|© Micaela Sullivan-Fowler|
Treatment of "resistant" fibromyalgia.
Cleveland Clinic Foundation, Ohio, USA.
Rheum Dis Clin North Am 1995 Feb;21(1):247-60
NLM CIT. ID:
Long-term outcome for the majority of patients with fibromyalgia is sufficiently
disappointing so that most patients can be considered to have "resistant" disease. Among
published treatments, education, active exercise, and nighttime antidepressant
medications perform best. Patients eligible for treatment include those with primarily
regional symptoms, wide-spread pain without 11 or fewer tender points, or "typical
patients" as defined by the American College of Rheumatology criteria. Factors important
in the process of prognosis of the syndrome should be identified and addressed in an
integrated therapeutic program in order to positively influence outcome.
Controlled trials of therapy in fibromyalgia syndrome.
Boston University School of Medicine, MA 02118.
Baillieres Clin Rheumatol 1994 Nov;8(4):917-34
NLM CIT. ID:
Many different interventions have been studied in the therapy of fibromyalgia syndrome
(Tables 1 and 2). While most have been effective, in general these trials have been short
term. Furthermore, important or substantial improvement, when it has been assessed,
occurs in only small proportions of patients. Long-term, comparative trials of both efficacy
and toxicity are necessary. Trials such as these require large numbers of patients
(compared with placebo-controlled trials, which are generally impractical in long-duration
trials due to the large numbers of dropouts in the placebo arm) and therefore are
expensive and difficult to accomplish. Two other approaches offer potential solutions to
the problem of adequate long-term comparative trials: (a) N-of-1 trials and (b)
meta-analysis. N-of-1 trials have the advantage of random assignment, double-blinding
and multiple potential comparisons in the same patient. Meta-analysis involves combining
the results of studies, which individually may have conflicting results and lack adequate
statistical power, to reach an overall result with sufficient statistical power to make
meaningful conclusions, especially with respect to comparative efficacy. Peluso and
colleagues (1993) have performed a recent meta-analysis of available therapies in
fibromyalgia syndrome and found that the effect-size (a standardized measure of the
efficacy of a given therapy) of several non-medication therapies such as
electroacupuncture exceeded that of traditional medication therapies. Unfortunately, lack
of uniformity in the use of outcome measures across included trials and the small numbers
of comparable non-medication trials makes definitive conclusions regarding relative
efficacy of therapies difficult. Nevertheless, application of meta-analytic methods such as
these should facilitate future comparisons of different interventions. Ideally, future
clinical trials in fibromyalgia syndrome should employ the same outcome measures to
permit application of these methods. Few trials have assessed improvement in functional
status. Functional status measures such as the HAQ (Fries et al., 1980), the Fibromyalgia
Impact Questionnaire (Burckhardt et al, 1991) or similar instruments should be employed
in future studies of therapy in fibromyalgia. Given that individual modalities appear to
confer relatively modest benefit on average. Combination approaches are reasonable,
although randomized, blinded trials to assess these approaches are methodologically
complex. Several preliminary studies which have addressed this approach appear
promising (see Chapter 12; Goldenberg et al, 1993). Finally, no studies have yet assessed
the comparative cost-efficacy of available treatments. Controlled trials which address the
cost-efficacy of commonly employed, but unproven treatments such as physiotherapy
chiropractic manipulation and injection techniques are urgently needed.
Physical medicine and rehabilitation approaches to the management of myofascial pain and
Rehabilitation and Pain Management Associates, Baltimore, MD 21204.
Baillieres Clin Rheumatol 1994 Nov;8(4):881-916
NLM CIT. ID:
In summary, we have presented the physical medicine and rehabilitation medicine
approaches for treating patients with fibromyalgia and the myofascial pain syndromes. The
importance of approaching these patients from a holistic and multidisciplinary standpoint
has been stressed, paying attention to the physical, emotional, spiritual and behavioural
components of the presentation. Although fibromyalgia and the myofascial pain syndromes
are two distinct conditions, they often overlap, and when they do the myofascial component
should be treated first. However, the clinician should remember that pain, tissue dysfunction
and disability from pain are all separate issues and should be treated as such. Treatment in
all cases should be individualized and comprehensive. It is imperative to make the patient
an active participant in his care and to establish mutually agreed upon goals at the outset of
treatment. It is important to establish an adequate and appropriate home exercise
programme to supplement formal treatment. A good home exercise programme should
stress both stretching and strengthening. Formal treatment programmes should not be
geared to pain relief alone but rather to restoration of function, and return to functioning
lifestyles. The clinician has available a wide array of modalities and tools to control pain, but
the major goal of all treatment programmes is to restore individuals to functional lifestyles
and to promote both physical and emotional flexibility, balance and 'wellness'. It is often
necessary to involve the family unit as an inherent and critical part of the treatment team,
particularly with the patient who continues to be dysfunctional despite apparently
appropriate treatment. Although treatment always starts at the tissue level, a good
treatment programme must always be holistic in nature and treat the tissues, the patient as
a whole, and his or her environmental stressors and contingencies as well.
[Autogenic training versus Erickson's analogical technique in treatment of fibromyalgia
Rucco V; Feruglio C; Genco F; Mosanghini R
Servizio di Terapia Fisica, Ospedale di Medicina Fisica e Riabilitazione, Udine.
Riv Eur Sci Med Farmacol 1995 Jan-Feb;17(1):41-50
NLM CIT. ID:
The AA have conducted a controlled trial to determine the efficacy of two verbal
techniques for muscular relaxation on 53 patients with fibromyalgia. The subjects were
assigned at random to a autogenous training group (27 patients) or a analogic Erickson's
techniques group (26 patients). The autogenous training showed the presence of various
limits: (1) application limits (in which notable difficulties had to be faced to train the
patients with fibromyalgia to practice the Autogenous training due to the revelation of
"intrusive thoughts" or "abreactions", or because of the incapacity of the patients to
practice the exercises at home without hearing the instructions of a therapist); (2) limits of
efficacy (the state of optimum training needed many therapeutic sittings in order to be
achieved and the improvements regarded nighttime sleep and morning rigidity, however,
these improvements were less than those obtained with the analogic Erickson's
techniques). The Erickson's techniques have showed, instead, many advantages:
numerous patients continued the treatment until it was finished; only a small number of
therapeutic sittings were necessary. There was an improvement of all the parameters
examined, superior compared to the results obtained in the group of patients treated with
A randomized, controlled clinical trial of education and physical training for women with
Burckhardt CS; Mannerkorpi K; Hedenberg L; Bjelle A
Department of Rheumatology, Sahlgren University Hospital, Gothenburg, Sweden.
J Rheumatol 1994 Apr;21(4):714-20
NLM CIT. ID:
To determine the effectiveness of self-management education and physical
training in decreasing fibromyalgia (FMS) symptoms and increasing physical and
psychological well being.
A pretest-posttest control group design was used.
Ninety-nine women with FMS were randomly assigned to 1 of 3 groups; 86 completed the
study. The education only group received a 6-week self-management course. The
education plus physical training group received the course and 6 h of training designed to
assist them to exercise independently. The control group got treatment after 3 months.
The experimental programs had a significant positive impact on quality of life
and self-efficacy. Helplessness, number of days feeling bad, physical dysfunction, and pain
in the tender points decreased significantly in one or both of the treated groups when
retested 6 weeks after the end of the program. Longterm followup of 67 treated subjects
showed significant positive changes on the Fibromyalgia Impact Questionnaire primarily in
the physical training group. Among all subjects, 87% were exercising at least 3 times/week
for 20 min or more; 46% said they had increased their exercise level since participating in
the program; 70% were practicing relaxation strategies as needed; 46% were working at
least half time as opposed to 37% at pretest.
Self-efficacy of the treated
groups was enhanced significantly by the program. Other changes were smaller and more
delayed than had been expected. Recommendations for future trials include a longer
education program, more vigorous physical training, and longterm followup.
Treatment of fibromyalgia syndrome with Super Malic: a randomized, double blind,
placebo controlled, crossover pilot study.
Russell IJ; Michalek JE; Flechas JD; Abraham GE
Department of Medicine, University of Texas Health Science Center, San Antonio 78284-7874, USA.
J Rheumatol 1995 May;22(5):953-8
NLM CIT. ID:
To study the efficacy and safety of Super Malic, a proprietary tablet
containing malic acid (200 mg) and magnesium (50 mg), in treatment of primary
fibromyalgia syndrome (FM).
METHODS Twenty-four sequential patients with primary
FM were randomized to a fixed dose (3 tablets bid), placebo controlled, 4-week/course,
pilot trial followed by a 6-month, open label, dose escalation (up to 6 tablets bid) trial. A
2-week, medication free, washout period was required before receiving treatment,
between blinded courses, and again before starting open label treatment. The 3 primary
outcome variables were measures of pain and tenderness but functional and psychological
measures were also assessed.
RESULTS. No clear treatment effect attributable to Super
Malic was een in the blinded, fixed low dose trial. With dose escalation and a longer
duration of treatment in the open label trial, significant reductions in the severity of all 3
primary pain/tenderness measures were obtained without limiting risks.
These data suggest that Super Malic is safe and may be beneficial in the treatment of
patients with FM. Future placebo-controlled studies should utilize up to 6 tablets of Super
Malic bid and continue therapy for at least 2 months.