Man as His Own Maker A Response to Leon R. Kass’s “Keeping Life Human,” A 32, Spring 2008 e nature of all other beings is limited and constrained within the boundsof laws prescribed by Us. ou, constrained by no limits, in accordancewith thine own free will, in whose hand We have placed thee, shalt ordain for thyself the limits of thy nature. Both common sense an
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Management of Fibromyalgia Syndrome
Don L. Goldenberg, MD
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 treat-
ment of FMS.
ized 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 per- formed by an interdisciplinary panel, composed of 13 experts in various pain management will fit the classification criteria for fi- disciplines, selected by the American Pain Society (APS), and supplemented by se- lected literature reviews by APS staff members and the Utah Drug Information Ser-vice. A total of 505 articles were reviewed.
Data Synthesis There are major limitations to the FMS literature, with many treat-
ment trials compromised by short duration and lack of masking. There are no medicaltherapies that have been specifically approved by the US Food and Drug Administra- tion 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 trig- ger point injections, have not been adequately evaluated.
ogy classification criteria for the diag- Conclusions Despite the chronicity and complexity of FMS, there are pharmaco-
logical and nonpharmacological interventions available that have clinical benefit. Based on current evidence, a stepwise program emphasizing education, certain medica- tions, exercise, cognitive therapy, or all 4 should be recommended.
using these criteria have found an FMSprevalence of 2% in the United States,including 3.4% of women and 0.5% of tologists (after osteoarthritis), yet rheu- Author Affiliations: Department of Rheumatology,
Newton-Wellesley Hospital, Newton, Mass, and De-
partment of Medicine, Tufts University School of Medi- cine, Boston, Mass (Dr Goldenberg); Psychiatric Men-tal Health Nursing, Oregon Health and Science University, School of Nursing, Portland (Dr Burck- hardt); and Department of Internal Medicine, Rheu- cal characteristics. Questions often arise matology Division, University of Michigan, School ofMedicine, Ann Arbor (Dr Crofford).
Corresponding Author: Don L. Goldenberg, MD,
Department of Rheumatology, Newton-WellesleyHospital, 2000 Washington St, Newton, MA 02462 Clinical Review Section Editor: Michael S. Lauer, MD.
CME available online at
We encourage authors to submit papers for con- www.jama.com
sideration as a “Clinical Review.” Please contact Michael S. Lauer, MD, at firstname.lastname@example.org.
2388 JAMA, November 17, 2004—Vol 292, No. 19 (Reprinted)
2004 American Medical Association. All rights reserved.
less, some clinicians have speculated that inconsistent results from RCTs, or both).
sive patient education is an effective treat- contribute greatly to the clinical expres- wait-listed or untreated controls or with ing scales or visual analog scales. Simi- tive treatment exists.25 Nevertheless, ap- from 6 to 17 sessions. Educational groups efficacy, quality of life, and the 6-minute lines for the optimal treatment of FMS.
Data Sources and Study Selection
ing tiredness, pain, stiffness, fatigue, and tients, demonstrated significant improve- well-being during the preceding week.
FIQ total score as well as in pain sever- Medications
Scale30). Most studies that evaluated ex- system agents (BOX 1). Although they
of activities in the brain and spinal cord, Diagnosis and Education
tently checked electronically for any rel- ture, none of the drugs reviewed here are the diagnosis, if integrated with patient 2004 American Medical Association. All rights reserved.
(Reprinted) JAMA, November 17, 2004—Vol 292, No. 19 2389
Box 1. Treatment of Fibromyalgia Syndrome
FMS. Many of these drugs are olderagents for which approval is unlikely to Medications
be sought. Furthermore, the Food andDrug Administration is just beginning Strong Evidence for Efficacy
Amitriptyline: often helps sleep and overall well-being; dose, 25-50 mg at bed- could be granted (J. Witter, written com- Cyclobenzaprine: similar response and adverse effects; dose, 10-30 mg at bedtime.39-41 Modest Evidence for Efficacy
Tricyclic Antidepressant Medica-
Tramadol: long-term efficacy and tolerability unknown; administered with or with- tions. The strongest evidence for medi-
out acetaminophen; dose, 200-300 mg/d.54-56 cation efficacy in FMS is for tricyclic an- Fluoxetine (only one carefully evaluated at this time): dose, 20-80 mg; may be used with tricyclic given at bedtime; uncontrolled report of efficacy using ser- Venlafaxine: 1 RCT ineffective but 2 case reports found higher dose effective.49-51 these results during the next decade.39Cyclobenzaprine, usually marketed as a muscle relaxant but structurally a tri- Pregabalin: second-generation anticonvulsant; effective in single RCT.57 Weak Evidence for Efficacy
Growth hormone: modest improvement in subset of patients with FMS with low 5-Hydroxytryptamine (serotonin): methodological problems.59,60 Tropisetron: not commercially available.58 clic antidepressants were better than pla- No Evidence for Efficacy
Opioids, corticosteroids, nonsteroidal anti-inflammatory drugs, benzodiazepene Keck42 found 9 of 16 studies suitable for and nonbenzodiazepene hypnotics, melatonin, calcitonin, thyroid hormone, guai- meta-analysis. Tricyclic agents were more fenesin, dehydroepiandrosterone, magnesium.
effective than placebo for all clinical out-comes, especially quality of sleep. A sig- Nonmedicinal Therapies
Strong Evidence for Efficacy (Wait-List or Flexibility Controls But Not Blinded
Cardiovascular exercise: efficacy not maintained if exercise stops.66-75 CBT: improvement often sustained for months.83-87 Patient education: group format using lectures, written materials, demonstra- tigue, pain, and sense of well-being, but tions; improvement sustained for 3 to 12 months.32-36 Multidisciplinary therapy, such as exercise and CBT or education and exer- better evidence for the efficacy of tricy-clic medications than other classes of an- Moderate Evidence for Efficacy
Strength training,75,79 acupuncture,104-106 hypnotherapy,99,100 biofeedback,101,103 longest study of tricyclic medications fol- Weak Evidence for Efficacy
Chiropractic, manual, and massage therapy; electrotherapy, ultrasound.107-110 triptyline, cyclobenzaprine, or placebofor 6 months and reported that the ini- No Evidence for Efficacy
Tender (trigger) point injections, flexibility exercise.
CBT indicates cognitive behavioral therapy; RCT, randomized controlled trial; SSRI, selec- Other Antidepressant Medications.
tive serotonin reuptake inhibitor; SNRI, serotonin and norepinephrine reuptake inhibitor.
There is moderate evidence that the se-lective serotonin reuptake inhibitor 2390 JAMA, November 17, 2004—Vol 292, No. 19 (Reprinted)
2004 American Medical Association. All rights reserved.
(SSRI) fluoxetine is effective in FMS. In Hormones and Supplements.The
treatment.55 The most recent article com- scores for pain, fatigue, and depression.
scores were not significantly improved.
ment for change in depression score.
RCTs of opioids in patients with FMS.
Exercise.There is strong evidence that
cardiovascular exercise is effective treat- Anticonvulsant Medications. Al-
pregabalin in 529 patients with FMS.
The benefits of aerobic exercise67-71 and –0.93; PϽ.001) and significantly more ever, it was found useful in 2 small open- tolerated and especially helpful.70,73,74 label studies using higher doses.50,51 Two Other Medications. Tropisetron, a
according to whether the intervention in- ter than placebo in a second study in pa- volved 1 type of exercise (aerobic train- Analgesic Medications. Tramadol,
ing, strength training, or flexibility train- controlled trial initially suggested that tra- 2004 American Medical Association. All rights reserved.
(Reprinted) JAMA, November 17, 2004—Vol 292, No. 19 2391
ies65,67,76-80 were high-quality training studies: 4 aerobic training, with 1 a mix- ture of aerobic, strength, and flexibility training; 1 strength training; and 2 with control group did. Eight sessions of hyp- Multidisciplinary Treatment. There
found beneficial effects on patient self- 6-minute walk.33,67,73,74,92,93 Treatment physical activity, and physician rating of not in global well-being or self-efficacy.80 perception and sleep quality, pain thresh- puncture control group.105 However, a re- being, fatigue, and sleep in patients with posttest clinical trials, using multidis- ness in patients with FMS.107,108 The chi- found significant positive changes in the efficacy for function in an aerobic train- FIQ, pain severity, self-efficacy, and the 6-minute walk.83,84,86,94-97 Five of these the trial.86,94-96 Improvements in the out- Cognitive Therapies.There is strong
Other Treatments. Although com-
monly used, there are no RCTs of trigger- related symptoms of pain, fatigue, stiff- 2392 JAMA, November 17, 2004—Vol 292, No. 19 (Reprinted)
2004 American Medical Association. All rights reserved.
Box 2. Stepwise Fibromyalgia
FUTURE TREATMENT TRIALS
plete results of some trials are not avail- ists for the efficacy of strength training ferences in FMS clinical trials may be re- lated to the heterogeneity of this illness.
thritis or systemic lupus erythematosus.
ommended (BOX 2).
the patient and family. Any comorbid ill- consider initially are low doses of tricy- groups.115 Such studies suggest that cer- tocols for all treatments, including both tain treatments may be differentially ef- gin a cardiovascular exercise program.
these steps should be referred to a rheu- matologist, physiatrist, psychiatrist, or such as individualized patient trials can doses during the clinical trial but failed 2004 American Medical Association. All rights reserved.
(Reprinted) JAMA, November 17, 2004—Vol 292, No. 19 2393
tion of noxious and innocuous heat stimulation among tion and physical training for women with fibromyalgia.
healthy women and women with fibromyalgia. Pain.
J Rheumatol. 1994;21:714-720.
34. Burckhardt CS, Bjelle A. Education programmes
12. Price DD, Staud R, Robinson ME, et al. En-
for fibromyalgia patients: description and evaluation.
hanced temporal summation of second pain and its Baillieres Clin Rheumatol. 1994;8:935-955.
central modulation in fibromyalgia patients. Pain. 2002; 35. Alamo M, Moral RR, Perula de Torres LA. Evalu-
ation of a patient-centered approach in generalized Funding/Support: This study was sponsored by the
13. Staud R, Cannon RC. Temporal summation of pain
musculoskeletal chronic pain/fibromyalgia patients in from mechanical stimulation of muscle tissue in nor- primary care. Patient Educ Couns. 2002;48:23-31.
Role of the Sponsor: The American Pain Society did
mal controls and subjects with fibromyalgia syndrome.
36. Pfeiffer A, Thompson JM, Nelson A, et al. Effects
not participate in the design and conduct of the study, in the collection, analysis, and interpretation of the data, of a 1.5-day multidiscplinary outpatient treatment pro- or in the preparation, review, or approval of the manu- 14. Mountz JM, Bradley LA, Modell JG, et al. Fibro-
gram for fibromyalgia: a pilot study. Am J Phys Med myalgia in women: abnormalities of regional cere- Acknowledgment: We thank the other members of
bral blood flow in the thalamus and the caudate nucleus 37. Carette S, Mccain GA, Bell DA, Fam AG. Evalu-
the American Pain Society Fibromyalgia Panel: Rob- are associated with low pain threshold levels. Arthri- ation of amitriptyline in primary fibrositis. Arthritis ert Gerwin, MD, Department of Neurology, The Johns Hopkins Hospital, Baltimore, Md; Sue Gowans, PhD, 15. Bradley LA, Mckendree-Smith NL, Alarcon GS,
38. Goldenberg DL, Felson DT, Dinerman HA. Ran-
PT, University Health Network Toronto General Hos- Cianfrini L. Is fibromyalgia a neurologic disease? Curr domized, controlled trial of amitriptyline and naproxen pital, Department of Rehabilitation Services, Toronto, Pain Headache Rep. 2002;6:106-114.
in the treatment of patients with fibromyalgia. Arthri- Ontario, Canada; Kenneth C. Jackson II, PharmD, Prac- 16. Gracely RH, Grant MA, Giesecke T. Evoked pain
tis Rheum. 1986;29:1371-1377.
tice-Pain Management, Texas Tech University Health measures in fibromyalgia. Best Pract Res Clin 39. Carette S, Bell MJ, Reynolds WJ, et al. Compari-
Sciences Center at Amarillo, School of Pharmacy, Lub- son of amitriptyline, cyclobenzaprine, and placebo in bock; Pearl Kugel, BBA, San Diego, Calif; William Mc- 17. Russell IJ, Orr MD, Littman B, et al. Elevated ce-
the treatment of fibromyalgia: a randomized, double- Carberg, MD, Chronic Pain Management Program, rebrospinal fluid levels of substance P in patients with blind clinical trial. Arthritis Rheum. 1994;37:32-40.
Kaiser Permanente, Escondido, Calif; Nathan J. Ru- the fibromyalgia syndrome. Arthritis Rheum. 1994;37: 40. Bennett RM, Gatter RA, Campbell SM, et al. A
din, MD, Department of Orthopedics and Rehabili- comparison of cyclobenzaprine and placebo in the tation, University of Wisconsin Medical School, Madi- 18. Offenbaecher M, Bondy B, Dejonge S, et al. Pos-
management of fibrositis. Arthritis Rheum. 1988;31: son; Laura Schanberg, MD, Pediatric Rheumatology sible association of fibromyalgia with a polymor- Division, Duke University Medical Center, Durham, NC; phism in the serotonin transporter gene regulatory 41. Tofferi JK, Jackson JL, O’Malley PG. Treatment
Ann G. Taylor, RN, EdD, Betty Norman Norris Pro- region. Arthritis Rheum. 1999;42:2482-2488.
of fibromyalgia with cyclobenzaprine: a meta-analysis.
fessor of Nursing, Center for the Study of Comple- 19. Gursoy S, Erdal E, Herken H, Madenci E, Alase-
Arthritis Rheum. 2004;51:9-13.
mentary and Alternative Therapies, University of Vir- hirli B. Association of T102C polymorphism of the 42. Arnold LM, Keck PE. Antidepressant treatment of
ginia Health System, Charlottesville; Janalee Taylor, 5-HT2A receptor gene with psychiatric status in fi- f i b r o m y a l g i a : a m e t a - a n a l y s i s a n d r e v i e w .
MS, RN, Clinical Nurse Specialist, Children’s Hospital bromyalgia syndrome. Rheumatol Int. 2001;21:58-61.
Medical Center, Cincinnati, Ohio; and Dennis C. Turk, 20. Gursoy S, Erdal E, Herken H, Madenci E, Alaae-
43. O’Malley PG, Balden E, Tomkins G, et al. Treat-
PhD, Department of Anesthesiology, University of hirli B, Erdal N. Significance of catechol-O- ment of fibromyalgia with antidepressants. J Gen In- Washington, Seattle. We also thank staff members of methyltransferase gene polymorphism in fibromyal- the American Pain Society and especially Ada Jacox, gia syndrome. Rheumatol Int. 2003;23:104-107.
44. Wolfe F, Cathey MA, Hawley DJA. Double-
PhD, RN, and Carol D. Spengler, PhD, RN, APS Clini- 21. Adler GK, Kinsley Bt, Hurwitz S, et al. Reduced
blind placebo controlled trial of fluoxetine in cal Practice Guidelines Program, University of Vir- hypothalamic-pituitary and sympathoadrenal re- fibromyalgia. Scand J Rheumatol. 1994;23:255-259.
ginia School of Nursing, Charlottesville; and the many sponses to hypoglycemia in women with fibromyal- 45. Arnold LM, Hess EV, Hudson JI, Berno SE, Keck PEA.
reviewers and staff who worked on the APS fibromy- gia syndrome. Am J Med. 1999;106:534-543.
Randomized, placebo-controlled, double-blind, flexible- 22. Crofford LJ, Pillemer SR, Kalogeras KT, et al. Hy-
dose study of fluoxetine in the treatment of women with pothalamic-pituitary-adrenal axis perturbations in pa- fibromyalgia. Am J Med. 2002;112:191-197.
tients with fibromyalgia. Arthritis Rheum. 1994;37: 46. Goldenberg D, Mayskiy M, Mossey CJ, Rutha-
zer R, Schmid CA. Randomized, double-blind cross- 1. Croft P, Rigby AS, Boswell R, et al. The preva-
23. Martinez-Lavin M, Hermosillo A, Rosas M, Soto
over trial of fluoxetine and amitriptyline in the treat- lence of chronic widespread pain in the general M. Circadian studies of autonomic nervous balance ment of fibromyalgia. Arthritis Rheum. 1996;39:1852- population. J Rheumatol. 1993;20:710-713.
in patients with fibromyalgia. Arthritis Rheum. 1998; 2. Croft P, Schollum J, Silman A. Population study of
47. Cantini F, Bellandi F, Niccolo L, et al. Fluoxetine
tender point counts and pain as evidence of 24. Benjamin S, Morris S, Mcbeth J, et al. The asso-
combined with cyclobenzaprine in the treatment of fibromyalgia. BMJ. 1994;309:696-699.
ciation between chronic widespread pain and mental fibromyalgia. Minerva Med. 1994;85:97-100.
3. Wolfe F, Smythe HA, Yunus MB, et al. The Ameri-
disorder. Arthritis Rheum. 2000;43:561-567.
48. Celiker R, Cagavi Z. Comparison of amitriptyline
can College of Rheumatology 1990 criteria for the clas- 25. Ehrlich GE. Pain is real; fibromyalgia isn’t.
and sertraline in the treatment of fibromyalgia syn- sification of fibromyalgia: report of the Multicenter Cri- J Rheumatol. 2003;30:1666-1667.
drome [abstract]. Arthritis Rheum. 2000;43:S332.
teria Committee. Arthritis Rheum. 1990;33:160-172.
26. Goldenberg D, Smith N. Fibromyalgia, rheuma-
49. Zijsltra TR, Barendregt PJ, van de Laar MA. Ven-
4. Wolfe F, Cathey MA. Prevalence of primary and
tologists, and the medical literature: a shaky alliance.
lafaxine in fibromyalgia: results of a randomized pla- secondary fibrositis. J Rheumatol. 1983;10:965-968.
J Rheumatol. 2003;30:151-153.
cebo-controlled, double-blind trial [abstract]. Arthri- 5. Wolfe F, Cathey MA. The epidemiology of tender
27. Burckhardt CS, Clark SR, Bennett RM. The fibro-
points. J Rheumatol. 1985;12:1164-1168.
myalgia impact questionnaire: development and 50. Dwight MM, Arnold LM, O’Brien H, et al. An open
6. Marder WD, Meenan RF, Felson DT, et al. Edito-
validation. J Rheumatol. 1991;18:728-733.
clinical trial of venlafaxine treatment of fibromyalgia.
rial: the present and future adequacy of rheumatol- 28. Dunkl PR, Taylor AG, Mcconnell GG, et al. Re-
ogy manpower: a study of health care needs and phy- sponsiveness of fibromyalgia clinical trial outcome 51. Sayar K, Aksu G, Ak I, Tosum M. Venlafaxine treat-
sician supply. Arthritis Rheum. 1991;34:1209-1217.
measures. J Rheumatol. 2000;27:2683-2691.
m e n t o f f i b r o m y a l g i a . A n n P h a r m a c o t h e r .
7. Crofford LJ, Clauw DJ. Fibromyalgia: where are we
29. Beck AT, Steer RA, Ball R, Ranieri W. Compari-
a decade after the American College of Rheumatol- son of Beck Depression Inventories IA and II in psy- 52. Gendreau RM, Mease PJ, Rao SR, Kranzler JD,
ogy classification criteria were developed? Arthritis chiatric outpatients. J Pers Assess. 1996;67:588-597.
Clauw DJ. Minacipran: a potential new treatment of 30. Hamilton M. A rating scale for depression. J Neu-
fibromyalgia [abstract]. Arthritis Rheum. 2003;48:S616.
8. Kroenke K, Harris L. Symptoms research: a fertile
rol Neurosurg Psych. 1960;23:56-62.
53. Arnold LM, Lu Y, Crofford LJ, et al. A double-
field. Ann Intern Med. 2001;134:801-802.
31. White KP, Nielson WR, Harth M, Ostbye T,
blind multicenter trial comparing duloxetine to pla- 9. Hudson JI, Mangweth B, Pope HG Jr, et al. Family
Speechley M. Does the label “fibromyalgia” alter health cebo in the treatment of fibromyalgia with or with- study of affective spectrum disorder. Arch Gen status, function, and health service utilization? Arthri- out major depressive disorder. Arthritis Rheum. 2004; 10. Gracely RH, Petzke F, Wolf JM, Clauw DJ. Func-
32. Nicassio PM, Radojevic V, Weisman MH, et al. A
54. Biasi G, Manca S, Manganelli S, Marcolongo R.
tional magnetic resonance imaging evidence of aug- comparison of behavioral and educational interven- Tramadol in the fibromyalgia syndrome: a controlled mented pain processing in fibromyalgia. Arthritis tions for fibromyalgia. J Rheumatol. 1997;24:2000-2007.
clinical trial versus placebo. Int J Clin Pharmacol Res.
33. Burckhardt CS, Mannerkorpi K, Hedenberg L, Bjelle
11. Geisser ME, Casey KL, Brucksch CB, et al. Percep-
AA. Randomized, controlled clinical trial of educa- 55. Russell J, Kamin M, Bennet RM, et al. Efficacy of
2394 JAMA, November 17, 2004—Vol 292, No. 19 (Reprinted)
2004 American Medical Association. All rights reserved.
tramadol in treatment of pain in fibromyalgia. J Clin C. Exercise for treating fibromyalgia syndrome. Coch- 98. Fors EA, Sexton H, Gotestam KG. The effect of
rane Database Syst Rev. 2003;3:CD003786.
guided imagery and amitriptyline on daily fibromyal- 56. Bennett RM, Kamin M, Karin R, Rosenthal N. Tra-
76. Buckelew SP, Conway R, Parker J, et al. Biofeed-
gia pain. J Psychiatr Res. 2002;36:179-187.
madol and acetaminophen combination tablets in the back/relaxation training and exercise interventions for 99. Haanen HC, Hoenderdos HT, van Romunde LK,
treatment of fibromyalgia pain. Am J Med. 2003;114: fibromyalgia. Arthritis Care Res. 1998;11:196-209.
et al. Controlled trial of hypnotherapy in the treat- 77. Mengshoel AM, Komnæs HB, Fqrre Æ. The ef-
ment of refractory fibromyalgia. J Rheumatol. 1991; 57. Crofford L, Russell IJ, Mease P, et al. Pregabalin
fects of 20 weeks of physical fitness training in fe- improves pain associated with fibromyalgia syn- male patients with fibromyalgia. Clin Exp Rheumatol.
100. Wik G, Fischer H, Bragee B, Finer B, Fredrikson
drome in a multicenter, randomized, placebo- M. Functional anatomy of hypnotic analgesia: a PET controlled monotherapy trial [abstract]. Arthritis 78. Wigers SH, Stiles TC, Vogal PA. Effects of aero-
study of patients with fibromyalgia. Eur J Pain. 1999; bic exercise versus stress management treatment in 58. Spath M, Stratz T, Neeck G, et al. Efficacy and
fibromyalgia. Scand J Rheumatol. 1996;25:77-86.
101. Ferraccioli G, Ghirelli L, Scita F, et al. EMG-
tolerability of intravenous tropisetron in the treat- 79. Hakkinen A, Hakkinen K, Alen M. Strength train-
biofeedback training in fibromyalgia syndrome.
ment of fibromyalgia. Scand J Rheumatol.
ing induced adaptations in neuromuscular function of J Rheumatol. 1987;14:820-825.
premenopausal women with fibromyalgia. Ann Rheum 102. Günther V, Mur E, Kinigadner U, Miller C. Fi-
59. Caruso I, Sarzi Puttini P, Cazzola M, Azzolini V.
bromyalgia: the effect of relaxation and hydrogal- Double-blind study of 5-hydroxytryptophan versus pla- 80. Martin L, Nutting A, Macintosh BR, Edworthy SM,
vanic bath therapy on the subjective pain experience.
cebo in the treatment of primary fibromyalgia Butterwick D, Cook J. An exercise program in the treat- Clin Rheumatol. 1994;13:573-578.
syndrome. J Int Med Res. 1990;18:201-209.
ment of fibromyalgia. J Rheumatol. 1996;23: 103. Sarnoch H, Adler F, Scholz OB. Relevance of mus-
60. Puttini PS, Caruso I. Primary fibromyalgia syn-
cular sentivity, muscular activity, and cognitive vari- drome and 5-hydroxy-L-tryptophan: a 90-day open 81. Mannerkorpi K, Iversen MD. Physical exercise in
ables for pain reduction associated with EMG bio- study. J Int Med Res. 1992;20:182-189.
fibromyalgia and related syndromes. Best Pract Res feedback in fibromyalgia. Percept Mot Skills. 1997;84: 61. Volkmann H, Norregaard J, Jacobsen S, et al.
Clin Rheumatol. 2003;17:629-647.
Double-blind, placebo-controlled cross-over study of 82. Valim V, Oliveira L, Suda A, et al. Aerobic fitness
104. Berman BM, Ezzo J, Hadhazy V, Swyers JP. Is
intravenous S-adenosyl-L-methionine in patients with effects in fibromyalgia. J Rheumatol. 2003;30:1060- acupuncture effective in the treatment of fibromyalgia? fibromyalgia. Scand J Rheumatol. 1997;26:206-211.
J Fam Pract. 1999;48:213-218.
62. Clark S, Tindall E, Bennett RM. A double blind
83. Nielson WR, Walker C, Mccain GA. Cognitive be-
105. Deluze C, Bosia L, Zirbs A, Chantraine A, Vischer
crossover trial of prednisone versus placebo in the treat- havioral treatment of fibromyalgia syndrome: prelimi- TL. Electroacupuncture in fibromyalgia: results of a con- ment of fibrositis. J Rheumatol. 1985;12:980-983.
nary findings. J Rheumatol. 1992;19:98-103.
trolled trial. BMJ. 1992;305:1249-1252.
63. Bennett RM, Clark SC, Walczyk JA. Random-
84. White KP, Nielson WR. Cognitive behavioral treat-
106. Harris RE, Tian X, Cupps TR, et al. The treat-
ized, double-blind, placebo-controlled study of growth ment of fibromyalgia syndrome: a follow-up ment of fibromyalgia with acupuncture [abstract]. Ar- hormone in the treatment of fibromyalgia. Am J Med.
assessement. J Rheumatol. 1995;22:717-721.
85. Hadhazy V, Ezzo JM, Berman BM, Creamer P,
107. Blunt KL, Rajwani MH, Guerriero RC. The ef-
64. Bennett RM, Degarmo P, Clark SR. A one year
Bausell B. Mind and body therapy for fibromyalgia: a fectiveness of chiropractic management of fibromy- double blind placebo controlled study of guaifenesin in systematic review. J Rheumatol. 2000;27:2911-2918.
algia patients. J Manipulative Physiol Ther. 1997;20: fibromyalgia [abstract]. Arthritis Rheum. 1996;39:S212.
86. Creamer P, Singh BB, Hochberg MC, Berman BM.
65. McCain GA, Bell DA, Mai FM, et al. A controlled
Sustained improvement produced by nonpharmaco- 108. Brattberg G. Connective tissue massage in
study of the effects of a supervised cardiovascular fit- logic intervention in fibromyalgia: results of a pilot the treatment of fibromyalgia. Eur J Pain. 1999;3: ness training program on the manifestations of pri- study. Arthritis Care Res. 2000;13:198-204.
mary fibromyalgia. Arthritis Rheum. 1988;31: 87. Singh BB, Berman BM, Creamer P. A pilot study
109. Gambert RG, Shores JH, Russo DP, et al. Os-
of cognitive behavioral therapy in fibromyalgia.
teopathic manipulative treatment in conjunction with 66. McCain GA. Role of physical fitness training in the
Altern Ther Health Med. 1998;4:67-70.
medication relieves pain associated with fibromyal- fibrositis/fibromyalgia syndrome. Am J Med. 1986;81: 88. Kaplan KH, Goldenberg DL, Galvin-Nadeau M.
gia syndrome. J Am Osteopath Assoc. 2002;102:321- The impact of a meditation-based stress reduction pro- 67. Gowans SE, Dehueck A, Voss S, Richardson M.
gram on fibromyalgia. Gen Hosp Psychiatry. 1993;15: 110. Almeida TF, Roizenblatt S, Benedito-Silva AA,
A randomized controlled trial of exercise and educa- Tufik S. The effect of combined therapy (ultrasound tion for individuals with fibromyalgia. Arthritis Care 89. De Gier M, Peters ML, Vlaeyan JW. Fear of pain,
and interferential current) on pain and sleep in physical performance, and attentional processes in pa- fibromyalgia. Pain. 2003;104:665-672.
68. Gowans SE, DeHueck A, Voss S, et al. Effect of a
tients with fibromyalgia. Pain. 2003;104:121-130.
111. Buskila D, Abu-Shakra M, Neumann L, et al. Bal-
randomized, controlled trial of exercise on mood and 90. Williams DA. Psychological and behavioural thera-
neotherapy for fibromyalgia at the Dead Sea. Rheu- physical function in individuals with fibromyalgia.
pies in fibromyalgia and related syndromes. Best Pract Arthritis Rheum. 2001;45:519-529.
Res Clin Rheumatol. 2003;17:649-665.
112. Sukenik S, Flusser D, Abu-Shakra M. The role
69. Gowans SE, Dehueck A, Abbey S. Measuring ex-
91. Rossy LA, Buckelew SP, Dorr N, et al. A meta-
of spa therapy in various rheumatic diseases. Rheum ercise-induced mood changes in fibromyalgia. Arthri- analysis of fibromyalgia treatment interventions. Ann Dis Clin North Am. 1999;25:883-891.
113. Turk DC, Okifuji A, Sinclair JD, Starz TW. Pain,
70. Jentoft ES, Kvalvik AG, Mengshoel AM. Effects
92. Keel PJ, Bodoky C, Gerhard U, Muller W. Com-
disability, and physical functioning in subgroups of pa- of pool-based and land-based aerobic exercise on parison of integrated group therapy and group relax- tients with fibromyalgia. J Rheumatol. 1996;23:1255- women with fibromyalgia/chronic widespread muscle ation training for fibromyalgia. Clin J Pain. 1998;14: pain. Arthritis Rheum. 2001;45:42-47.
114. Jensen MP, Nielson WR, Turner JA, et al. Readi-
71. Schachter CL, Busch AJ, Peloso PM, Sheppard MS.
93. King SJ, Wessel J, Bhambhani Y, Sholter D, Maksy-
ness to self-manage pain is associated with coping and Effects of short versus long bouts of aerobic exercise mowych W. The effects of exercise and education, in- with psychological and physical functioning among pa- in sedentary women with fibromyalgia: a random- dividually or combined, in women with fibromyalgia.
tients with chronic pain. Pain. 2003;104:529-537.
ized controlled trial. Phys Ther. 2003;83:340-358.
J Rheumatol. 2002;29:2620-2627.
115. Giesecke T, Williams DA, Harris RE, et al. Sub-
72. Jones KD, Burckhardt C, Clark SR, Bennett RM,
94. Mengshoel AM, Forseth KO, Haugen M, et al.
grouping of fibromyalgia patients on the basis of pres- Potempa KM. A randomized controlled trial of muscle Multidisciplinary approach to fibromyalgia: a pilot study.
sure-pain thresholds and psychological factors. Ar- strengthening versus flexibility training in fibromyalgia.
Clin Rheumatol. 1995;14:165-170.
thritis Rheum. 2003;48:2916-2922.
J Rheumatol. 2002;29:1041-1048.
95. Bennett RM. Multidisciplinary group programs to
116. Isomeri R, Mikkelsson M, Latikka P, Kam-
73. Mannerkorpi K, Nyberg B, Ekdahl C. Pool exer-
treat fibromyalgia patients. Rheum Dis Clin North Am.
monen K. Effects of amitriptyline and cardiovascular cise combined with an education program for pa- fitness training on pain in patients with primary tients with fibromyalgia syndrome: a prospective, ran- 96. Turk DC, Okifuji A, Sinclair JD, Starz TW. Differ-
fibromyalgia. J Musculoskel Pain. 1993;1:253-260.
domized study. J Rheumatol. 2000;27:2473-2481.
ential responses by psychosocial subgroups of fibro- 117. Guyatt G, Sackett D, Taylor DW, et al. Deter-
74. Mannerkorpi K, Ahlmen M, Ekdahl C. Six- and
myalgia syndrome patients to an interdisciplanary mining optimal therapy: randomized trials in indi- 24-month follow-up of pool exercise therapy and treatment. Arthritis Care Res. 1998;11:397-404.
vidual patients. N Engl J Med. 1986;314:889-892.
education for patients with fibromyalgia. Scand 97. Bailey A, Starr L, Alderson M, Moreland J. A com-
118. Jaeschke R, Adachi J, Guyatt G, Keller J, Wong
J Rheumatol. 2002;31:306-310.
parative evaluation of a fibromyalgia rehabilitation B. Clinical usefulness of amitriptyline in fibromyalgia.
75. Busch A, Schachter CL, Peloso PM, Bombardier
program. Arthritis Care Res. 1999;12:336-340.
J Rheumatol. 1991;18:447-451.
2004 American Medical Association. All rights reserved.
(Reprinted) JAMA, November 17, 2004—Vol 292, No. 19 2395
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