Exercise and antidepressants improve fibromyalgia

Journal of Family Practice, April, 2004 by Anna Quisel, James Gill, Dene Walters

The authors noted that the magnitude of the positive effects of physically-based treatments on fibromyalgia were comparable with drug treatment judged effective for arthritis. (51)

Less certain nonpharmacologic therapies Other nonpharmacologic treatments for fibromyalgia are educational interventions, relaxation therapy, cognitive-behavioral therapy, and acupuncture. These therapies have undergone rigorous analysis, but studies have been too heterogeneous to allow for strong conclusions across the studies. (50)

A recent Cochrane review concluded that although physical training plus education had a positive effect at long-term follow up, evidence is insufficient to recommend multidisciplinary rehabilitation, defined as the care of a physician plus psychological, social, and vocational interventions (SOR: C). (52)

In contrast, other investigators have concluded that multidisciplinary treatment incorporating physically and psychologically based treatments was more successful than treatment with a single modality. (51) A systematic review of acupuncture identified only 1 high-quality randomized controlled trial (Table 2), which did show some improvement in symptoms (SOR: C). (53)

Therapy with antidepressants

Of all pharmacologic treatments, antidepressants have undergone the most thorough study. Although the optimal role of medications in fibromyalgia has not been delineated, 3 meta-analyses have reported that antidepressants, most commonly amitriptyline, reduce symptoms during treatment of a few months duration (SOR: A) (Table 3). (54,55)

Any antidepressants. Pooled results from 13 studies (8 of tricyclics, 3 of selective serotonin reuptake inhibitors, 2 of s-adenosyl-methionine) revealed a moderate effect on pain, sleep, and global well-being, and a mild effect on fatigue and number of trigger points. (54) The authors calculated that persons with fibromyalgia treated with antidepressants were 4 times more likely to improve than persons treated with placebo (number need to treat [NNT]=4). Adverse effects appeared insignificant but were poorly reported in the individual studies.

Tricyclics only. In another meta-analysis, 9 high-quality studies of tricyclic antidepressants (amitriptyline, dothiepin, clomipramine, maprotiline and cyclobenzaprine--classified by the authors as a tricyclic antidepressant) were analyzed for 7 outcomes (patient self-rating of pain, fatigue, stiffness, and sleep; the patient and physician global assessment of improvement; and tenderness of tender points). Significant responses were observed in 25% to 37% of patients. On meta-analysis, outcome measures improved moderately overall with tricyclic treatment, mostly in sleep and global assessment, least in stiffness and tenderness. Long-term safety (more than 8 weeks) and efficacy of tricyclic therapy for fibromyalgia have not been demonstrated. (55)

Combined trials. A third meta-analysis demonstrated improvement when trials of different antidepressants were combined. (51) By pooling studies of antidepressants (amitriptyline, dothiepin, fluoxetine, citalopram, and S-adenosylmethionine) improvements in physical status, fibromyalgia symptoms, and psychological status were found, with no improvement in daily functioning. (51) Although the effect was smaller than physically-based treatments, the effect size was still comparable to drug treatment for arthritis. (51)