A host of other treatments, such as acupuncture and chiropractic manipulations, have been evaluated. The results of these trials are mixed and even the positive results are modest, and the trials have been of short duration.45

Psychological treatments
Hypnosis, biofeedback, relaxation, behavior therapy, and cognitive-behavioral therapy (CBT) have all been evaluated as treatments for FM. CBT has been the most extensively investigated.47 Two recent clinical practice guidelines reviewed the literature and recommended CBT in combination with other treatments for FM.2,41

Multicomponent treatment
Although no single intervention has been shown to be highly effective for most patients with FM, there is reasonably good evidence that multicomponent approaches, which include education, exercise, and CBT, delivered to groups of patients by a multidisciplinary team may be helpful.43,47,48

Based on the available research through 2003, the American Pain Society (APS) proposed an evidence-based clinical practice guideline that recommended a stepwise or a combination approach to treating FM2:

• Education
• TCAs
• Exercise
• CBT

The APS guideline was published before the approval of the SSRIs duloxetine and pregabalin. Two evidence-based guidelines have since recommended these 2 medications for treating FM symptoms.41,42 Table 5 provides an integration of these 3 treatment guidelines.2,41,42 

PATIENT HETEROGENEITY

A number of investigators have suggested that patients who have FM may not be a homogeneous group. Rather, there may be subgroups of people with FM. Studies have focused on differences based on symptom onset (eg, idiopathic vs traumatic), symptom presentation, and psychological distress.49,50 Delineation of the relevant subgroups may facilitate the identification of the mechanisms that underly the symptoms of FM and the development of treatments customized to address the specific needs of patients.

CONCLUSIONS
FM is a perplexing condition of unknown cause that has no cure. Many treatments have some beneficial effects, but the syndrome remains a chronic problem. Research is needed to determine the type of treatment for each subset of patients. The failure to achieve and maintain positive outcomes in many patients indicates, most assuredly, that one size does not fit all.

Health care providers need to consider not only the physical basis of symptoms (the nociceptive, sensory component) but also patients’ moods, fears, expectancies, coping resources, coping efforts, and the responses of significant others (including themselves). Regardless of whether there is an identifiable physical basis for the reported symptoms, psychosocial and behavioral factors interact to influence the nature, severity, and persistence of pain and disability. In particular, behavioral, emotional, and cognitive variables should be addressed.

An integrative treatment model for FM needs to incorporate the interrelationships among physical, psychological, and social factors—and the changes that occur among these relationships over time.51,52 Treatment approaches that focus on only one set of factors will inevitably be incomplete. Because there is no cure for FM, patients need to be given realistic expectations. They need to understand that, at least for the foreseeable future, they will need to learn to self-manage their symptoms for an extended period.

Drugs Mentioned in This Article
Amitriptyline (Elavil, Endep)
Cyclobenzapine (Flexeril)
Duloxetine (Cymbalta)
Gabapentin (Neurontin)
Milnacipran
Pregabalin (Lyrica)
Tramadol (Ultram)

 

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