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Am Fam Physician. 2005;72(5):936

Fibromyalgia, as defined by the presence of widespread bodily pain and the presence of excessive tenderness at 11 out of 18 pressure points, affects about 2 percent of the U.S. population. Fibromyalgia often is associated with mood disorders and comorbidities, and psychosocial factors often are implicated. Overall, patients with fibromyalgia appear to have an altered response to pain. Goldenberg and colleagues review the evidence-based findings of the American Pain Society’s commissioned report on fibromyalgia treatment.

Evidence was categorized as “strong” if there was support from a meta-analysis or more than one randomized controlled trial (RCT); “moderate” if positive findings from one RCT or consistent positive findings came from several RCT’s or multiple non-RCT studies; and “weak” with positive results from lower-quality trials. Outcome measures were predominantly levels of pain; they also included physical, psychologic, and social function.

From a pharmacologic perspective, the strongest evidence supported the efficacy of tricyclic antidepressants such as amitriptyline (Elavil) and cyclobenzaprine (Flexeril). Moderate evidence suggested benefit from selective serotonin reuptake inhibitors as well as from two new dual serotonin and norepinephrine uptake inhibitors, milnacipran (Ixel) and duloxetine (Cymbalta). The analgesic tramadol (Ultram) also was modestly effective. Evidence is lacking for other analgesics, such as nonsteroidal anti-inflammatory drugs and opioids. Benefit also was modestly associated with the anticonvulsant pregabalin (Lyrica). Results from a trial using gabapentin (Neurontin) are pending, and many other medications, such as benzodiazepines and corticosteroids are lacking evidence or have weak evidence of efficacy.

Of the nonmedical therapies, the strongest evidence supports aerobic exercise. Moderate evidence exists to support the use of muscle-strengthening exercises. Cognitive behavior therapy (CBT) also is effective, with strong evidence showing decreased pain and improved function. Other psychologic interventions also appear to be beneficial. In particular, multidisciplinary approaches that combine exercise, CBT, and other modalities appear to maintain treatment gains over long periods. Relaxation, hypnosis, biofeedback, massage, and warm water baths have moderate clinical support.

One drawback of most trials is their short duration. The authors recommend a step-wise approach beginning with thorough patient education, followed by a trial of low-dose tricyclic antidepressants, an exercise program, and CBT. For refractory cases, referral and combination medications are warranted.

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