During my Family Practice rotation, I only saw a handful of patients more than once in my short 6 week stint. Usually, they were following up after a URI, or to get their hypertensve medications inceased. One patient I saw more than any other though. She was a 42 year old woman with fibromyalgia. She came in each time complaining of pain all over. While she noticed that it had gotten better compared to when she was first diagnosed, her pain was ever-present. Her chart was filled with different prescriptions for various doses of analgesics, I also noticed that she was started om Amytriptiline a few months earlier. I didn't undersatnd why. Her chart revealed nothing about depression or other psychological problems, and she wasn't being followed by psychiatry. The resident finally told me that she was taking it for fibromyalgia.
    I wondered if it actually worked, and what other things may work for her, and others with chronic pain like this. I came across an excellent article in the Journal of Family Practice, which was a review of the current management options for this condition. It showed evidence suggesting that cardiovascular exercise inreased patients overall sense of well-being by 17%, and decreased tender-point palpation pain by 35%.
    Another review of the management in fibromyalgia syndrome showed strong evidence for the use of the tricyclic amitryptiline in dealing with the improvement of overall sense of wellbeing in patients with fibromyalgia. Patient education regarding their disease was also associated with improved outcomes.
    Most of the articles related to fibromyalgia treatment are either review articles, meta-analysese, or are to small to suggest a benefit for a large group of fibromyalgia patients. There was one randomized double blind trial that showed a significant benefit of using amitryptiline in 208 patients after 1 month; 21% improvement compered to placebo (p = 0.002). This effect unfortunately did not hold after 6 months.
    The best evidence to date then, seems to be a combined approach in treating patients woth fibromyalgia. This approach should include patients understanding of the disease, cardiovascular exercise, and tricyclic antidepressants.

    

Will! That's really interesting...especially since Fibromyalgia doesn't seem to be understood very well. My FP doc shares an office with a (really cool) rheumatologist. He treats a lot of fibromyalgia with point tenderness injections, which as your article points out, has no evidence supporting it yet. However, I believe he injects glucose solutions - it's a brand new therapy called Prolotherapy...

I have met patient with fribromyalgia and some of them are seriously debilitated. I did not find that exercise was heping that much. One of my patient is exercising religiously everyday but still have excessive pain and fatigue. Depression usualy end-up taking a toll on those people. I am not sure but since some of it seem to be due to sleep depravation, I feel sometime that these patient should endergo sleep reabilitation.

My preceptor also prescribes amitriptyline for her patients with fibromyalgia, and she is considering prescribing Cymbalta (duloxetine, an SSNRI) to more and more of her patients wtih fibromyalgia every day. It seems to make sense that fibromyalgia would be associated with depression, but so are other chronic illnesses. I wonder if there are other studies on antidepressants and improvement in symptoms of other chronic illnesses.

Very interesting! The doctor I'm working with also prescribes amitryptiline for fibromyalgia, as well as for migraine headaches. Apparently the mechanism of how pain is controlled is unknown. I saw a woman whose pain was not lessened with medication, and the doctor recommended acupuncture.

i appreciate you interest in this disease since old school medicine seems to laugh at it-thinking its a psychosomatic disease like IBS, espeically the orthopods. i hear accupunture is great too. it even cured my father of his smoking addiction. im all for it!

Fibromyalgia is a difficult disorder to manage. The patient that I saw with it had a very difficult time in the beginning. I agree that a multipronged approach, not just medications, is best.

The disease seems like such a headache to manage. Each patient with it seems to have different responses to any treatment attempted. I can't say that my preceptor has suggested exercise, but the patients have been diagnosed long ago and are coasting at this point. I find that the patients need to come into the office, not only to seek management of pain but to talk to someone and feel that they're being taken care of.

I dont like Fibromyalgia. I cannot wrap my mind around disease for which there exists no evidence for. Perhaps the fact that a psychotropic helps this disease supports the "orthopods" fuz speaks of that chalk it down to a psych illness.

Fibromyalgia is a very real, debilitating disease. Those who dismiss it have never experienced the severe chronic flu-like symptoms, daily pain, cognition impairment and weakness. I've been a pharmacist for 24 years and am a current sufferer. Currently on an SSRI and pain reliever, receiving physical therapy and light daily exercise have improved things slightly, but I can't see myself returning to work soon. I awake every morning in severe pain and am barely able to get out of bed and stand up. Respect your fibro patients: this is a real disease and many are suffering.