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Patients presenting with widespread musculoskeletal pain frequently are diagnosed with fibromialgia syndrome, which has also been refered to as fibrositis. Fibromialgia can be thought of as widespread myofascial pain, in that such patients have multiple myofascial tender points. There is now good evidence that such patients have an abnormality in their central processing of both pain sensations (hyperalgesia) and nonpain sensations (allodynia).

The American College of Rheumatology has defined the fibromialgia syndrome in terms of widespread musculoskeletal pain (defined as pain in three or more quadrants of the body plus axial pain) and the presence of 11 or more of 18 specifically designated tender points fibromialgia, fibrositis, fibromialgia. In reality, most fibromialgia patients present with a syndrome of complicated somatic distress that is thought to be both a manifestation of a "pain centralization state" (neuroplasticity) and the psychologic distress engendered by chronic pain. There is no cure for this disorder, and most patients can be expected to be symptomatic for many years with a reduced quality of life and varied levels of psychosocial dysfunction. However, engagement in a productive lifestyle and minimization of dysfunction can often be achieved by paying attention to four major , fibrositis, fibromialgia


The use of NSAIDs in these patients is usually disappointing; it is unusual for fibromialgia patients to experience more than a 20% relief of their pain, but many consider this to be worthwhile. Narcotics (propoxyphene, codeine, oxycodone) may provide a worthwhile short-term relief of pain, but tolerance quickly develops in most patients, and their prescription needs to be restricted in a fibrositis

Tramadol (Ultram), a recently introduced analgesic, seems to provide partial, but significant, pain attenuation in many fibromialgia patients--it is currently undergoing controlled trials. The severity of pain and the location of

Evaluation by an occupational and physical therapist often provides worthwhile advice on improved ergonomics, biomechanical imbalance, and the formulation of a regular stretching program. Hands-on physical therapy with heat modalities is reserved for major flares of pain, as there is no evidence that long-term therapy alters the


A gentle program of stretching and aerobic exercise is essential to counteract the tendency for deconditioning that leads to progressive dysfunction in fibromialgia patients. Before stretching, muscles should be warmed either actively by gentle exercise or passively by a heating pad, warm bath, or hot tub. Stretching aids in the release of

There is good evidence that fibromialgia patients benefit from increased aerobic conditioning, but many are reluctant to exercise because of increased pain and fatigue. However, most patients can be motivated to increase their level of fitness if they are provided realistic guidelines for exercise and have regular follow-up. Exercise

All fibromialgia patients complain of fragmented nonrefreshing sleep. A treatable cause of the sleep disturbance should always be sought. For instance, a small number of patients have sleep apnea and benefit from continuous

Other patients find TCAs unacceptable owing to anticholinergic side effects, such as tachycardia, dry mouth, and constipation. Most TCAs cause some weight gain, but in certain patients this may amount to 20% of their initial body weight and is thus unacceptable. I often initiate TCA therapy with a trial of four medications taken for 6 days each with

If the patient has not taken a TCA before, the following drugs and dosages can typically be used: amitriptyline (Elavil, Endep),* 10 mg at bedtime; doxepin (Sinequan, Adapin),* 10 mg at bedtime; nortriptyline (Pamelor, Aventyl),* 10 mg at bedtime; trazodone (Desyrel),* 25 mg at bedtime; and cyclobenzaprine (Flexeril), 10 mg at bedtime--cyclobenzaprine has a TCA structure and

Unless the patient has a concomitant major depressive illness, I do not routinely advocate selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), because they may exacerbate insomnia and cause agitation. When SSRIs are used in patients with concomitant major depression, I usually prescribe a low-dose TCA, such as trazodone, 50 mg at bedtime. Some fibromyalgia patients are intolerant of TCAs due to a

Patients with chronic pain often develop secondary psychologic disturbances, such as depression, anger, fear, withdrawal, and anxiety. Sometimes these secondary reactions become the major problem; however, it is a