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Important Note: The following information is provided for your education. It should not be relied upon for personal diagnosis or treatment. If you believe that a particular therapy applies to you or someone you care about, be sure to consult a doctor before trying it.
   

Fibromyalgia Research: 2002-2006
     
Curr Pain Headache Rep. 2006 Oct;10(5):333-8.
Physical Therapy and OtherNonpharmacologic Approachesto Fibromyalgia Management.
Blehm R.
Portland VA Medical Center, 3710 SW US Vets Hospital Road, P3-PM&RS, Portland, OR 97207, USA.

Fibromyalgia is a vague and changing syndrome that comprises many symptoms. Due to the confounding nature of fibromyalgia syndrome, there has been much debate about which interventions and therapies should be considered as viable treatment options. Opinions continue to shift in publication and research circles, with little documentation to show good, long-term outcomes. Several studies have shown promise, with initial improvement in symptoms, but in many cases, these improvements were not lasting or the patients were then unable to continue/replicate the program on their own. In this article, some of the more recently published findings regarding the efficacy of exercise are explored, specifically physical therapy and other nonpharmacologic interventions, for managing fibromyalgia syndrome.

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Scand J Caring Sci. 2006 Sep;20(3):315-22.
Long-term follow up of a physical therapy programme for patients with fibromyalgia syndrome.
Havermark AM, Langius-Eklof A.
Halsopoolens Rehabklinik, Stockholm, Sweden.

The purpose of this study was to evaluate, in a long-term perspective, the impact of a physical therapy-based educational programme on patients with fibromyalgia syndrome (FMS). The programme includes information about the syndrome, information about pain and muscle physiology, training in warm water, stretching, body awareness therapy and relaxation in groups of 15 patients twice weekly, 2 hours during 10 weeks. A total of 240 patients with FMS participated in the study before and immediately after the programme and at a follow up with a mean of 35 months after the programme. Health status as measured with the Fibromyalgia Impact Questionnaire was answered by the patients at all three measurement points. Questionnaires concerning self-care, self-motivation and sense of coherence (SOC) were distributed at the follow up. The results showed a significant improvement on several symptoms when comparing before and after the programme, and at the time of follow up the patients' rated well-being was still improved. The results also showed that the patients' pretreatment perception of symptoms, well-being and SOC are predictors to the perception of general health at the follow up of a physical therapy programme. The conclusion is that a physical therapy programme for patients with FMS may have a positive impact on patients' general well-being but not on other symptoms.

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Ann Rheum Dis. 2006 Aug 17; [Epub ahead of print]
A Review of cognitive behaviour therapies and exercise programmes for fibromyalgia patients: State of the art and future directions.
Koulil SV, Effting M, Kraaimaat FW, Lankveld WV, Helmond TV, Cats H, van Riel P, de Jong A, Haverman J, Evers A.
Radboud University Nijmegen Medical Centre, Netherlands.

This review provides an overview of the effects of non- pharmacological treatments for patients with fibromyalgia (FM), including cognitive behaviour therapy, exercise training programmes or a combination of the two. After summarizing and discussing preliminary evidence of the rationale of non-pharmacological treatment in FM, we will review and examine controlled trials for possible predictors of treatment success such as patient and treatment characteristics. Despite support for their suitability in FM, the effects of non- pharmacological interventions are limited and positive outcomes largely disappear in the long term. However, within the various FM populations treatment outcomes showed considerable individual variations. In particular, specific subgroups of patients characterized by relatively high levels of psychological distress seem to benefit most from non-pharmacological interventions. Preliminary evidence of retrospective treatment analyses suggest that the efficacy may be enhanced by offering tailored treatment approaches in an early stage to patients who are at risk of developing chronic physical and psychological impairments.

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Nat Clin Pract Rheumatol. 2006 Aug;2(8):416-24.
Cognitive behavioral therapy for fibromyalgia.
Bennett R, Nelson D.
Oregon Health & Science University, Portland, OR 97239, USA. bennetrob1@comcast.net

Cognitive behavioral therapy (CBT) techniques offer short-term, goal-oriented psychotherapy. In this respect, it differs from classical psychoanalysis in emphasizing changes in thought patterns and behaviors rather than providing 'deep insight'. Importantly, the beneficial effects of CBT can be achieved in 10-20 sessions, compared with the many years required for classical psychoanalysis. Although CBT is often done on a one-to-one basis, it also lends itself to a group therapeutic setting. CBT was initially used in the treatment of mood disorders, but its use has subsequently been expanded to include various other medical conditions, including chronic pain states. Over the past 18 years, several chronic pain treatment programs have used CBT techniques in the management of fibromyalgia. In this review, the results from 13 programs using CBT, alone or in combination with other treatment modalities, are analyzed. In most studies, CBT provided worthwhile improvements in pain-related behavior, self-efficacy, coping strategies and overall physical function. Sustained improvements in pain were most evident when individualized CBT was used to treat patients with juvenile fibromyalgia. The current data indicate that CBT, as a single treatment modality, does not offer any distinct advantage over well-planned group programs of education or exercise, or both. Its role in the management of fibromyalgia patients needs further research.

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Eur J Pain. 2006 Aug 2; [Epub ahead of print]
Effect of hypnotic suggestion on fibromyalgic pain: Comparison between hypnosis and relaxation.
Castel A, Perez M, Sala J, Padrol A, Rull M.
Pain Clinic and UFISS Palliative Care. Hospital Universitari de Tarragona Joan XXIII and Gestio i Prestacio de Serveis de Salut, C/Doctor Mallafre Guasch 4, 43007 Tarragona, Spain.

The main aims of this experimental study are: (1) to compare the relative effects of analgesia suggestions and relaxation suggestions on clinical pain, and (2) to compare the relative effect of relaxation suggestions when they are presented as "hypnosis" and as "relaxation training". Forty-five patients with fibromyalgia were randomly assigned to one of the following experimental conditions: (a) hypnosis with relaxation suggestions; (b) hypnosis with analgesia suggestions; (c) relaxation. Before and after the experimental session, the pain intensity was measured using a visual analogue scale (VAS) and the sensory and affective dimensions were measured with the McGill Pain Questionnaire. The results showed: (1) that hypnosis followed by analgesia suggestions has a greater effect on the intensity of pain and on the sensory dimension of pain than hypnosis followed by relaxation suggestions; (2) that the effect of hypnosis followed by relaxation suggestions is not greater than relaxation. We discuss the implications of the study on our understanding of the importance of suggestions used in hypnosis and of the differences and similarities between hypnotic relaxation and relaxation training.

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Prog Neuropsychopharmacol Biol Psychiatry. 2006 Aug 2; [Epub ahead of print]
An open-label study of quetiapine in the treatment of fibromyalgia.
Hidalgo J, Rico-Villademoros F, Calandre EP.
Instituto de Neurociencias, Universidad de Granada, Avda de Madrid 11, 18012 Granada, Spain.

The aim of this exploratory study was to systematically assess the potential effectiveness and tolerability of quetiapine, an atypical antipsychotic, for the treatment of patients with fibromyalgia. This was a unicentre, open-label study conducted in thirty-five outpatients, 18 years or older, who met the ACR criteria for fibromyalgia and who had not satisfactorily responded to their previous fibromyalgia treatment. Quetiapine, flexibly dosed (25-100 mg/day), was added to their original treatment regimen for 12 weeks. The primary outcome measure was the mean change from baseline to endpoint in the Fibromyalgia Impact Questionnaire (FIQ) total score. Secondary efficacy measures included mean changes from baseline to endpoint in the scores of the Clinical Global Impression (CGI) of Severity scale, Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), 12-Item Short Form Health Survey (SF-12), and individual items of the FIQ. Thirty (85.7%) patients (mean age 47+/-7.9, 93.3% females) had a postbaseline evaluation and constituted the intent-to-treat efficacy sample. Mean FIQ total score decreased significantly by 10.2 points from a baseline of 63.2 to 53.0 at study endpoint (p<0.001). A statistically significant reduction was observed in FIQ stiffness and FIQ fatigue subscores but not in FIQ pain subscore. Large effect sizes were observed for the FIQ total (1.04), CGI-severity (1.00) and PSQI (1.07), while moderate effect sizes (i.e.>/=0.50) were encountered in the FIQ fatigue, FIQ stiffness and SF-12 mental component summary. Quetiapine was safely administered and well tolerated. Despite the lack of effect on pain, the significant and relevant improvement in overall efficacy measures and quality of life suggests that quetiapine may be a valuable drug for treatment of patients with fibromyalgia that should be further tested in double-blind, placebo-controlled trials.

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Nat Clin Pract Rheumatol. 2006 Jul;2(7):364-72.
Therapy Insight: fibromyalgia--a different type of pain needing a different type of treatment.
Dadabhoy D, Clauw DJ.
Chronic Pain and Fatigue Research Center, The University of Michigan, 24 Frank Lloyd Wright Drive, Box 385, Ann Arbor, MI 48106, USA. dadabhoy@umich.edu

In the past decade, we have made tremendous progress in our understanding of fibromyalgia, which is now recognized as one of many 'central' pain syndromes that are common in the general population. Specific genes that might confer an increased risk of developing fibromyalgia syndrome are beginning to be identified and the environment (in this case exposure to stressors) might also have a significant effect on triggering the expression of symptoms. After developing the syndrome, the hallmark aberration noted in individuals with fibromyalgia is augmented central pain processing. Insights from research suggest that fibromyalgia and related syndromes require a multimodal management program that is different from the standard used to treat peripheral pain (i.e. acute or inflammatory pain). Instead of the nonsteroidal anti-inflammatory drugs and opioids commonly used in the treatment of peripheral pain, the recommended drugs for central pain conditions are neuroactive compounds that downregulate sensory processing. The most efficacious compounds that are currently available include the tricyclic drugs and mixed reuptake inhibitors that simultaneously increase serotonin and norepinephrine concentrations in the central nervous system. Other compounds that increase levels of single monoamines (serotonin, norepinephrine or dopamine), and anticonvulsants also show efficacy in this condition. In addition to these pharmacologic therapies, which are useful in improving symptoms, nonpharmacologic therapies such as exercise and cognitive behavioral therapy are useful treatments for restoring function to an individual with fibromyalgia.

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Curr Opin Investig Drugs. 2006 Jul;7(7):637-42.
Clinical potential of milnacipran, a serotonin and norepinephrine reuptake inhibitor, in pain.
Leo RJ, Brooks VL.
Department of Psychiatry, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Erie County Medical Center, NY 14215, USA. Rleomd@aol.com

Milnacipran is a serotonin (5-HT) and norepinephrine (NE) reuptake inhibitor currently available for use as an antidepressant in several countries. Phase III clinical trials are currently underway to assess its potential role in the treatment of fibromyalgia syndrome, and in pursuit of US Food and Drug Administration approval for this indication. Evidence has accumulated suggesting that in animal models, milnacipran may exert pain-mitigating influences involving NE- and 5-HT-related processes at supraspinal, spinal and peripheral levels of pain transmission. Preliminary evidence suggests that milnacipran may be useful in mitigating pain and fatigue associated with fibromyalgia. However, its role in addressing comorbidities associated with fibromyalgia, including visceral pain and migraine, has yet to be investigated.

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Altern Ther Health Med. 2006 Mar-Apr;12(2):34-41.
Effectiveness of acupuncture in the treatment of fibromyalgia.
Singh BB, Wu WS, Hwang SH, Khorsan R, Der-Martirosian C, Vinjamury SP, Wang CN, Lin SY.
Southern California University of Health Sciences, Whittier, USA.

CONTEXT: Fibromyalgia syndrome (FMS) is a prevalent musculoskeletal disorder associated with pain, mood state alteration, and disability. A structured and effective treatment plan for palliative care has not been established. The genesis of FMS is not clear. FMS occurs primarily in adult women. DESIGN: Using a quasi-experimental clinical design and following the criteria of the American College of Rheumatology (ACR), for FMS, 21 participants completed the study. The mean age was 53.6 years. The data were collected at baseline and at 1 and 2 months. Acupuncture treatments included 17 points for FMS symptoms, and 8 outcome measures were collected. RESULTS: The Fibromyalgia Impact Questionnaire (FIQ) showed significant differences at 1 and 2 months. For the SF-12, 3 subscales showed significant differences between baseline and 2 months. Four of 6 items were significantly changed. The mean number of general health symptoms was significantly decreased by 2 months. For the Catastrophe Index, significant differences were found for baseline vs 2 months. Pain threshold scores were significantly different at end of treatment for 5 bilateral tender points. There was significant improvement in Beck Depression items for both 1- and 2-month periods. In a multivariate regression model, 5 covariates were included--age, number of weeks in treatment, number of doctors treating, number of general symptoms, and baseline FIQ score. The results indicated significant age effect. This analysis showed that the higher the FIQ score, the more positive the change experienced by study participants. Number of weeks in treatment, number of doctors who treated, and total number of general health symptoms did not have a significant effect on outcomes. CONCLUSIONS: Significant improvement was experienced by participants at 8 weeks of treatment. Acupuncture treatment as delivered was effective at reducing FMS symptoms in this outcome study.

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CNS Spectr. 2006 Mar;11(3):212-22.
Antidepressants and cognitive-behavioral therapy for symptom syndromes.
Jackson JL, O'Malley PG, Kroenke K.
Department of Medicine, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA. jejackson@usuhs.mil

Somatic symptoms are common in primary care and clinicians often prescribe antidepressants as adjunctive therapy. There are many possible reasons why this may work, including treating comorbid depression or anxiety, inhibition of ascending pain pathways, inhibition of prefrontal cortical areas that are responsible for "attention" to noxious stimuli, and the direct effects of the medications on the syndrome. There are good theoretical reasons why antidepressants with balanced norepinephrine and serotonin effects may be more effective than those that act predominantly on one pathway, though head-to-head comparisons are lacking. For the 11 painful syndromes review in this article, cognitive-behavioral therapy is most consistently demonstrated to be effective, with various antidepressants having more or less randomized controlled data supporting or refuting effectiveness. This article reviews the randomized controlled trial data for the use of antidepressant and cognitive-behavior therapy for 11 somatic syndromes: irritable bowel syndrome, chronic back pain, headache, fibromyalgia, chronic fatigue syndrome, tinnitus, menopausal symptoms, chronic facial pain, noncardiac chest pain, interstitial cystitis, and chronic pelvic pain. For some syndromes, the data for or against treatment effectiveness is relatively robust, for many, however, the data, one way or the other is scanty.

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Sleep Med. 2006 Mar 22; [Epub ahead of print]
Hydrotherapy and conventional physiotherapy improve total sleep time and quality of life of fibromyalgia patients: Randomized
clinical trial.

Vitorino DF, Carvalho LB, Prado GF.
UNILAVRAS, Lavras, MG, Brazil.

OBJECTIVE: To compare hydrotherapy (HT) and conventional physiotherapy (CP) in the treatment of fibromyalgia (FM), regarding quality of life (QOL), total sleep time (TST), and total nap time (TNT). METHODS: Fifty outpatients, all female, 30-60 years old, diagnosed with FM, were randomly assigned to two groups to carry out 3 weeks of treatment with HT or CP. In the beginning and in the end of treatment, patients were evaluated with the SF-36 questionnaire to measure QOL and the sleep diary for TST and TNT. Data analyses were blind. RESULTS: All 24 HT patients increased 1h in TST compared to 19 CP patients. TNT decreased in the HT group. QOL improved for the two groups in all domains when pre- and post-intervention were compared, but there was no difference between groups. CONCLUSION: HT is more effective than CP to improve TST and to decrease TNT in FM patients.

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Int J Immunopathol Pharmacol. 2006 Jan-Mar;19(1):5-10.
Fibromyalgia - new concepts of pathogenesis and treatment.
Lucas HJ, Brauch CM, Settas L, Theoharides TC.
Special Clinic for FMS and CFS, Trier, Germany.

Fibromyalgia (FMS) is a debilitating disorder characterized by chronic diffuse muscle pain, fatigue, sleep disturbance, depression and skin sensitivity. There are no genetic or biochemical markers and patients often present with other comorbid diseases, such as migraines, interstitial cystitis and irritable bowel syndrome. Diagnosis includes the presence of 11/18 trigger points, but many patients with early symptoms might not fit this definition. Pathogenesis is still unknown, but there has been evidence of increased corticotropin-releasing hormone (CRH) and substance P (SP) in the CSF of FMS patients, as well as increased SP, IL-6 and IL-8 in their serum. Increased numbers of activated mast cells were also noted in skin biopsies. The hypothesis is put forward that FMS is a neuro-immunoendocrine disorder where increased release of CRH and SP from neurons in specific muscle sites triggers local mast cells to release proinflammatory and neurosensitizing molecules. There is no curative treatment although low doses of tricyclic antidepressants and the serotonin-3 receptor antagonist tropisetron, are helpful. Recent nutraceutical formulations containing the natural anti-inflammatory and mast cell inhibitory flavonoid quercetin hold promise since they can be used together with other treatment modalities.

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Rev Med Liege. 2006 Feb;61(2):109-16.
[Value of aerobic rehabilitation in the management of fibromyalgia]
[Article in French]
Maquet D, Croisier JL, Demoulin C, Faymonville M, Crielaard JM.
Medecine de l'Appareil locomoteur, Departement de Medecine Physique et de Kinesitherapie-Readaptation, ULg, CHU Sart Tilman, Liege. D.Maquet@ulg.ac.be

This study assesses the influence of a muscular aerobic revalidation program on the management of the fibromyalgia syndrome. After 3 months, benefits consisting of increased muscle performances associated with a reduction of pain and an improvement of quality of life were documented. This study confirms the value of aerobic muscle exercise in fibromyalgia patients.

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Arthritis Rheum. 2006 Feb 15;55(1):57-65.
A randomized controlled trial of deep water running: clinical effectiveness of aquatic exercise to treat fibromyalgia.
Assis MR, Silva LE, Alves AM, Pessanha AP, Valim V, Feldman D, Neto TL, Natour J.
Division of Rheumatology, Sao Paulo Federal University, Rua Botucatu 740, 04023-900 Sao Paulo, Brazil.

OBJECTIVE: To compare the clinical effectiveness of aerobic exercise in the water with walking/jogging for women with fibromyalgia (FM). METHODS: Sixty sedentary women with FM, ages 18-60 years, were randomly assigned to either deep water running (DWR) or land-based exercises (LBE). Patients were trained for 15 weeks at their anaerobic threshold. Visual analog scale of pain, Fibromyalgia Impact Questionnaire (FIQ), Beck Depression Inventory, Short Form 36 Health Survey (SF-36), and a patient's global assessment of response to therapy (PGART) were measured at baseline, week 8, and week 15. Statistical analysis included all patients. RESULTS: Four patients dropped out from each group. Both groups improved significantly at week 15 compared with baseline, with an average 36% reduction in pain intensity. For PGART, 40% of the DWR group and 30% of the LBE group answered "much better" at posttreatment. FIQ total score and FIQ depression improvements in the DWR group were faster (week 8) than the LBE group and kept improving (week 15; P < 0.05). Only the DWR group showed improvements in SF-36 role emotional (P = 0.006). No significant between-group differences were observed for peak oxygen uptake and other outcomes. CONCLUSION: DWR is a safe exercise that has been shown to be as effective as LBE regarding pain. However, it has been shown to bring more advantages related to emotional aspects. Aerobic gain was similar for both groups, regardless of symptom improvement. Therefore, DWR could be studied as an exercise option for patients with FM who have problems adapting to LBE or lower limbs limitations.

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Arthritis Rheum. 2006 Feb 15;55(1):66-73.
Exercise in waist-high warm water decreases pain and improves health-related quality of life and strength in the lower extremities in women with fibromyalgia.
Gusi N, Tomas-Carus P, Hakkinen A, Hakkinen K, Ortega-Alonso A.
Fitness and Lifequality Laboratory, Sports Sciences Faculty, University of Extremadura, Avenue Universidad s/n, 10071 Caceres, Spain. ngusi@unex.es

OBJECTIVE: To evaluate the short- and long-term efficacy of exercise therapy in a warm, waist-high pool in women with fibromyalgia. METHODS: Thirty-four women (mean +/- SD tender points 17 +/- 1) were randomly assigned to either an exercise group (n = 17) to perform 3 weekly sessions of training including aerobic, proprioceptive, and strengthening exercises during 12 weeks, or to a control group (n = 17). Maximal unilateral isokinetic strength was measured in the knee extensors and flexors in concentric and eccentric actions at 60 degrees /second and 210 degrees /second, and in the shoulder abductors and adductors in concentric contractions. Health-related quality of life (HRQOL) was assessed using the EQ-5D questionnaire; pain was assessed on a visual analog scale. All were measured at baseline, posttreatment, and after 6 months. RESULTS: The strength of the knee extensors in concentric actions increased by 20% in both limbs after the training period, and these improvements were maintained after the de-training period in the exercise group. The strength of other muscle actions measured did not change. HRQOL improved by 93% (P = 0.007) and pain was reduced by 29% (P = 0.012) in the exercise group during the training, but pain returned close to the pretraining level during the subsequent de-training. However, there were no changes in the control group during the entire period. CONCLUSION: The therapy relieved pain and improved HRQOL and muscle strength in the lower limbs at low velocity in patients with initial low muscle strength and high number of tender points. Most of these improvements were maintained long term.

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Minerva Med. 2005 Dec;96(6):417-23.
[Fibromyalgic syndrome: new perspectives in rehabilitation and management. A review]
[Article in Italian]
Melillo N, Corrado A, Quarta L, D'Onofrio F, Trotta A, Cantatore FP.
Clinica Reumatologica Mario Carrozzo, Universita degli Studi di Foggia, Foggia.

Fibromyalgia is a chronic syndrome, characterized by widespread body pain and pain at specific tender points, whose etiology and pathogenesis is still unknown. Patient can also exhibit a range of other symptoms including irritable bowel syndrome, chest pain, anxiety, fatigue, sleep disturbance, headache. The prevalence of fibromyalgia ranges from 1-3% in the general population, and the condition is more common among female than males. Contrary to the situation a few years ago, the most widely accepted hypothesis now evoke central nervous system mechanisms, whose local functions could influence also periferical microvascular activity at tender points. There are many findings supporting the hypothesis of different endogenic and exogenic factors that lead to chronic local hypoxia in muscle tissue. Currently, therapy is polipragmatic and is aimed at reducing the pain. A range of medical treatment had been used to treat fibromyalgia. Pharmacological therapy aims to enhance the pain threshold and to support sleep. Nonpharmaceutical treatment modalities, such as exercise, massage, idrotherapy can be helpful. Future studies should investigate the possible benefits of new strategies that may combine the effects of hot pool water, stretching exercises, massage and relaxation benefits of balneotherapy.

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J Psychosom Res. 2005 Nov;59(5):275-82.
A pilot study of the effects of behavioral weight loss treatment on fibromyalgia symptoms.
Shapiro JR, Anderson DA, Danoff-Burg S.
Department of Psychology, University at Albany, State University of New York, Albany, NY, USA.

OBJECTIVE: Previous studies have found a relation between weight loss and pain severity in various chronic pain populations. However, there has been little research examining the relation between body mass index (BMI) and fibromyalgia syndrome (FMS). The purpose of this pilot study was to investigate the relationship between BMI and FMS symptoms and to determine if FMS symptoms would decrease following weight loss. METHODS: Overweight and obese women participated in a 20-week behavioral weight loss treatment. RESULTS: Participants, on average, lost 9.2 lbs (4.4% of their initial weight), and there were significant pre-postimprovements on several outcome measures. Although weight was not significantly related to pain at baseline, weight loss significantly predicted a reduction in FMS, pain interference, body satisfaction, and quality of life (QOL). CONCLUSION: Findings suggest that behavioral weight loss treatment could be included in the treatment for overweight/obese women with FMS.

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Ann Pharmacother. 2005 Nov;39(11):1812-6. Epub 2005 Oct 11.
Open trial of pindolol in the treatment of fibromyalgia.
Wood PB, Kablinger AS, Caldito GS.
Department of Family Medicine, Louisiana State University Health Science Center-Shreveport, LA.

BACKGROUND: Evidence suggests that fibromyalgia is related to both chronic sympathetic hyperactivity and decreased levels of serotonin. OBJECTIVE: To examine the efficacy of pindolol, a mixed serotonin (5-HT)(1A) presynaptic autoreceptor/beta-adrenergic receptor antagonist, in the treatment of fibromyalgia. METHODS: An open trial was conducted using 20 female patients who met the American College of Rheumatology criteria for fibromyalgia. Treatment was initiated with pindolol 7.5 mg/day and titrated to a maximum dose of 15 mg/day for a total of 90 days. Primary outcome measures were tender point analysis and the Fibromyalgia Impact Questionnaire (FIQ). Anxiety and depression were measured with the Hamilton Depression and Anxiety Scales and Beck Depression Inventory. RESULTS: There was significant improvement in primary outcome measures, including Tender Point Count (mean +/- SD, 16.3 +/- 2.2 vs 12.3 +/- 5.0; F = 8.9; p < 0.001), Tender Point Score (24.4 +/- 5.7 vs 17.5 +/- 9.4; F = 7.8; p < 0.001), and FIQ (45.3 +/- 10.8 vs 35.0 +/- 15.0; F = 5.6; p < 0.005). The depression and anxiety scores did not change significantly among women who completed the study, while the impact on cardiovascular parameters was clinically insignificant. CONCLUSIONS: While the current results are encouraging, further studies are needed to determine whether pindolol might be effective in the treatment of fibromyalgia. Limitations of this study include small group size and lack of placebo control.

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J Rheumatol. 2005 Oct;32(10):1975-85.
Efficacy of milnacipran in patients with fibromyalgia.
Gendreau RM, Thorn MD, Gendreau JF, Kranzler JD, Ribeiro S, Gracely RH, Williams DA, Mease PJ, McLean SA, Clauw DJ.
Cypress Biosciences, 4350 Executive Drive, San Diego, CA 92121, USA. mgendreau1@cypressbio.com

OBJECTIVE: Fibromyalgia (FM) is a common musculoskeletal condition characterized by widespread pain, tenderness, and a variety of other somatic symptoms. Current treatments are modestly effective. Arguably, the best studied and most effective compounds are tricyclic antidepressants (TCA). Milnacipran, a nontricyclic compound that inhibits the reuptake of both serotonin and norepinephrine, may provide many of the beneficial effects of TCA with a superior side effect profile. METHODS: One hundred twenty-five patients with FM were randomly assigned in a 3:3:2 ratio to receive milnacipran twice daily, milnacipran once daily, or placebo for 3 months in a double-blind dose-escalation trial; 92% of twice-daily and 81% of once-daily participants achieved dose escalation to the target milnacipran dose of 200 mg. RESULTS: The primary endpoint was reduction of pain. Both the once- and twice-daily groups showed statistically significant improvements in pain, as well as improvements in global well being, fatigue, and other domains. Response rates for patients receiving milnacipran were equal in patients with and without comorbid depression, but placebo response rates were considerably higher in depressed patients, leading to significantly greater overall efficacy in the nondepressed group. CONCLUSION: In this Phase II study, milnacipran led to statistically significant improvements in pain and other symptoms of FM. The effect sizes were equal to those previously found with TCA, and the drug was generally well tolerated.

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Curr Pain Headache Rep. 2005 Oct;9(5):301-6.
Pharmacologic treatment of fibromyalgia.
Baker K, Barkhuizen A.
Arthritis & Rheumatic Diseases, Oregon Health & Science University, OP-09, Portland, OR 97239, USA. bakerk@ohsu.edu

Fibromyalgia is a syndrome of widespread pain, nonrestorative 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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Psychosomatics. 2005 Sep-Oct;46(5):379-84.
Evaluation of reboxetine, a noradrenergic antidepressant, for the treatment of fibromyalgia and chronic low back pain.
Krell HV, Leuchter AF, Cook IA, Abrams M.
Laboratory of Behavioral Pharmacology, UCLA Neuropsychiatric Institute, 37-452 NPI, 760 Westwood Plaza, Los Angeles, CA 90024, USA. hkrell@mednet.ucla.edu

Clinical experience supports the use of antidepressant medications to treat chronic pain syndromes, such as low back pain and fibromyalgia. Although this use of antidepressants is common in clinical practice, the literature supporting this off-label use has some limitations. In this report, the authors review the body of clinical data on the use of antidepressants in treating pain and present a case series of depressed patients with these syndromes who experienced relief of pain symptoms while being treated with the noradrenergic antidepressant reboxetine. These subjects experienced significant relief of pain before any significant improvement in actual mood symptoms. Our experience with reboxetine suggests that this noradrenergic antidepressant may have efficacy in the treatment of chronic pain in patients with depression.

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Internist (Berl). 2005 Sep 27; [Epub ahead of print]
[Fibromyalgia—An update.]
[Article in German]
Bruckle W, Zeidler H.
Rheumaklinik, Bad Nenndorf.

Fibromyalgia is a common syndrome of unknown etiology characterized by chronic widespread pain and polysymptomatic autonomic disturbances and often mental features. The American College of Rheumatology's classification criteria define fibromyalgia by widespread pain and 11 of 18 tender points. Fibromyalgia is a diagnosis of exclusion as long as stand none laboratory or technical tests. The major role in pathogenesis appears to be central and involves the subcortical pain modulation, psychical stress especially in early childhood, endocrinological and genetic factors. There is no evidence of abnormalities in muscle and tendon. The goal of therapy in fibromyalgia is pain, reduced physical function and sleep disturbance. Actual evidence of effects of pharmacological and nonpharmacological interventions are summarized. Tricyclic agents, aerobic exercises, patient education and combined therapies can reduce effectively symptoms and disability.

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Arch Phys Med Rehabil. 2005 Sep;86(9):1713-21.
The effects of a 12-week strength-training program on strength and functionality in women with fibromyalgia.
Kingsley JD, Panton LB, Toole T, Sirithienthad P, Mathis R, McMillan V.
Department of Nutrition, Food and Exercise Sciences, Florida State University, Tallahassee, FL 32306, USA.

OBJECTIVE: To determine whether women with fibromyalgia benefit from strength training. DESIGN: Randomized controlled trial. SETTING: Testing was completed at the university and training was completed at a local community wellness facility. PARTICIPANTS: Twenty-nine women (age range, 18-54 y) with fibromyalgia participated. Subjects were randomly assigned to a control (n=14; wait-listed for exercise) or strength (n=15) group. After the first 4 weeks, 7 (47%) women dropped from the strength group. INTERVENTION: Subjects underwent 12 weeks of training on 11 exercises, 2 times a week, performing 1 set of 8 to 12 repetitions at 40% to 60% of their maximal lifts and were progressed to 60% to 80%. MAIN OUTCOME MEASURES: Subjects were measured for strength, functionality, tender point sensitivity, and fibromyalgia impact. RESULTS: The strength group significantly (P< or =.05) improved upper- (strength, 39+/-11 to 42+/-12 kg; control, 38+/-13 to 38+/-12 kg) and lower- (strength, 68+/-28 to 82+/-25 kg; control, 61+/-25 to 61+/-26 kg) body strength. Upper-body functionality measured by the Continuous-Scale Physical Functional Performance test improved significantly (strength, 44+/-11 to 50+/-16U; control, 51+/-11 to 49+/-13U) after training. Tender point sensitivity and fibromyalgia impact did not change. CONCLUSIONS: Strength training improved strength and some functionality in women with fibromyalgia. Interventions with resistance have important implications on independence and quality of life issues for women with fibromyalgia.

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J Altern Complement Med. 2005 Aug;11(4):663-71.
Treatment of fibromyalgia with formula acupuncture: investigation of needle placement, needle stimulation, and treatment frequency.
Harris RE, Tian X, Williams DA, Tian TX, Cupps TR, Petzke F, Groner KH, Biswas P, Gracely RH, Clauw DJ.
Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI.

Objectives: The objective of this study was to investigate whether typical acupuncture methods such as needle placement, needle stimulation, and treatment frequency were important factors in fibromyalgia symptom improvement. Design/settings/subjects: A single-site, single-blind, randomized trial of 114 participants diagnosed with fibromyalgia for at least 1 year was performed. Intervention: Participants were randomized to one of four treatment groups: (1) T/S needles placed in traditional sites with manual needle stimulation (n = 29): (2) T/0 traditional needle location without stimulation (n = 30); (3) N/S needles inserted in nontraditional locations that were not thought to be acupuncture sites, with stimulation (n = 28); and (4) N/0 nontraditional needle location without stimulation (n = 2 7). All groups received treatment once weekly, followed by twice weekly, and finally three times weekly, for a total of 18 treatments. Each increase in frequency was separated by a 2-week washout period. Outcome measures: Pain was assessed by a numerical rating scale, fatigue by the Multi-dimensional Fatigue Inventory, and physical function by the Short Form-36. Results: Overall pain improvement was noted with 25%-35% of subjects having a clinically significant decrease in pain; however this was not dependent upon "correct" needle stimulation (t = 1.03; p = 0.307) or location (t = 0.76; p = 0.450). An overall dose effect of treatment was observed, with three sessions weekly providing more analgesia than sessions once weekly (t = 2.10; p = 0.039). Among treatment responders, improvements in pain, fatigue, and physical function were highly codependent (all p </= 0.002). Conclusions: Although needle insertion led to analgesia and improvement in other somatic symptoms, correct needle location and stimulation were not crucial.

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J Psychosom Res. 2005 Nov;59(5):275-82.
A pilot study of the effects of behavioral weight loss treatment on fibromyalgia symptoms.
Shapiro JR, Anderson DA, Danoff-Burg S.
Department of Psychology, University at Albany, State University of New York, Albany, NY, USA.

OBJECTIVE: Previous studies have found a relation between weight loss and pain severity in various chronic pain populations. However, there has been little research examining the relation between body mass index (BMI) and fibromyalgia syndrome (FMS). The purpose of this pilot study was to investigate the relationship between BMI and FMS symptoms and to determine if FMS symptoms would decrease following weight loss. METHODS: Overweight and obese women participated in a 20-week behavioral weight loss treatment. RESULTS: Participants, on average, lost 9.2 lbs (4.4% of their initial weight), and there were significant pre-postimprovements on several outcome measures. Although weight was not significantly related to pain at baseline, weight loss significantly predicted a reduction in FMS, pain interference, body satisfaction, and quality of life (QOL). CONCLUSION: Findings suggest that behavioral weight loss treatment could be included in the treatment for overweight/obese women with FMS.

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Ann Pharmacother. 2005 Nov;39(11):1812-6. Epub 2005 Oct 11.
Open trial of pindolol in the treatment of fibromyalgia.
Wood PB, Kablinger AS, Caldito GS.
Department of Family Medicine, Louisiana State University Health Science Center-Shreveport, LA.

BACKGROUND: Evidence suggests that fibromyalgia is related to both chronic sympathetic hyperactivity and decreased levels of serotonin. OBJECTIVE: To examine the efficacy of pindolol, a mixed serotonin (5-HT)(1A) presynaptic autoreceptor/beta-adrenergic receptor antagonist, in the treatment of fibromyalgia. METHODS: An open trial was conducted using 20 female patients who met the American College of Rheumatology criteria for fibromyalgia. Treatment was initiated with pindolol 7.5 mg/day and titrated to a maximum dose of 15 mg/day for a total of 90 days. Primary outcome measures were tender point analysis and the Fibromyalgia Impact Questionnaire (FIQ). Anxiety and depression were measured with the Hamilton Depression and Anxiety Scales and Beck Depression Inventory. RESULTS: There was significant improvement in primary outcome measures, including Tender Point Count (mean +/- SD, 16.3 +/- 2.2 vs 12.3 +/- 5.0; F = 8.9; p < 0.001), Tender Point Score (24.4 +/- 5.7 vs 17.5 +/- 9.4; F = 7.8; p < 0.001), and FIQ (45.3 +/- 10.8 vs 35.0 +/- 15.0; F = 5.6; p < 0.005). The depression and anxiety scores did not change significantly among women who completed the study, while the impact on cardiovascular parameters was clinically insignificant. CONCLUSIONS: While the current results are encouraging, further studies are needed to determine whether pindolol might be effective in the treatment of fibromyalgia. Limitations of this study include small group size and lack of placebo control.

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J Rheumatol. 2005 Oct;32(10):1975-85.
Efficacy of milnacipran in patients with fibromyalgia.
Gendreau RM, Thorn MD, Gendreau JF, Kranzler JD, Ribeiro S, Gracely RH, Williams DA, Mease PJ, McLean SA, Clauw DJ.
Cypress Biosciences, 4350 Executive Drive, San Diego, CA 92121, USA. mgendreau1@cypressbio.com

OBJECTIVE: Fibromyalgia (FM) is a common musculoskeletal condition characterized by widespread pain, tenderness, and a variety of other somatic symptoms. Current treatments are modestly effective. Arguably, the best studied and most effective compounds are tricyclic antidepressants (TCA). Milnacipran, a nontricyclic compound that inhibits the reuptake of both serotonin and norepinephrine, may provide many of the beneficial effects of TCA with a superior side effect profile. METHODS: One hundred twenty-five patients with FM were randomly assigned in a 3:3:2 ratio to receive milnacipran twice daily, milnacipran once daily, or placebo for 3 months in a double-blind dose-escalation trial; 92% of twice-daily and 81% of once-daily participants achieved dose escalation to the target milnacipran dose of 200 mg. RESULTS: The primary endpoint was reduction of pain. Both the once- and twice-daily groups showed statistically significant improvements in pain, as well as improvements in global well being, fatigue, and other domains. Response rates for patients receiving milnacipran were equal in patients with and without comorbid depression, but placebo response rates were considerably higher in depressed patients, leading to significantly greater overall efficacy in the nondepressed group. CONCLUSION: In this Phase II study, milnacipran led to statistically significant improvements in pain and other symptoms of FM. The effect sizes were equal to those previously found with TCA, and the drug was generally well tolerated.

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Curr Pain Headache Rep. 2005 Oct;9(5):301-6.
Pharmacologic treatment of fibromyalgia.
Baker K, Barkhuizen A.
Arthritis & Rheumatic Diseases, Oregon Health & Science University, OP-09, Portland, OR 97239, USA. bakerk@ohsu.edu

Fibromyalgia is a syndrome of widespread pain, nonrestorative 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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Psychosomatics. 2005 Sep-Oct;46(5):379-84.
Evaluation of reboxetine, a noradrenergic antidepressant, for the treatment of fibromyalgia and chronic low back pain.
Krell HV, Leuchter AF, Cook IA, Abrams M.
Laboratory of Behavioral Pharmacology, UCLA Neuropsychiatric Institute, 37-452 NPI, 760 Westwood Plaza, Los Angeles, CA 90024, USA. hkrell@mednet.ucla.edu

Clinical experience supports the use of antidepressant medications to treat chronic pain syndromes, such as low back pain and fibromyalgia. Although this use of antidepressants is common in clinical practice, the literature supporting this off-label use has some limitations. In this report, the authors review the body of clinical data on the use of antidepressants in treating pain and present a case series of depressed patients with these syndromes who experienced relief of pain symptoms while being treated with the noradrenergic antidepressant reboxetine. These subjects experienced significant relief of pain before any significant improvement in actual mood symptoms. Our experience with reboxetine suggests that this noradrenergic antidepressant may have efficacy in the treatment of chronic pain in patients with depression.

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Internist (Berl). 2005 Sep 27; [Epub ahead of print]
[Fibromyalgia - An update.]
[Article in German]
Bruckle W, Zeidler H.
Rheumaklinik, Bad Nenndorf.

Fibromyalgia is a common syndrome of unknown etiology characterized by chronic widespread pain and polysymptomatic autonomic disturbances and often mental features. The American College of Rheumatology's classification criteria define fibromyalgia by widespread pain and 11 of 18 tender points. Fibromyalgia is a diagnosis of exclusion as long as stand none laboratory or technical tests. The major role in pathogenesis appears to be central and involves the subcortical pain modulation, psychical stress especially in early childhood, endocrinological and genetic factors. There is no evidence of abnormalities in muscle and tendon. The goal of therapy in fibromyalgia is pain, reduced physical function and sleep disturbance. Actual evidence of effects of pharmacological and nonpharmacological interventions are summarized. Tricyclic agents, aerobic exercises, patient education and combined therapies can reduce effectively symptoms and disability.

-----

Arch Phys Med Rehabil. 2005 Sep;86(9):1713-21.
The effects of a 12-week strength-training program on strength and functionality in women with fibromyalgia.
Kingsley JD, Panton LB, Toole T, Sirithienthad P, Mathis R, McMillan V.
Department of Nutrition, Food and Exercise Sciences, Florida State University, Tallahassee, FL 32306, USA.

OBJECTIVE: To determine whether women with fibromyalgia benefit from strength training. DESIGN: Randomized controlled trial. SETTING: Testing was completed at the university and training was completed at a local community wellness facility. PARTICIPANTS: Twenty-nine women (age range, 18-54 y) with fibromyalgia participated. Subjects were randomly assigned to a control (n=14; wait-listed for exercise) or strength (n=15) group. After the first 4 weeks, 7 (47%) women dropped from the strength group. INTERVENTION: Subjects underwent 12 weeks of training on 11 exercises, 2 times a week, performing 1 set of 8 to 12 repetitions at 40% to 60% of their maximal lifts and were progressed to 60% to 80%. MAIN OUTCOME MEASURES: Subjects were measured for strength, functionality, tender point sensitivity, and fibromyalgia impact. RESULTS: The strength group significantly (P< or =.05) improved upper- (strength, 39+/-11 to 42+/-12 kg; control, 38+/-13 to 38+/-12 kg) and lower- (strength, 68+/-28 to 82+/-25 kg; control, 61+/-25 to 61+/-26 kg) body strength. Upper-body functionality measured by the Continuous-Scale Physical Functional Performance test improved significantly (strength, 44+/-11 to 50+/-16U; control, 51+/-11 to 49+/-13U) after training. Tender point sensitivity and fibromyalgia impact did not change. CONCLUSIONS: Strength training improved strength and some functionality in women with fibromyalgia. Interventions with resistance have important implications on independence and quality of life issues for women with fibromyalgia.

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J Altern Complement Med. 2005 Aug;11(4):663-71.
Treatment of fibromyalgia with formula acupuncture: investigation of needle placement, needle stimulation, and treatment frequency.
Harris RE, Tian X, Williams DA, Tian TX, Cupps TR, Petzke F, Groner KH, Biswas P, Gracely RH, Clauw DJ.
Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI.

Objectives: The objective of this study was to investigate whether typical acupuncture methods such as needle placement, needle stimulation, and treatment frequency were important factors in fibromyalgia symptom improvement. Design/settings/subjects: A single-site, single-blind, randomized trial of 114 participants diagnosed with fibromyalgia for at least 1 year was performed. Intervention: Participants were randomized to one of four treatment groups: (1) T/S needles placed in traditional sites with manual needle stimulation (n = 29): (2) T/0 traditional needle location without stimulation (n = 30); (3) N/S needles inserted in nontraditional locations that were not thought to be acupuncture sites, with stimulation (n = 28); and (4) N/0 nontraditional needle location without stimulation (n = 2 7). All groups received treatment once weekly, followed by twice weekly, and finally three times weekly, for a total of 18 treatments. Each increase in frequency was separated by a 2-week washout period. Outcome measures: Pain was assessed by a numerical rating scale, fatigue by the Multi-dimensional Fatigue Inventory, and physical function by the Short Form-36. Results: Overall pain improvement was noted with 25%-35% of subjects having a clinically significant decrease in pain; however this was not dependent upon "correct" needle stimulation (t = 1.03; p = 0.307) or location (t = 0.76; p = 0.450). An overall dose effect of treatment was observed, with three sessions weekly providing more analgesia than sessions once weekly (t = 2.10; p = 0.039). Among treatment responders, improvements in pain, fatigue, and physical function were highly codependent (all p </= 0.002). Conclusions: Although needle insertion led to analgesia and improvement in other somatic symptoms, correct needle location and stimulation were not crucial.

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Arthritis Rheum. 2005 Aug 15;53(4):519-27.
Impact of fibromyalgia pain on health-related quality of life before and after treatment with tramadol/acetaminophen.
Bennett RM, Schein J, Kosinski MR, Hewitt DJ, Jordan DM, Rosenthal NR.
Oregon Health and Science University, Portland.

OBJECTIVE: To assess health-related quality of life (HRQOL) in patients with moderate-to-severe fibromyalgia pain compared with the general population, and to assess the relationship between pain severity and HRQOL before and after treatment with an analgesic. METHODS: Data were obtained from a randomized, double-blind study of patients with moderate-to-severe fibromyalgia pain. Patients received either tramadol/acetaminophen or placebo 4 times/day as needed for 91 days. HRQOL was measured with the Short Form 36 Health Survey (SF-36) and the Fibromyalgia Impact Questionnaire (FIQ). Baseline HRQOL scores were compared with a national sample of noninstitutionalized adults and a sample of patients with impaired HRQOL due to congestive heart failure. Patients with fibromyalgia were divided into tertiles by change in pain severity, and SF-36 scores were compared across the tertiles. Mean changes in SF-36 and FIQ scores were compared between treatment groups. RESULTS: Patients with fibromyalgia scored lower than the US norm on all SF-36 scales (P < 0.0001) and lower than patients with congestive heart failure on most scales. More severe pain was associated with greater impairment of HRQOL compared with less severe pain (P < 0.0001). Patients in the highest tertile for improved pain severity had greater improvement in HRQOL scores than patients in the lower tertiles. Compared with patients who received placebo (n = 157), patients treated with tramadol/acetaminophen (n = 156) showed greater improvement on SF-36 physical functioning, role physical, bodily pain, and physical summary scales, as well as FIQ scales for ability to do job, pain, and stiffness (P < 0.01). CONCLUSION: Moderate-to-severe fibromyalgia pain significantly impairs HRQOL, and effective pain relief in these patients significantly increases HRQOL.

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J Rheumatol Suppl. 2005 Aug;75:6-21.
Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment.
Mease P.
>From the Seattle Rheumatology Associates, Division of Rheumatology Clinical Research, Swedish Hospital Medical Center, University of Washington School of Medicine, Seattle, Washington, USA.

Fibromyalgia syndrome (FM) is a common chronic pain condition that affects at least 2% of the adult population in the USA and other regions in the world where FM is studied. Prevalence rates in some regions have not been ascertained and may be influenced by differences in cultural norms regarding the definition and attribution of chronic pain states. Chronic, widespread pain is the defining feature of FM, but patients may also exhibit a range of other symptoms, including sleep disturbance, fatigue, irritable bowel syndrome, headache, and mood disorders. Although the etiology of FM is not completely understood, the syndrome is thought to arise from influencing factors such as stress, medical illness, and a variety of pain conditions in some, but not all patients, in conjunction with a variety of neurotransmitter and neuroendocrine disturbances. These include reduced levels of biogenic amines, increased concentrations of excitatory neurotransmitters, including substance P, and dysregulation of the hypothalamic-pituitary-adrenal axis. A unifying hypothesis is that FM results from sensitization of the central nervous system. Establishing diagnosis and evaluating effects of therapy in patients with FM may be difficult because of the multifaceted nature of the syndrome and overlap with other chronically painful conditions. Diagnostic criteria, originally developed for research purposes, have aided our understanding of this patient population in both research and clinical settings, but need further refinement as our knowledge about chronic widespread pain evolves. Outcome measures, borrowed from clinical research in pain, rheumatology, neurology, and psychiatry, are able to distinguish treatment response in specific symptom domains. Further work is necessary to validate these measures in FM. In addition, work is under way to develop composite response criteria, intended to address the multidimensional nature of this syndrome. A range of medical treatments, including antidepressants, opioids, nonsteroidal antiinflammatory drugs, sedatives, muscle relaxants, and antiepileptics, have been used to treat FM. Nonpharmaceutical treatment modalities, including exercise, physical therapy, massage, acupuncture, and cognitive behavioral therapy, can be helpful. Few of these approaches have been demonstrated to have clear-cut benefits in randomized controlled trials. However, there is now increased interest as more effective treatments are developed and our ability to accurately measure effect of treatment has improved. The multifaceted nature of FM suggests that multimodal individualized treatment programs may be necessary to achieve optimal outcomes in patients with this syndrome.

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J Rheumatol. 2005 Aug;32(8):1594-602.
Efficacy of cognitive-behavioral intervention for juvenile primary fibromyalgia syndrome.
Kashikar-Zuck S, Swain NF, Jones BA, Graham TB.
>From the Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.

OBJECTIVE: There are currently no controlled studies of behavioral interventions for juvenile primary fibromyalgia syndrome (JPFM). In this small-sample randomized study, we tested the efficacy of a behavioral intervention, i.e., coping skills training (CST), for the treatment of adolescents with JPFM. Outcomes tested in this study were functional disability, pain intensity, pain-coping efficacy, and depressive symptoms. METHODS: Thirty patients with JPFM were randomly assigned to 8 weeks of either CST or self-monitoring. Adolescents in the CST condition received training in active pain-coping techniques, while those in the self-monitoring condition monitored daily pain intensity and sleep quality with no instructions about behavior change. After posttreatment assessment, subjects were crossed over into the opposite treatment arm for 8 weeks (so that all adolescents eventually received both CST and self-monitoring) and were reassessed at Week 16. RESULTS: At Week 8, adolescents in both conditions showed significant decrease in depressive symptoms and functional disability. Those who received CST showed significantly greater ability to cope with pain than those in the self-monitoring condition and a trend toward decreased pain intensity. At Week 16, adolescents had significantly lower levels of disability and depressive symptoms compared to baseline, but those who received self-monitoring followed by CST seemed to receive the most benefit. CONCLUSION: CST can lead to improved functioning among JPFM patients. Although some of the improvement may be due to increased monitoring and attention, CST provides the specific benefit of improving adolescents' ability to cope with pain.

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Arthritis Rheum. 2005 Aug;52(8):2495-505.
A randomized, double-blind, placebo-controlled trial of pramipexole, a dopamine agonist, in patients with fibromyalgia receiving concomitant medications.
Holman AJ, Myers RR.
Pacific Rheumatology Associates, Renton, Washington.

OBJECTIVE: To assess the efficacy and safety of pramipexole, a dopamine 3 receptor agonist, in patients with fibromyalgia. METHODS: In this 14-week, single-center, double-blind, placebo-controlled, parallel-group, escalating-dose trial, 60 patients with fibromyalgia were randomized 2:1 (pramipexole:placebo) to receive 4.5 mg of pramipexole or placebo orally every evening. The primary outcome was improvement in the pain score (10-cm visual analog scale [VAS]) at 14 weeks. Secondary outcome measures were the Fibromyalgia Impact Questionnaire (FIQ), the Multidimensional Health Assessment Questionnaire (MDHAQ), the pain improvement scale, the tender point score, the 17-question Hamilton Depression Inventory (HAM-d), and the Beck Anxiety Index (BAI). Patients with comorbidities and disability were not excluded. Stable dosages of concomitant medications, including analgesics, were allowed. RESULTS: Compared with the placebo group, patients receiving pramipexole experienced gradual and more significant improvement in measures of pain, fatigue, function, and global status. At 14 weeks, the VAS pain score decreased 36% in the pramipexole arm and 9% in the placebo arm (treatment difference -1.77 cm). Forty-two percent of patients receiving pramipexole and 14% of those receiving placebo achieved >/=50% decrease in pain. Secondary outcomes favoring pramipexole over placebo included the total FIQ score (treatment difference -9.57) and the percentages of improvement in function (22% versus 0%), fatigue (29% versus 7%), and global (38% versus 3%) scores on the MDHAQ. Compared with baseline, some outcomes showed a better trend for pramipexole treatment than for placebo, but failed to reach statistical significance, including improvement in the tender point score (51% versus 36%) and decreases in the MDHAQ psychiatric score (37% versus 28%), the BAI score (39% versus 27%), and the HAM-d score (29% versus 9%). No end points showed a better trend for the placebo arm. The most common adverse events associated with pramipexole were transient anxiety and weight loss. No patient withdrew from the study because of inefficacy or an adverse event related to pramipexole. CONCLUSION: In a subset of patients with fibromyalgia, approximately 50% of whom required narcotic analgesia and/or were disabled, treatment with pramipexole improved scores on assessments of pain, fatigue, function, and global status, and was safe and well-tolerated.

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Rheumatology (Oxford). 2005 Jul 19; [Epub ahead of print]
A randomized clinical trial of an individualized home-based exercise programme for women with fibromyalgia.
Da Costa D, Abrahamowicz M, Lowensteyn I, Bernatsky S, Dritsa M, Fitzcharles MA, Dobkin PL.
Division of Clinical Epidemiology, McGill University Health Centre, Montreal, Canada; Department of Medicine, McGill University, Montreal, Canada.

Objective. To determine the efficacy of a 12-week individualized home-based exercise programme on physical functioning, pain severity and psychological distress for women with fibromyalgia (FM). Methods. Seventy-nine women with a primary diagnosis of FM were randomized to a 12-week individualized home-based moderate-intensity exercise programme or to a usual care control group. Outcomes were functional capacity (Fibromyalgia Impact Questionnaire), pain severity and psychological distress. Outcomes were measured at study entry, at the end of the 12-week intervention, and at 3 and 9 months following completion of the intervention. Results. On the basis of intention-to-treat analyses, a significant improvement in functional capacity at 3 and 9 months following treatment for participants in the exercise group who were more functionally disabled at study entry was observed. At both 3 and 9 months post-treatment, the mean estimated benefit of the intervention was more than 10 points [-12.3 (95% CI, -21.9 to -2.8); -10.8 (95% CI, -21.5 to -0.2)]. Compared with the control group, statistically significant improvements in upper body pain were evident in the exercise group at post-treatment. These between-group differences in upper body pain were maintained at 3 and 9 months post-treatment. No statistically significant group differences on lower body pain and psychological distress were found. Conclusions. Home-based exercise, a relatively low-cost treatment modality, has the potential to improve important health outcomes in FM.

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Ann Intern Med. 2005 Jul 5;143(1):10-9.
A randomized clinical trial of acupuncture compared with sham acupuncture in fibromyalgia.
Assefi NP, Sherman KJ, Jacobsen C, Goldberg J, Smith WR, Buchwald D.
The Group Health Cooperative Center for Health Studies, and University of Washington, Seattle, Washington, USA.

BACKGROUND: Fibromyalgia is a common chronic pain condition for which patients frequently use acupuncture. OBJECTIVE: To determine whether acupuncture relieves pain in fibromyalgia. DESIGN: Randomized, sham-controlled trial in which participants, data collection staff, and data analysts were blinded to treatment group. SETTING: Private acupuncture offices in the greater Seattle, Washington, metropolitan area. PATIENTS: 100 adults with fibromyalgia. INTERVENTION: Twice-weekly treatment for 12 weeks with an acupuncture program that was specifically designed to treat fibromyalgia, or 1 of 3 sham acupuncture treatments: acupuncture for an unrelated condition, needle insertion at nonacupoint locations, or noninsertive simulated acupuncture. MEASUREMENTS: The primary outcome was subjective pain as measured by a 10-cm visual analogue scale ranging from 0 (no pain) to 10 (worst pain ever). Measurements were obtained at baseline; 1, 4, 8, and 12 weeks of treatment; and 3 and 6 months after completion of treatment. Participant blinding and adverse effects were ascertained by self-report. The primary outcomes were evaluated by pooling the 3 sham-control groups and comparing them with the group that received acupuncture to treat fibromyalgia. RESULTS: The mean subjective pain rating among patients who received acupuncture for fibromyalgia did not differ from that in the pooled sham acupuncture group (mean between-group difference, 0.5 cm [95% CI, -0.3 cm to 1.2 cm]). Participant blinding was adequate throughout the trial, and no serious adverse effects were noted. LIMITATIONS: A prescription of acupuncture at fixed points may differ from acupuncture administered in clinical settings, in which therapy is individualized and often combined with herbal supplementation and other adjunctive measures. A usual-care comparison group was not studied. CONCLUSION: Acupuncture was no better than sham acupuncture at relieving pain in fibromyalgia.

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J Rheumatol. 2005 Jul;32(7):1336-40.
A randomized controlled trial of dehydroepiandrosterone in postmenopausal women with fibromyalgia.
Finckh A, Berner IC, Aubry-Rozier B, So AK.
Rheumatology Department, University Hospital of Vaud (CHUV), Lausanne, Switzerland. afinckh@post.harvard.edu

OBJECTIVE: Patients with fibromyalgia (FM) consistently have adrenal hyporesponsiveness and low dehydroepiandrosterone (DHEA) levels. DHEA is promoted for and used by patients with FM. We tested the efficacy and safety of DHEA supplementation in ameliorating the symptoms of FM. METHODS: In a double-blind crossover study, postmenopausal women with FM were randomized to DHEA supplementation (50 mg/day) or placebo for 3 months, with a one-month washout period in between. Patients were assessed monthly for well-being and pain and by medical evaluations at the beginning and the end of each treatment period. The primary outcome was well being; secondary outcomes were pain, fatigue, cognition, sexuality, functional impairment, depression, and anxiety. RESULTS: A total of 52 patients were randomized, 47 patients completed the DHEA treatment period, and 45 the placebo treatment period. After 3 months of treatment with 50 mg of DHEA, median DHEA sulfate blood levels had tripled, but there was no improvement in well-being, pain, fatigue, cognitive dysfunction, functional impairment, depression, or anxiety, nor in objective measurements made by physicians. Androgenic side effects (greasy skin, acne, and increased growth of body hair) were more common during the DHEA treatment period (p = 0.02). CONCLUSION: DHEA does not improve quality of life, pain, fatigue, cognitive function, mood, or functional impairment in FM.

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Disabil Rehabil. 2005 Jun 17;27(12):725-8.
Body awareness therapy for patients with fibromyalgia and chronic pain.
Gard G.
Department of Health Sciences, Lulea University, Hedenbrovagen, 961 3b, Boden, Sweden. gunvord.gard@Hu.se

There are several therapies designed to increase body awareness. They are commonly known as body awareness therapies (BAT) and include Basic BAT, Mensendieck and Feldenkrais therapy. A focus on emotions is important in all these therapies. In this article the aim and development of Basic BAT is described together with evaluations of treatments including Basic BAT. Multidisciplinary studies have shown that Basic BAT can increase health-related quality of life and cost-effectiveness. However Basic BAT needs to be further studied in relation to patients with fibromyalgia (FM) and chronic pain. Studies so far indicate that Basic BAT has positive effects.

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Disabil Rehabil. 2005 Jun 17;27(12):711-23.
Rehabilitation approaches in fibromyalgia.
Adams N, Sim J.
Centre for Research in Health Care, Liverpool John Moores University, Great Crosshall Street, Liverpool, UK. j.sim@keele.ac.uk

PURPOSE: This paper provides an overview of the evidence for the principal approaches taken to the rehabilitation of patients with fibromyalgia (FM): exercise, psychologically-based approaches, multimodal approaches, self-management approaches, and complementary and alternative therapies. METHOD: A review of current published evidence. RESULTS: Owing to factors such as methodological shortcomings of existing studies, and the lack of evidence on individual modalities, it is difficult to draw definitive conclusions as to which is the most appropriate rehabilitation approach in FM. However, there is growing evidence for the role of exercise training, and clear indications that if appropriately prescribed, this can be undertaken without adverse effects. Similarly, psychologically-based interventions such as cognitive-behavioural therapy have received some support from the literature. Evidence for other interventions is more equivocal. CONCLUSIONS: It appears that a combination of interventions, in a multimodal approach (e.g., exercises combined with education and psychologically-based interventions) is the most promising means of managing patients with FM.

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Prog Neuropsychopharmacol Biol Psychiatry. 2005 Jan;29(1):161-4.
Atypical antipsychotics in the treatment of fibromyalgia: a case series with olanzapine.
Rico-Villademoros F, Hidalgo J, Dominguez I, Garcia-Leiva JM, Calandre EP.
Biometrica, Departamento Medico, Eloy Gonzalo 27, 28010 Madrid, Spain.

Fibromyalgia is a common and disabling chronic pain syndrome. Although a wide array of symptomatic pharmacological treatments has been used to treat this condition, only modest results have been obtained. Olanzapine has been proven effective in some chronic pain conditions. The authors present a case series of patients suffering from fibromyalgia who received olanzapine as add-on therapy during a 3-month period. Olanzapine (2.5-20.0 mg/day) was administered to 25 consecutive patients (24 females, 1 male) meeting the American College of Rheumatology diagnostic criteria for fibromyalgia, and who were receiving nonsteroidal anti-inflammatory drugs (NSAIDs; 68%), benzodiazepines/zolpidem (48%), antidepressants (32%), and cyclobenzaprine (4%), either alone or in combination. Overall, 6 of the 14 patients (43%) who completed the 12-week trial reported to be much or very much improved ('responders'), according to the Clinical Global Impression (CGI) scale and 7 of them (50%) reported a good or very good sense of well-being. Olanzapine's modal dose among responders was 10.0 mg/day. It was discontinued in 11 patients (44%) due to adverse reactions, most commonly weight gain (n=5, 20%). Our preliminary findings suggest a possible role for olanzapine in treating fibromyalgia. Unfortunately, the beneficial outcome of olanzapine was largely obscured by its poor tolerability, which could be explained by the greater propensity of patients with fibromyalgia to adverse drug reactions, and the greater risk of antipsychotic-induced weight gain among women. Whether other atypical antipsychotics will provide similar symptomatic relief, while showing a better tolerability profile than olanzapine in patients with fibromyalgia, should be further investigated.

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Arthritis Rheum. 2004 Dec 15;51(6):890-8.
Six-month and one-year followup of 23 weeks of aerobic exercise for individuals with fibromyalgia.
Gowans SE, Dehueck A, Voss S, Silaj A, Abbey SE.
University Health Network and University of Toronto, Toronto, Ontario, Canada.

OBJECTIVE: To measure mood and physical function of individuals with fibromyalgia, 6 and 12 months following 23 weeks of supervised aerobic exercise. METHODS: This is a followup report of individuals who were previously enrolled in 23 weeks of land-based and water-based aerobic exercise classes. Outcomes included the 6-minute walk test, Beck Depression Inventory (BDI), State-Trait Anxiety Inventory, Arthritis Self-Efficacy Scale (ASES), Fibromyalgia Impact Questionnaire (FIQ), tender point count, patient global assessment score, and exercise compliance. Outcomes were measured at the start and end of the exercise classes and 6 and 12 months later. RESULTS: Analyses were conducted on 29 (intent-to-treat) or 18 (efficacy) subjects. Six-minute walk distances and BDI total scores were improved at followup (all analyses). BDI cognitive/affective scores were improved at the end of 23 weeks of exercise (both analyses) and at the 12-month followup (efficacy analysis only). BDI somatic scores were improved at 6-month (both analyses) and 12-month followup (intent-to-treat only). FIQ and ASES function were improved at all followup points. ASES pain was improved in efficacy analyses only (all followup points). Tender points were unchanged after 23 weeks of exercise and at followup. Exercise duration at followup (total minutes of aerobic plus anaerobic exercise in the preceding week) was related to gains in physical function (6- and 12-month followup) and mood (6-month followup). CONCLUSION: Exercise can improve physical function, mood, symptom severity, and aspects of self efficacy for at least 12 months. Exercising at followup was related to improvements in physical function and perhaps mood.

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JAMA. 2004 Nov 17;292(19):2388-95.
Management of fibromyalgia syndrome.
Goldenberg DL, Burckhardt C, Crofford L.
Department of Rheumatology, Newton-Wellesley Hospital, Newton, Mass 02462, USA. dgoldenb@massmed.org

CONTEXT: The optimal management of fibromyalgia syndrome (FMS) is unclear and comprehensive evidence-based guidelines have not been reported. OBJECTIVE: To provide up-to-date evidence-based guidelines for the optimal treatment of FMS. DATA SOURCES, SELECTION, AND EXTRACTION: A search of all human trials (randomized controlled trials and meta-analyses of randomized controlled trials) of FMS was made using Cochrane Collaboration Reviews (1993-2004), MEDLINE (1966-2004), CINAHL (1982-2004), EMBASE (1988-2004), PubMed (1966-2004), Healthstar (1975-2000), Current Contents (2000-2004), Web of Science (1980-2004), PsychInfo (1887-2004), and Science Citation Indexes (1996-2004). The literature review was performed by an interdisciplinary panel, composed of 13 experts in various pain management disciplines, selected by the American Pain Society (APS), and supplemented by selected literature reviews by APS staff members and the Utah Drug Information Service. A total of 505 articles were reviewed. DATA SYNTHESIS: There are major limitations to the FMS literature, with many treatment trials compromised by short duration and lack of masking. There are no medical therapies that have been specifically approved by the US Food and Drug Administration for management of FMS. Nonetheless, current evidence suggests efficacy of low-dose tricyclic antidepressants, cardiovascular exercise, cognitive behavioral therapy, and patient education. A number of other commonly used FMS therapies, such as trigger point injections, have not been adequately evaluated. CONCLUSIONS: Despite the chronicity and complexity of FMS, there are pharmacological and nonpharmacological interventions available that have clinical benefit. Based on current evidence, a stepwise program emphasizing education, certain medications, exercise, cognitive therapy, or all 4 should be recommended.

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Am J Manag Care. 2004 Nov;10(11 Pt 1):794-800.
A review of fibromyalgia.
Nampiaparampil DE, Shmerling RH.
Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA 02114, USA. dnampiaparampil@partners.org

Characterized by chronic widespread joint and muscle pain, fibromyalgia is a syndrome of unknown etiology. The American College of Rheumatology's classification criteria for fibromyalgia include diffuse soft tissue pain of at least 3 months' duration and pain on palpation in at least 11 of 18 paired tender points. Symptoms are often exacerbated by exertion, stress, lack of sleep, and weather changes. Fibromyalgia is primarily a diagnosis of exclusion, established only after other causes of joint or muscle pain are ruled out. The initial workup for patients who present with widespread musculoskeletal pain should include a complete blood count, erythrocyte sedimentation rate, liver function tests, hepatitis C antibody, calcium, and thyrotropin. The musculoskeletal system, the neuroendocrine system, and the central nervous system, particularly the limbic system, appear to play major roles in the pathogenesis of fibromyalgia. The goal in treating fibromyalgia is to decrease pain and to increase function without promoting polypharmacy. Brief interdisciplinary programs have been shown to improve subjective pain. Fibromyalgia is a complex syndrome associated with significant impairment on quality of life and function and substantial financial costs. Once the diagnosis is made, providers should aim to increase patients' function and minimize pain. This can be accomplished through nonpharmacological ahd pharmacological interventions. With proper management, the rate of disability appears to be significantly reduced.

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Scand J Rheumatol Suppl. 2004;(119):72-5.
Intravenous treatment of fibromyalgia with the 5-HT3 receptor antagonist tropisetron in a rheumatological practice.
Tolk J, Kohnen R, Muller W.
Rheumatology practice, Kiel, Germany. JochenTolk@aol.com

In 223 fibromyalgia (FM) patients in a rheumatology practice, a follow-up postal survey was carried out 0.5-2 years after a 5-day intravenous (i.v.) treatment with 5 mg of the 5-HT3 receptor antagonist tropisetron daily on the effect of this treatment. 121 patients returned the completed questionnaire. After subtraction of 22 undeliverable questionnaires, this represented 60.2% of patients contacted for whom an assessment of the tropisetron treatment was possible. A good to very good effect of the treatment on the pain was reported by 45% of the patients, and only 25% reported an unsatisfactory effect. The effect of tropisetron IV lasted between one day and 12 weeks (mean 8.6 +/- 13.6 d). Sleep and general condition were also assessed as good or very good by almost half of the patients. The tolerance of tropisetron was generally good. In comparison with the current treatment and the best treatment with other drugs ever received, tropisetron was rated as more efficacious in almost half of the cases, though an unsatisfactory effect of tropisetron compared to other treatments was reported in 30% of the cases. Considered in comparison to less or at most equally efficacious alternatives, according to this open respective study, IV tropisetron treatment represents a promising option for the treatment of FM even though the study design incorporated many imponderables. Particularly the question of whether the success of treatment can be improved further with a longer lasting treatment or a selection of the patients still needs to be settled.

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Scand J Rheumatol Suppl. 2004;(119):63-6.
Treatment of fibromyalgia with tropisetron--dose and efficacy correlations.
Spath M, Stratz T, Farber L, Haus U, Pongratz D.
Friedrich-Baur-Institute, University of Munich, Munich, Germany. michael.spaeth@lrz.uni-muenchen.de

Previous studies evaluating the efficacy and tolerance of tropisetron for the treatment of fibromyalgia (FM) used the drug either intravenously or orally, and at different dosage levels ranging from 2 mg to 15 mg daily. The shortest treatment was a single dose and the longest treatment period covered 28 days. A significant reduction of the pain intensity was achieved by using tropisetron 5 mg per day. Apart from the fact that treatment periods were different, the efficacy of oral and intravenous administration did not differ significantly. Tropisetron was well tolerated; but in the 15 mg group in one of the studies, the decrease in pain was less than in the placebo group, however, the frequency of constipation and other gastrointestinal symptoms increased. Furthermore, it was hypothesized that due to the impacts of CYP2D6 activities, a daily dose of tropisetron 2 mg may be efficacious in slow metabolizers only. Although tropisetron proved to be efficacious in a group of fibromyalgia patients, the dose-response curves cannot yet be explained in a fully satisfactory manner, which may encourage research focusing on possible subgroups of FM.

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Tidsskr Nor Laegeforen. 2004 Oct 7;124(19):2475-8.
[Fibromyalgia—effect of exercise]
[Article in Norwegian]
Kurtze N.
HUNT forskningssenter, Institutt for samfunnsmedisin, Det medisinske fakultet, Norges teknisk-naturvitenskapelige universitet, Neptunveien 1 7650 Verdal. nanna.kurtze@medisin.ntnu.no

BACKGROUND: Fibromyalgia is a chronic widespread unexplained musculoskeletal pain syndrome with decreased pain threshold. Because the etiology of fibromyalgia is unknown and the pathogenesis is unidentified, treatment is largely symptomatic and not standardised. The pain and fatigue reported by individuals with fibromyalgia results in a relative sedentary lifestyle, hence also a decrease in the fitness level of skeletal muscles. MATERIAL AND METHODS: In order to assess the effect of exercise in fibromyalgia, the Cochrane Controlled Trials Register was reviewed; 17 studies of exercise interventions on cardiorespiratory endurance, muscle strength and/or flexibility were selected. RESULTS: The results from the studies are inconsistent but low-intensity aerobic exercise regimens were found to be one of the few effective treatments. In these studies, however, subjective pain levels fail to show significant improvement, although improvements are seen on other parameters such as improvement in the number of tender points, in total myalgic scores and reduced tender point tenderness, improved aerobic capacity, physical function, subjective well-being and self-efficacy. INTERPRETATION: The group exercises varied from 1-3 times per week, sessions from 25 minutes to 90 minutes; the duration of the programmes from 6 weeks to 6 month. Most of the programmes were low-intensity dynamic endurance training with a working rate at 50-70 % of maximal heart rate in relation to age.

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Hum Psychopharmacol. 2004 Oct;19 Suppl 1:S27-35.
A double-blind placebo-controlled trial of milnacipran in the treatment of fibromyalgia.
Vitton O, Gendreau M, Gendreau J, Kranzler J, Rao SG.
Cypress Bioscience, San Diego, CA 9212, USA. ovitton@cypressbio.com

Fibromyalgia syndrome is a systemic disorder of widespread pain which is thought to result from abnormal pain processing within the central nervous system. There are no currently approved treatments for this indication. Antidepressants appear, however, to be effective, especially those with an action on noradrenergic neurotransmission. The objective of the present study was to test the efficacy of the dual action noradrenaline and serotonin reuptake inhibitor antidepressant, milnacipran, in the treatment of fibromyalgia. The 125 patients, who were enrolled in a double-blind, placebo-controlled, flexible dose escalation trial, were randomized to receive placebo or milnacipran for 4 weeks of dose escalation (up to 200 mg/day), followed by 8 weeks at a constant dose. The study evaluated the efficacy and safety of milnacipran for the treatment of pain and associated symptoms such as fatigue, depressed mood and sleep. 75% of milnacipran-treated patients reported overall improvement, compared with 38% in the placebo group (p < 0.01). Furthermore, 37% of twice daily milnacipran-treated patients reported at least 50% reduction in pain intensity, compared with 14% of placebo-treated patients (p < 0.05). 84% of all milnacipran patients escalated to the highest dose (200 mg/day) with no tolerability issues. Most adverse events were mild to moderate in intensity, and transient in duration. These results suggest that milnacipran may have the potential to relieve not only pain but several of the other symptoms associated with fibromyalgia. 2004 John Wiley & Sons, Ltd.

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Eur J Pain. 2004 Aug;8(4):371-6.
Electroconvulsive therapy in patients with depression and fibromyalgia.
Huuhka MJ, Haanpaa ML, Leinonen EV.
Department of Psychogeriatrics, Tampere University Hospital, Pitkaniemi Fin-33380, Finland.

The effect of electroconvulsive therapy (ECT) on depression and other symptoms of fibromyalgia was studied in a prospective 3-month trial in 13 patients with fibromyalgia and concomitant depression. All the patients met the DSM-IV diagnostic criteria for Major Depressive Disorder and fulfilled the American College of Rheumatology diagnostic criteria for fibromyalgia. The Montgomery and Asberg Depression Rating Scale (MADRS) and the clinical global impression scale (CGI) were used to assess the severity of depression and the clinical change of the patients. The fibromyalgia impact questionnaire (FIQ) was used to evaluate the severity of the fibromyalgia symptoms. The intensity of pain was evaluated using a 6-point scale (0=no pain, 5=very severe pain), and tender point palpation. All assessments were performed at baseline and at follow-up visits, which took place one week, one month and three months after ECT. There was a significant improvement in depression after ECT according to MADRS. Using CGI, six patients were much or very much improved, while four patients were minimally improved and three patients had no change. There was significant improvement in four out of ten FIQ item scores, "feel good", "fatigue", "anxiety" and "depression". No significant change was found in the FIQ item scores "physical function", "pain", "stiffness" and "morning tiredness" or number of tender points and self-reported pain. We conclude that ECT is a safe and effective treatment for depression in fibromyalgia patients, but has no effect on the pain or other physical symptoms of these patients.

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MCN Am J Matern Child Nurs. 2004 Jul-Aug;29(4):248-253.
Breastfeeding in Chronic Illness: The Voices of Women With Fibromyalgia.
Schaefer KM.
Karen Moore Schaefer is an Assistant Professor, Temple University, College of Health Professions, Department of Nursing, Philadelphia, PA. She can be reached via e-mail at karen.schaefer@temple.edu.

PURPOSE:: To describe what it is like for women with fibromyalgia (FM) to breastfeed their infants. STUDY DESIGN AND METHODS:: Nine women with FM who chose to breastfeed their infants were the sample for this qualitative study. van Manen's phenomenological method of reflection, writing, and rewriting was used to analyze the data collected through in-depth tape-recorded interviews and written stories. RESULTS:: All nine women felt that they were not successful in their attempts to breastfeed, and felt frustrated. Themes included (a) muscle soreness, pain, and stiffness made it difficult to breastfeed the baby; (b) fatigue interfered with the breastfeeding process; (c) the need for medication, perceived insufficient milk supply, and sore nipples led to forced unplanned weaning; and (d) being forced to wean the infant when not ready to do so created sadness and a feeling of depression. CLINICAL IMPLICATIONS:: Nurses who work with women with FM who choose to breastfeed need to be proactive in providing informational, emotional, and physical support to facilitate a successful breastfeeding experience for these women. Knowing that the pain, muscle soreness, stiffness, and fatigue of FM may affect breastfeeding can direct nurses to help women with FM plan for support after childbirth and learn techniques to control/reduce the muscle pain and stiffness. Nurses are encouraged to refer breastfeeding women with FM to lactation consultants and support groups for encouragement and validation regarding their concerns about breastfeeding. It is important that nurses continue to serve as advocates for breastfeeding women with FM and keep other healthcare providers informed about the issues related to breastfeeding for women with FM.

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J Altern Complement Med. 2004 Jul;10(3):468-80.
Clinical research on acupuncture: part 1. What have reviews of the efficacy and safety of acupuncture told us so far?
Birch S, Hesselink JK, Jonkman FA, Hekker TA, Bos A.
Foundation for the Study of Traditional East Asian Medicine, Amsterdam, The Netherlands.

Overview and methods: This paper discusses those medical conditions in which clinical trials of acupuncture have been conducted, and where meta-analyses or systematic reviews have been published. It focuses on the general conclusions of these reviews by further examining official reviews conducted in the United States, United Kingdom, Europe, and Canada each of which examined available systematic reviews. While all reviews agree that the methodological rigor of acupuncture clinical trials has generally been poor and that higher quality clinical trials are necessary, this has not completely hampered the interpretation of the results of these clinical trials. In some conditions the evidence of efficacy has clearly reached a sufficient critical mass from enough well-designed studies to draw clear conclusions; for the rest, the evidence is difficult to clearly interpret. This paper also examines conclusions from the same international reviews on the safety and adverse effects of acupuncture. Here, conclusions are more easily drawn and there is good agreement about the safety of acupuncture. Results and conclusions: General international agreement has emerged that acupuncture appears to be effective for postoperative dental pain, postoperative nausea and vomiting, and chemotherapy-related nausea and vomiting. For migraine, low-back pain, and temporomandibular disorders the results are considered positive by some and difficult to interpret by others. For a number of conditions such as fibromyalgia, osteoarthritis of the knee, and tennis elbow the evidence is considered promising, but more and better quality research is needed. For conditions such as chronic pain, neck pain, asthma, and drug addiction the evidence is considered inconclusive and difficult to interpret. For smoking cessation, tinnitus, and weight loss the evidence is usually regarded as negative. Reviews have concluded that while not free from serious adverse events, they are rare and that acupuncture is a relatively safe procedure.

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Pain. 2004 Jun;109(3):233-41.
Relationship between changes in coping and treatment outcome in patients with Fibromyalgia Syndrome.
Nielson WR, Jensen MP.
Department of Medicine (Division of Rhematolody), University of Western Ontario, London, Ont. Canada. warren.nielson@sjhc.london.on.ca

The present study utilized a sample of 198 individuals with Fibromyalgia Syndrome (FMS) to examine the association between treatment process variables (beliefs, coping strategies) and treatment outcomes (pain severity, activity level, emotional distress and life interference) related to a 4-week multidisciplinary fibromyalgia treatment program. Multiple regression analyses were utilized to evaluate these relationships pretreatment to posttreatment as well as from pretreatment to 3- and 6-month follow-ups. The results indicated that outcomes were most closely related to: (1) an increased sense of control over pain, (2) a belief that one is not necessarily disabled by FM, (3) a belief that pain is not necessarily a sign of damage, (4) decreased guarding, (5) increased use of exercise, (6) seeking support from others, (7) activity pacing and (8) use of coping self-statements. These findings are consistent with a cognitive-behavioural model of fibromyalgia, and suggest targets for therapeutic change.

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Holist Nurs Pract. 2004 May-Jun;18(3):142-51.
Touch the pain away: new research on therapeutic touch and persons with fibromyalgia syndrome.
Denison B.
Wichita State University and the Kansas Heart Hospital, Wichita, KS, USA. bdenison@sbcusa.com

This pilot study tested the effectiveness of 6 therapeutic touch treatments on the experience of pain and quality of life for persons with fibromyalgia syndrome. Its findings support that subjects who received therapeutic touch had a statistically significant decrease in pain for each pretherapeutic to posttherapeutic touch treatment, as well as significant improvement in quality of life from pre-first to pre-sixth treatment. Therapeutic touch may be an effective treatment for relieving pain and improving quality of life in this specific population of persons with fibromyalgia syndrome.

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J Int Med Res. 2004 May-Jun;32(3):263-7.
A new treatment modality for fibromyalgia syndrome: hyperbaric oxygen therapy.
Yildiz S, Kiralp MZ, Akin A, Keskin I, Ay H, Dursun H, Cimsit M.
GATA Haydarpasa Military Hospital, Istanbul, Turkey. senolyildiz@hotmail.com

Fibromyalgia syndrome (FMS) is characterized by longstanding multifocal pain with generalized allodynia/hyperalgesia. There are several treatment methods but none has been specifically approved for this application. We conducted a randomized controlled study to evaluate the effect of hyperbaric oxygen (HBO) therapy in FMS (HBO group: n = 26; control group: n = 24). Tender points and pain threshold were assessed before, and after the first and fifteenth sessions of therapy. Pain was also scored on a visual analogue scale (VAS). There was a significant reduction in tender points and VAS scores and a significant increase in pain threshold of the HBO group after the first and fifteenth therapy sessions. There was also a significant difference between the HBO and control groups for all parameters except the VAS scores after the first session. We conclude that HBO therapy has an important role in managing FMS.

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Pharmacotherapy. 2004 May;24(5):621-9.
Treatment of pain syndromes with venlafaxine.
Grothe DR, Scheckner B, Albano D.
Global Medical Communications, Neuroscience, Wyeth Pharmaceuticals, Collegeville, Pennsylvania 19426, USA.

Major depressive disorder (MDD) and anxiety disorders such as generalized anxiety disorder (GAD) are often accompanied by chronic painful symptoms. Examples of such symptoms are backache, headache, gastrointestinal pain, and joint pain. In addition, pain generally not associated with major depression or an anxiety disorder, such as peripheral neuropathic pain (e.g., diabetic neuropathy and postherpetic neuralgia), cancer pain, and fibromyalgia, can be challenging for primary care providers to treat. Antidepressants that block reuptake of both serotonin and norepinephrine, such as the tricyclic antidepressants (e.g., amitriptyline), have been used to treat pain syndromes in patients with or without comorbid MDD or GAD. Venlafaxine, a serotonin and norepinephrine reuptake inhibitor, has been safe and effective in animal models, healthy human volunteers, and patients for treatment of various pain syndromes. The use of venlafaxine for treatment of pain associated with MDD or GAD, neuropathic pain, headache, fibromyalgia, and postmastectomy pain syndrome is reviewed. Currently, no antidepressants, including venlafaxine, are approved for the treatment of chronic pain syndromes. Additional randomized, controlled trials are necessary to fully elucidate the role of venlafaxine in the treatment of chronic pain.

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J Rheumatol. 2004 Apr;31(4):783-4.
No effect of antiviral (valacyclovir) treatment in fibromyalgia: a double blind, randomized study.
Kendall SA, Schaadt ML, Graff LB, Wittrup I, Malmskov H, Krogsgaard K, Bartels EM, Bliddal H, Danneskiold-Samsoe B.
Parker Institute, Department of Rheumatology, Frederiksberg Hospital, Frederiksberg, Denmark.

OBJECTIVE: To investigate the effect of an antiviral compound, valacyclovir, on pain and tenderness in patients with the fibromyalgia (FM) syndrome. METHODS: Sixty patients were randomized into a double blind, placebo controlled 6 week trial. Primary outcome was pain intensity change (on visual analog scale). Secondary outcome measures were tender points (myalgic score) and Fibromyalgia Impact Questionnaire (FIQ). RESULTS: Fifty-two patients completed the study. The numbers of dropouts due to adverse events were equal in valacyclovir (2) and placebo (2) groups. The effect of valacyclovir on pain and tenderness and FIQ did not differ from placebo. CONCLUSION: Valacyclovir cannot be recommended as a therapy for FM at this point.

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Arthritis Rheum. 2004 Apr 15;51(2):184-92.
Long-term efficacy of therapy in patients with fibromyalgia: a physical exercise-based program and a cognitive-behavioral approach.
Redondo JR, Justo CM, Moraleda FV, Velayos YG, Puche JJ, Zubero JR, Hernandez TG, Ortells LC, Pareja MA.
Instituto Provincial de Rehabilitacion, Hospital Universitario Gregorio Maranon, Madrid, Spain. javierrivera@ser.es

OBJECTIVE: To analyze the long-term efficacy of 2 interventions for female fibromyalgia (FM) patients: 1) cognitive-behavioral therapy (CBT), and 2) a physical exercise (PE)-based strategy. METHODS: We conducted a prospective, long-term, randomized, parallel clinical trial. The outcome variables are physical activity, aerobic capacity, and results of the Fibromyalgia Impact Questionnaire (FIQ), Short Form 36, Beck Anxiety and Depression Inventory, Chronic Pain Self-Efficacy Scale, and Chronic Pain Coping Inventory. All were measured at baseline, posttreatment, 6 months, and 1 year. The duration of both treatments was 8 weeks. RESULTS: Some items of the FIQ and some strategies to cope with pain improved significantly in both groups after treatment. All variables measuring functional capacity improved significantly in the PE group, whereas only physical activity of the vertebral column improved in the CBT group. There were no differences in anxiety, depression, and self efficacy after treatment in either group. After 1 year of followup, most of the parameters had returned to baseline values in both groups. However, in the PE group, functional capacity remained significantly better. CONCLUSIONS: PE and CBT improve clinical manifestations in FM patients only for short periods of time. Improvement in self efficacy and physical fitness are not associated with improvement in clinical manifestations.

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Schmerz. 2004 Apr;18(2):118-24.
[Fibromyalgia]
[Article in German]
Biewer W, Conrad I, Hauser W.
Internistisch-rheumatologische Schwerpunktpraxis, Saarbrucken. Drwerner@biewer.com

Within clinical practice fibromyalgia is diagnosed according to the classification criteria of the American College of Rheumatology. The examination of the tender points is still to be standardized. By using additional diagnostic criteria fibromyalgia changes into a polysymptomatic syndrom with multiple functional and psychic symptoms. The prevalence of FMS is estimated to range between 1,3-4,8% in the general population. Relative hypocortisolism, sensory hypervigilance, adverse life experiences and psychiatric disorders are discussed as main pathophysiological mechanisms. There are no evidence-based guidelines of scientific societies for the management of fibromyalgia available. Patient education, medical training therapy, physical therapy (heat or cold) and relaxation therapy are recommended. There is a moderate evidence for the effectiveness of tricyclic antidepressants and aerobic training. The effectiveness of multicomponent therapy in fibromyalgia is still to be demonstrated.

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Eur J Pain. 2004;8(2):163-71.
Peripheral effects of needle stimulation (acupuncture) on skin and muscle blood flow in fibromyalgia.
Sandberg M, Lindberg LG, Gerdle B.
Department of Biomedical Engineering, Linkoping University, Linkoping SE-581 85, Sweden.

Acupuncture has become a widely used treatment modality in various musculoskeletal pain conditions. Acupuncture is also shown to enhance blood flow and recovery in surgical flaps. The mechanisms behind the effect on blood flow were suggested to rely on vasoactive substances, such as calcitonin gene-related peptide, released from nociceptors by the needle stimulation. In a previous study on healthy subjects, one needle stimulation into the anterior tibial muscle was shown to increase both skin and muscle blood flow. The aim of this study was to examine the effect of needle stimulation on local blood flow in the anterior tibial muscle and overlying skin in patients suffering from a widespread chronic pain condition. Fifteen patients with fibromyalgia (FM) participated in the study. Two modes of needling, deep muscle stimulation and subcutaneous needle insertion were performed at the upper anterior aspect of the tibia, i.e., in an area without focal pathology or ongoing pain in these patients. Blood flow changes were assessed non-invasively by photoplethysmography (PPG). The results of the present study were partly similar to those earlier found at a corresponding site in healthy female subjects, i.e., deep muscle stimulation resulted in larger increase in skin blood flow (mean (SE)): 62.4% (13.0) and muscle blood flow: 93.1% (18.6), compared to baseline, than did subcutaneous insertion (mean (SE) skin blood flow increase: 26.4% (6.2); muscle blood flow increase: 46.1% (10.2)). However, in FM patients subcutaneous needle insertion was followed by a significant increase in both skin and muscle blood flow, in contrast to findings in healthy subjects where no significant blood flow increase was found following the subcutaneous needling. The different results of subcutaneous needling between the groups (skin blood flow: [Formula: see text]; muscle blood flow: [Formula: see text] ) may be related to a greater sensitivity to pain and other somatosensory input in FM.

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Ann Rheum Dis. 2004 Mar;63(3):290-6.
Fibromyalgia: a randomised, controlled trial of a treatment programme based on self management.
Cedraschi C, Desmeules J, Rapiti E, Baumgartner E, Cohen P, Finckh A, Allaz AF, Vischer TL.
Division of Rheumatology, Geneva University Hospital, 1211 Geneva, Switzerland. Christine.Cedraschi@hcuge.ch

OBJECTIVE: To evaluate the efficacy of a treatment programme for patients with fibromyalgia (FM) based on self management, using pool exercises and education. METHODS: Randomised controlled trial with a 6 month follow up to evaluate an outpatient multidisciplinary programme; 164 patients with FM were allocated to an immediate 6 week programme (n = 84) or to a waiting list control group (n = 80). The main outcomes were changes in quality of life, functional consequences, patient satisfaction and pain, using a combination of patient questionnaires and clinical examinations. The questionnaires included the Fibromyalgia Impact Questionnaire (FIQ), Psychological General Well-Being (PGWB) index, regional pain score diagrams, and patient satisfaction measures. RESULTS: 61 participants in the treatment group and 68 controls completed the programme and 6 month follow up examinations. Six months after programme completion, significant improvements in quality of life and functional consequences of FM were seen in the treatment group as compared with the controls and as measured by scores on both the FIQ (total score p = 0.025; fatigue p = 0.003; depression p = 0.031) and PGWB (total score p = 0.032; anxiety p = 0.011; vitality p = 0.013,). All four major areas of patient satisfaction showed greater improvement in the treatment than the control groups; between-group differences were statistically significant for "control of symptoms", "psychosocial factors", and "physical therapy" No change in pain was seen. CONCLUSION: A 6 week self management based programme of pool exercises and education can improve the quality of life of patients with FM and their satisfaction with treatment. These improvements are sustained for at least 6 months after programme completion.

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Am J Med. 2003 May;114(7):537-45.
Tramadol and acetaminophen combination tablets in the treatment of fibromyalgia pain: a double-blind, randomized, placebo-controlled study.
Bennett RM, Kamin M, Karim R, Rosenthal N.
Department of Medicine, Oregon Health and Science University, Portland 97201, USA. bennetro@ohsu.edu

PURPOSE: To evaluate the efficacy and safety of a combination analgesic tablet (37.5 mg tramadol/325 mg acetaminophen) for the treatment of fibromyalgia pain. METHODS: This 91-day, multicenter, double-blind, randomized, placebo-controlled study compared tramadol/acetaminophen combination tablets with placebo. The primary outcome variable was cumulative time to discontinuation (Kaplan-Meier analysis). Secondary measures at the end of the study included pain, pain relief, total tender points, myalgia, health status, and Fibromyalgia Impact Questionnaire scores. RESULTS: Of the 315 subjects who were enrolled in the study, 313 (294 women [94%], mean [+/- SD] age, 50 +/- 10 years) completed at least one postrandomization efficacy assessment (tramadol/acetaminophen: n = 156; placebo: n = 157). Discontinuation of treatment for any reason was less common in those treated with tramadol/acetaminophen compared with placebo (48% vs. 62%, P = 0.004). Tramadol/acetaminophen-treated subjects also had significantly less pain at the end of the study (53 +/- 32 vs. 65 +/- 29 on a visual analog scale of 0 to 100, P <0.001), and better pain relief (1.7 +/- 1.4 vs. 0.8 +/- 1.3 on a scale of -1 to 4, P <0.001) and Fibromyalgia Impact Questionnaire scores (P = 0.008). Indexes of physical functioning, role-physical, body pain, health transition, and physical component summary all improved significantly in the tramadol/acetaminophen-treated subjects. Discontinuation due to adverse events occurred in 19% (n = 29) of tramadol/acetaminophen-treated subjects and 12% (n = 18) of placebo-treated subjects (P = 0.09). The mean dose of tramadol/acetaminophen was 4.0 +/- 1.8 tablets per day. CONCLUSION: A tramadol/acetaminophen combination tablet was effective for the treatment of fibromyalgia pain without any serious adverse effects.

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J Natl Med Assoc. 2003 Apr;95(4):278-85.
A practical approach to fibromyalgia.
Cymet TC.
Johns Hopkins School of Medicine, Section Head, Family Medicine, Sinai Hospital of Baltimore, Maryland 21215, USA.

Fibromyalgia is the name given to a collection of symptoms with no clear physiologic cause, The constellation of symptoms are clearly recognizable as a distinct pathologic entity. The diagnosis is made through clinical observations made by the examiner. Differential diagnosis must include other somatic syndromes as well as disease entities like hepatitis, hypothyroidism, diabetes mellitus, electrolyte imbalance, multiple sclerosis, and cancer. Diagnostic criteria are given as guidelines for the diagnosis, not as absolute requirements. Treatment of this condition remains individualized and relies heavily on having a therapeutic relationship with a provider. Treatment of this syndrome needs to be looked at as an ongoing process. Goal oriented treatment aimed at maintaining specific functions can be directed at helping a patient get restorative sleep, alleviating the somatic pains that ail the patient, keeping a person productive, regulating schedules or through goal oriented agreements made with the patient. Since this syndrome is chronic and may effect all areas of a persons functioning the family and social support system of the person being treated need to be evaluated. Patients often seek alternative medical treatments for this problem including diet therapy, acupuncture, and herbal therapy. Treatment must involve more than just the symptoms presented and the patient can only be treated successfully if they are willing to work at changing their own perceptions, and ways of relating to stressors in their world.

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Arthritis Rheum. 2003 Jun 15;49(3):314-20.
Operant behavioral treatment of fibromyalgia: a controlled study.
Thieme K, Gromnica-Ihle E, Flor H.
Department of Psychosomatic and Psychotherapeutic Medicine, University of Heidelberg, Central Institute of Mental Health, Mannheim, Germany. thieme@zi-mannheim.de

OBJECTIVE: To evaluate the efficacy of operant pain treatment for fibromyalgia syndrome (FMS) in an inpatient setting. METHODS: Sixty-one patients who fulfilled the American College of Rheumatology criteria for FMS were randomly assigned to the operant pain treatment group (OTG; n = 40) or a standardized medical program with an emphasis on physical therapy (PTG; n = 21). Pain assessments were performed before, immediately after, 6 months after, and 15 months after treatment. RESULTS: The OTG patients reported a significant and stable reduction in pain intensity, interference, solicitous behavior of the spouse, medication, pain behaviors, number of doctor visits, and days at a hospital as well as an increase in sleeping time. Sixty-five percent of the OTG compared with none of the patients in the PTG showed clinically significant improvement. CONCLUSION: These results suggest that operant pain treatment provided in an inpatient setting is an effective treatment for FMS, whereas a purely somatically oriented program may lead to a deterioration of the pain problem.

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Medsurg Nurs. 2003 Jun;12(3):145-59, 190; quiz 160.
Fibromyalgia: evolving concepts and management in primary care settings.
Lash AA, Ehrlich-Jones L, McCoy D.
Northern Illinois University School of Nursing, DeKalb, IL, USA.

During the last 10 years, fibromyalgia (FM) research shifted focus from psychological and behavioral issues to sleep, nociception, and neuroendocrinology. Although there are still no definitive markers of the disease, a barrage of studies in physiological, psychological, and behavioral sciences have now dispelled the belief that FM is solely psychosomatic. Studies in the late 1990s as well as in the early part of the current decade reaffirm earlier research that sleep abnormalities and alterations in nociception may partly be responsible for FM. While sleep research shows that FM patients typically are deficient in stage IV (restorative) sleep, most current studies in nociception now affirm that patients with FM exhibit low serum serotonin in combination with increased substance P levels in the cerebrospinal fluid. Although there is still no cure, treatment aimed at promoting sleep, interrupting nociception, and actively involving patient and family in FM management can bring lifetime control for the disease.

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IDrugs. 2003 Jul;6(7):668-73.
Fibromyalgia Syndrome: An overview of potential drug targets.
Briley M, Moret C.
NeuroBiz Consulting and Communications, Les Grezes, La Verdarie, 81100 Castres, France. mike.briley@neurobiz.com

Fibromyalgia syndrome (FMS) is a chronic disease of widespread and debilitating pain. The cause of FMS is unknown and its risk factors are poorly understood. It occurs frequently in the general population where it is often co-morbid with other rheumatoid and pain disorders, and psychiatric disorders such as anxiety and depression, making diagnosis particularly difficult. Several types of drugs are used to treat FMS, but none are specifically approved for this indication. FMS appears to be strongly associated with depression or at least with some symptoms of depression, and antidepressants appear to be effective in the treatment of this disorder. The advent of new classes of antidepressants with fewer side effects than older drugs has suggested new avenues of therapy for patients diagnosed with FMS.

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Clin J Pain. 2002 Nov-Dec;18(6 Suppl):S147-54.
Botulinum toxin in pain management of soft tissue syndromes.
Smith HS, Audette J, Royal MA.
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.

Botulinum toxin is approved for the treatment of muscle overactivity associated with several disorders, such as dystonias. However, control of muscle spasm often results in pain relief as well. Effective relief of pain associated with myofascial pain syndrome provides a model for the use of botulinum toxin to relieve pain associated with other types of soft-tissue syndromes, such as fibromyalgia. Although the mechanisms that trigger the pain in these syndromes vary, recent data suggest that a central neuroplastic mechanism may contribute to many complex pain syndromes. Botulinum toxin therapy may be particularly useful in soft-tissue syndromes that are refractory to traditional treatment with physical therapy, electrical muscle stimulation, and other approaches. Although not used as first-line therapy for pain relief, botulinum toxin may decrease pain long enough for patients to resume more conservative therapy. A primary benefit of treatment with botulinum toxin is its long duration of action. Several studies have demonstrated the efficacy of botulinum toxin types A and B in treating several neuropathic pain disorders. Proper patient selection, injection technique, and dosing are critical to obtaining the best outcomes in managing pain with botulinum toxin. Additional study is needed to better characterize its use for the treatment of pain.

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Best Pract Res Clin Rheumatol. 2003 Aug;17(4):667-83.
Complementary and alternative medicine in fibromyalgia and related syndromes.
Holdcraft LC, Assefi N, Buchwald D.
Department of Psychiatry and Behavioral Sciences, Harborview Medical Center, University of Washington School of Medicine, Box 359797, 325 Ninth Ave, 98104-2499, Seattle, WA, USA

Complementary and alternative medicine (CAM) has gained increasing popularity, particularly among individuals with fibromyalgia syndrome (FMS) for which traditional medicine has generally been ineffective. A systematic review of randomized controlled trials (RCTs) and non-RCTs on CAM studies for FMS was conducted to evaluate the empirical evidence for their effectiveness. Few RCTs achieved high scores on the CONSORT, a standardized evaluation of the quality of methodology reporting. Acupuncture, some herbal and nutritional supplements (magnesium, SAMe) and massage therapy have the best evidence for effectiveness with FMS. Other CAM therapies have either been evaluated in only one RCT with positive results (Chlorella, biofeedback, relaxation), in multiple RCTs with mixed results (magnet therapies), or have positive results from studies with methodological flaws (homeopathy, botanical oils, balneotherapy, anthocyanidins, dietary modifications). Lastly, other CAM therapies have neither well-designed studies nor positive results and are not currently recommended for FMS treatment (chiropractic care).

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Best Pract Res Clin Rheumatol. 2003 Aug;17(4):649-65.
Psychological and behavioural therapies in fibromyalgia and related syndromes.
Williams DA.
University of Michigan, Room 5510D, MSRB-1, 1150 W. Medical Center Dr., 48109-0680, Ann Arbor, MI, USA

Psychological and behavioural therapies are being applied to patients with fibromyalgia (FM) with increasing frequency. The rationale for including psychological therapies is not for the treatment of co-morbid mood disorders, but rather to manage the many non-psychiatric psychological and social factors that comprise pain perception and its maintenance. This chapter reviews the involvement of mental health professionals under both the biomedical and biopsychosocial models of illness and describes cognitive behavioural therapy (CBT), a commonly used form of psychological therapy in the management of chronic pain conditions. The empirical literature supports the use of CBT with FM in producing modest outcomes across multiple domains, including pain, fatigue, physical functioning and mood. Greatest benefits appear to occur when CBT is used adjunctively with exercise. While the benefits are not curative or universally obtained by all patients, the benefits are sufficiently large to encourage future refinement of CBT for this population of patients.

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Best Pract Res Clin Rheumatol. 2003 Aug;17(4):629-47.
Physical exercise in fibromyalgia and related syndromes.
Mannerkorpi K, Iversen MD.
Department of Rheumatology and Inflammation Research, Goteborg University, and Department of Health Sciences, Division of Physical Therapy, Lulea University of Technology, Sweden

Fibromyalgia and related syndromes are characterized by chronic pain and fatigue. This chapter identifies the types of exercise that are effective for these patients and provides recommendations for exercise prescriptions. Based on a systematic review of randomized controlled studies of exercise, we suggest that low-intensity aerobic exercise, such as walking, can improve function and symptoms. Aerobic exercise performed twice a week at moderate intensity can improve aerobic capacity and reduce tenderness. Pool exercise can improve function, distress and symptoms. Strength training at adequate load can improve strength without exacerbation of symptoms. Most patients tolerate low-intensity exercise. High-intensity exercise should be undertaken with caution. Due to the large variability of functioning and symptom severity in patient populations, exercise prescriptions should be individualized and should include a long-term plan to maximize functioning and wellbeing. Studies with larger populations, allowing subgroup analyses regarding benefits and adverse effects of programmes, are needed.

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Best Pract Res Clin Rheumatol. 2003 Aug;17(4):611-27.
Pharmacological therapies in fibromyalgia.
Rao SG, Bennett RM.
Cypress Bioscience, 4350 Executive Drive, Suite 325, 92121, San Diego, CA, USA

The fibromyalgia syndrome (FMS) is a common, chronic, widespread pain disorder that mainly affects middle-aged women. In addition to pain complaints, fatigue and disturbed sleep are symptoms frequently reported by these patients. Many FMS patients also meet diagnostic criteria for mood disorders (e.g. depression) as well as other so-called 'functional somatic syndromes', including irritable bowel syndrome, temporomandibular joint disorder, and subsets of chronic low-back pain. A wide variety of medications are used to manage the eclectic symptomatology of FMS patients, although relatively few have been rigorously tested. This chapter provides a contemporary update of the state of FMS pharmacotherapy, with an emphasis on compounds that have been tested in double-blind, randomized, controlled trials. Particular attention is paid to the efficacy of these therapies on the associated symptoms and co-morbid syndromes commonly seen in FMS patients.

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Scand J Rheumatol. 2002;31(5):306-10.
Six- and 24-month follow-up of pool exercise therapy and education for patients with fibromyalgia.
Mannerkorpi K, Ahlmen M, Ekdahl C.
Department of Physical Therapy, Sahlgrenska University Hospital, Goteborg, Sweden. Kaisa.Mannerkorpi@vgregion.se

OBJECTIVE: To follow patients with fibromyalgia six and 24 months after they finished a six-month treatment programme. The programme comprised pool exercise therapy, adjusted to the patients' limitations, and education based on their health problems. METHODS: Twenty-six patients were examined six and 24 months after the completion of the treatment programme with the Fibromyalgia Impact Questionnaire (FIQ), SF-36, the 6-minute walk test, and the Grippit measure. The values obtained at the follow-up examinations were compared with the baseline and post-treatment values. RESULTS: As compared with baseline, symptom severity (FIQ, SF-36), physical function (FIQ, SF-36, 6-minute walk test) and quality of life (SF-36) still showed improvements six months after the completion of treatment (p <0.05). Pain (FIQ, SF-36), fatigue (FIQ, SF-36), walking ability, and social function (SF-36) still showed improvements 2 years after the completion of the programme as compared with the baseline values (p < 0.05). No significant changes were found for these variables, when the values obtained at the two follow-up examinations were compared with those of the post-treatment examination. CONCLUSIONS: Improvements in symptom severity, physical function and social function were still found six and 24 months after the completed treatment programme.

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Altern Med Rev. 2002 Oct;7(5):389-403.
Intravenous nutrient therapy: the "Myers' cocktail".
Gaby AR.

Building on the work of the late John Myers, MD, the author has used an intravenous vitamin-and-mineral formula for the treatment of a wide range of clinical conditions. The modified "Myers' cocktail," which consists of magnesium, calcium, B vitamins, and vitamin C, has been found to be effective against acute asthma attacks, migraines, fatigue (including chronic fatigue syndrome), fibromyalgia, acute muscle spasm, upper respiratory tract infections, chronic sinusitis, seasonal allergic rhinitis, cardiovascular disease, and other disorders. This paper presents a rationale for the therapeutic use of intravenous nutrients, reviews the relevant published clinical research, describes the author's clinical experiences, and discusses potential side effects and precautions.

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Clin J Pain. 2002 Sep-Oct;18(5):324-36.
Systematic review of randomized controlled trials of nonpharmacological interventions for fibromyalgia.
Sim J, Adams N.
Primary Care Sciences Research Center, Keele University, Keele, Staffordshire, UK. pta05@keele.ac.uk

OBJECTIVE: Little is known of the effectiveness of nonpharmacological interventions for fibromyalgia syndrome (FMS). The authors therefore carried out a systematic review from 1980 to May 2000 of randomized controlled trials (RCTs) of nonpharmacological interventions for FMS. METHOD: A search of computerized databases was supplemented by hand searching of bibliographies of key publications. The methodological quality of studies included in the review was evaluated independently by two researchers according to a set of formal criteria. Discrepancies in scoring were resolved through discussion. RESULTS: The review yielded 25 RCTs, and the main categories of interventions tested in the studies were exercise therapy, educational intervention, relaxation therapy, cognitive-behavioral therapy, acupuncture, and forms of hydrotherapy. Methodological quality of studies was fairly low (mean score = 49.5/100). Most studies had small samples (median for individual treatment groups after randomization = 20), and the mean power of the studies to detect a medium effect ( > or = 0.5) was 0.36. Sixteen studies had blinded outcome assessment, but patients were blinded in only 6 studies. The median longest follow-up was 16 weeks. Statistically significant between-group differences on at least one outcome variable were reported in 17 of the 24 studies. CONCLUSIONS: The varying combinations of interventions studied in the RCTs and the wide range of outcome measures used make it hard to form conclusions across studies. Strong evidence did not emerge in respect to any single intervention, though preliminary support of moderate strength existed for aerobic exercise. There is a need for larger, more methodologically rigorous RCTs in this area.

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Rheumatol Int. 2002 Sep;22(5):188-93. Epub 2002 Jul 06.
Effects of low power laser and low dose amitriptyline therapy on clinical symptoms and quality of life in fibromyalgia: a single-blind, placebo-controlled trial.
Gur A, Karakoc M, Nas K, Cevik R, Sarac J, Ataoglu S.
Department of Physical Medicine and Rehabilitation, Dicle University School of Medicine, 21280 Diyarbakir, Turkey. alig@dicle.edu.tr

The purpose of this study was to examine the effectiveness of low power laser (LPL) and low-dose amitriptyline therapy and to investigate effects of these therapy modalities on clinical symptoms and quality of life (QOL) in patients with fibromyalgia (FM). Seventy-five patients with FM were randomly allocated to active gallium-arsenide (Ga-As) laser (25 patients), placebo laser (25 patients), and amitriptyline therapy (25 patients). All groups were evaluated for the improvement in pain, number of tender points, skin fold tenderness, morning stiffness, sleep disturbance, muscular spasm, and fatigue. Depression was evaluated by a psychiatrist according to the Hamilton Depression Rate Scale and DSM IV criteria. Quality of life of the FM patients was assessed according to the Fibromyalgia Impact Questionnaire (FIQ). In the laser group, patients were treated for 3 min at each tender point daily for 2 weeks, except weekends, at each point with approximately 2 J/cm(2) using a Ga-As laser. The same unit was used for the placebo treatment, for which no laser beam was emitted. Patients in the amitriptyline group took 10 mg daily at bedtime throughout the 8 weeks. Significant improvements were indicated in all clinical parameters in the laser group (P = 0.001) and significant improvements were indicated in all clinical parameters except fatigue in the amitriptyline group (P = 0.000), whereas significant improvements were indicated in pain (P = 0.000), tender point number (P = 0.001), muscle spasm (P = 0.000), morning stiffness (P = 0.002), and FIQ score (P = 0.042) in the placebo group. A significant difference was observed in clinical parameters such as pain intensity (P = 0.000) and fatigue (P = 0.000) in favor of the laser group over the other groups, and a significant difference was observed in morning stiffness (P = 0.001), FIQ (P = 0.003), and depression score (P = 0.000) after therapy. A significant difference was observed in morning stiffness (P = 0.001), FIQ (P = 0.003), and depression (P = 0.000) in the amitriptyline group compared to the placebo group after therapy. Additionally, a significant difference was observed in depression score (P = 0.000) in the amitriptyline group in comparison to the laser group after therapy. Our study suggests that both amitriptyline and laser therapies are effective on clinical symptoms and QOL in fibromyalgia and that Ga-As laser therapy is a safe and effective treatment in cases with FM. Additionally, the present study suggests that the Ga-As laser therapy can be used as a monotherapy or as a supplementary treatment to other therapeutic procedures in FM.

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Curr Pain Headache Rep. 2002 Oct;6(5):379-83.
Pain treatment with acupuncture for patients with fibromyalgia.
Targino RA, Imamura M, Kaziyama HH, Souza LP, Hsing WT, Imamura ST.
Division of Physical Medicine, Department of Orthopedics and Traumatology, University of Sao Paulo School of Medicine, Ave. Giovanni Gronchi, 1106 San Paulo, Brazil. ucklrsu@ucl.ac.uk

Fibromyalgia is a chronic, painful musculoskeletal syndrome of unknown etiopathogenesis. In addition to medicamentous and physical and psychologic therapies, several other adjunct therapies have been used as alternatives in the attempt to obtain analgesia and decrease the symptoms that are characteristic of this problem. This article presents a literary review on the use of acupuncture as an adjunct or chief treatment for patients with fibromyalgia, comparing it with an ongoing clinical experience that has been carried out at Hospital das Clinicas in the city of Sao Paulo. The results were found by applying traditional acupuncture, which demonstrated positive rates in the Visual Analogue Scale, myalgic index, number of tender points, and improvement in quality of life based on the SF-36 questionnaire.

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BMJ. 2002 Jul 27;325(7357):185.
Prescribed exercise in people with fibromyalgia: parallel group randomised controlled trial.
Richards SC, Scott DL.
Poole Hospital NHS Trust, Poole, Dorset BH15 2JB. srichards@poole-tr.swest.nhs.uk

OBJECTIVES: To evaluate cardiovascular fitness exercise in people with fibromyalgia. DESIGN: Randomised controlled trial. Setting: Hospital rheumatology outpatients. Group based classes took place at a "healthy living centre." PARTICIPANTS: 132 patients with fibromyalgia. INTERVENTIONS: Prescribed graded aerobic exercise (active treatment) and relaxation and flexibility (control treatment). MAIN OUTCOME MEASURES: Participants' self assessment of improvement, tender point count, impact of condition measured by fibromyalgia impact questionnaire, and short form McGill pain questionnaire. RESULTS: Compared with relaxation exercise led to significantly more participants rating themselves as much or very much better at three months: 24/69 (35%) v 12/67 (18%), P=0.03. Benefits were maintained or improved at one year follow up when fewer participants in the exercise group fulfilled the criteria for fibromyalgia (31/69 v 44/67, P=0.01). People in the exercise group also had greater reductions in tender point counts (4.2 v 2.0, P=0.02) and in scores on the fibromyalgia impact questionnaire (4.0 v 0.6, P=0.07). CONCLUSIONS: Prescribed graded aerobic exercise is a simple, cheap, effective, and potentially widely available treatment for fibromyalgia.

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Cochrane Database Syst Rev. 2002;(3):CD003786.
Exercise for treating fibromyalgia syndrome.
Busch A, Schachter CL, Peloso PM, Bombardier C.
1121 College Drive, Saskatoon, Saskatchewan, Canada, S7N 0W3. angela.busch@usask.ca

BACKGROUND: Fibromyalgia (FMS) is a syndrome expressed by chronic widespread body pain which leads to reduced physical function and frequent use of health care services. Exercise training is commonly recommended as a treatment. OBJECTIVES: The objective of this systematic review was to examine the efficacy of exercise training as an treatment for FMS. SEARCH STRATEGY: We searched 6 electronic bibliographies for studies of exercise training in FMS: MEDLINE (1966-12/2000), CINAHL (1982-12/2000), HealthSTAR (1990-12/2000), Sports Discus (1975-05/2000), EMBASE (1974-05/2000) and the Cochrane Controlled Trials Register (2000, issue 4). We also reviewed the reference lists from identified articles including reviews and meta-analyses of treatment studies. SELECTION CRITERIA: Randomized trials focused on cardiorespiratory endurance, muscle strength and/or flexibility as treatment for FMS were selected. DATA COLLECTION AND ANALYSIS: Two reviewers independently identified trials meeting inclusion criteria, rated the methodologic quality using 2 standardized validated instruments, evaluated the adequacy of the exercise training stimulus using the American College of Sports Medicine (ACSM) criteria and evaluated the results. Disagreements were resolved through active discussion and consensus. High quality training studies had scores of 50% or greater on van Tulder methodologic criteria and met the minimum training standards of ACSM. Outcome variables were grouped into 7 constructs: pain, tender points, physical function, global well being, self efficacy, fatigue & sleep, and psychological function. Two reviewers independently extracted data on study characteristics, results and point estimates for selected variables, and used consensus to address discrepancies. MAIN RESULTS: Sixteen trials involving a total of 724 participants were assigned at random to: exercise intervention groups (n=379), control groups (n=277), or groups receiving an alternate treatment (n=68). Seven studies were high quality training studies: 4 aerobic training, 1 a mixture of aerobic, strength and flexibility training, 1 strength training and 2 with exercise training as part of a composite treatment. Flexibility protocols were never described in sufficient detail to allow evaluation. The four high quality aerobic training studies reported significantly greater improvements in the exercise groups versus control groups in aerobic performance (17.1% increase in aerobic performance with exercise versus 0.5% increase in the control groups), tender point pain pressure threshold (28.1% increase versus 7.0% decrease) and improvements in pain (11.4% decrease in pain versus 1.6% increase). Poor description of exercise protocols was common, with insufficient information on intensity, duration, frequency and mode of exercise. Adverse events were also poorly reported. REVIEWER'S CONCLUSIONS: Supervised aerobic exercise training has beneficial effects on physical capacity and FMS symptoms. Strength training may also have benefits on some FMS symptoms. Further studies on muscle strengthening and flexibility are needed. Research on the long-term benefit of exercise for FMS is needed.

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Rheum Dis Clin North Am. 2002 May;28(2):405-17.
The management of fibromyalgia-associated syndromes.
Silver DS, Wallace DJ.
Division of Rheumatology, Cedars-Sinai Medical Center, UCLA School of Medicine, Los Angeles, CA 90048, USA. davids@omcresearch.org

Most of the six million Americans with fibromyalgia have at least one associated syndrome which mandates specialized attention in addition to traditional therapeutic approaches. These include localized procedures, regional blocks, antiinflammatory or antimicrobial regimens, attention to non soft tissue sources of psychosocial distress, and classes of medicines not usually prescribed for fibromyalgia. The successful treatment of fibromyalgia-associated syndromes improves the symptoms, quality of life, and prognosis of fibromyalgia.

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Rheum Dis Clin North Am. 2002 May;28(2):291-304.
Nonpharmacologic management strategies in fibromyalgia.
Burckhardt CS.
School of Nursing, SN-5N, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97201, USA. burckhac@ohsu.edu

Clinicians using the results of the extant research base can take an optimistic view of the role of nonpharmacologic treatment strategies for fibromyalgia. There were no negative outcomes in any of the reviewed studies, although in a few studies the experimental treatment did not prove to be more effective than the attention control. Rather than viewing this negatively, one could look more closely at the attention control groups and attempt to better understand what they contained that worked as an active treatment. A number of trials include a follow-up component and all but one of them find maintenance of at least one outcome change. Maintenance of changes is more likely to occur when the patient continues to participate in the experimental activity long-term. Patients especially need strategies that help them continue in exercise regimens. Unlike cognitive skills strategies that once learned are likely to become part of a person's coping repertoire, both exercise and behavioral strategies, like progressive muscle relaxation, need to be performed on a consistent basis in order to have their effect. The goals of increased self-efficacy, symptom reduction, increased functional status and quality of life along with decreased inappropriate use of health care resources are realistic when patients persevere in their use of strategy combinations and receive support from their providers.

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J Am Osteopath Assoc. 2002 Jun;102(6):321-5.
Osteopathic manipulative treatment in conjunction with medication relieves pain associated with fibromyalgia syndrome: results of a randomized clinical pilot project.
Gamber RG, Shores JH, Russo DP, Jimenez C, Rubin BR.
Department of Osteopathic Manipulative Medicine, Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth 76107, USA. rgamber@hsc.unt.edu

Osteopathic physicians caring for patients with fibromyalgia syndrome (FM) often use osteopathic manipulative treatment (OMT) in conjunction with other forms of standard medical care. Despite a growing body of evidence on the efficacy of manual therapy for the treatment of selected acute musculoskeletal conditions, the role of OMT in treating patients with chronic conditions such as FM remains largely unknown. Twenty-four female patients meeting American College of Rheumatology criteria for FM were randomly assigned to one of four treatment groups: (1) manipulation group, (2) manipulation and teaching group, (3) moist heat group, and (4) control group, which received no additional treatment other than current medication. Participants' pain perceptions were assessed by use of pain thresholds measured at each of 10 bilateral tender points using a 9-kg dolorimeter, the Chronic Pain Experience Inventory, and the Present Pain Intensity Rating Scale. Patients' affective response to treatment was assessed using the Self-Evaluation Questionnaire. Activities of daily living were assessed using the Stanford Arthritis Center Disability and Discomfort Scales: Health Assessment Questionnaire. Depression was assessed using the Center for Epidemiological Studies Depression Scale. Significant findings between the four treatment groups on measures of pain threshold, perceived pain, attitude toward treatment, activities of daily living, and perceived functional ability were found. All of these findings favored use of OMT. This study found OMT combined with standard medical care was more efficacious in treating FM than standard care alone. These findings need to be replicated to determine if cost savings are incurred when treatments for FM incorporate nonpharmacologic approaches such as OMT.

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Rheumatol Int. 2002 Jun;22(2):56-9. Epub 2002 Mar 29.
The effects of balneotherapy on fibromyalgia patients.
Evcik D, Kizilay B, Gokcen E.
A.K.U. Arastirma Hastanesi, Fiziksel Tip ve Reh A.D. Inonu Bulvan; 03200 Afyon, Turkey. ezgievcik@ixir.c

Fibromyalgia syndrome (FMS) is a very common rheumatological diagnosis. There are various treatment modalities. This study was planned to investigate the effects of balneotherapy in the treatment of FMS. A total of 42 primary fibromyalgia patients diagnosed according to American College of Rheumatology criteria were included in the study. Their ages ranged between 30 and 55 years. Patients were randomly assigned to two groups. None of them had had a cardiovascular disease before. Group 1 n=22) received 20-min bathing, once a day and five times per week. Patients participated in the study for 3 weeks (total of 15 sessions). Group 2 (n=20) was accepted as the control group. Patients were evaluated by the number of tender points, Visual Analogue Scale for pain, Beck's Depression Index for depression, and Fibromyalgia Impact Questionnaire for functional capacity. Measurements were assessed initially, after the therapy, and at the end of the 6th month. In group 1, there were statistically significant differences in numbers of tender points, Visual Analogue scores, Beck's Depression Index, and Fibromyalgia Impact Questionnaire scores after the therapy program (P<0.001). Also, 6 months later in group 1, there was still an improvement in the number of tender points (P<0.001), Visual Analogue scores, and Fibromyalgia Impact Questionnaire (P<0.005). But there was not a statistical difference in Beck's Depression Index scores compared to the control group (P>0.05). Patients with FMS mostly complain about pain, anxiety, and the difficulty in daily living activities. This study shows that balneotherapy is effective and may be an alternative method in treating fibromyalgia patients.

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J Rheumatol. 2002 Jun;29(6):1280-6.
Improving physical functional status in patients with fibromyalgia: a brief cognitive
behavioral intervention.
Williams DA, Cary MA, Groner KH, Chaplin W, Glazer LJ, Rodriguez AM, Clauw DJ.
Department of Psychiatry, Georgetown University Medical Center, Washington, DC 20007, USA. daw27@georgetown.edu

OBJECTIVE: Sustained improvement in physical functional status was the primary goal of a brief, 6 session cognitive behavioral therapy (CBT) protocol for fibromyalgia (FM). METHODS: One hundred forty-five patients with FM were randomly assigned to either (1) standard medical care that included pharmacological management of symptoms and suggestions for aerobic fitness, or (2) the same standard medical treatment plus 6 sessions of CBT aimed at improving physical functioning. Outcome measures included the Medical Outcome Study Short Form-36 Physical Component Score and McGill ratings of pain. Outcomes were treated dichotomously using a preestablished criterion for clinically significant success based upon the reliability of change index from baseline to one year posttreatment. RESULTS: Twenty-five percent of the patients receiving CBT were able to achieve clinically meaningful levels of longterm improvement in physical functioning, whereas only 12% of the patients receiving standard care achieved the same level of improvement. There were no lasting differences on pain ratings between groups. CONCLUSION: Lasting improvements in physical functioning have been among the most difficult outcomes to obtain in studies of FM. These data suggest that the inclusion of CBT to a standard medical regimen for FM can favorably influence physical functioning in a subset of patients.

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J Rheumatol. 2002 May;29(5):1041-8.
A randomized controlled trial of muscle strengthening versus flexibility training in fibromyalgia.
Jones KD, Burckhardt CS, Clark SR, Bennett RM, Potempa KM.
School of Nursing, The Oregon Health and Science University, Portland 97201, USA. joneskim@ohsu.edu

OBJECTIVE: To determine the effectiveness of a muscle strengthening program compared to a stretching program in women with fibromyalgia (FM). METHODS: Sixty-eight women with FM were randomly assigned to a 12 week, twice weekly exercise program consisting of either muscle strengthening or stretching. Outcome measures included muscle strength (main outcome variable), flexibility, weight, body fat, tender point count, and disease and symptom severity scales. RESULTS: No statistically significant differences between groups were found on independent t tests. Paired t tests revealed twice the number of significant improvements in the strengthening group compared to the stretching group. Effect size scores indicated that the magnitude of change was generally greater in the strengthening group than the stretching group. CONCLUSION: Patients with FM can engage in a specially tailored muscle strengthening program and experience an improvement in overall disease activity, without a significant exercise induced flare in pain. Flexibility training alone also results in overall improvements, albeit of a lesser degree.

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Ann Pharmacother. 2002 Apr;36(4):707-12.
Serotonergic agents in the treatment of fibromyalgia syndrome.
Miller LJ, Kubes KL.
Pharmacy Department, Memorial Hermann Southwest Hospital, Houston, TX 77074, USA. lisa_miller@mhhs.org

OBJECTIVE: To evaluate literature that discusses the treatment of fibromyalgia syndrome (FMS) with agents that involve the neurotransmitter serotonin. DATA SOURCES: Biomedical literature accessed through MEDLINE (1966-August 2001) and International Pharmaceutical Abstracts. DATA SYNTHESIS: The cause and pathophysiology of FMS remain elusive, although abnormalities in the serotonin pathway have been implicated. Several serotonergic agents have been studied for use in FMS. Trials and case reports focusing on the use of newer agents: the selective serotonin reuptake inhibitors, venlafaxine and tramadol, were reviewed. CONCLUSIONS: Current research suggests that the serotonergic agents may reduce at least some of the symptoms of FMS. However, medications that act on multiple neurotransmitters may prove to be more effective in symptom management. Additional long-term studies are required in order to validate these results.

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J Rheumatol. 2002 Mar;29(3):582-7.
High or low intensity aerobic fitness training in fibromyalgia: does it matter?
van Santen M, Bolwijn P, Landewe R, Verstappen F, Bakker C, Hidding A, van Der Kemp D, Houben H, van der Linden S.
Department of Internal Medicine, University Hospital, Maastricht, The Netherlands. msa@sint.azm.nl

OBJECTIVE: To determine the efficacy of training in fibromyalgia (FM), we compared the effects of high intensity fitness training (HIF) and low intensity fitness training (LIF). METHODS: Thirty-seven female patients with FM were randomly allocated to either a HIF group (n = 19) or a LIF group (n = 18). Four patients (1 HIF group, 3 LIF group) refused to participate after randomization but before the start of the intervention. They were excluded from the analysis. Assessments were performed at baseline and after 20 weeks of HIF or LIF. The primary outcome was patient's global assessment [on 100 mm visual analog scale (VAS)]. Secondary endpoints were pain, number of tender points, total myalgic score, physical fitness, health status, and psychological distress. RESULTS: One patient in the HIF group (n = 18) and 2 in the LIF group (n = 15) stopped training sessions during the course of the study. Nine of 18 patients in the HIF group compared to 8 of 15 patients in the LIF group achieved a participation rate of 67% or more. Most important reasons for nonadherence were postexercise pain and fatigue, time consumption, and stress. The VAS for global well being improved slightly from 64 to 56 mm in the HIF group, and did not change in the LIF group (58 to 61 mm) (p = 0.07). The Wmax (physical fitness) changed modestly from 110 to 123 watt in the HIF group, and from 97 to 103 watt in the LIF group (p = 0.3). VAS for pain increased from 53 to 64 mm in the HIF group and from 52 to 54 mm in the LIF group. The large standard deviations around mean change in global assessments, number of tender points, total myalgic score, and psychological distress (by SCL-90) severely influenced the power to detect within- and between-group differences. Analysis limited to those patients who accomplished a high attendance rate (> 67%) showed similar results. CONCLUSION: High intensity physical fitness training compared to low intensity physical fitness training leads to only modest improvements in physical fitness and general well being in patients with FM, and does not positively affect psychological status and general health.

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J Rheumatol. 2002 Mar;29(3):575-81.
A randomized clinical trial comparing fitness and biofeedback training versus basic treatment in patients with fibromyalgia.
van Santen M, Bolwijn P, Verstappen F, Bakker C, Hidding A, Houben H, van der Heijde D, Landewe R, van der Linden S.
Department of Internal Medicine, University Hospital Maastricht, The Netherlands. msa@sint.azm.nl

OBJECTIVE: To compare the therapeutic effects of physical fitness training or biofeedback training with the results of usual care in patients with fibromyalgia (FM). METHODS: One hundred forty-three female patients with FM (American College of Rheumatology criteria) were randomized into 3 groups: a fitness program (n = 58), biofeedback training (n = 56), or controls (n = 29). Half the patients in the active treatment groups also received an educational program aimed at improving compliance. Assessments were done at baseline and after 24 weeks. The primary outcome was pain [visual analog scale (VAS)]. Other endpoints were the number of tender points, total myalgic score (dolorimetry), physical fitness, functional ability (Arthritis Impact Measurement Scale and Sickness Impact Profile), psychological distress (Symptom Checklist-90-Revised), patient global assessment (5 point scale), and general fatigue (VAS). RESULTS: Baseline scores were similar in all 3 groups. Altogether 25 (17.5%) patients dropped out; they were similarly distributed over all groups: 14 patients after randomization and 11 (8%) during the study. A true high impact level for fitness training was not attained by any patient. After treatment, no significant differences in change scores of any outcome were found between the groups (ANOVA, p > 0.05). All outcome measures showed large variations intra- and interindividually. The educational program did not result in higher compliance with training sessions (62% vs 71%). Analysis of the subgroup of subjects with a high attendance rate (> 67%) also showed no improvement. CONCLUSION: In terms of training intensity and maximal heart rates, the high impact fitness intervention had a low impact benefit. Therefore effectiveness of high impact physical fitness training cannot be demonstrated. Thus compared to usual care, the fitness training (i.e., low impact) and biofeedback training had no clear beneficial effects on objective or subjective patient outcomes in patients with FM.

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Drugs. 2002;62(4):577-92.
Management of fibromyalgia: what are the best treatment choices?
Forseth K KO, Gran JT.
Department of Rheumatology, Betanien Hospital, Skien, Norway. karin.forseth@tss.telemax.no

Fibromyalgia still represents an enigma to modern medicine and the aetiopathogenesis is far from explored. The management of patients with fibromyalgia is thus mostly based on empirical research, and only a few controlled studies have been performed. Basic drug therapy rests on the administration of amitriptyline and conventional analgesics. Such therapy should be initiated only after careful patient information and delineation of therapeutic goals are provided. Any drug therapy should be administered in combination with physical treatment and cognitive behavioural therapy. Because of the appearing contours of pathogenic mechanisms, hopefully a number of new drugs will be available to the patients with this complex pain syndrome in the near future.

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J Psychiatr Res. 2002 May-Jun;36(3):179-87.
The effect of guided imagery and amitriptyline on daily fibromyalgia pain: a prospective, randomized, controlled trial.
Fors EA, Sexton H, Gotestam KG.
Department of Psychiatry and Behavioural Medicine, Norwegian University of Science and Technology (NTNU), PO Box 3008 Lade, NO-7441, Trondheim, Norway. eafors@online.no

OBJECTIVE: The effectiveness of an attention distracting and an attention focusing guided imagery as well as the effect of amitriptyline on fibromyalgic pain was studied prospectively. METHODS: Fifty-five women with previously diagnosed fibromyalgia were monitored for daily pain (VAS) in a randomized, controlled clinical trial. One group received relaxation training and guided instruction in "pleasant imagery" (PI) in order to distract from the pain experience (n=17). Another group received relaxation training and attention imagery upon the "active workings of the internal pain control systems", "attention imagery" (AI) (n=21). The control group (CG) received treatment as usual (n=17). Patients were also randomly assigned to 50-mg amitriptyline/day or placebo. Some psychological and socio-demographic variables were also measured initially. The slopes of diary pain ratings over a 4-week period were used as the outcome measures. RESULTS: We found significant differences of the pain-slopes between the three psychological conditions (P=0.0001). The pleasant imagery (P<0.005), but not the attention imagery group's slope, declined significantly when compared with the control group (P>0.05). There was neither a difference between the amitriptyline and placebo slopes (main effects, P=0.98) nor a significant amitriptyline x psychological interaction (P=0.76). CONCLUSION: Pleasant imagery (PI) was an effective intervention in reducing fibromyalgic pain during the 28-day study period. Amitriptyline had no significant advantage over placebo during the study period.

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Lasers Med Sci. 2002;17(1):57-61.
Efficacy of low power laser therapy in fibromyalgia: a single-blind, placebo-controlled trial.
Gur A, Karakoc M, Nas K, Cevik R, Sarac J, Demir E.
Physical Medicine and Rehabilitation, School of Medicine, Dicle University, Diyarbakir, Turkey. alig@dicle.edu.tr

Low energy lasers are widely used to treat a variety of musculoskeletal conditions including fibromyalgia, despite the lack of scientific evidence to support its efficacy. A randomised, single-blind, placebo-controlled study was conducted to evaluate the efficacy of low-energy laser therapy in 40 female patients with fibromyalgia. Patients with fibromyalgia were randomly allocated to active (Ga-As) laser or placebo laser treatment daily for two weeks except weekends. Both the laser and placebo laser groups were evaluated for the improvement in pain, number of tender points, skinfold tenderness, stiffness, sleep disturbance, fatigue, and muscular spasm. In both groups, significant improvements were achieved in all parameters (p<0.05) except sleep disturbance, fatigue and skinfold tenderness in the placebo laser group (p>0.05). It was found that there was no significant difference between the two groups with respect to all parameters before therapy whereas a significant difference was observed in parameters as pain, muscle spasm, morning stiffness and tender point numbers in favour of laser group after therapy (p<0.05). None of the participants reported any side effects. Our study suggests that laser therapy is effective on pain, muscle spasm, morning stiffness, and total tender point number in fibromyalgia and suggests that this therapy method is a safe and effective way of treatment in the cases with fibromyalgia.

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Curr Opin Rheumatol. 2002 Jan;14(1):45-51.
Central nervous system mechanisms of pain in fibromyalgia and other musculoskeletal disorders: behavioral and psychologic treatment approaches.
Bradley LA, McKendree-Smith NL.
Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 35294, USA. Larry.Bradley@ccc.uab.edu

Pain is one of the most important and challenging consequences of musculoskeletal disorders. This article examines the role of central nervous system structures in the physiology of pain. It also describes the neuromatrix, a construct that provides a framework for understanding the interaction between physiologic mechanisms and psychosocial factors in the development and maintenance of chronic pain. This construct suggests that behavioral and psychologic interventions may alter the pain experience primarily through their effects on emotional states and cognitive processes. The literature on cognitive-behavioral interventions for patients with rheumatoid arthritis and osteoarthritis indicates that they are well-established treatments for these disorders. However, the efficacy of these interventions for patients with fibromyalgia has not been established. It is anticipated that the development of valid measures of readiness for behavioral change may allow investigators to identify the patients with musculoskeletal disorders who are most likely to benefit from cognitive-behavioral intervention.

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Clin Exp Rheumatol. 2001 Nov-Dec;19(6):697-702.
A double-blind, randomized, controlled study of amitriptyline, nortriptyline and placebo in patients with fibromyalgia. An analysis of outcome measures.
Heymann RE, Helfenstein M, Feldman D.
Department of Medicine, Federal University of Sao Paulo, Escola Paulista de Medicina, SP, Brazil.

OBJECTIVE: To study the efficacy and tolerability of amitriptyline and nortriptyline in a Brazilian population with fibromyalgia and to evaluate the instruments used to measure the efficacy of the treatment. METHODS: A total of 118 fibromyalgia patients were randomly assigned to 3 groups: amitriptyline (AM, n = 40), nortriptyline (NOR, n =38) and placebo (PL, n = 40), and were blindly given 25 mg at bedtime of the assigned treatment for 8 weeks. Clinical evaluation before and at the end of the study included the number of tender points (NTP), FIQ score (FIQ), and global improvement as reported by the patients on a verbal scale (VSGI). RESULTS: The 3 groups were comparable at baseline for all the parameters studied. After 8 weeks, the 3 groups improved in all parameters: (36.5% AM, 26.7% NOR and 24% PL patients improved on FIQ; 13.9% AM, 19.5% NOR and 8.57% PL patients improved on NTP; 86.5% AM, 72.2% NOR and 57.6% PL patients improved on VSGI). Only the AM group differed from the PL group on VSGI. Side effects were noted among the groups, but none were serious (16 in the AM group, 31 in the NOR group, and 25 in the PL group). CONCLUSION: All three groups improved after treatment. Only the patient's subjective global assessment of improvement differed between the AM patients and the PL group (p < or = 0.03). In fibromyalgia, placebo groups are important in drug trials. Different measures of therapeutic effect are not better than the patient's self assessment.


 
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