it is likely that study duration was not long enough to demonstrate any significant benefit. The improvement in both the groups could be linked to Hawthorn effect or regression towards the mean. It does not mean that both treatments are effective. This could be a major limitation. There could be a possibility that the improvement observed in both the groups could, to some extent, be attributed to the use of tramadol. Keeping a control group receiving only tramadol could have helped to assess this possibility. Lastly, the rate of loss to follow-up was relatively important and patients lost to follow-up were excluded in the statistical analyses. Despite tracing them to their residential addresses we could not obtain cooperation and decided to exclude them from the final analysis. We did not find any co-morbid psychiatric illness based on the questionnaire used. It is likely that we underestimated the prevalence of depression, anxiety which are common associations of the disease. There could have been cultural issues which could have prevented expression of psycho-social concerns. Future studies are required to bring out the psychiatric associations in these patients. We reviewed similar studies which were done in past to compare the effects of amitriptyline and physiotherapy. We found that a study evaluating the combined benefit of amitriptyline and exercise [21] showed that only the combination of amitriptyline and exercise had significant improvements at three months. [21] Recently, Salek et al. found no significant differences between exercise and anti-depressant group vs. amitriptyline only groups in a randomized trial. [22] None of the studies have evaluated predictors which explain benefit. Our study indicates that amitriptyline and physiotherapy are equally beneficial in patients of fibromyalgia. Our study is also unique in the respect that we have studied factors which could help to predict response to either therapy. We found that patients with low socioeconomic scale had better response to therapy. This could be due to the fact that these patients have poor access to health facility and feel psychologically better on receiving care. We also found that patients with high disability score had better outcomes, probably due to higher quantum of relief expected. We conclude that amitriptyline and physiotherapy are equally beneficial in improving outcome in patients of fibromyalgia, as seen in the study population in a rural-based tertiary care hospital in central India. Considering the cost of drug therapy we recommend use of physiotherapy over amitriptyline in resource-limited settings

Effects of 2 physiotherapy programs on pain perception, muscular flexibility, and illness impact in women withfibromyalgia: a pilot study.
Valencia M, Alonso B, Alvarez MJ, Barrientos MJ, Ayn C, Martn Snchez V. Source
Department of Nursing and Physiotherapy, University of Len, Len, Spain.

Abstract
OBJECTIVE: This study assessed the effect of 2 physiotherapy programs designed to improve flexibility and to reduce the impact of the illness andpain perception in women with the fibromyalgia syndrome (FMS), and compared the effects of the 2 programs in the short and intermediate term. METHODS: Twenty FMS patients were randomly assigned to 2 training groups, one following a program of kinesiotherapy and active muscular stretching and one using techniques of Global Myofascial Physiotherapy, according to the Mzires method. Both groups met twice a week for 12 weeks, for a total of 150 minutes each week. Flexibility and illness impact were measured by means of a standard test, whereas pain was assessed by means of thumb palpation. Measurements were taken at the beginning and end of the program and 24 weeks after its end. RESULTS: Patients had achieved a statistically significant reduction in the severity of the disease and improved their flexibility level by the end of the program, but had returned to initial values after follow-up. Significant differences were not observed between the 2 treatment groups in the initial values or in the results at the end of the program or after the follow-up, so neither program proved better than the other. CONCLUSION: The FMS patients in this study improved their flexibility level and general well-being using both kinesiotherapy and stretching exercises techniques.