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Fibromyalgia


Fibromyalgia or Fibromyalgia Syndrome (FMS) is a condition that elicits different responses from various groups. As with many chronic conditions it has a heritage of diagnostic misunderstanding, debates over its etiology, and confusion over its treatment. And as with many other such conditions, it can take over people’s lives, whether in finding an empathetic practitioner, coaxing family members and friends to understand the debilitation, or coping with the chronic aching and stiffness. Information on Fibromyalgia on the Internet abounds, but it is not all well-organized or definitive. Below are some alternative and conventional Web sites that are helpful, discussion groups that are useful, and some carefully selected (again, there are hundreds) Medline citations on treatment and other social issues when dealing with either the condition or the patient. There’s some repetition in what the first few sites offer, i.e., information on support groups, etc., but as with many chronic conditions the support from others is one of the most important factors in dealing with the condition. Any questions? E-mail the Cybrarian.


1) If you essentially want it all (though you can get lost in the hyperlinks), start with http://prairie.lakes.com/~roseleaf/fibro/index.html It’s the Fibromyalgia Information Page, maintained by Sheri Graber. It’s first paragraph includes the listserv information for Fibrom-L, a Fibromyalgia support group. Includes humor too!


2) A less imposing(but rather busy-looking) place is FIBROMYALGIA Information at: http://www.alternatives.com/cfs-news/fibro.htm#ABOUT The basics on description are covered nicely, the links are appropriate. It is one place (there are many) to find information by Dr. Devin Starlanyl (Starlanyl is also on Sheri’s site). There is a pain management page, useful papers by Dr. David Nye, the newsgroup, alt.med.fibromyalgia, the USA Fibrositis Association, and the USA National Fibromyalgia Research Association. Currently includes a piece on the experimental therapy, Guaifenesin.


3) An even tidier list of hyperlinks is at Emory University’s MedWeb at: http://www.gen.emory.edu/medweb/medweb.rheumatology.html Click on Fibromyalgia up in their Table of Contents.


4) There’s a visually pleasing, easy to decipher site called Fibromyalgia Support Groups, at: http://fmpsc.powerpark.com/support.html It includes Emotional Support Guides and hyperlinks to Chat groups.


5) Need succinct description of FMS to share with loved ones or patients? (originally from the Arthritis Foundation). Go to: http://weber.u.washington.edu/


6) For publications suggested by The Arthritis Foundation: try: http://ucsub.colorado.edu/~gorman/RMC/fib.html This annotated list of brochures, video tapes, newsletters, and pamphlets, includes prices and ordering information.


7) Fibromyalgia Educational Systems, Inc. at http://www.fmsedsys.com/ offers for sale a 170-page handbook, Taking Charge of Fibromyalgia, for patients, their families, and health professionals. An educational program is also offered for health professionals and support groups. These educational resources provide the most up-to-date information available for understanding, managing, and coping with fibromyalgia. Authored by Julie Kelly, M.S., R.N., and Rosalie Devonshire, B.S. Phone (419) 843-3153 · Fax (419) 843-3155


8) Good basic information, including Patient and Physician FAQ’s can be found at http://www.hsc.missouri.edu/fibro/fibrotp.html from, MARRTC Missouri Arthritis Rehabilitation Research and Training Center.


9) The Fibromyalgia Association UK at http://www.community-care.org.uk/charity/fmauk.html is a British group that understands the need for “holding the hands” of fibromyalgia sufferers. Includes a succinct description of FMS, its etiology, treatment, notes the Fibromyalgia Support Newsgroup has an interesting Community Care Front Page, and a nicely done Internet Health Resources page.


10) This one is of particular interest to patients, it’s visually appealing and cleverly presented. It’s the Fibromyalgia Patient Support Center at http://fmpsc.powerpark.com They have a Discussion Wall and a
A Graffiti Wall, the purpose being to provide an on-line resource for the patient exchange of information about Fibromyalgia. Their links to other Web sites are expansive, and they are equitable in their sharing of information. Includes a “mini-FAQ” by David A. Nye MD (nyeda@uwec.edu) on the differences between Fibromyalgia and Chronic Fatigue Syndromes.


11) Though the Cybrarian Service does not recommend individual clinics, a very succinct description of Fibromyalgia can be found at: http://medhlp.netusa.net/www/piic3.htm The Pain Institute in Chicago appears to be taking innovative approaches to the syndrome, that might be of use to patient and practitioners.


12) There’s an FMS Chat room at http://www.geocities.com/SoHo/Lofts/1505/powwow.html The Cybrarian Service was unable to access it, but it could be helpful for keeping up-to-date with fellow sufferers and/or clinicians.


13) Click Here for an naturopathic/osteopathic approach to Fibromyalgia. What Treatment Seems Most Effective in Treatment of Fibromyalgia by Leon Chaitow N.D., D.O. that includes the need for Aerobic Exercise, acupuncture, cognitive training, herbal remedies, dietary supplements, and the like.


14) Still need some sites or ideas? Try: Best Links to Other Sites at:
http://home.earthlink.net/~fotojoy/fmslinks6.htm It’s not annotated but it covers the spectrum of issues related to Fibromyalgia.


15) Sapient Health Network at http://www.shn.net/about.html is an interactive service for people with chronic and serious illnesses, their families, and their friends. Their mission is to provide you with timely and accurate information and support so you can successfully manage your illness and be your own best advocate in the healthcare system. All their services are free. Their especially helpful Library offers journals, a medical dictionary, a drug database, and Medline. In Newsstand, you can read the latest news from around the world, specific to your condition. And finally, “Community,” includes interactive message boards, live chats with other survivors, and online workshops with experts and health care professionals.


The Clinical Stuff

The following search on the etiology, screening, treatment, and psychological aspects of fibromyalgia was performed in Medline. Included are 10 carefully selected bibliographic citations and abstracts from 1994-1997. The “Source” is the journal abbreviation. For the document delivery referred to on the Cybrarian Service: 1) take these citations and go to a local library for copies of the articles, or 2) go or HealthGate (www.healthgate.com) with the NLM Cit. ID (see below) and order copies of the articles. Any questions about what you’ve received? Don’t hesitate to E-Mail Cybrarian.


P.S. A book came out in 1994 called The Fibromyalgia Syndrome: Current Research and Future Directions in Epidemiology, Pathogenesis and Treatment, by Stanley R. Pillemer. Haworth Medical Press.
Check it out!


There’s also a fine review article in Patient Care, March 15, 1995 (v. 29, n 5) p 29- (10 pages), entitled “Coping Successfully with Fibromyalgia.” By Robert M. Bennett and Glenn McCain




1)
TITLE:

A randomized, double-blind crossover trial of fluoxetine and amitriptyline in the treatment of fibromyalgia.

AUTHOR:

Goldenberg D; Mayskiy M; Mossey C; Ruthazer R; Schmid C

AUTHOR AFFILIATION:

Newton-Wellesley Hospital, Massachusetts, USA.

SOURCE:

Arthritis Rheum 1996 Nov;39(11):1852-9

NLM CIT. ID:

97069524

ABSTRACT:

OBJECTIVE:

To study the effect of fluoxetine (FL) and amitriptyline (AM), alone and in combination, in patients with fibromyalgia (FM). METHODS: Nineteen patients with FM completed a randomized, double-blind crossover study, which consisted of 4 6-week trials of FL (20 mg), AM (25 mg), a combination of FL and AM, or placebo. Patients were evaluated on the first and last day of each trial period. Outcome measures included a tender point score, the Fibromyalgia Impact Questionnaire (FIQ), the Beck Depression Inventory (BDI) scale, and visual analog scales (VAS) for global well-being (1 completed by the physician and 1 by the patient), pain, sleep trouble, fatigue, and feeling refreshed upon awakening. RESULTS: Both FL and AM were associated with significantly improved scores on the FIQ and on the VAS for pain, global well-being, and sleep disturbances. When combined, the 2 treatments worked better than either medication alone. Similar, but nonsignificant, improvement occurred in the BDI scale, the physician global VAS, and the VAS for fatigue and feeling refreshed upon awakening. Trends were less clear for the tender point score. CONCLUSION: Both FL and AM are effective treatments for FM, and they work better in combination than either medication alone.


1a) A related article comes in “Fluoxetine and amitriptyline in the treatment of fibromyalgia.” By SP Johnson, in the Journal of Family Practice 44 (2) : 128-130, Feb. 1997




2)
TITLE:

Fibromyalgia syndrome: a review.

AUTHOR:

Reiffenberger DH; Amundson LH

AUTHOR
AFFILIATION:


Brown Clinic, Watertown, South Dakota, USA.

SOURCE:

Am Fam Physician 1996 Apr;53(5):1698-712

NLM CIT. ID:

96209653

ABSTRACT:

Fibromyalgia syndrome includes symptoms of widespread, chronic musculoskeletal aching
and stiffness and soft tissue tender points. It is frequently accompanied by fatigue and
sleep disturbance. Fibromyalgia is more common in women than in men, and it occurs at a
mean age of 49 years. Differential diagnosis includes myofascial pain syndrome and
chronic fatigue syndrome. Fibromyalgia is a multifactorial problem and no universal
treatment guidelines apply to all cases. Pharmacologic therapy may include tricyclic
antidepressants. In addition to commonly used pharmacologic therapies, patient education,
reassurance and an exercise program can each play an important role in relieving the
symptoms associated with this common musculoskeletal syndrome.




3)
TITLE:

An analytical review of 24 controlled clinical trials for fibromyalgia syndrome (FMS).

AUTHOR:

White KP; Harth M

AUTHOR
AFFILIATION:


University of Western Ontario, University Hospital Rheumatic Disease Unit, London, Canada.

SOURCE:

Pain 1996 Feb;64(2):211-9

NLM CIT. ID:

96303769

ABSTRACT:

We performed a combined manual and computer search of the FMS literature to identify
controlled clinical trials in FMS from 1980 to June 1994 inclusive. Our specific objectives
were: 1) to determine which outcome measures have been used in clinical trials for FMS,
and the methods utilized to measure these outcomes; 2) to identify which outcome
measures were most and least sensitive in distinguishing between treatment groups, and
3) to identify weakness in trial design. Our analysis of 24 clinical trials demonstrates the
large diversity of outcome measures and measurement instruments that have been used
to detect differences between treatment and placebo in the management of FMS.
Whereas certain outcomes, such as self-reported pain and sleep quality, were frequently
measured, other clinically important outcomes, such as functional and psychological
status, were infrequently included in data collection. Finally, we identified several
significant potential sources of bias, including potential flaws in subject selection and
group allocation, inadequate randomization, incomplete blinding, errors in outcome
measurement, and inappropriate analysis of data.




4)
TITLE:

A guide to the understanding and use of tricyclic antidepressants in the overall
management of fibromyalgia and other chronic pain syndromes.

AUTHOR:

Godfrey RG

AUTHOR AFFILIATION:


Department of Medicine, University of Kansas School of Medicine, Kansas City, USA.

SOURCE:

Arch Intern Med 1996 May 27;156(10):1047-52

NLM CIT. ID:

96224800

ABSTRACT:

The purpose of this review is to present relatively detailed information on the
characteristics of tricyclic antidepressants, mainly amitriptyline hydrochloride and doxepin
hydrochloride, for use as an integral part of the safe and effective management of
fibromyalgia and, to a lesser extent, other chronic pain syndromes. Data sources include
MEDLINE searches in English, relevant reference books and textbooks, my personal
database and library, as well as personal clinical experience. I discuss these data with
regard to the pharmacologic characteristics, mechanisms of action, adverse effects, and
precautions involved with the use of tricyclic antidepressants. Additional information is
given on drug selection and dosage titration. Much emphasis is placed on the fact that
while tricyclic antidepressants play a major role in the management of fibromyalgia and
other chronic pain syndromes, lifestyle alterations (eg. physical reconditioning and
exercise), as well as behavior modification, are also vital to a successful outcome in
management.




5)
TITLE:

Treatment of “resistant” fibromyalgia.

AUTHOR:

Wilke WS

AUTHOR
AFFILIATION:


Cleveland Clinic Foundation, Ohio, USA.

SOURCE:

Rheum Dis Clin North Am 1995 Feb;21(1):247-60

NLM CIT. ID:

95249759

ABSTRACT:

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.




6)
TITLE:

Controlled trials of therapy in fibromyalgia syndrome.

AUTHOR:

Simms RW

AUTHOR
AFFILIATION:


Boston University School of Medicine, MA 02118.

SOURCE:

Baillieres Clin Rheumatol 1994 Nov;8(4):917-34

NLM CIT. ID:

95153772

ABSTRACT:

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.




7)
TITLE:

Physical medicine and rehabilitation approaches to the management of myofascial pain and
fibromyalgia syndromes.

AUTHOR:

Rosen NB

AUTHOR
AFFILIATION:


Rehabilitation and Pain Management Associates, Baltimore, MD 21204.

SOURCE:

Baillieres Clin Rheumatol 1994 Nov;8(4):881-916

NLM CIT. ID:

95153771

ABSTRACT:

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.




8)
TITLE:

[Autogenic training versus Erickson’s analogical technique in treatment of fibromyalgia
syndrome]

AUTHOR:

Rucco V; Feruglio C; Genco F; Mosanghini R

AUTHOR AFFILIATION:


Servizio di Terapia Fisica, Ospedale di Medicina Fisica e Riabilitazione, Udine.

SOURCE:

Riv Eur Sci Med Farmacol 1995 Jan-Feb;17(1):41-50

NLM CIT. ID:

96094214

ABSTRACT:

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
autogenous training.




9)
TITLE:

A randomized, controlled clinical trial of education and physical training for women with
fibromyalgia.

AUTHOR:

Burckhardt CS; Mannerkorpi K; Hedenberg L; Bjelle A

AUTHOR
AFFILIATION:


Department of Rheumatology, Sahlgren University Hospital, Gothenburg, Sweden.

SOURCE:

J Rheumatol 1994 Apr;21(4):714-20

NLM CIT. ID:

94309040

ABSTRACT:

OBJECTIVE:
To determine the effectiveness of self-management education and physical
training in decreasing fibromyalgia (FMS) symptoms and increasing physical and
psychological well being.

METHODS:
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.

RESULTS:
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.

CONCLUSION:
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.




10)
TITLE:

Treatment of fibromyalgia syndrome with Super Malic: a randomized, double blind,
placebo controlled, crossover pilot study.

AUTHOR:

Russell IJ; Michalek JE; Flechas JD; Abraham GE

AUTHOR AFFILIATION:


Department of Medicine, University of Texas Health Science Center, San Antonio 78284-7874, USA.

SOURCE:

J Rheumatol 1995 May;22(5):953-8

NLM CIT. ID:

96172499

ABSTRACT:

OBJECTIVE

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.

CONCLUSIONS

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.




11)
TITLE:

Electroacupuncture in fibromyalgia: results of a controlled trial

AUTHORS:

Deluze C, Bosia L, Zirbs A, Chantraine A, Vischer TL

AFFILIATION:

Division of Physical Medicine and Rehabilitation, University Hospital, Geneva, Switzerland

SOURCE:
Journal: BMJ 305 (6864): 1249-1252 (Nov 21 1992)

NLM ID:

93120934.

OBJECTIVE
To determine the efficacy of electroacupuncture in patients with fibromyalgia, a syndrome of unknown origin causing diffuse musculoskeletal pain. DESIGNThree weeks’ randomised study with blinded patients and evaluating physician.
SETTING
University divisions of physical medicine and rehabilitation and rheumatology, Geneva.
PATIENTS
70 patients (54 women) referred to the division for fibromyalgia as defined by the American College of Rheumatology. INTERVENTIONS–Patients were randomised to electroacupuncture (n = 36) or a sham procedure (n = 34) by means of an electronic numbers generator. MAIN
OUTCOME MEASURES
Pain threshold, number of analgesic tablets used, regional pain score, pain recorded on visual analogue scale, sleep quality, morning stiffness, and patient’s and evaluating physician’s appreciation.
RESULTS
Seven of the eight outcome parameters showed a significant improvement in the active treatment group whereas none were improved in the sham treatment group. Differences between the groups were significant for five of the eight outcome measures after treatment.
CONCLUSIONS
Electroacupuncture is effective in relieving symptoms of fibromyalgia. Its potential in long term management should now be studied. Electroacupuncture*




12)
TITLE:
Coping with chronic pain: assessing narrative approaches.

AUTHORS:
Kelley P, Clifford P

AFFILIATION:
School of Social Work, University of Iowa, Iowa City, USA. patricia-kelley@uiowa.edu

SOURCE:
Soc Work 42 (3): 266-277 (May 1997)

NLM CIT ID
97297626


Individuals suffering from chronic pain are of concern to social workers because such pain disrupts job, family, and overall social functioning and can lead to depression, excessive health concerns, and withdrawal from activities. This article discusses a project developed to gain understanding of the experiences of people suffering from fibromyalgia, a chronic pain condition with no visible symptoms, and to test the use of narrative approaches in group work with this population. The study used a qualitative ethnographic approach as the primary method and also used some quantitative measures to assess the usefulness of the approach. Both qualitative and quantitative findings suggest that narrative approaches helped participants find their own strengths and means of coping and helped them find identities other than as patients.




(13)
TITLE:
Psychiatric and psychologic aspects of fibromyalgia syndrome.

AUTHOR
Goldenberg DL

AFFILIATION:

Tufts University School of Medicine, Boston, Massachusetts.

SOURCE:
Rheum Dis Clin North Am 15 (1): 105-114 (Feb 1989)

NLM CIT. ID:

89129518


Most previous psychologic and psychiatric studies of patients with fibromyalgia have utilized instruments that do not control for pain and therefore may be falsely interpreted as indicative of increased depression, hysteria, or hypochondriasis. Future studies must utilize psychiatric techniques that take into account a coexistent medical condition and such evaluation should include patients with varying levels of severity of fibromyalgia symptoms and utilization of health care.


Avatar Written by Micaela Sullivan-Fowler

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