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Latest Research on Fibromyalgia
     
Acupunct Med. 2008 Mar;26(1):33-45.
Is it all about sex? Acupuncture for the treatment of pain from a biological and gender perspective.
Lund I, Lundeberg T.

Pain is a unique personal experience showing variability where gender and sex related effects might contribute. The mechanisms underlying the differences between women and men are currently unknown but are likely to be complex and involving interactions between biological, sociocultural and psychological aspects. In women, painful experimental stimuli are generally reported to produce a greater intensity of pain than in men. Clinical pain is often reported with higher severity and frequency, longer duration, and present in a greater number of body regions in women than in men. Women are also more likely to experience a number of painful conditions such as fibromyalgia, temporomandibular dysfunction, migraine, rheumatoid arthritis and irritable bowel syndrome. With regard to biological factors, quantitative as well as qualitative differences in the endogenous pain inhibitory systems have been implicated, as well as an influence of gonadal hormones. Psychosocial factors like sex role beliefs, pain coping strategies, and pain related expectancies may also contribute to the differences. Being exposed to repeated painful visceral events (eg menses, labour) during life may contribute to an increased sensitivity to, and greater prevalence of, pain among women. When assessing the outcome of pharmacological and non-pharmacological therapies in pain treatment, the factors of gender and sex should be taken into account as the response to an intervention may differ. Preferably, treatment recommendations should be based on studies using both women and men as the norm. Due to variability in results, findings from animal studies and experiments in healthy subjects should be interpreted with care.

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Curr Opin Rheumatol. 2008 Mar;20(2):208-12.
Talking to patients with fibromyalgia about physical activity and exercise.
Rooks DS.
Division of Rheumatology, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA. daniel.rooks@novartis.com

PURPOSE OF REVIEW: The purpose of this article is to describe the application of basic exercise principles to individuals with fibromyalgia to encourage clinicians to discuss with their patients ways of becoming more physically active. RECENT FINDINGS: The goals of increased physical activity and exercise for individuals with fibromyalgia are to improve or maintain general fitness, physical function, emotional well being, symptoms and overall health, and provide them with a feeling of control over their well being. Describing ways of increasing activity through home, work and leisure-related tasks or exercise provides a universal approach to increasing physical activity that applies to individuals with fibromyalgia and fits a counseling model of health behavior familiar to clinicians. The patient-clinician relationship provides a unique opportunity for health professionals to counsel individuals with fibromyalgia to become and remain more physically active. SUMMARY: Regular physical activity and exercise has numerous physical, psychological, and functional benefits for individuals with fibromyalgia and should be included in treatment plans. Clinicians can help patients adopt a more physically active lifestyle through targeted discussions, support and consistent follow up.

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J Rheumatol. 2008 Mar;35(3):502-14. Epub 2008 Feb 15.
A Randomized, Double-blind, Placebo-Controlled, Phase III Trial of Pregabalin in the Treatment of Patients with Fibromyalgia.
Mease PJ, Russell IJ, Arnold LM, Florian H, Young JP Jr, Martin SA, Sharma U.
From Seattle Rheumatology Associates and Swedish Medical Center, Seattle, Washington, USA.

OBJECTIVE: To evaluate the efficacy and safety of pregabalin for symptomatic relief of pain associated with fibromyalgia (FM) and for management of FM. METHODS: This multicenter, double-blind, placebo-controlled trial randomly assigned 748 patients with FM to receive placebo or pregabalin 300, 450, or 600 mg/day (dosed twice daily) for 13 weeks. The primary outcome variable for study objective 1, symptomatic relief of pain associated with FM, was comparison of endpoint mean pain scores between each pregabalin group and placebo. The outcome variable for study objective 2, management of FM, included endpoint mean pain scores, Patient Global Impression of Change (PGIC), and Fibromyalgia Impact Questionnaire (FIQ)-Total Score. Secondary outcomes included assessments of sleep, fatigue, and mood disturbance. RESULTS: Patients in all pregabalin groups showed statistically significant improvement in endpoint mean pain score and in PGIC response compared with placebo. Improvements in FIQ-Total Score for the pregabalin groups were numerically but not significantly greater than those for the placebo group. Compared with placebo, all pregabalin treatment groups showed statistically significant improvement in assessments of sleep and in patients' impressions of their global improvement. Dizziness and somnolence were the most frequently reported adverse events. CONCLUSION: Pregabalin at 300, 450, and 600 mg/day was efficacious and safe for treatment of pain associated with FM. Pregabalin monotherapy provides clinically meaningful benefit to patients with FM.

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Neuroscientist. 2008 Feb 12 [Epub ahead of print]
Fibromyalgia: A Disorder of the Brain?
Schweinhardt P, Sauro KM, Bushnell MC.
Center for Research on Pain, McGill University.

This article presents evidence that fibromyalgia patients have alterations in CNS anatomy, physiology, and chemistry that potentially contribute to the symptoms experienced by these patients. There is substantial psychophysical evidence that fibromyalgia patients perceive pain and other noxious stimuli differently than healthy individuals and that normal pain modulatory systems, such as diffuse noxious inhibitory control mechanisms, are compromised in fibromyalgia. Furthermore, functional brain imaging studies revealing enhanced pain-related activations corroborate the patients' reports of increased pain. Neurotransmitter studies show that fibromyalgia patients have abnormalities in dopaminergic, opioidergic, and serotoninergic systems. Finally, studies of brain anatomy show structural differences between the brains of fibromyalgia patients and healthy individuals. The cerebral alterations offer a compelling explanation for the multiple symptoms of fibromyalgia, including widespread pain and affective disturbances. The frequent comorbidity of fibromyalgia with stress-related disorders, such as chronic fatigue, posttraumatic stress disorder, irritable bowel syndrome, and depression, as well as the similarity of many CNS abnormalities, suggests at least a partial common substrate for these disorders. Despite the numerous cerebral alterations, fibromyalgia might not be a primary disorder of the brain but may be a consequence of early life stress or prolonged or severe stress, affecting brain modulatory circuitry of pain and emotions in genetically susceptible individuals.

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Arthritis Rheum. 2008 Feb;58(2):612-22.
A six-month randomized controlled trial of exercise and pyridostigmine in the treatment of fibromyalgia.
Jones KD, Burckhardt CS, Deodhar AA, Perrin NA, Hanson GC, Bennett RM.
Oregon Health & Science University School of Nursing, Portland 97239, USA. joneskim@ohsu.edu

OBJECTIVE: A subset of fibromyalgia (FM) patients have a dysfunctional hypothalamic-pituitary-insulin-like growth factor 1 (IGF-1) axis, as evidenced by low serum levels of IGF-1 and a reduced growth hormone (GH) response to physiologic stimuli. There is evidence that pyridostigmine (PYD) improves the acute response of GH to exercise in FM patients. The purpose of this study was to evaluate the clinical effectiveness of 6 months of PYD and group exercise on FM symptoms. METHODS: FM patients were randomized to 1 of the following 4 groups: PYD plus exercise, PYD plus diet recall but no exercise, placebo plus exercise, and placebo plus diet recall but no exercise. The primary outcome measures were the visual analog scale (VAS) score for pain, tender point count, and total myalgic score. Secondary outcome measures were the total score on the Fibromyalgia Impact Questionnaire (FIQ) and FIQ VAS scores for individual symptoms (fatigue, poor sleep, stiffness, and anxiety), as well as
quality of life (QOL) and physical fitness (lower body strength/endurance, upper and lower body flexibility, balance, and time on the treadmill). RESULTS: A total of 165 FM patients completed baseline measurements; 154 (93.3%) completed the study. The combination of PYD and exercise did not improve pain scores. PYD groups showed a significant improvement in sleep and anxiety in those who completed the study and in QOL in those who complied with the therapeutic regimen as compared with the placebo groups. Compared with the nonexercise groups, the 2 exercise groups demonstrated improvement in fatigue and fitness. PYD was generally well tolerated. CONCLUSION: Neither the combination of PYD plus supervised exercise nor either treatment alone yielded improvement in most FM symptoms. However, PYD did improve anxiety and sleep, and exercise improved fatigue and fitness. We speculate that PYD may have improved vagal tone, thus benefiting sleep and anxiety; this notion warrants further study.

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Neurotherapeutics. 2008 Jan;5(1):100-6.
Peripheral nerve stimulation for neuropathic pain.
Slavin KV.
Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois 60612.

Peripheral nerve stimulation (PNS) has been used for treatment of neuropathic pain for more than 40 years. Recent resurgence of interest to this elegant surgical modality came from the introduction of less invasive implantation techniques and the wider acceptance of neuromodulation as a treatment of medically refractory cases. This article reviews the literature on the use of PNS for neuropathic pain and describes current indications and hardware choices in frequent use. Published experience indicates that neuropathic pain responds to PNS in many patients. PNS works well in both established indications, such as post-traumatic and postsurgical neuropathy, occipital neuralgia, and complex regional pain syndromes, and in relatively new indications for neuromodulation, such as migraines and daily headaches, cluster headaches, and fibromyalgia. Future research and growing clinical experience will help in identifying the best candidates for PNS, choosing the best procedure and best hardware for each individual patient, and defining adequate expectations for patients and pain specialists.

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J Altern Complement Med. 2007 Dec;13(10):1107-1114.
Effects of Yoga and the Addition of Tui Na in Patients with Fibromyalgia.
da Silva GD, Lorenzi-Filho G, Lage LV.
Pulmonary Division, Faculty of Medicine, University of São Paulo, São Paulo, Brazil.

Objectives: This study aimed to verify whether techniques of yoga with and without the addition of Tui Na might improve pain and the negative impact of fibromyalgia (FMS) on patients' daily life. Design: Forty (40) FMS women were randomized into two groups, Relaxing Yoga (RY) and Relaxing Yoga plus Touch (RYT), for eight weekly sessions of stretching, breathing, and relaxing yogic techniques. RYT patients were further submitted to manipulative techniques of Tui Na. Outcome measure: Outcome measures comprised the Fibromyalgia Impact Questionnaire (FIQ), pain threshold at the 18 FMS tender points, and a verbal graduation of pain assessed before treatment and on the followup. The visual analog scale (VAS) for pain was assessed before and after each session and on the follow-up. Results: Seventeen (17) RYT and 16 RY patients completed the study. Both RY and RYT groups showed improvement in the FIQ and VAS scores, which decreased on all sessions. The RYT group showed lower VAS and verbal scores for pain on the eighth session, but this difference was not maintained on the follow-up. Conversely, RY VAS and verbal scores were significantly lower just on the follow-up. Conclusions: These study results showed that yogic techniques are valid therapeutic methods for FMS. Touch addition yielded greater improvement during the treatment. Over time, however, RY patients reported less pain than RYT. These results suggest that a passive therapy may possibly decrease control over FMS symptoms.

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J Altern Complement Med. 2007 Dec;13(10):1099-1106.
Effects of Topical Essential Oil on Exercise Volume After a 12-Week Exercise Program for Women with Fibromyalgia: A Pilot Study.
Rutledge DN, Jones CJ.
Department of Nursing, California State University, Fullerton, CA.

Objectives: We determined-in women with fibromyalgia (FM)-effects of essential oils used with a 12-week exercise program on exercise volume, pain, physical performance, and physical function. Design: This was a randomized clinical trial comparing 024 essential oil with sham oil combined with exercise. Settings: Settings included community sites in southern California. Subjects: The study included 20 women randomized to 024 oil, 23 to sham oil. Interventions: Women were trained in oil application before exercise, at bedtime on exercise days; the 12-week program included weekly group sessions with trained leaders guided by a prerecorded regimen (allowing choice of program level) plus 2 days of home exercise with the recorded regimen. Outcome measures: Primary: Exercise volume (number of days exercised multiplied by exercise level- intensity and duration). Secondary: Pain (Brief Pain Inventory), measures of physical performance (30-second chair stands, 6-minute walk, multidimensional balance), and self-reported physical function (Composite Physical Function scale). Results: The average participant was 54 years old, had some college education, was married, Caucasian, and minimally/mildly depressed. There was no significant difference in exercise volume between women using 024 as compared with those using sham oil after 12 weeks (depression as covariate). There were no significant group nor pre- to postexercise changes in pain intensity or interference. There were greater positive changes in 30-second chair stands, 6-minute walk distance, and multidimensional balance scores in the 024 group than in the sham group, but these were not significant. The counterirritant 024 oil was not different from the sham oil in its effect on exercise volume (frequency, exercise level-intensity and duration) for women with FM. It is unknown whether 024 actually decreases local pain when used with exercise. Conclusions: Increases in physical function found, while not significant, may be attributable to the exercise regimen or to the interaction of the oils and exercise regimen.

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Acupunct Med. 2007 Dec;25(4):137-47.
Acupuncture in the treatment of fibromyalgia in tertiary care - a case series.
Duncan B, White A, Rahman A.

AIMS: Fibromyalgia is a common cause of chronic widespread pain. The benefit of medication is often limited by its side effects, and the improvements obtained with exercise and education are inconsistent. Many patients seek acupuncture treatment, which is reported to be helpful in some cases. This study aimed to explore the acceptability and benefits of acupuncture offered in the setting of a tertiary referral clinic. METHODS: An open, uncontrolled observational study was conducted among patients who met the usual fibromyalgia criteria and who had a pain score of at least 30 on a 100mm Visual Analogue Scale (VAS). Patients were allowed to continue other treatments but not to introduce new ones. Acupuncture was given using a Western approach according to a protocol developed by consensus. Patients were offered eight treatments in eight weeks. Outcome measures included VAS of pain intensity and Fibromyalgia Impact Questionnaire (range 0 - 100), and were taken before and after treatment, and at 14, 20 and 34 weeks from enrolment. RESULTS: Twenty four eligible patients were enrolled in a 12 month period. Baseline mean pain VAS score for these 24 patients was 74 (SD 18) and mean Fibromyalgia Impact Questionnaire score 78 (SD 12.4). Only 14 patients completed the course of treatment within about 10 weeks. Compliance was poor in the remaining patients because of difficulty attending clinic, and in two cases because of exacerbation of pain. Completion of outcome measures was variable and therefore the analysis of data is limited. Five patients scored at least 20% reduction in Fibromyalgia Impact Questionnaire score which is a clinically relevant improvement. Two of these scored at least 50% reduction. CONCLUSION: Acupuncture appears to offer symptomatic improvement to some patients with fibromyalgia in a tertiary clinic who have failed to respond to other treatments. In view of its safety, further acupuncture research is justified in this population.

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Reumatismo. 2007 Oct-Dec;59(4):316-21.
[Efficacy of Cellfood(R)'s therapy (deutrosulfazyme) in fibromyalgia.]
[Article in Italian]
Nieddu ME, Menza L, Baldi F, Frediani B, Marcolongo R.
Servizio di Reumatologia, Clinica Rugani, 53035 Monteriggioni (SI), Italia. mariaelenanieddu@tiscali.it.

OBJECTIVE: To assess the efficacy of Cellfood(R)'s therapy in the treatment of fibromyalgia. METHODS: This study was a single-blind, cross-over, randomized placebo-controlled trial. Forty female were selected from 320 cases investigated in the period 2003-2005 of June. To be included in this study, it was required that the diagnosis of fibromyalgia was made by a specialist in according to the ACR classification criteria of 1990. The patient's age was between 35-47 years, the choice of criteria were the absence of improvements with the conventional therapy and the normality of medical check-up. The patients were divided into two different-groups of thirty-one and nine subjects, each-one (group A) treated with Cellfood(R) for six months in according to the Eurodream's scheme, and each-other (group B) treated with placebo for three months and successively with Cellfood(R) for three months. Besides we have estimated the tender points with algometer and the health status of women with the Fibromyalgia Impact Questionnaire (FIQ) at the baseline (T0) and at three (T1) and six month (T2). RESULT: The group A had an appreciable improvement of the parameters at T1 statistically significant compared to the group B, while we observed a stability of they at T2 on the group A and an improvement of the parameters of the group B statistically non significant compared to each-one. CONCLUSION: Our result suggest that the Cellfood(R)'s therapy improve fibromyalgia symptoms and health-related quality of life.

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Reumatismo. 2007 Oct-Dec;59(4):280-91.
[Pharmacological treatment of fibromyalgia.]
[Article in Italian]
Cazzola M, Sarzi-Puttini P, Buskila D, Atzeni F.
U.O. Reumatologia, Azienda Ospedaliera "L. Sacco", 20157 Milano, Italia. atzenifabiola@hotmail.com.

Fibromyalgia syndrome (FM) is a condition of chronic and diffuse muscular pain affecting particularly middle aged women. The aetiology of FM is not completely understood and it is currently considered a disorder of pain regulation. The most efficacious compounds include the tricyclic drugs and mixed reuptake inhibitors. Recent works suggest that the anticonvulsant medications pregabalin and gabapentin are also effective. Moreover, two serotonin and norepinephrine-reuptake inhibitors-duloxetine and milnacipran show encouraging results in treating FM symptoms. The results of clinical trials of anti-inflammatory medications have been generally disappointing, but three RCTs have found that tramadol (with or without acetaminophen) is effective in FM.

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Brain. 2007 Oct;130(Pt 10):2661-70. Epub 2007 Sep 14.
Effects of unilateral repetitive transcranial magnetic stimulation of the motor cortex on chronic widespread pain in fibromyalgia.
Passard A, Attal N, Benadhira R, Brasseur L, Saba G, Sichere P, Perrot S, Januel D, Bouhassira D.
INSERM U-792, Boulogne-Billancourt F-92100 France.

Non-invasive unilateral repetitive transcranial magnetic stimulation (rTMS) of the motor cortex induces analgesic effects in focal chronic pain syndromes, probably by modifying central pain modulatory systems. Neuroimaging studies have shown bilateral activation of a large number of structures, including some of those involved in pain processing, suggesting that such stimulation may induce generalized analgesic effects. The goal of this study was to assess the effects of unilateral rTMS of the motor cortex on chronic widespread pain in patients with fibromyalgia. Thirty patients with fibromyalgia syndrome (age: 52.6 +/- 7.9) were randomly assigned, in a double-blind fashion, to two groups, one receiving active rTMS (n = 15) and the other sham stimulation (n = 15), applied to the left primary motor cortex in 10 daily sessions. The primary outcome measure was self-reported average pain intensity over the last 24 h, measured at baseline, daily during the stimulation period and then 15, 30 and 60 days after the first stimulation. Other outcome measures included: sensory and affective pain scores for the McGill pain Questionnaire, quality of life (assessed with the pain interference items of the Brief Pain Inventory and the Fibromyalgia Impact Questionnaire), mood and anxiety (assessed with the Hamilton Depression Rating Scale, the Beck Depression Inventory and the Hospital Anxiety and Depression Scale). We also assessed the effects of rTMS on the pressure pain threshold at tender points ipsi- and contralateral to stimulation. Follow-up data were obtained for all the patients on days 15 and 30 and for 26 patients (13 in each treatment group) on day 60. Active rTMS significantly reduced pain and improved several aspects of quality of life (including fatigue, morning tiredness, general activity, walking and sleep) for up to 2 weeks after treatment had ended. The analgesic effects were observed from the fifth stimulation onwards and were not related to
changes in mood or anxiety. The effects of rTMS were more long-lasting for affective than for sensory pain, suggesting differential effects on brain structures involved in pain perception. Only few minor and transient side effects were reported during the stimulation period. Our data indicate that unilateral rTMS of the motor cortex induces a long-lasting decrease in chronic widespread pain and may therefore constitute an effective alternative analgesic treatment for fibromyalgia.

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Acupunct Med. 2007 Sep;25(3):100-6.
Are reviews based on sham acupuncture procedures in fibromyalgia syndrome (FMS) valid?
Lundeberg T, Lund I.

In recent reviews regarding the efficacy of acupuncture in fibromyalgia syndrome (FMS) it has been concluded that acupuncture has no specific effect since the control procedure (superficial needling and/or needling away from 'specific' points) had similar effects. These conclusions may be questioned since superficial needling and/or needling away from specific trigger points is not inert. Also, manual acupuncture or mild electroacupuncture (EA) may not be sufficient to activate the endogenous pain inhibiting system. Patients with FMS suffer from allodynia, fatigue and muscle ache, which is partly explained by peripheral and central sensitisation. Sensitisation results in augmented and altered stimulus responses whereby light stimulation of the skin has as strong an effect as regular needling on the pain inhibitory system in FMS. Central sensitisation in FMS is also associated with expanded receptive fields of central neurons resulting in a larger topographic distribution of the pain. This would suggest that control procedures using needling away from the 'specific site' might have as strong an effect as needling within the most painful area. Also, repeated nociceptive input from muscles (as obtained by de qi) results in expansion of receptive fields which in turn may result in activation of descending pain inhibition outside the stimulated myotome. Sensitisation to pain, such as in FMS, may also be related to abnormalities in descending efferent pathways. As there is likely to be an imbalance between excitatory and inhibitory systems in FMS, stronger stimulation may therefore be needed to activate the descending pain inhibitory system. In studies using mild manual acupuncture or weak EA stimulation optimal pain inhibition may therefore not have been obtained. When conducting studies on acupuncture, the clinical condition or syndrome needs to be taken into account and the control procedure designed accordingly.

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Ann Rheum Dis. 2007 Sep 17; [Epub ahead of print]
EULAR evidence based recommendations for the management of fibromyalgia syndrome.
Carville SF, Arendt-Nielsen S, Bliddal H, Blotman F, Branco JC, Buskilla D, Da Silva JA, Danneskiold-Samsøe B, Dincer F, Henriksson C, Henriksson K, Kosek E, Longley K, McCarthy GM, Perrot S, Puszczewicz MJ, Sarzi-Puttini P, Silman A, Späth M, Choy EH.
King's College London, United Kingdom.

OBJECTIVE: To develop evidence based recommendations for the management of fibromyalgia syndrome (FMS). METHODS: A multidisciplinary task force was formed representing eleven European Countries. The design of the study including search strategy, participants, interventions, outcome measures, data collection and analytical method was defined at the outset. A systematic review was undertaken with the keywords 'fibromyalgia', 'treatment or management' and 'trial'. Studies were excluded if they did not utilise the ACR classification criteria, were not clinical trials, or included patients with chronic fatigue syndrome or myalgic encephalomyelitis. Primary outcome measures were change in pain assessed by visual analogue scale (VAS) and fibromyalgia impact questionnaire (FIQ). The quality of the studies was categorised based on randomisation, blinding and allocation concealment. Only the highest quality studies were used to base recommendations on. When there was insufficient evidence from the literature, a Delphi process was used to provide basis for recommendation. RESULTS: One hundred and forty six studies were eligible for the review. Thirty nine pharmacologic intervention studies and 59 non-pharmacologic were included in the final recommendation summary tables once those of a lower quality or with insufficient data were separated. The categories of treatment identified were antidepressants, analgesics, and 'other pharmacological' and exercise, cognitive behavioural therapy, education, dietary interventions and 'other non-pharmacological'. In many studies sample size was small and the quality of the study was insufficient for strong recommendations to be made. CONCLUSION: Nine recommendations for the management of FMS were developed using a systematic review and expert consensus.

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Expert Opin Pharmacother. 2007 Aug;8(11):1629-42.
Treatment of fibromyalgia and its symptoms.
Staud R.
University of Florida College of Medicine, Department of Medicine, Division of Rheumatology and Clinical Immunology, McKnight Brain Institute, Gainesville, FL 32610-0221, USA. staudr@ufl.edu

The main symptoms of fibromyalgia syndrome (FM) are pain, stiffness, subjective weakness and muscle fatigue. Pain in FM usually fluctuates, as well as being 'deep' and is always associated with local or generalized tenderness (hyperalgesia and allodynia). The pathogenesis of such peripheral and/or CNS changes in FM is unclear, but peripheral tissue changes, specifically in muscles, have been implicated. Indirect evidence from interventions that attenuate tonic peripheral impulse input in patients with FM suggest that overall FM pain is dependent on nociception. More importantly, FM-associated widespread mechanical hyperalgesia and allodynia can also be improved or abolished by removal of peripheral pain impulse input. In addition, FM patients show evidence of abnormal stress reactivity, including blunting of the hypothalamic-pituitary-adrenal axis and increased autonomic nervous system responsiveness. Thus, therapeutic interventions in FM should target not only pain reductions, but also improvements of peripheral/central sensitization and neuroendocrine/autonomic abnormalities. Despite the complexity of FM, there are pharmacologic and non-pharmacologic interventions that are available that have clinical benefit. Present evidence indicates efficacy of antidepressants, cardiovascular exercise and cognitive behavioral therapy. Based on this evidence, a stepwise program emphasizing education, medications, exercise and cognitive therapy can be recommended.

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Clin Exp Rheumatol. 2007 Jul-Aug;25(4):529-33.
Physical activity protects male patients with post-traumatic stress disorder from developing severe fibromyalgia.
Arnson Y, Amital D, Fostick L, Silberman A, Polliack ML, Zohar J, Rubinow A, Amital H.
Department of Medicine 'D', Meir Medical Center, Kfar-Saba, Israel (affiliated with the Sackler Faculty of Medicine, Tel-Aviv University).

OBJECTIVES:Fibromyalgia syndrome (FMS) has been associated with various psychiatric and other, ill-defined disorders. We recently showed that fibromyalgia is more prevalent in men suffering from combat-related Post Traumatic Stress Disorder (PTSD). In this paper we analyze the relationship between engagement in physical activity, the psycho-metric traits of PTSD and the future development of FMS. METHODS:Fifty-five male patients, all known to have combat-related PTSD, were investigated for the presence of fibro-myalgia according to the American College of Rheumatology (ACR) criteria. Each patient completed questionnaires characterizing his quality of sleep, and the Sheehan Disability Scale measuring performance in the familial, social and vocational spheres. Additionally, each of the enrollees was interviewed by an experienced psychiatrist, who then completed a Clinician Administered PTSD Scale, a Clinical Global Impression Scale, and calculated an SF-36 score. Each patient was asked whether he exercised often, occasionally or not at all. The data was analyzed by the Xi² test and by ANOVA.RESULTS:PTSD patients who also suffered from FMS had a more severe form of disease as measured by the Clinician Administered PTSD Scale (CAPS) score, 88.2 +/- 14.0 (n = 28) compared to 97.6 +/- 13.2 of patients with PTSD and FMS (n = 27) (p = 0.013, F<inf>(d.f 2)</inf>-6.61, ANOVA test). Interestingly, engaging in physical exercise was also associated with less severe disease. When the patients were analyzed based on their tender point count (0-5, 6-10, or > 11), the number of tender points decreased with increasing physical activity (p = 0.02, Xi²<inf>(d.f.-4)</inf> = 11.3). CONCLUSION: Physical exercise in male patients with combat-related PTSD provides protection from the future development of fibromyalgia. Furthermore, physical activity is related in this group of patients to a better perception of their quality of life.

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Am Fam Physician. 2007 Jul 15;76(2):247-54. Comment in: Am Fam Physician. 2007 Jul 15;76(2):195-6, 202.
Fibromyalgia.
Chakrabarty S, Zoorob R.
Department of Family and Community Medicine, Meharry Medical College, Nashville, TN 37208, USA. schakrabarty@mmc.edu

Fibromyalgia is an idiopathic, chronic, nonarticular pain syndrome with generalized tender points. It is a multisystem disease characterized by sleep disturbance, fatigue, headache, morning stiffness, paresthesias, and anxiety. Nearly 2 percent of the general population in the United States suffers from fibromyalgia, with females of middle age being at increased risk. The diagnosis is primarily based on the presence of widespread pain for a period of at least three months and the presence of 11 tender points among 18 specific anatomic sites. There are certain comorbid conditions that overlap with, and also may be confused with, fibromyalgia. Recently there has been improved recognition and understanding of fibromyalgia. Although there are no guidelines for treatment, there is evidence that a multidimensional approach with patient education, cognitive behavior therapy, exercise, physical therapy, and pharmacologic therapy can be effective.

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Rev Med Suisse. 2007 Jun 20;3(116):1575-8.
[Medication to treat fibromyalgia?]
[Article in French]
Perot S.
Service de médecine interne et consultation de la douleur, Hôtel Dieu, 75004 Paris, France. serge.perrot@htd.aphp.fr

The present therapeutic approach is aimed at controlling central sensitisation that is supposed to be the core of fibromyalgia's physiopathological mechanisms. The tricyclic antidepressants have some effects on sleep and the improvement of physical activities. Encouraging results have been observed with the serotonin and noradrenaline reuptake inhibitors such as venlafaxine, milnacipran or duloxetine. New Dopamine D3 receptor agonists as well as the new anticonvulsivants such as gabapentine and pregabalin are equally promising. However the prescription of any medication should take place within a multidisciplinary approach.

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MMW Fortschr Med. 2007 Jun 21;149(25-26):37-9.
[Acupuncture in pain therapy]
[Article in German]
Grasmüller S, Irnich D.
Interdisziplinäre Schmerzambulanz, Klinik für Anästhesiologie, LMU München. sybille.grasmueller@med.uni-muenchen.de

The neurobiological mechanisms of acupuncture have been investigated in many cases and provide plausible explanatory approaches for its effectiveness. However, only some of these mechanisms depend on the "point-specifity". Evaluation following evidence-based medicine criteria shows level 1 evidence for the efficacy of acupuncture for post-operative dental pain as well as for nausea and vomiting. In addition there are positive results for the efficacy of acupuncture for treating headaches, lumbar spine pain, temporomandibular dysfunction, fibromyalgia, osteoarthritis of the knee and epicondylitis. Acupuncture can be part of a multimodal therapeutic concept for chronic pain disorders with biopsychosocial components.

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Disabil Rehabil. 2007 May 8;:1-9 [Epub ahead of print]
Experience of physical activity in patients with fibromyalgia and chronic widespread pain.
Mannerkorpi K, Rivano-Fischer M, Ericsson A, Nordeman L, Gard G.
Department of Rheumatology and Inflammation Research, Sahlgrenska Academy, Göteborg University, Göteborg.

Purpose. Patients with fibromyalgia (FM) and chronic widespread pain (CWP) find physical activity troublesome. The purpose was to develop a questionnaire to investigate the experience of physical activity in FM and CWP populations. Method. A questionnaire was developed from a qualitative study. After that, a total of 204 patients with FM or CWP completed the questionnaire. A factor analysis was conducted and the internal consistency was investigated. The relationship between the factors and pain, health status (the Fibromyalgia Impact Questionnaire, FIQ), distress (the Hospital Anxiety and Distress scale, HAD) and leisure time physical activity (the Leisure Time Physical Activity Instrument, LTPAI) was investigated. Results. Five factors were identified: Physical Relaxation (PR), Well-being (WB), Activity Beliefs (AB), Activity-related Symptoms (AS) and Activity Habits (AH). Cronbach's alpha ranged from 0.57 to 0.86. The PR showed a correlation (rho 0.28, p < 0.01) with the FIQ Pain. The AS showed a correlation (rho 0.25, p < 0.01) with the FIQ total score, while the AH showed a correlation with the HAD Depression (0.26, p < 0.01) and with strenuous physical activity (LTPAI) (-0.32, p < 0.01). Conclusion. A new instrument was developed to study the experience of physical activity in persons with long-lasting pain. Five factors were identified using factor analysis, and three of them showed fair associations with FM symptoms, distress or physical activity.

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Eur Spine J. 2007 Apr 11; [Epub ahead of print]
Treatment of cervical myelopathy in patients with the fibromyalgia syndrome: outcomes and implications.
Heffez DS, Ross RE, Shade-Zeldow Y, Kostas K, Morrissey M, Elias DA, Shepard A.
Chicago Institute of Neurosurgery and Neuroresearch Medical Group, Chicago, USA.

Some patients with fibromyalgia also exhibit the neurological signs of cervical myelopathy. We sought to determine if treatment of cervical myelopathy in patients with fibromyalgia improves the symptoms of fibromyalgia and the patients' quality of life. A non-randomized, prospective, case control study comparing the outcome of surgical (n = 40) versus non-surgical (n = 31) treatment of cervical myelopathy in patients with fibromyalgia was conducted. Outcomes were compared using SF-36, screening test for somatization, HADS, MMPI-2 scale 1 (Hypochondriasis), and self reported severity of symptoms 1 year after treatment. There was no significant difference in initial clinical presentation or demographic characteristics between the patients treated by surgical decompression and those treated by non-surgical means. There was a striking and statistically significant improvement in all symptoms attributed to the fibromyalgia syndrome in the surgical patients but not in the non-surgical patients at 1 year following the treatment of cervical myelopathy (P </= 0.018-0.001, Chi-square or Fisher's exact test). At the 1 year follow-up, there was a statistically significant improvement in both physical and mental quality of life as measured by the SF-36 score for the surgical group as compared to the non-surgical group (Repeated Measures ANOVA P < 0.01). There was a statistically significant improvement in the scores from Scale 1 of the MMPI-2 and the screening test for somatization disorder, and the anxiety and depression scores exclusively in the surgical patients (Wilcoxon signed rank, P < 0.001). The surgical treatment of cervical myelopathy due to spinal cord or caudal brainstem compression in patients carrying the diagnosis of fibromyalgia can result in a significant improvement in a wide array of symptoms usually attributed to fibromyalgia with attendant measurable improvements in the quality of life. We recommend detailed neurological and neuroradiological evaluation of patients with fibromyalgia in order to exclude compressive cervical myelopathy, a potentially treatable condition.

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Arthritis Rheum. 2007 Apr;56(4):1336-44.
Gabapentin in the treatment of fibromyalgia: a randomized, double-blind, placebo-controlled, multicenter trial.
Arnold LM, Goldenberg DL, Stanford SB, Lalonde JK, Sandhu HS, Keck PE Jr, Welge JA, Bishop F, Stanford KE, Hess EV, Hudson JI.
University of Cincinnati College of Medicine, Cincinnati, Ohio 45219, and Newton-Wellesley Hospital, Newton, MA, USA. Lesley.Arnold@uc.edu

OBJECTIVE: To assess the efficacy and safety of gabapentin in patients with fibromyalgia. METHODS: A 12-week, randomized, double-blind study was designed to compare gabapentin (1,200-2,400 mg/day) (n=75 patients) with placebo (n=75 patients) for efficacy and safety in treating pain associated with fibromyalgia. The primary outcome measure was the Brief Pain Inventory (BPI) average pain severity score (range 0-10, where 0=no pain and 10=pain as bad as you can imagine). Response to treatment was defined as a reduction of >or=30% in this score. The primary analysis of efficacy for continuous variables was a longitudinal analysis of the intent-to-treat sample, with treatment-by-time interaction as the measure of effect. RESULTS: Gabapentin-treated patients displayed a significantly greater improvement in the BPI average pain severity score (P=0.015; estimated difference between groups at week 12=-0.92 [95% confidence interval -1.75, -0.71]). A significantly greater proportion of gabapentin-treated patients compared with placebo-treated patients achieved response at end point (51% versus 31%; P=0.014). Gabapentin compared with placebo also significantly improved the BPI average pain interference score, the Fibromyalgia Impact Questionnaire total score, the Clinical Global Impression of Severity, the Patient Global Impression of Improvement, the Medical Outcomes Study (MOS) Sleep Problems Index, and the MOS Short Form 36 vitality score, but not the mean tender point pain threshold or the Montgomery Asberg Depression Rating Scale. Gabapentin was generally well tolerated. CONCLUSION: Gabapentin (1,200-2,400 mg/day) is safe and efficacious for the treatment of pain and other symptoms associated with fibromyalgia.

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Pharmacopsychiatry. 2007 Mar;40(2):68-71.
Pregabalin augmentation of quetiapine therapy in the treatment of fibromyalgia: an open-label, prospective trial.
Calandre EP, Morillas-Arques P, Rodriguez-Lopez CM, Rico-Villademoros F, Hidalgo J.
1Instituto de Neurociencias, Universidad de Granada, Granada, Spain.

INTRODUCTION: Quetiapine has been shown to improve fibromyalgia symptoms, especially sleep disturbance, fatigue, morning stiffness, and mental well-being, but lacks an effect on pain. The purpose of this study was to evaluate if pregabalin, which has shown antialgic activity in fibromyalgia, added to quetiapine treatment additionally improved fibromyalgia symptomatology. METHODS: This was an open-label, 12-week study. Pregabalin was administered to 19 female fibromyalgia patients at a starting dose of 75 mg/day subsequently adjusted in according to the drug's efficacy and tolerability. Outcome measures included the Fibromyalgia Impact Questionnaire (FIQ), the Pittsburgh Sleep Quality Index, the Beck Depression Inventory, the State and Trait Anxiety Inventory, and the SF-12 Health Survey. RESULTS: Data analysis was done on the Intention-To-Treat sample which included 18 patients. Pregabalin significantly improved the pain and tiredness after awakening subscales of the FIQ as well as the physical component of the SF-12. Six patients withdrew from the study, 3 because of side effects. CONCLUSIONS: Our results suggest that the use of pregabalin can be a useful augmentation strategy in fibromyalgia patients partially responding to quetiapine.

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Curr Opin Rheumatol. 2007 Mar;19(2):168-73.
Pool exercise for individuals with fibromyalgia.
Gowans SE, deHueck A.
aAllied Health, University Health Network, University of Toronto, Toronto, Ontario, Canada. sue.gowans@uhn.on.ca

PURPOSE OF REVIEW: The benefits of general aerobic exercise for individuals with fibromyalgia have been established. Recently, there have been a number of randomized controlled trials that evaluate the benefits of pool exercise for fibromyalgia. This review will integrate the results of eight pool exercise studies that have been published in the last 7 years. RECENT FINDINGS: Pool exercise has been evaluated against sedentary control groups, land-based exercise and immersion in a warm, mineralized pool. Pool exercise has been shown to be as effective as land-based exercise and may have greater benefits with respect to mood and sleep duration. Based on follow-up studies, exercise-induced improvements in physical function, pain and mood may persist for up to 2 years. Pool exercise may be better tolerated as an initial means of exercise by individuals with arthritis in weight-bearing joints (because of water buoyancy) or by individuals who fear exercise will exacerbate their pain. SUMMARY: Pool exercise can be an effective intervention for individuals with fibromyalgia. Future studies should reassess subjects at multiple time points to determine the time course of exercise-induced improvements and further explore the effects of pool exercise on mood and sleep quality.

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Pain. 2007 Mar 30; [Epub ahead of print]
Coping with fibromialgia: Usefulness of the Chronic Pain Coping Inventory-42.
Garcia-Campayo J, Pascual A, Alda M, Gonzalez Ramirez MT.
Department of Psychiatry, Miguel Servet University Hospital, Avda Gomez Laguna 52, 4D, 50.009 Zaragoza, Spain; University of Zaragoza, Spain.

There are few studies on coping with fibromyalgia (FM). The aim of the present study was to assess the usefulness of a Spanish version of the Chronic Pain Coping Inventory-42 (CPCI-42) in patients with FM. A random sample (N=402) of patients with FM was obtained from the Fibromyalgia Association of Aragon, Spain. Patients were assessed with the CPCI-42, the Fibrofatigue Scale (FFS), the EuroQol-5D (EQ-5D), and the Hospital Anxiety and Depression Scale (HADS). The psychometric properties of the CPCI-42 were valid and factor analyses supported the eight-factor structure described in patients with chronic pain. Illness-focused coping strategies (i.e., guarding, resting, and asking for assistance) were strongly correlated with each other, positively correlated with disability and depression, and negatively correlated with quality of life, indicating construct validity. Seeking social support was weakly correlated with any other scale or outcome, confirming it belongs to a different group of coping strategies. The wellness-focused group of coping strategies was the most incoherent group. Task persistence correlated with illness-focused strategies and negative outcomes, indicating that it should be included in the illness-focused group. However, other wellness-focused strategies, including relaxation, exercise, and coping self-statements, were correlated with each other, negatively correlated with depression, and positively correlated with quality of life. Future research directions and clinical implications are discussed.

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Tidsskr Nor Laegeforen. 2007 Mar 1;127(5):604-8.
[Rehabilitation of chronic myofascial pain disorders]
[Article in Norwegian]
Wigers SH, Finset A.
Opptreningssenteret Jeloy Kurbad, Bratengaten 94, 1515 Moss. sigrid.wigers@c2i.net

BACKGROUND: Chronic musculoskeletal pain of diffuse origin affects many, and at a significant cost. Evidence-based guidelines for therapeutic interventions are presented and exemplified. MATERIAL AND METHODS: 200 patients with chronic myofascial pain and/or fibromyalgia who participated in a 4-week multidimensional rehabilitation programme, were included in the study. The programme included education and pain management in a cognitive setting, various forms of aerobic exercises, myofascial pain treatment, relaxation and medication as needed. The patients filled in questionnaires on arrival, at follow-up after six and 12-months and at discharge. They completed visual analogue scales (pain, fatigue, sleep problems, depression), the Nottingham Health Profile, the Fibromyalgia Impact Questionnaire, global subjective improvement, and during the follow-up period also the physical activity level, changes in quality of life and occupational workload. Work capacity, a tender point count and whether patients met the diagnostic criteria for fibromyalgia were assessed at baseline and at discharge. RESULTS: Significant improvements were seen in all variables throughout the follow-up period. 30% of the fibromyalgia patients no longer met the diagnostic criteria at discharge. There was a significant increase in quality of life over time. After one year, more patients had returned to work and fewer were off sick, but there was also an increased number on disability pensions. The majority did exercise training on a regular basis. INTERPRETATION: Our findings confirm the existing evidence-based guidelines by showing that multidimensional rehabilitation is an effective intervention for patients with widespread chronic pain. It is a challenge for health politicians to change today's common practice towards that described in evidence-based guidelines.

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Best Pract Res Clin Rheumatol. 2007 Feb;21(1):153-66.
Management of musculoskeletal pain.
Bergman S.
Spenshult Hospital, SE 313 92 Oskarstrom, Sweden.

Chronic musculoskeletal pain is a major public health problem affecting about one third of the adult population. Pain is often present without any specific findings in the musculoskeletal system and a strictly biomedical approach could be inadequate. A biopsychosocial model could give a better understanding of symptoms and new targets for management. Identification of risk factors for chronicity is important for prevention and early intervention. The cornerstones in management of chronic non-specific, and often widespread, musculoskeletal pain are non-pharmacological. Physical exercise and cognitive behavioral therapy, ideally in combination, are first line treatments in e.g. chronic low back pain and fibromyalgia. Analgesics are useful when there is a specific nociceptive component, but are often of limited usefulness in non-specific or chronic widespread pain (including fibromyalgia). Antidepressants and anticonvulsants could be of value in some patients but there is a need for more knowledge in order to give general recommendations.

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Pain Med. 2007 Jan-Feb;8(1):8-16.
Treatment outcomes after multidisciplinary pain rehabilitation with analgesic medication withdrawal for patients with fibromyalgia.
Hooten WM, Townsend CO, Sletten CD, Bruce BK, Rome JD.
Departments of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.

Objective. This study of patients with a diagnosis of fibromyalgia (FM) was conducted to test the hypothesis that immediate posttreatment measures of psychosocial functioning, health attributes, negative pain-related emotions, and depressive symptoms improve significantly during multidisciplinary pain rehabilitation while concurrently withdrawing analgesic medications. Design. Prospective case series. Setting. Multidisciplinary pain rehabilitation center at a tertiary referral medical center. Patients. In total, 159 consecutive patients with a diagnosis of FM admitted to the pain rehabilitation program from January 2002 to December 2003. Interventions. A 3-week outpatient multidisciplinary pain rehabilitation program based on a cognitive-behavioral model that incorporates analgesic medication withdrawal. Outcome Measures. Multidimensional Pain Inventory (MPI), Short Form-36 Health Status Questionnaire (SF-36), Coping Strategies Questionnaire-Catastrophizing subscale (CSQ-C), and the Center for Epidemiologic Studies-Depression scale (CES-D) were administered at admission and dismissal and the mean differences in scores were compared using paired t-tests. The number of patients using opioid analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, and muscle relaxants at admission and dismissal were compared using chi-squared analyses. Results. The difference in admission and dismissal scores from the MPI, SF-36, CSQ-C, and CES-D demonstrated a favorable response to treatment (P < 0.001). Compared with admission, the number of patients using opioids (P < 0.001), NSAIDs (P < 0.001), benzodiazepines (P < 0.001), and muscle relaxants (P < 0.01) at program dismissal was significantly reduced. Conclusion. The results of this study support the hypothesis that immediate posttreatment measures of physical and emotional functioning are favorable for patients with FM following multidisciplinary pain rehabilitation that incorporates withdrawal of analgesic medications.

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Appl Psychophysiol Biofeedback. 2007 Jan 12; [Epub ahead of print]
A Pilot Study of the Efficacy of Heart Rate Variability (HRV) Biofeedback in Patients with Fibromyalgia.
Hassett AL, Radvanski DC, Vaschillo EG, Vaschillo B, Sigal LH, Karavidas MK, Buyske S, Lehrer PM.
Department of Medicine, Division of Rheumatology, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School (UMDNJ-RWJMS), P.O. Box 19, MEB-484, New Brunswick, NJ, USA, a.hassett@umdnj.edu.

Fibromyalgia (FM) is a non-inflammatory rheumatologic disorder characterized by musculoskeletal pain, fatigue, depression, cognitive dysfunction and sleep disturbance. Research suggests that autonomic dysfunction may account for some of the symptomatology of FM. An open label trial of biofeedback training was conducted to manipulate suboptimal heart rate variability (HRV), a key marker of autonomic dysfunction. Methods: Twelve women ages 18-60 with FM completed 10 weekly sessions of HRV biofeedback. They were taught to breathe at their resonant frequency (RF) and asked to practice twice daily. At sessions 1, 10 and 3-month follow-up, physiological and questionnaire data were collected. Results: There were clinically significant decreases in depression and pain and improvement in functioning from Session 1 to a 3-month follow-up. For depression, the improvement occurred by Session 10. HRV and blood pressure variability (BPV) increased during biofeedback tasks. HRV increased from Sessions 1-10, while BPV decreased from Session 1 to the 3 month follow-up. Conclusions: These data suggest that HRV biofeedback may be a useful treatment for FM, perhaps mediated by autonomic changes. While HRV effects were immediate, blood pressure, baroreflex, and therapeutic effects were delayed. This is consistent with data on the relationship among stress, HPA axis activity, and brain function.

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Clin Rheumatol. 2007 Jan 11; [Epub ahead of print]
Efficacy of Farabloc as an analgesic in primary fibromyalgia.
Bach GL, Clement DB.
Department of Medicine/Rheumatology, University of Munich, Munich, Germany.

The goal of our study was to determine the efficacy of Farabloc, an electromagnetic shielding fabric compared to placebo fabric when worn as a nightgown, as an analgesic in patients hospitalized with fibromyalgia. In a rheumatologic and rehabilitation hospital, we performed a phase 1, single-blind study of patients using Farabloc (F) or placebo (P) gowns for 8 h per night during the 20-day hospitalization and a phase 2, single-blind crossover study of patients using both F and P gowns randomly and alternatively switching after 10 of 21 days hospitalization (phase 1: 42 F, mean age 49.02 years, 35 female, 7 male; 84 P, mean age 48.08 years, 72 female, 12 males; phase 2: 25 F/P, P/F, or P/P, mean age 44.0 years, 24 female, 1 male). The study involved randomly selected and blinded use of hospital gown 8 h per night of either F or P fabric. The main outcome measures were changes from admission or midpoint to discharge in quantity of pain (QN), quality of pain (QL), and paracetamol use (PU). In phase 1, all three variables significantly favored F over P when using paired t test, two sample t test, Mann-Whitney, and analysis of covariance tests. QN was reduced (F = -2.03 -/+ 0.99*, P = 0.59 -/+ 0.71). QL was reduced (F = -10.64 -/+ 5.69*, P = -2.54 -/+ 3.40). PU was reduced (F = 10.69 -/+ 6.68*, P = 26.12 -/+ 9.37). In phase 2, comparing midpoint to discharge levels in the three variables again favored P/F over F/P and P/P (>0.001): QN (P/F +16.00 -/+ 8.35* F/P -13.27 -/+ 11.40), QL (P/F +8.71 -/+ 4.75* F/P -6.55 -/+ 5.59), and PU (F -9.29 -/+ 4.39* P -18.00 -/+ 5.27) (*p = <0.001). Patients with fibromyalgia had less pain after sleeping in a gown made of Farabloc than with a placebo fabric. This suggests that Farabloc, an electromagnetic shielding fabric, has analgesic properties in fibromyalgia. Reduced pain observation is consistent with previous studies in phantom limb pain and delayed onset muscle pain. Limitations of this study include single blind design, small sample size, and in phase 2, a lack of washout period and a F/F group.

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Rheumatology (Oxford). 2006 Dec 19; [Epub ahead of print]
Acupuncture for fibromyalgia--a systematic review of randomized clinical trials.
Mayhew E, Ernst E.
Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, 25 Victoria Park Road, Exeter EX2 4NT, UK.

Objective. Acupuncture is often used and frequently advocated for the symptomatic treatment of fibromyalgia. A systematic review has previously demonstrated encouraging findings. As it is now outdated, we wanted to update it. Methods. We searched seven electronic databases for relevant randomized clinical trials (RCTs). The data were extracted and validated independently by both authors. As no meta-analysis seemed possible, the results were evaluated in narrative form. Results. Five RCTs met our inclusion criteria, all of which used acupuncture as an adjunct to conventional treatments. Their methodological quality was mixed and frequently low. Three RCTs suggested positive but mostly short-lived effects and two yielded negative results. There was no significant difference between the quality of the negative and the positive RCTs. All positive RCTs used electro-acupunture. Conclusion. The notion that acupuncture is an effective symptomatic treatment for fibromyaligia is not supported by the results from rigorous clinical trials. On the basis of this evidence, acupuncture cannot be recommended for fibromyalgia.

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Curr Psychiatry Rep. 2006 Dec;8(6):464-9.
Pharmacologic treatment of fibromyalgia.
Baker K, Barkhuizen A.
Arthritis & Rheumatic Diseases, Oregon Health & Science University, Portland, OR 97239, USA. bakerk@ohsu.edu

Fibromyalgia is a syndrome of widespread pain, non-restorative sleep, disturbed mood, and fatigue. Optimal treatment involves a multidisciplinary approach with a team of health care providers using pharmacologic and nonpharmacologic treatment. Because of the heterogeneity of the illness, management should be individualized for the patient. Pharmacologic treatment should address issues of pain control, sleep disturbance, fatigue, and any underlying coexisting mood disorder. Nonpharmacologic treatment should include patient education, a regular exercise and stretching program, and cognitive behavioral therapy. All of these are essential to improving functional capacity and quality of life. This review provides general guidelines in initiating a successful pharmacologic treatment program for patients with fibromyalgia.

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Arthritis Rheum. 2006 Dec;54(12):3988-98.
A randomized, sham-controlled, proof of principle study of transcranial direct current stimulation for the treatment of pain in fibromyalgia.
Fregni F, Gimenes R, Valle AC, Ferreira MJ, Rocha RR, Natalle L, Bravo R, Rigonatti SP, Freedman SD, Nitsche MA, Pascual-Leone A, Boggio PS.
Harvard Medical School, Boston, Massachusetts 02215, USA. ffregni@bidmc.harvard.edu

OBJECTIVE: Recent evidence suggests that fibromyalgia is a disorder characterized by dysfunctional brain activity. Because transcranial direct current stimulation (tDCS) can modulate brain activity noninvasively and can decrease pain in patients with refractory central pain, we hypothesized that tDCS treatment would result in pain relief in patients with fibromyalgia. METHODS: Thirty-two patients were randomized to receive sham stimulation or real tDCS with the anode centered over the primary motor cortex (M1) or the dorsolateral prefrontal cortex (DLPFC) (2 mA for 20 minutes on 5 consecutive days). A blinded evaluator rated the patient's pain, using the visual analog scale for pain, the clinician's global impression, the patient's global assessment, and the number of tender points. Other symptoms of fibromyalgia were evaluated using the Fibromyalgia Impact Questionnaire and the Short Form 36 Health Survey. Safety was assessed with a battery of neuropsychological tests. To assess potential confounders, we measured mood and anxiety changes throughout the trial. RESULTS: Anodal tDCS of the primary motor cortex induced significantly greater pain improvement compared with sham stimulation and stimulation of the DLPFC (P < 0.0001). Although this effect decreased after treatment ended, it was still significant after 3 weeks of followup (P = 0.004). A small positive impact on quality of life was observed among patients who received anodal M1 stimulation. This treatment was associated with a few mild adverse events, but the frequency of these events in the active-treatment groups was similar to that in the sham group. Cognitive changes were similar in all 3 treatment groups. CONCLUSION: Our findings provide initial evidence of a beneficial effect of tDCS in fibromyalgia, thus encouraging further trials.
 

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