Talk:Fibromyalgia

This is a talk page

I feel for anyone who is under your "care" — Preceding unsigned comment added by 98.207.197.166 (talk) 09:06, 18 January 2013 (UTC)

The following is AN ADVERTISEMENT: Blondesareeasy (talk) —Preceding undated comment added 19:55, 10 December 2012 (UTC)

You had placed your new section before the "Natural Suggestions for Pain Relief" section to which you refer, but the Wikipedia standard is to put new sections at the bottom of the talk page. See WP:TALKNEW.

While you may well have a point that much of the information in the "Natural Suggestions for Pain Relief" section is advertising per WP:LINKSPAM, much of you posting involves using the talk page to promote your personal views on fibromyalgia. This is also inappropriate. See WP:NOTFORUM. -- JTSchreiber (talk) 06:44, 17 December 2012 (UTC)

AGAIN, this is a talk page. And you deleted the advertisement, thereby promoting your personal beliefs. That's okay. But you should have left MY personal views on good old "fibro" intact. Restore the advertisement. Blondesareeasy (talk) —Preceding undated comment added 05:59, 22 February 2013 (UTC)

Actually, you'll find the section was automatically archived, as talk pages often are to keep them neat. Although as with most people whose views are to the extreme of any given subject, you will no doubt crow 'conspiracy'. This, again, is not a forum, and our articles are meant to provide a balanced view of the informed opinions on the matter. There are many places on the internet for uninformed opinion and the unbalanced, and what makes this website so important is it's dedication to the verifiable. Thus, both advertising, and opinions are pretty much unwelcome, both on talk pages, and in the articles themselves. In conclusion, please desist, or move it to Youtube or the Daily Mail website, both bastions of the rage of the impotent, maladjusted and ill informed. Benny Digital ^{Speak Your Brains} 11:33, 22 February 2013 (UTC)

Sodium Oxybate reseach results

I am wondering if my edit regarding the clinical trial results for Sodium Oxybate can be reinstated. The reference I provided to PubMed (http://www.ncbi.nlm.nih.gov/pubmed/21679091) is a secondary source (review article) per Wikipedia's source guidelines. My edit was undone for also referencing a primary source, the Annals of the Rheumatic Diseases. This information is significant as it supports a link between sleep disturbance and fibromyalgia. Projecto2501 (talk) 22:24, 8 February 2013 (UTC)

You're right, that is my error in removing it as a violation of WP:MEDRS. This may be useful in the treatment section, will look into this further. Yobol (talk) 22:29, 8 February 2013 (UTC)

...and added to treatment section. Yobol (talk) 22:37, 8 February 2013 (UTC)

That study should not be used as a source to say that the cause of fibromyalgia is sleep disturbance; all that article shows is that sodium boxyrate can be used as a treatment, but extrapolating any information about the cause of fibromyalgia would seem to be WP:OR. Yobol (talk) 23:14, 8 February 2013 (UTC)

You are right, this information should be in the Treatment section and not under Pathophysiology. If I add to the Investigational Treatments section: Sodium Oxybate was studied is several, large placebo controlled trials and was found to improve fibromyalgia pain and fatigue. However it was not approved by the FDA due to potential abuse concerns. Does that sound about right?Projecto2501 (talk) 00:18, 9 February 2013 (UTC)

I have already included a section in the treatment section under the heading "narcolepsy medication". Yobol (talk) 00:20, 9 February 2013 (UTC)

Looks good to me. Thank you.Projecto2501 (talk) 00:24, 9 February 2013 (UTC)

Neurobiological or psychosomatic

This condition has been described as both by the medical literature as per this ref [1]. Neither position has very good evidence but if we are going to mention any we should mention both. Doc James (talk · contribs · email) (if I write on your page reply on mine) 19:59, 2 March 2013 (UTC)

The reference that you give, the book source actually states that the view that fibromyalgia is purely psychosomatic/psychogenic in origin is an extreme viewpoint that is counterproductive in a patient's care and they also argue that the other view that the condition is entirely physical is also extreme. They actually recommend giving a medical diagnosis for the fibromyalgia and then using the DSM-IV to diagnose psychiatric symptoms which may be part of the picture. Your reference actually supports my view as I think it has neurophysiological and neuropsychiatric components to it based on what the neuroscience research has found which this article summarises. This high quality source says that there is 'extensive research' that has determined that the primary symptom of the pain is neurogenic in origin, i.e, the pain is due to dysfunction of certain pathways in the brain rather than being 'psychogenic' in origin. This source states that research has now determined that the condition cannot be viewed as purely a psychosomatic disorder and instead describe it as a central sensitisation syndrome.

I disagree that we should mention both as I think that it is a misrepresentation of the dominant view of the literature. The dominant view in particular the past 5-10 years supports the view of it being a neurobiological/neurogenic disorder with often neuropsychiatric comorbidity and these physical and psychological symptoms share genetics and have similar neurobiological causes. I think mentioning the link between fibromyalgia and neuropsychiatric disorders, particularly major depressive disorder could be mentioned in the lead but I think defining it as a psychosomatic disorder is giving undue weight to a minority view not supported by most experts and researchers. Doc James have you ever spent a significant amount of time reading the recent research on fibromyalgia?--MrADHD | T@1k? 22:18, 2 March 2013 (UTC)

The reference also states that the extreme viewpoint of it being a neurobiological disorder/organic disorder is also unhelpful. And may cause "doctors to endlessly seek pathology while the patient adopts the life of the helpless invalid." It finishes by recommending that biological, psychological, and social factors be taken into account.Doc James (talk · contribs · email) (if I write on your page reply on mine) 22:29, 2 March 2013 (UTC)

Okay but the source is saying the right way of interpreting the condition is to recognise the contribution of biological, psychological and social/lifestyle contributions to the picture. The main body of this article discusses this and I agree that psychological and environmental factors (including obesity which may interest you) contribute to the initiation and maintenance of the disease. The idea that fibromyalgia is a conversion disorder is probably WP:FRINGE or at least a minority view and psychosomatic in my mind implies a conversion disorder and this is not at all reflective of the literature. I would happily add in the lead sentence and better summarise the body of the article that there are neurobiological, psychological and social/environmental contributions to the syndrome. The research definitely supports stress and other psychological factors as contributing to initiating and possibly maintaining the syndrome and it is tied in with biological depression with which it shares similar pathophysiology.--MrADHD | T@1k? 22:45, 2 March 2013 (UTC)

I think the one thing most of the literature agrees on is that the cause is unknown [2][3]. With respect to the associated psychiatric issues it is unknown which causes which.[4]. I would support removing both and simply stating "of unknown cause." I would disagree that the attribution to psychosomatic medicine is fringe especially as the field claims it as a problem they treat. [5] Doc James (talk · contribs · email) (if I write on your page reply on mine) 22:51, 2 March 2013 (UTC)

This text describes it as a "somatic symptom unexplained by somatic pathology" [6] Doc James (talk · contribs · email) (if I write on your page reply on mine) 23:01, 2 March 2013 (UTC)

The source says that the 'precise cause' is unknown but then documents a range of neurobiological abnormalities found in fibromyalgia patients. Precise cause unknown is not the same thing as cause unknown. The source does say that it is unknown whether the psychological symptoms cause the physical symptoms or vice versa which is chicken and egg. Your second reference is similar, it says 'specific cause unknown' which again is not the same thing as 'cause unknown' and then they list neurobiological abnormalities and genetic contributions to the disorder. Neither of your sources support fibromyalgia as a psychosomatic disorder in the pure sense anyway. Everybody claims they can treat fibromyalgia - if you look at this recent systematic review and meta-analysis of the literature it found that CBT had no effect on pain levels but could help in coping with the pain.[7] Yes psychological therapies can help with coping with the pain but medication is what is often needed for what is a syndrome which has a strong neurobiological component to it as both of your references document. As explained your sources don't at all describe it as a disorder of 'unknown cause' but say the specific or precise cause is unknown like many many things in medicine, especially psychiatry and neuroscience exact causes are not known. 'Unknown cause' implies researchers are clueless or can't find any abnormalities which is inaccurate and not true.--MrADHD | T@1k? 23:33, 2 March 2013 (UTC)

When arguing in support of fibromyalgia being of pure psychological origin or its cause being known, no evidence is given by proponents and they ignore probably unwittingly enormous amounts of neuroscience. I gave a good source which says there is extensive research to support a neurogenic origin for the pain but you don't offer extensive evidence to debunk the neuroscience, but don't mean to sound rude just evidence-less opinions of a psychiatrist by doing a search on google books. Okay seriously spend an hour or two or three just reading systematic reviews done on fibromyalgia not using any biased keyword searches. Just type fibromyalgia into pubmed and restrict to systematic reviews and the past 5 years and read and you will see what the real dominant view of the researchers currently is and you will see that describing fibromyalgia as a pure psychological disorder is very much a minority viewpoint among experts.--MrADHD | T@1k? 23:33, 2 March 2013 (UTC)

I am not arguing for one or the other. I am simply stating that their is high quality sources to support both and to support neither. I have no personal opinion in the matter at hand. Now if you are wanting evidence to support null hypothesis or a mechanism behind psychosomatics there of course is not any. My reading of the literature is that many still are not convinced by the conclusiveness of a neurological cause which is of course why the cause remains unknown. This of course is different than a neurological mechanism which I think no one denies. For example just because gout causes pain and pain is a neurological problem it does not follow that gout is caused by a neurological disease but it does mean that it is associated with brain changes that can be picked up on PET or fMRI. Neither useful in diagnosis gout. Doc James (talk · contribs · email) (if I write on your page reply on mine) 23:47, 2 March 2013 (UTC)

(Outdent) The lead does need to describe the syndrome as a syndrome with a range of causes including genetic, neurobiological, psychological and environmental contributions with the exact cause or precise cause being unknown.--MrADHD | T@1k? 23:44, 2 March 2013 (UTC)

Yes I think that would be more useful. "Fibromyalgia is characterized by chronic widespread pain and allodynia (a heightened and painful response to pressure). Its exact cause is unknown but is beleived to involve psychological, social, genetic, neurobiological and environment factors." Or some such wording. Stating that it is either neurobiological or psychosomatic in the lead without context may not be useful. Doc James (talk · contribs · email) (if I write on your page reply on mine) 23:47, 2 March 2013 (UTC)

ref simply states that it is a complex disorder. {{PMID: 21993145}} Doc James (talk · contribs · email) (if I write on your page reply on mine) 00:44, 3 March 2013 (UTC)

I was wrong about neuro imaging and somatoform disorders. Supposedly they do provide evidence {{PMID:21217095}}Doc James (talk · contribs · email) (if I write on your page reply on mine) 00:47, 3 March 2013 (UTC)

And this text from 2011 includes this condition with "undifferentiated somatoform disorder" but only tentatively which is a DSM4TR diagnosis meaning "When a patient's physical complaints cannot be fully explained by a medical condition or use of a drug"[8].Doc James (talk · contribs · email) (if I write on your page reply on mine) 00:57, 3 March 2013 (UTC)

Also refered to as "functional somatic syndromes" [9] and evidence in support is that few people are found to have organic disease after long term follow up. [10] It is grouped with IBS and chronic fatigue by some [11] Doc James (talk · contribs · email) (if I write on your page reply on mine) 00:59, 3 March 2013 (UTC)

Thanks as always for the good feedback - you help challenge me sometimes and get me thinking a bit as I am sure I do to you to, lol. I have added into the classifications section about fibromyalgia being a functional somatic syndrome - I am not sure that is the same thing as psychosomatic but anyway as it does not appear to be classed as such in the ICD-10. Lack of organic disease in long-term follow-up just means that doctors in general are doing a good job and are not misdiagnosing organic disorders or the early stages of an organic disorder as fibromyalgia a functional disorder of the central nervous system, at least that is how I interpret that. Anyhow I have done some major rewrites and added text which hopefully will address all concerns. Let me know your thoughts. :-) Are there any major problems with the article?--MrADHD | T@1k? 20:34, 3 March 2013 (UTC)

Have not looked much past the first sentence :-). Why is 6 references needed for that one line in the lead? One would think one ref should be able to sum it up, two at most. And than lower in the article we have 11 lefts many of them fairly old. Investigation medications should be moved to a section on research. Doc James (talk · contribs · email) (if I write on your page reply on mine) 20:55, 3 March 2013 (UTC)

Took a little closer look at things. Made a few minor changes. I would consider most of the causes mentioned to actually be pathophysiology. The first line of serotonin metabolism even says as much. This would also include the sections on dopamine dusfunction and growth hormone. I would see sleep disturbances as being a cause rather than part of pathophysiology. Doc James (talk · contribs · email) (if I write on your page reply on mine) 21:22, 3 March 2013 (UTC)

Many of the refs are still in need of updating. Many are from the 90s and pubmed lists ~500 reviews from the last 5 years. Doc James (talk · contribs · email) (if I write on your page reply on mine) 21:27, 3 March 2013 (UTC)

I have fixed the issue of excessive references and I believe that I have fixed the core issues with the causes and pathophysiology sections. I don't think that I have the energy or interest to do an extensive rework of the references. I just wanted to deal with the core issues. I am hoping to get back to work on the main ADHD article soon where I want to devote my time to get it to good article status. We have done good work here and the article is in better shape. Thanks. :)--MrADHD | T@1k? 22:35, 3 March 2013 (UTC)

Great. Not sure if I would go this far though "However, there is extensive research evidence to support the view that the central symptom of fibromyalgia, namely pain, has a neurogenic cause" It has a neurological and maybe endocrinological pathophysiology but the underlying cause is unknown. :-) The chicken and egg thing again. When you hit your thumb with a hammer the sensation/pathophysiology of pain in neurogenic but not the cause. But yes lots of work to do. Good to see you back. Doc James (talk · contribs · email) (if I write on your page reply on mine) 23:05, 3 March 2013 (UTC)

I have changed word to origin which is what the source says. Is that okay? Or no? Do you feel I am still misinterpreting or misquoting from reference? Thanks. :)--MrADHD | T@1k? 23:18, 3 March 2013 (UTC)

How about "the pathophysiology of fibromyalgia involves a number of neurological and endocrinology mechanisms." or "the pain of fibromyaligia is related to a number of neurological and endocrinological mechanisms"? I am always hesitant of phrases like "However, there is extensive research evidence" I like to keep text low key. Doc James (talk · contribs · email) (if I write on your page reply on mine) 23:41, 3 March 2013 (UTC)

Okay fair enough Doc - I deleted the sentence. :-) I have made some more additional changes. Are they improvements or have I made the problem worse?--MrADHD | T@1k? 23:17, 17 March 2013 (UTC)

Diagnosis section

Just an observation, but the intro paragraph in the current diagnosis section is about 66% non-referenced editorial content. Seems very much in need of the editorial cutting blade...!216.45.254.174 (talk) 23:43, 9 April 2013 (UTC)

Tramadol

Is classified as a type of opioid and thus does not need its own section. Doc James (talk · contribs · email) (if I write on your page reply on mine) 23:32, 16 April 2013 (UTC)

I think it does need its own section. Tramadol doesn't share the other characteristics of opioids and is actually recommended for Fibromyalgia. It has serotonin and norepinephrine effects that make it unique. What benefit is there from combining it? 98.207.197.166 (talk) 09:32, 18 April 2013 (UTC)

The distinction between tramadol and other opioids is made clear in the first sentence of the section, so it doesn't need a sub-section of its own. --Anthonyhcole (talk · contribs · email) 10:23, 18 April 2013 (UTC)

You still haven't named a benefit from combining it. There are things in the opioid section that contradict information on Tramadol such as "Long-term use of opioids may worsen pain in some people." Tramadol may be technically an opioid, but this does not apply. Thus combining this information seems confusing. 98.207.197.166 (talk) 17:40, 18 April 2013 (UTC)

Splitting tramadol from other opioids does not make sense, and will only confuse readers. Should be in the same section. -- Scray (talk) 03:49, 19 April 2013 (UTC)

We do need to make it clear that, due to its specificity for neuropathic pain, its tolerance profile, its low sedative properties, and other benefits in comparison to conventional opioids, it is the recommended opioid. That can be done under the heading "Opioids" though. I guess I'm saying what's needed is a better clarification of the distinction and benefits of tramadol, not a new sub-heading. Do you feel like having a go at that? I'm doing other stuff with my wiki-time at the moment. --Anthonyhcole (talk · contribs · email) 05:06, 19 April 2013 (UTC)

What if it had a subsection under opoids. It would therefore be classified correctly but the exceptions would also be made quite clear. Benny Digital ^{Speak Your Brains} 07:59, 19 April 2013 (UTC)

I think the distinctions are overwrought - the US FDA has warned the company about this, so it's clearly an issue. I also think the Brazilian recommendation for use in fibromyalgia is being used to support a statement that appears to apply more globally - the Brazilian recommendations are neither global nor published in a high-impact general-readership journal. Tramadol is an opioid. -- Scray (talk) 15:40, 19 April 2013 (UTC)

I see that the AWMF guideline (linked below) excluded one Bennett study from 2005 because it was a double publication of their 2003 report. Was that the problem with the FDA? --Anthonyhcole (talk · contribs · email) 12:35, 20 April 2013 (UTC)

The US FDA has warned the company about what? I think the distinction is still important, and I think this could be achieved by a subsection. The tramadol section could come first and the opioid section could come second and refer to "strong" opioids. Anthonyhcole is right that it is the recommended pain medication for fibromyalgia, and this is supported by more than the Brazilian study. I'm surprised by the rush to lump Tramadol with other opioids when it could just as easily fit under anti-depressants with its SNRI properties. That's why I thought it deserved its own unique heading. The first sentence says it has opioid activity after all. Not sure how that's confusing. The separate heading for Tramadol has been like that for months. 98.207.197.166 (talk) 04:05, 20 April 2013 (UTC)

I was relying on the Brazilian guideline for my "recommended" comment. The Brazilian guideline in turn relies on European League Against Rheumatism (EULAR) (2007) for the assertion "Tramadol was recommended for treating pain in fibromyalgia" and The American Pain Society (APS) (2005) for the assertion "[Tramadol's] association with paracetamol was considered effective in the treatment of fibromyalgia".

I'm familiar with tramadol's particular usefulness in the treatment of (especially neuropathic) cancer pain, but I'm new to its use in FM. --Anthonyhcole (talk · contribs · email) 08:09, 20 April 2013 (UTC)

Häuser, Thieme and Turk (2010) identified three evidence-based professional guidelines for the management of FMS:

1. The American Pain Society (APS) (2005)
2. European League Against Rheumatism (EULAR) (2007)
3. Association of the Scientific Medical Societies in Germany (AWMF) (2008)

The APS guideline appears to have been withdrawn. The AWMF guideline has been updated,^[12]

Häuser says of the working groups behind the three guidelines:

The steering committees and panels of APS and AWMF were comprised of multiple disciplines engaged in the management of FMS and included patients, whereas the task force of EULAR only consisted of physicians, predominantly rheumatologists. APS and AWMF ascribed the highest level of evidence to systematic reviews and meta-analyses, whereas EULAR credited the highest level of evidence to randomised controlled studies. Both APS and AWMF assigned the highest level of recommendation to aerobic exercise, cognitive-behavioral therapy, amitriptyline, and multicomponent treatment. In contrast, EULAR assigned the highest level of recommendation to a set of to pharmacological treatment. Although there was some consistency in the recommendations regarding pharmacological treatments among the three guidelines, the APS and AWMF guidelines assigned higher ratings to CBT and multicomponent treatments. The inconsistencies across guidelines are likely attributable to the criteria used for study inclusion, weighting systems, and composition of the panels.

AWMF (2012) says:

Due to the limited data available (tramadol) or lack of data (other weak opioids) neither a positive nor a negative recommendation is possible for weak opioids. Strong consensus. [...] Strong opioids should not be used. Strong negative recommendation, strong consensus.

EULAR (2007) says:

Tramadol is recommended for the management of pain in fibromyalgia. Simple analgesics such as paracetamol and other weak opioids can also be

considered in the treatment of fibromyalgia. Corticosteroids and strong opioids are not recommended.

Regarding tramadol, two randomised controlled trials were identified as eligible for the review. One was a high quality study of large sample size and 13 weeks duration. The second was preceded by an open label study and only included responders. Bennett et al. reported positive effects for pain and function, and Russell et al. reported improved pain levels but no change in function. There was no difference between placebo and treated group for adverse event withdrawals (high but non-serious). Bennett et al. restricted concomitant medications, but Russell et al. disallowed sedative hypnotics only. Tramadol should be used with some caution due to the possibility of typical opiate withdrawal symptoms with discontinuation and the risk of abuse and dependence.

The recommendation for simple analgesics and other weak opioids is based mainly on expert opinion due to insufficient data.

The Canadian Pain Society (2012) says:

Tramadol, an opioid with more than one analgesic mechanism, is the only opioid that has been studied in FM, with positive effect on pain and improved quality of life. Treatment trials in patients with non-cancer pain, including some with FM, report that opioids offer good short-term analgesia, although treatments are often discontinued. Due to lack of evidence opioid use is not recommended by any previous FM guidelines.

Opioids are used by up to 30% of FM patients and are perceived to provide best symptom relief when surveyed by internet. Opioids are associated with negative psychosocial effects including unstable psychiatric disorder, history of substance abuse, unemployment and disability payments. [...]

In clinical practice opioids may be useful in selected patients, but with caution. Treatments should be initiated with weaker opioid agonists such as codeine or tramadol, before moving to the stronger opioids, but without any convincing evidence. [...] Currently, tramadol, tapentadol and methadone are analgesic agents with multiple effects. The parent compound tramadol has added serotonin and norepinephrine effects, whereas tapentadol has effects on noradrenergic receptors. [...] These agents could be used for pain relief as a step up from acetaminophen and prior to the use of more potent opioid analgesics.

The progressive increase in opioid prescription has seen a parallel increase in their use as drugs of abuse, with reports of increased deaths associated with overdosing especially when combined alcohol or benzodiazepines. Guidelines for safe and effective use of opioids for chronic pain have been published by the APS and also in Canada, with notes of caution. Physicians should practice responsible prescribing behaviours, pay attention to physical and psychosocial aspects, and constantly re-evaluate the risk benefit ratio. Long term effects of chronic opioid use are not yet fully clarified, but effects on mood, cognitive function, hormonal effects and increased pain due to hyperalgesia, need to be constantly re-evaluated. Although extended-release formulations are touted as advantageous, evidence is lacking. Recommendations:

• A trial of opioids, beginning with a weak opioid such as tramadol, should be reserved for treatment of patients with moderate to severe pain that is unresponsive to other treatment modalities
• Strong opioid use is discouraged, and patients who continue to use opioids should show improved pain and function. Healthcare professionals must monitor for continued efficacy, side effects or evidence of aberrant drug behaviours

These are the only current professional guidelines covering opioids in FM that I could find. Can we use these to construct the "Opioids" section?

How about

Due to the limited data supporting the use of tramadol in fibromyalgia and the absence of any data supporting the use of other weak opioids, the Association of the Scientific Medical Societies in Germany makes no recommendation against or in favor of their use, but strongly advises against using strong opioids; the European League Against Rheumatism, based mainly on expert opinion (due to the insufficient data) recommends tramadol but not strong opioids; and the Canadian Pain Society says that opioids, starting with a weak opioid like tramadol, can be tried but only for patients with otherwise intractable moderate to severe pain, and that strong opioids are discouraged, only to be used by patients who show ongoing improved pain and function. Healthcare providers must monitor patients on opioids for ongoing effectiveness, side effects and possible unwanted drug behaviours.

The paraphrasing is a little close but what do you think of the general idea? The claim that "37.4% of patients with a diagnosis of FMS received short-acting opioids and 8.3% received long-acting opioids" is found in PMID 21303476. If someone has access to that article, can they confirm that it is "in any given year" as our article claims; and could you also check if it is an official guideline of the Asia Pacific League of Associations for Rheumatology, or just the opinion of the three authors? --Anthonyhcole (talk · contribs · email) 13:41, 20 April 2013 (UTC)

The Ngian article about which you ask clearly is NOT a guideline - it's just a review article in a journal published by the APLAR (the only occurrence of the word "guideline" is in references to the EULAR guidelines, and the article doesn't mention the APLAR at all). The sentence about which you ask states, "Furthermore, analysis of an American health insurance database over a period of 3 years found that 37.4% of patients with a diagnosis of FMS received short-acting opioids and 8.3% received long-acting opioids.²⁹", with reference 29 being "Berger A. Patterns of use of opioids in patients with fibromyalgia. In: EULAR; 2009:SAT0461." This is clearly in reference to this abstract; not something I think deserves that much coverage in our article. -- Scray (talk) 05:37, 21 April 2013 (UTC)

Great, thanks. I don't think we should labour the point but an indication of the proportion of FMS patients using opioids would be appropriate, since the Canadians and Ngian opted to. The Canadians' "Opioids are used by up to 30% of FM patients" comes from Fitzcharles (2011) "opioid use by 32% of 457 patients referred to a multidisciplinary fibromyalgia clinic, with over two thirds using strong opioids". I think the study Ngian (2011) cites, because of its size (N = 51,885) is worthy of mentioning. We could paraphrase "37.4% of patients with a diagnosis of FMS received short-acting opioids and 8.3% received long-acting opioids." Perhaps, "A 2011 study of 51,885 US fibromyalgia patients over three years found that 8.3% were prescribed long-acting opioids and 37.4% received short-acting opioids." Given the emphasis each of the guidelines gives tramadol, we could also mention from the primary source, "with around 10% of those prescribed short-acting opioids using tramadol." I suppose we might mention the Canadian results, too, if the trial was conducted in Canada. --Anthonyhcole (talk · contribs · email) 16:19, 21 April 2013 (UTC)

I've added

A study of 51,885 US fibromyalgia patients from 2005 to 2007 found that 37.4% were prescribed short-acting opioids and 8.3% were prescribed long-acting opioids, with around 10% of those prescribed short-acting opioids using tramadol; and a 2011 Canadian study of 457 FM patients found 32% used opioids and two thirds of those used strong opioids.

--Anthonyhcole (talk · contribs · email) 07:21, 22 April 2013 (UTC)

OK. I've replaced the existing text with

Due to the limited data supporting the use of tramadol in fibromyalgia and the absence of any data supporting the use of other weak opioids, the Association of the Scientific Medical Societies in Germany makes no recommendation against or in favor of their use, but strongly advises against using strong opioids; the European League Against Rheumatism, based mainly on expert opinion (due to the insufficient data) recommends tramadol but not strong opioids; and the Canadian Pain Society says that opioids, starting with a weak opioid like tramadol, can be tried but only for patients with otherwise intractable moderate to severe pain, and that strong opioids are discouraged, only to be used by patients who show ongoing improved pain and function. Healthcare providers must monitor patients on opioids for ongoing effectiveness, side effects and possible unwanted drug behaviours. The combination of tramadol and paracetemol has demonstrated efficacy, safety and tolerability for up to two years in the management of other pain conditions without the development of tolerance. It is as effective as codeine plus paracetamol but produces less sleepiness and constipation.

Anthonyhcole (talk · contribs · email) 05:18, 21 April 2013 (UTC)

On which reference is the penultimate sentence based? With the "other pain conditions" phrase it looks like WP:SYNTH, but maybe one of the review articles said something equivalent? Also, I think the EULAR guideline lists the evidence quality as "Ib" (evidence from at least one randomized controlled trial), though that could be equivalent to "mainly on expert opinion". -- Scray (talk) 05:52, 21 April 2013 (UTC)

The cited source for the last two sentences, Schug (2006) says in its abstract "In the setting of chronic pain, paracetamol plus tramadol has shown sustained efficacy, safety and tolerability for up to 2 years without the development of tolerance." The "2 years" refers to (page S19) a trial in the management of chronic low back pain and/or osteoarthritis pain (possibly others too - I haven't read the paper for a couple of years). Schug's evidence for tramadol plus paracetamol in FM is Bennet's 2003 3-month trial. I'm trying to make it clear that the "2 years" doesn't apply to FM. Probably could do better. I'll think about it. Suggestions?

The EULAR guideline (page 12) says "The recommendation for simple analgesics and other weak opioids is based mainly on expert opinion due to insufficient data"

The citation to the German guideline needs correcting, too (it presently cites the 2008 version but links to the 2012 version). I've got guests coming so won't be able to get to it straight away. --Anthonyhcole (talk · contribs · email) 09:28, 21 April 2013 (UTC)

I've added brackets to remove the ambiguity: "The combination of tramadol and paracetemol has demonstrated efficacy, safety and tolerability (for up to two years in the management of other pain conditions) without the development of tolerance" and fixed that citation. --Anthonyhcole (talk · contribs · email) 07:21, 22 April 2013 (UTC)

The overall changes read too complex to me. The sentences are long and unwieldy. Look how long the first sentence is. Its hard to differentiate between strong opioids (which are strongly advised against) and Tramadol (which is recommended or at worst neutral due to insufficient evidence). Then there are weak opioids other than Tramadol which have only insufficient evidence. I think it needs a section on weak opioids and strong opioids. 98.207.197.166 (talk) 22:43, 22 April 2013 (UTC)

T'ai chi

Presently, we say: "Tai chi may result in benefit," citing this review by a single author. The author says about t'ai chi in the management of FMS specifically, "Both studies suggested that Tai Chi may be a useful treatment in the multidisciplinary management of this therapeutically challenging disorder", citing

• one small 2003 study (PMID 8307341, n = 39, 6 weeks of 1-hour, twice weekly t'ai chi exercise classes) and
• the author's own small 2010 trial (PMC 3023168, n = 66, 12 weeks of 1-hour, twice weekly t'ai chi exercise classes)

I'm concerned that the reviewer is not sufficiently independent, and that two small trials is not enough evidence to say anything at all worth saying about t'ai chi in FMS. I've removed it for now. --Anthonyhcole (talk · contribs · email) 08:56, 22 April 2013 (UTC)