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Patients presenting with widespread musculoskeletal pain frequently are diagnosed with fibromyalgia syndrome, which has also been referred to as fibrositis. Fibromyalgia 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.

The American College of Rheumatology has defined the fibromyalgia 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. In reality, most fibromyalgia 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.


The use of NSAIDs in these patients is usually disappointing; it is unusual for fibromyalgia 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.

Tramadol (Ultram), a recently introduced analgesic, seems to provide partial, but significant, pain attenuation in many fibromyalgia patients--it is currently undergoing controlled trials.

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.


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

There is good evidence that fibromyalgia 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.

All fibromyalgia 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.

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.

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.

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.


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.