1813 01 REUMA3 Editoriale - ME/CFS Australia

60 R. Casale et al.cal exercise and other therapies that are used infancy and pseudophilosophical ways, and it rendersevaluation of possible positive results nearly impossiblein the absence of a defined diagnosis andrecognised treatment protocols.The second onion layer is related to the possiblepresence of FM subset as well as to the erratic presentationof multiple painful muscle spots and correlatedsymptoms (1).A third layer recognizes the presence of different approachto management objectives and treatmentchoices by the various medical professionals involvedin the treatment of FM. For instance occupationaltherapists consider an increasing level of activityas the major treatment objective, followed bypain control and fatigue management while physicaltherapists are more concerned with improvingexercise tolerance and fitness followed by pain controland functional abilities. Fatigue managementand endurance exercise are the most frequent interventionaltargets across both professions (2).The last and most important layer addresses thepresence of a neuropathic component in the manifestationof pain in FM. In other words, if the painexpression in FM is only due to nociceptive pain(peripheral and related to an activation in musclenociceptors), or if the pain felt by FM patients intheir muscle is more or less dependent on functionalalteration in the sensory decoding of afferentinputs as well as in altered descending paincontrol systems. These last theories have gainedstrength recently based on several studies as wellas clinical reports (see other chapters in this issue).This is the most important point to keep in mindwhen prescribing non pharmacological treatmentsin FM, as the two types of pain, namely neuropathicand nociceptive, require different non pharmacologicalapproaches (3). Unfortunately, thisconcept is rarely considered when tailoring nonpharmacological treatments for pain control, ingeneral, and particularly, in FM. This oversight canresult in inappropriate application of otherwise usefulnon pharmacological pain control techniques..For the sake of systematic organization, the mostcommonly used forms of non pharmacologicaltreatment in FM can be divided into four majorcategories:- Physical therapies- Movement and exercises.- Cognitive-behavioural treatments.- Complementary and alternative treatments.Of note, the majority of non pharmacological treatmentstudies utilise multimodal therapies, whichrenders comparison and critical analysis on the efficacyof a single treatment difficult and a possibleguideline on these techniques a source of majorcriticism.PHYSICAL THERAPIESThe definition of physical therapies encompassesall treatment using a physical activity or techniqueto induce some therapeutic effect. These techniquesare mainly used in a rehabilitation context, althoughsome are also used as complementary andalternative treatments. These two approaches arequite divergent, however. In the rehabilitation context,physical therapies are used on the basis oftheir ascertained mechanism of action (i.e., the activationof the spinal gate, release of endogenousopiates, local metabolic action, etc.), but when usedas alternative treatments this linkage is completelylost.Physical therapies include thermal (both heat andcold), mechanical, light, electrical and magneticstimulation. In this context, acupuncture as well asmechanical stimulation that is induced by someform of massage (i.e. connective tissue massage)can be considered as particular forms of physicaltreatment. Each technique claims its own mechanismof action, although peer-reviewed evidence oftheir effectiveness in FM is lacking and recent reviewshave reached non homogeneous conclusions.While some reviews, based only on few randomized,controlled trials, are cautious in stating efficacy,they strongly suggest conducting more soundstudies and demonstrating a long-term, effectiveintervention for managing the symptoms associatedwith FM (4). Other reviews, which have includedanecdotal evidence or small, observationalphysiotherapy studies, indicate that physical therapiescan be efficacious for different symptoms (5).Heat and coldAlthough beneficial in other forms of muscle pain,local application of cold therapy by means of icecubes or cooling sprays does not seem to have anyefficacy in FM. Cold sprays are used within thestretch and spray techniques (see below). On thecontrary whole body criotherapy at -67°C seems tohave some short-term effect on the number of activetrigger points and intensity of pain. No data areavailable on its long-term efficacy (6). Superficialheat and deep heat with infrared and ultrasound applicationas well as the local thermal effect induced