China's first "fibromyalgia" rehabilitation guide, answers 20 important questions!

*For medical professionals only for reference Rehabilitation is the foundation and main treatment for fibromyalgia! Fibromyalgia, also known as fibromyalgia syndrome, is a disorder characterized by chronic generalized musculoskeletal pain, often accompanied by fatigue, nonrestorative sleep, cognitive impairment, depression, and anxiety
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Its prevalence in the general population is as high as 2% to 4%, and it is the third most common musculoskeletal related disorder, second only to low back pain and osteoarthritis
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Many previous management guidelines for fibromyalgia have clearly stated that the treatment of fibromyalgia is mainly non-drug therapy, and drug therapy is suitable for patients with severe pain or sleep disorders; Comprehensive treatment including drug therapy and non-drug therapy
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Rehabilitation therapy is the most important non-drug therapy, but there is no evidence-based rehabilitation guidelines for fibromyalgia in China, which is not conducive to the standardization of clinical rehabilitation of fibromyalgia in China
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Fortunately, we have recently ushered in a piece of good news: in January 2022, the first domestic "Guidelines for Fibromyalgia Rehabilitation in China (2021)" were officially published! The guideline was led by Professor Liang Dongfeng and Professor Ye Chaoqun, and cooperated with the Physical Medicine and Rehabilitation Branch of the Beijing Medical Association and the Psychosomatic Rheumatism Collaborative Group of the Chinese Medical Association Psychosomatic Medicine Branch.
The evidence-based guideline development process was developed using the Graded Assessment, Development and Evaluation (GRADE) methodology
.

For 20 questions about fibromyalgia rehabilitation principles, rehabilitation assessment and rehabilitation treatment, the guideline puts forward corresponding recommendations, aimed at rehabilitation and rheumatology immunologists, physical therapists and related practitioners in fibromyalgia rehabilitation Practice provides the best basis
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Rehabilitation principles: individualized, step-by-step, multidisciplinary collaboration Q Question 1: What principles should be followed in the rehabilitation of patients with fibromyalgia? ▎Opinion 1: Individualized, step-by-step, multidisciplinary collaborative comprehensive rehabilitation is recommended for patients with fibromyalgia (1B)
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Fibromyalgia is a chronic psychosomatic disease that affects multiple systems throughout the body, and there is no cure
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Guidelines and consensus on the diagnosis and treatment of fibromyalgia point out that fibromyalgia should be diagnosed as soon as possible
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Individualization: Immediately after the diagnosis, a comprehensive rehabilitation evaluation of the patient is required to identify the symptoms that have the greatest impact on the patient, as well as pain intensity, function, mood, fatigue, and sleep disorders, and an individualized treatment plan is formulated based on the patient's specific situation
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Step-by-step: Following the principle of step-by-step, education and exercise intervention are used first.
Education focuses on cultivating self-management strategies for patients to actively participate; aerobic exercise and strength exercises are the basis of exercise therapy
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Cognitive-behavioral therapy can be used in patients with emotional disturbances, inadequate coping strategies, and poor response to education and exercise rehabilitation
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Drugs are suitable for people with severe pain or sleep disturbances and poor rehabilitation treatment; drugs approved by the U.
S.
Food and Drug Administration (FDA) and recommended by different national fibromyalgia management guidelines include pregabalin, duloxetine and milnacip Len, low-dose amitriptyline, tramadol, and cyclobenzaprine are also recommended in some fibromyalgia treatment guidelines
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Multidisciplinary collaboration: For people with severe functional disabilities, multidisciplinary collaborative treatment that combines rehabilitation therapy and drug therapy should be adopted, that is, a multidisciplinary collaborative team including rheumatology, pain, psychology, nutrition and rehabilitation majors in a comprehensive assessment of the effectiveness of various treatment methods.
After benefits and risks, patient preferences, and comorbidities, develop a systematic, step-by-step rehabilitation plan
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Diagnosis Basis: 2016 ACR Criteria Q Question 2: What is the basis for the diagnosis of fibromyalgia? ▎Opinion 2: The diagnosis of fibromyalgia is recommended according to the revised version of the 2010/2011 fibromyalgia diagnostic criteria of the American College of Rheumatology (ACR) in 2016 (1B)
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The specific revision of the ACR 2010/2011 diagnostic criteria for fibromyalgia in 2016 is: fibromyalgia can be diagnosed when the patient's clinical manifestations meet the first three of the following: ① Diffuse Pain Index (WPI) >7 points and SSS ≥5 points; or WPI is 4-6 points and SSS>9 points; ② Generalized pain, that is, pain occurs in at least 4 areas out of 5 areas, and pain in the jaw, chest, and abdomen is not included in generalized pain Within the definition; ③ the symptoms persisted at the same level for more than 3 months; ④ the diagnosis of fibromyalgia is valid even in the presence of other diseases, and the diagnosis of fibromyalgia does not exclude the existence of other clinically important diseases
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Among them, WPI refers to the score of the number of pains in 19 parts (5 regions) of the body in the past 1 week, and pain in each part is scored as 1 point (total score 19 points); SSS refers to the three main symptoms in the past 1 week (Fatigue, sleepiness after waking, cognitive symptoms) Severity score (0=no problem; 1=mild, mild or intermittent; 2=moderate, frequent and/or moderate; 3=severe , the total score (0-9 points) plus the occurrence of 3 main symptoms (headache, lower abdominal pain or colic, depression) in the past 6 months (0=no; 1=yes) Sum (0~3 points)
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Table 1 WPI Currently, the 2016 revised fibromyalgia diagnostic criteria have not been approved by the ACR, and their reliability and validity have only been validated in Korean patients
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The study showed that its sensitivity and specificity were 93.
1% and 90.
7%, respectively; the positive predictive rate was 90.
0%, and the negative predictive rate was 93.
6%
.

And this version is easier to use than the 2010 version, and has been widely used in clinical practice
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Rehabilitation Assessment: Assessment Methods for Severity, Emotion, Function, Quality of Life Q Question 3: What is the content and method of fibromyalgia pain assessment? ▎Opinion 3: It is recommended to use the visual analogy (VAS) score to evaluate the pain level in the past 1 week and the past 24 hours, and to evaluate the tenderness points according to the 1990 version of ACR when necessary (2C)
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Q4: What method is used to evaluate the severity of disease in patients with fibromyalgia? ▎Opinion 4: The fibromyalgia severity (FS) score is recommended to evaluate the severity of disease in patients with fibromyalgia (1C)
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Using the FS score can provide guidance for the diagnosis of fibromyalgia, and can evaluate its severity and improvement
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Compared with non-fibromyalgia patients, the best cut-off value for FS score was 10, with a sensitivity of 94%, a specificity of 91%, a positive predictive rate of 96%, a negative predictive rate of 87%, and a positive likelihood ratio.
is 10.
1, and FS points are simple, practical and easy to operate
.

Q5: What method is used to evaluate the emotions of patients with fibromyalgia? ▎Opinion 5: It is recommended to use the Baker Depression Inventory (BDI) and Baker Anxiety Inventory (BAI) to evaluate the patient's mood (2D)
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Q Question 6: What method is used to evaluate the function and activity of patients with fibromyalgia? ▎Opinion 6: It is recommended to use the 2009 revised version of the Fibromyalgia Impact Questionnaire (FIQR) to evaluate the function of patients with fibromyalgia (2C)
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FIQR has become the most commonly used and well-validated tool for evaluating function and overall impact in patients with fibromyalgia
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It contains 21 questions in three parts: symptoms, their impact on daily life in the past week, and their overall impact.
Each question is evaluated by VAS, with a maximum score of 100
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The calculation method is: FIOR total score = functional total score ÷ 3 + overall impact total score + symptom total score ÷ 2
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Q7: What method is used to evaluate the quality of life of patients with fibromyalgia? ▎Opinion 7: It is recommended to use the SF-36 Concise Health Questionnaire to evaluate the quality of life of patients with fibromyalgia (2D)
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Rehabilitation therapy: The 6 aspects of treatment and adjuvant therapy guidelines recommend rehabilitation therapy including patient education, exercise therapy, physical factor therapy, acupuncture therapy, massage therapy, cognitive behavior and psychological intervention
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1.
Patient Education Q Question 8: What is the role of education in fibromyalgia rehabilitation? ▎Opinion 8: Patient education is recommended as the primary treatment for fibromyalgia (1C)
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Patient education is the preferred basic treatment for fibromyalgia.
The purpose of education is to help patients correctly understand and treat the disease positively and optimistically, making it clear that the treatment goals are to relieve symptoms, maintain function, and improve quality of life, thereby improving their self-management of the disease.
ability
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Educational content includes: disease knowledge, treatment plans and strategies, expected outcomes, and self-management; self-management specifically includes pain coping, improved sleep hygiene, scientific exercise, and reasonable diet (patients with fibromyalgia can use low-carb, protein-rich, vitamin- , minerals, a nutritionally well-rounded diet), pharmacological and non-pharmacological treatments
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2.
Exercise therapy In terms of exercise therapy, the guidelines recommend aerobic exercise, muscle strength exercises, flexibility exercises, joint exercise, tai chi and water exercise
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Q: What is the effect of aerobic exercise on patients with fibromyalgia? ▎Opinion 9: Long-term regular and moderate aerobic exercise is recommended for patients with fibromyalgia, including walking, jogging, cycling, and dancing (1C)
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Long-term regular and moderate aerobic exercise, also known as endurance exercise, is mainly used to control blood sugar, regulate blood pressure, improve blood circulation, enhance metabolism, improve cardiopulmonary function, regulate emotions, and promote enkephalin secretion
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The guidelines recommend that patients choose appropriate aerobic exercise according to their own environmental conditions and personal preferences, and the exercise intensity is gradually increased from the initial low intensity (less than 30% of the heart rate reserve) to the moderate intensity (40% to 59% of the heart rate reserve) to high intensity.
Intensity (60% to 89% heart rate reserve)
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Time from 10min/d to a total of 30~60min/d; frequency from 1~2 times/week to 3~5 times/week
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Q10: The impact of strength training on patients with fibromyalgia? ▎Opinion 10: It is recommended that patients with fibromyalgia undergo long-term regular, step-by-step strength exercises for large muscle groups throughout the body (1B)
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The primary effects of muscle strength exercises include increased strength, muscular endurance, and improved muscle morphology, and together with aerobic exercise form the basis for nonpharmacological management of fibromyalgia
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The guidelines recommend that muscle strength exercises should be resistance exercises that use elastic bands, dumbbells or body weights with medium and high loads of large muscle groups in the whole body.
To 60%~80% of 1RM, increase from 4~5 reps/group to 8~12 reps/group, gradually increase from 1 group at a time to repeat 2~4 groups, rest at least 2~3min between groups
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In order to improve muscular endurance, the exercise load should not exceed 50% of 1RM, repeat 15-25 times per group, repeat 2 groups each time, the interval between groups is slightly shorter, and the exercise frequency should be at least 2-3 times per week
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Q11: What is the effect of flexibility exercises on people with fibromyalgia? ▎Opinion 11: Flexibility exercises are recommended as a rehabilitation method for fibromyalgia (2D)
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Considering that flexibility is the basic quality of the body, it is the basis of body stability and strength, and flexibility exercises are simple and easy to do, not limited by time and place, and are often used as preparation and relaxation activities for other sports
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Therefore, flexibility exercises can be applied to the rehabilitation of patients with fibromyalgia
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The exercise method is to stretch the muscles of the trunk and limbs.
Initially, each lasts for 30s, and gradually increases to 60s for each, and repeats 2 to 4 times
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Q12: Can patients with fibromyalgia take a combination of several exercises? How to combine application? ▎Opinion 12: Combined exercise is recommended for patients with fibromyalgia (1C)
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Endurance, strength and flexibility are the basic qualities of the body, and aerobic exercise and strength exercises are the basis of exercise therapy
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The American College of Sports Medicine guidelines specifically recommend joint exercise for patients with fibromyalgia: aerobic exercise is gradually increased from 1~2 times/week to 2~3 times/week, strength exercises 2~3 times/week, 2 exercises The interval is 48 hours; the flexibility exercises are gradually increased from 1 to 3 times/week to 5 times/week, arranged after preparation activities and relaxation activities, 10min/time
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Therefore, it is recommended to take aerobic exercise combined with strength exercises as the basis of exercise therapy, and flexibility exercises after preparation and relaxation activities
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Q13: What is the effect of Tai Chi on fibromyalgia patients? ▎Opinion 13: Taijiquan is recommended as a rehabilitation intervention method for patients with fibromyalgia (2C)
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Tai Chi is a traditional Chinese national sports therapy that includes specific physical activities and breathing exercises
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Its mechanism of promoting the recovery of fibromyalgia patients and inhibiting the sympathetic nervous system signaling of β-adrenergic receptors, regulating the sensitivity of glucocorticoid receptors, increasing the signaling of anti-inflammatory glucocorticoid receptors and exerting anti-inflammatory effects.
related to inflammation
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Q14: What is the effect of water exercise on fibromyalgia patients? ▎Opinion 14: Advise patients with fibromyalgia to perform water sports or hydrotherapy (2C)
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Different forms of hydrotherapy include water with or without exercise, mineral or thermal baths (mineral or hot water, thermal spa, thalassotherapy, thermotherapy, colloids, natural healing gases), thermal treatments (mineral baths, mud compresses) and hot bath) significantly improved VAS score, number of tender points, FIQ score and health-related quality of life in patients with fibromyalgia, especially the pain improvement could be maintained to the end of follow-up
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Both water and ground exercises are beneficial for fibromyalgia, and each has its own strengths
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The Turkish Society of Physical Medicine and Rehabilitation recommends that patients choose ground or water therapy based on their personal preferences, use of the environment, and compliance with exercise
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3.
Physical factor therapy Q Question 15: What is the effect of low-energy laser on patients with fibromyalgia? ▎Opinion 15: Low-level lasers are recommended as adjuvant therapy in patients with severe fibromyalgia (2C)
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Low-energy laser (LLLT) changes cell membrane permeability through photochemical reactions, increases messenger RNA accumulation, promotes cell proliferation, changes cell function, and promotes tissue healing; by reacting with cytochrome C oxidase, it increases the production of adenosine triphosphate and reduces the level of reactive oxygen species , thereby reducing cellular inflammation and death
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Q16: What is the effect of transcranial magnetic stimulation and transcranial electrical stimulation on patients with fibromyalgia? ▎Opinion 16: It is recommended that patients with conditional fibromyalgia should be treated with transcranial magnetic stimulation and transcranial direct current stimulation when the condition is severe (2C)
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Non-invasive neuromodulation technology Transcranial Magnetic Stimulation and Transcranial Direct Current Stimulation respectively utilize pulsed magnetic and direct current transcranial repetitive stimulation of specific brain regions to achieve therapeutic effects
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When combined with aerobic exercise, M1 stimulation produces more sustained improvements in pain and quality of life
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In addition, acupuncture and massage therapy are also recommended by guidelines as adjunctive therapy for patients with fibromyalgia
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4.
Acupuncture Q Question 17: What effect does acupuncture have on fibromyalgia patients? ▎Opinion 17: Acupuncture is recommended as adjuvant therapy for patients with fibromyalgia (2C)
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‍‍‍‍‍5.
Massage therapy Q Question 18: How does massage affect patients with fibromyalgia? ▎Opinion 18: Massage is recommended as adjunctive therapy in patients with fibromyalgia (2C)
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6.
Cognitive-behavioral and psychotherapy Q Question 19: What are the effects of cognitive-behavioral therapy (CBT) on patients with fibromyalgia? ▎Opinion 19: CBT is recommended for patients with depression and anxiety symptoms (1B)
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CBT has short- and long-term advantages over nonpharmacological treatment in improving key symptoms and disability in fibromyalgia, and has advantages over drug treatment in pain management strategies
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Q20: How does mindfulness therapy affect people with fibromyalgia? ▎Opinion 20: Mindfulness therapy is recommended as adjunctive therapy for fibromyalgia (2B)
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Mindfulness-based and acceptance-based interventions include mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), and acceptance and commitment therapy (ACT), which addresses the relationship between people and their inner experiences
.

The aim is to train participants to consciously observe thoughts, emotions and bodily sensations in an open, non-judgmental manner, including mindfulness training such as body scans, sitting and walking mindfulness, mindfulness yoga exercises,
etc.

 MBCT, adapted from MBSR, educates depressed patients prone to negative thoughts, as an alternative to some MBSR-based content to prevent recurrent depression
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Whereas ACT is designed to focus on other cognitive skills, such as the participant's ability to define and articulate values ​​in different areas of life, identify achievable goals that embody those values, and plan for the future based on established life goals
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Summary This article is the first fibromyalgia rehabilitation guideline in China based on WHO guidelines and international standards.
It makes recommendations based on evidence-based medicine for a total of 20 important issues related to fibromyalgia rehabilitation evaluation and rehabilitation intervention.
It is of positive significance to promote the standardization of fibromyalgia rehabilitation in China
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However, the use of this guideline in clinical rehabilitation needs to be combined with the actual situation
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In addition, due to the small number of studies or the low quality of the studies, there are currently no recommendations for manual therapy, occupational therapy, vibration, and hyperbaric oxygen therapy, and further clinical research is needed
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References: [1] China Fibromyalgia Rehabilitation Practice Guidelines Development Working Group, etc.
Chinese Fibromyalgia Rehabilitation Guidelines (2021).
Chinese Journal of Physical Medicine and Rehabilitation, January 2022, Volume 44, Issue 1.