Talk:Fibromyalgia/Archive 4

"Non-Disease" statement in article into
The introduction to this article includes the statement:


 * "Many members of the medical community consider fibromyalgia a ‘non-disease’ because of a lack of abnormalities on physical examination, the absence of objective diagnostic tests"

One of the sources cited does not appear to have an abstract available, but the second source does have the full text available. The second source does not seem to support this statement. Well, I suppose that it does state that "some" consider it a non-disease, but then goes on to detail why it should not be considered a non-disease.

Now, as I said, the first source has no abstract, and it is hard to determine its conclusions based upon the brief introduction given, but the second source most definitely does not support the statement, and I find this a bit disconcerting. It strikes me as being a bit akin to citing Richard Dawkins to support the concept of a controversy over evolution. The second source is actually titled "Fibromyalgia: why such a controversy?"

I don't want to change it, at least partly because I really am not very well-read on the literature regarding this topic, but...when I see statements like this that have possible weasel-words ("many members") that are sourced to papers that conclude the opposite of the statement, it throws up some red flags. Surely if many members of the medical community consider this to be a non-disease, there ought to be many reliable sources within the medical community who have published studies to that effect. Citing a paper that states that:


 * "In conclusion, the clinical syndrome that we recognise as fibromyalgia has been with us for centuries and is here to stay."

does not strike me as supporting the statement in the introduction of the article. If there are no reliable sources that call fibromyalgia a "non-disease" then that statement should be removed. If there are reliable sources that state that fibromyalgia is a non-disease, then I am sure that this can be resolved rather easily. As I said, I am not well-read on the literature regarding this topic, so I do not know whether such sources exist. ~ Hyperion35 (talk) 08:47, 24 August 2009 (UTC)

There is no valid medical journal or source that states that Fibro is a "non-disease." In fact there are FDA approved medications which would verify that Fibro is, in fact, a disease. —Preceding unsigned comment added by 70.57.228.12 (talk) 06:29, 7 January 2010 (UTC)


 * I think the contention is as to whether it is an actual "physical" disease, or if it is psychiatric, in as far as the two can be separated. 129.176.151.10 (talk) 03:37, 25 April 2010 (UTC)

quote: The fact is that all physical manifestations of fibromyalgia are in the brain.--end Quote. I take exception to that being a "generally accepted fact," within the medical community. Show me even one obscure publication of viable research to prove this.

A data base of over 10,000 case histories of patients diagnosed as having Fibromyalgia by various doctors from many specialties, including Rheumatology where the AMA places it right now, over and over presents concrete evidence that there are physical abnormalities, as well as atypical functions, of the brain as well as in the skeletal structure, muscle, tendon, ligament, and tissue areas, digestive system, neurological system, elimination system, glandular system, reproductive system etc. Fibromyalgia is on the Social Security Disability list of verified Syndromes and Diseases and is not challenged as to its reality before paying SSDI. Having endured 14 months of reviews by their choice of Doctors and Psychiatrists and even the Vocational Rehabilitation Department's Physical and Occupational Therapists who searched for ways to make me employable, I know the extent to which they try to check out and prove the malingering charge. In the end, my claim for disability was subjected to all three reviews and then granted on the first application. In the state of NE its pretty well unheard of to win the claim the first time. Both government and AMA websites discuss Fibromyalgia without a mention of a question about its authenticity. Fibromyalgia is a disease of mimicry in that it mimics the symptoms of other diseases but the known treatments do not affect those symptoms because it is not those other diseases, it is Fibro. It's no wonder that causality can't be included extensively in this wiki article. The Rheumatologist who diagnosed me, admitted that "nobody knows the cause, or the cure, or even a very good treatment." He told me something inaccurate as well, he said it was not degenerative. Yet, 10 years later at 59 I was in a wheelchair and unable to work, dealing with spastic colon advanced to diverticulitis and joint pain advanced to osteo-arthritis. My daughter suffered spontaneous rupture of cervical disks, without trauma to the area, several years after being diagnosed. Anecdotal evidence among the aforementioned 10,000 patients is plentiful. That's a huge sampling.

There are additional private research and studies for articles recently conducted which should be included. One shows Guaifenesin to be more improvement producing than any treatment being used by the test sampling save opiates. Here is the site information for that one. Journal of Women's Health Self-Reported Medication and Herb/Supplement Use by Women with and without Fibromyalgia

To cite this article: Joan L. Shaver, JoEllen Wilbur, Hyeongkyeong Lee, F. Patrick Robinson, Edward Wang. Journal of Women's Health. May 2009, 18(5): 709-716. doi:10.1089/jwh.2008.1194. Published in Volume: 18 Issue 5: May 17, 2009 Full Text: • PDF for printing (10,573.3 KB) • PDF w/ links (164.9 KB)

Joan L. Shaver, Ph.D., R.N.,1 JoEllen Wilbur, Ph.D., A.P.N.,2 Hyeongkyeong Lee, Ph.D.,3 F. Patrick Robinson, Ph.D., R.N.,1 and Edward Wang, Ph.D.1 1University of Illinois at Chicago, College of Nursing, Chicago, Illinois. 2Rush University College of Nursing, Chicago, Illinois. 3Yonsei University, Seoul, Korea.

Address reprint requests to: Joan L. Shaver, Ph.D., R.N. Professor and Dean University of Illinois at Chicago College of Nursing 845 S. Damen M/C 802 Chicago, IL 60612

Here is the second research study to isolate and identify genetic markers showing the familial genetic component of Fibromyalgia. Citation: Feng J, Zhang Z, Li W, Shen X, Song W, et al. (2009) Missense Mutations in the MEFV Gene Are Associated with Fibromyalgia Syndrome and Correlate with Elevated IL-1b Plasma Levels. PLoS ONE 4(12): e8480. doi:10.1371/journal.pone.0008480 Editor: Derya Unutmaz, New York University, United States of America Received October 24, 2009; Accepted November 22, 2009; Published December 30, 2009 Copyright: � 2009 Feng et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: This research was supported by a grant from the Los Angeles Fibromyalgia Foundation and in part by an National Institutes of Health General Clinical Research Center Grant, M01 RR00043. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist.
 * E-mail: jshively@coh.org (JES); ssommer@medomics.com (SSS) . These authors contributed equally to this work.

There is another Beckman Research Institute, City of Hope Study which I'm unable to cite because it's a PDF from which I'm unable to copy even the title and citation. That one reports on research showing an Immunological Basis for Fibromyalgia. It was accepted April 22, 2008 by the Society for Experimental Biology and Medicine. Contact person is jshively@coh.org

This comment and information added 6/11/2010 by Sandra Fackler, sandy.fackler@gmail.com —Preceding unsigned comment added by 174.27.3.196 (talk) 23:51, 11 June 2010 (UTC)


 * Genetic predisposition and guaifenesin are already covered in the article. Note that the studies we use in the article should all be high quality reviews - the studies you mention above would probably all fail the WP:MEDRS criteria for inclusion. But as I said, all of this is seems to be already covered in the article. If you think anything is missing or incorrect, feel free to post a message here (or go ahead and change it yourself, but please read WP:MEDRS and WP:WEIGHT first of all). --sciencewatcher (talk) 01:37, 12 June 2010 (UTC)

Orphaned references in Fibromyalgia
I check pages listed in Category:Pages with incorrect ref formatting to try to fix reference errors. One of the things I do is look for content for orphaned references in wikilinked articles. I have found content for some of Fibromyalgia's orphans, the problem is that I found more than one version. I can't determine which (if any) is correct for this article, so I am asking for a sentient editor to look it over and copy the correct ref content into this article.

Reference named "FDA": From Gabapentin: Gabapentin Official FDA information, side effects and uses From Cyclobenzaprine:  From Duloxetine:  From Selective serotonin reuptake inhibitor:  

I apologize if any of the above are effectively identical; I am just a simple computer program, so I can't determine whether minor differences are significant or not. AnomieBOT ⚡ 20:25, 2 July 2010 (UTC)

Symptoms image not up to article standards; Removed
Regarding: I removed this image from the article because the symptoms list does not agree with the data in the article. How does fibromyalgia directly cause weight gain? This is not mentioned in the article at all. Also under the skin section, "Various complaints" is listed as a symptom. This is not suitable, those 'various complaints' should be enumerated. Further, the only reference for this image was the website http://www.fibromyalgia-symptoms.org/, which has no original research, and is simply a link-farm.

Perhaps someone can edit the image to bring it back in line with what is said in the article.Tom (talk) 11:40, 10 August 2010 (UTC)

Is there a cure for Fibromyalgia
I have recently read on a forum of a so called cure to fibromyalgia could anybody tell me if this is genuine. Cures For Fibromyalgia —Preceding unsigned comment added by 82.22.131.165 (talk) 12:39, 30 September 2010 (UTC)


 * Pretty obviously a scam. --sciencewatcher (talk) 15:48, 30 September 2010 (UTC)

Semi-protection request
-- Brangifer (talk) 23:56, 11 November 2010 (UTC)
 * I semi-protected the article for one week. Next time, please file a request at requests for page protection. — GorillaWarfare talk 00:22, 12 November 2010 (UTC)


 * Thanks. I'll try to remember. -- Brangifer (talk) 00:46, 12 November 2010 (UTC)

fibromyalgia cure
I have suffered fibromyalgia for years and i am wondering if there is something in this so called "fibromyalgia cure" has anybody else tried it. http://my-fibromyalgia-cure.blogspot.com —Preceding unsigned comment added by 82.132.248.85 (talk) 17:39, 9 August 2010 (UTC)


 * There is no 'known cure' for fibromyalgia, however stress is a major factor in the illness and techniques like this one are likely to help. However that article is not suitable for inclusion here, and this is not the right place to have a general discussion about what helps with fibromyalgia. I'd be happy to continue this discussion by email, or you can post here if you want to discuss the wikipedia article. --sciencewatcher (talk) 17:55, 9 August 2010 (UTC)

I am a different poster but I was interested how one can discuss via email on wikipedia? sorry im new! —Preceding unsigned comment added by 86.143.165.195 (talk) 18:16, 10 January 2011 (UTC)


 * If you have registered as a user on wikipedia, you can optionally set up an email address where people can email you (just click on 'my preferences' at the top). If you want to email a user, just click on their name, and then click on 'E-mail this user' (at the left-hand side in the Toolbox). If you don't see an 'email this user' link, it means they haven't set up an email address with wikipedia. --sciencewatcher (talk) 18:47, 10 January 2011 (UTC)

I dont see a email button on your profile Jakobson1 (talk) 14:54, 17 January 2011 (UTC)
 * Go to sciencewatcher's user page by clicking sciencewatcher, or go to their (talk) page. On the left side of those pages you'll find "email this user". --Anthonyhcole (talk) 16:01, 17 January 2011 (UTC)

still cant see itJakobson1 (talk) 16:45, 17 January 2011 (UTC)


 * It's the fifth item from the top in the box headed "Toolbox". It may only be visible to autoconfirmed users. If so, you'll need to make 10 edits to unprotected articles before you can access it. I can see
 * What links here
 * Related changes
 * User contributions
 * Logs
 * E-mail this user
 * Upload file
 * Special pages
 * Permanent link
 * --Anthonyhcole (talk) 16:57, 17 January 2011 (UTC)

Hi pH diets and water
76.176.18.6 (talk) 15:57, 21 January 2011 (UTC)Some have claimed to find relief from Fibromyalgia by following a diet with a high pH value. There are many experts in the field and it is lacking in case studies. High pH producing water filters are also an option to try. Some prefer the water option because there are no strict diets to follow.

main heading of article
perhaps some reference to the text of the "controversies" section should be included in the inital sentences of the article text —Preceding unsigned comment added by 91.216.236.52 (talk) 04:15, 20 December 2010 (UTC)


 * You are referring to what we call the "lead" section, IOW the part above the table of contents. Your concern is legitimate. I believe the last paragraph in the lead does mention elements from the controversies section without unbalancing or overwhelming the lead with criticism. That wouldn't be very good since the diagnosis is officially recognized. It's no longer a fad diagnosis, even though there are still problems with its misuse or lack of understanding. Do you feel there is something that should be added or changed there? Let us know. -- Brangifer (talk) 04:52, 20 December 2010 (UTC)


 * I think your article is perfect as it stands. There are still no chemical or neurological tests for FM.  In fact, it has all the earmarks of conversion disorder.  The so-called "tender points" of the diagram are universal (http://www.fibro-myalgia.com/tenderpoints.html) and therefore qualify as triggers for conversion hysteria, considering that even Freud insisted that all conversion starts out with a physical problem. For instance, victims of lightning strikes that temporarily blind them continue to be blind even after their eyes have completely healed.  However, eyesight is easily restored by hypnotic suggestion.  It might be of interest to note that Freud and Breuer reported in *Studies on Hysteria* that they cured cases with all the earmarks of F.M.  Snud (talk) 19:19, 23 January 2011 (UTC)

Sarno
I have a problem with this paragraph"An alternative, but also controversial, hypothesis pertains the development of fibromyalgia in relationship to psychological conflict proposes that the disorder may be a psychosomatic illness as described by John E. Sarno's writing related to 'tension myositis syndrome', in which chronic pain is proposed to be a psychic diathesis of the mind's subconscious strategy of distracting painful or dangerous emotions. Education, attitude change, and in some cases, psychotherapy are proposed as treatments. Sarno, Dr. John E. et al. (2006). The Divided Mind: The Epidemic of Mindbody Disorders. New York: HC. pp. 21–2, 235–7, 294–8. ISBN 0-06-085178-3."Apart from the poor expression, it gives undue weight to Sarno (psychosomatic explanations for medically unexplained symptoms have been around since before Charcot and Freud), and makes no mention of the fact that these theories have no support from independently replicated randomised control trials, and implementation of these theories is no more effective than homeopathy. Unless someone can make the case that this complies with reliable sources policy, I'll rewrite this or delete it. --Anthonyhcole (talk) 01:57, 24 January 2011 (UTC)


 * For the undue weight issue, you could add the names of other notable researchers who have suggested that fibromyalgia is psychosomatic and you could remove the verbage that is more Sarno-specific. I wouldn't broaden the discussion to medically unexplained symptoms in general because that may violate WP:SYNTH.  As far as treatment effectiveness, please see this abstract  of a new peer-reviewed article describing a controled trial sponsored by the University of Michigan (see ).  Given this study, what evidence to you have to support the claim that homeopathy just as effective?  -- JTSchreiber (talk) 05:58, 26 January 2011 (UTC)


 * That study you point to compares an intervention with no intervention but not with placebo. With the "homeopathy" comment, I was observing that psychological interventions for chronic pain are not much better than placebo... but the results of that small trial are impressive. :) The results of further, larger trials with a sham arm would be worth watching for; and separate trials of the four different elements of the intervention would be worthwhile, too. Thanks for pointing that out. How's this? I've left it citing Sarno but there must be a more appropriate general survey of psychosomatic theories of fibromyalgia, somewhere."Another theory, also controversial, proposes that fibromyalgia is a psychosomatic illness. Sarno, Dr. John E. et al. (2006). The Divided Mind: The Epidemic of Mindbody Disorders. New York: HC. pp. 21–2, 235–7, 294–8. ISBN 0-06-085178-3."--Anthonyhcole (talk) 10:04, 26 January 2011 (UTC)


 * Placebo IS a psychological treatment, so obviously it will have the same effect as any other psychological treatment (bearing in mind, obviously, that different psychological treatments and placebos will have different effectiveness, and some might be more effective than others for each patients). Not sure how this has anything to do with the article though. I agree we should probably use someone other than Sarno - his papers don't have very many citations. --sciencewatcher (talk) 15:42, 26 January 2011 (UTC)


 * Anthonyhcole and Sciencewatcher, I'm still undecided what to do about the proposed new wording. The problems I have with it are (1) that it is a short, one sentence paragraph and (2) that it has some overlap with the depression paragraph (if FM is caused by depression or shares the same cause as depression, that might mean FM is psychosomatic.)  Here is an alternate wording, which would be placed as the first sentence of the depression paragraph:  "Controversial theories propose that fibromyalgia is a psychosomatic illness(Sarno ref here for now to be replaced by another ref later) or that its cause may be related to depression."The study I mentioned before is relevant to the treatment section of the article, not the causation section.  -- JTSchreiber (talk) 06:19, 28 January 2011 (UTC)


 * I like your proposal. --Anthonyhcole (talk) 07:12, 28 January 2011 (UTC)


 * I think Sarno's information should be stripped from this article. If his theories aren't accepted by the mainstream medical community, why is it being used here? The abstract mentioned by JTSchreiber makes more sense, as long as it is in treatments and it is cited that further studies are needed. Spdem2 (talk) 09:00, 28 January 2011 (UTC)


 * If you search PubMed for articles with "fibromyalgia" in the title, containing the word "sarno" (fibromyalgia[Title] sarno) you get zero. I see no place for him here. But we need a source for the above claim, which I think we're agreed is true. If no one can think of the ideal source, I'll have a look in the next day or so.


 * That study mentioned by JTSchreiber is a single small trial, so isn't appropriate here per WP:WEIGHT, WP:CRYSTAL and WP:MEDRS. --Anthonyhcole (talk) 10:00, 28 January 2011 (UTC)


 * OK, there's definitely a WP:WEIGHT issue, so the existing Sarno info needs to be removed and the new study is not appropriate. There are other treatments described in the article which have WP:WEIGHT issues, such as guaifenesin and T'ai Chi.  Should we take those out as well?  -- JTSchreiber (talk) 06:18, 29 January 2011 (UTC)
 * I've removed mention of t'ai chi, acupuncture, massage and heat, because claims about treatment efficacy should be supported by systematic reviews, medical textbooks or medical guidelines/position statements from nationally or internationally reputable expert bodies, per WP:MEDRS. These were either not supported or supported by primary research papers. --Anthonyhcole (talk) 07:16, 29 January 2011 (UTC)

And I've removed mention of Sarno and his theories, per the above. You wanted to move the remnant elsewhere, JT, but I wasn't sure what you had in mind, so have left that for you. --Anthonyhcole (talk) 07:25, 29 January 2011 (UTC)
 * OK, I moved it. -- JTSchreiber (talk) 01:00, 30 January 2011 (UTC)


 * I don't think it's correct to say that theories linking FM to depression are 'controversial' - those theories seem to be supported by all the major reviews. --sciencewatcher (talk) 01:27, 30 January 2011 (UTC)
 * I agree. The association is covered in the following sentence. I've deleted it. --Anthonyhcole (talk) 01:38, 30 January 2011 (UTC)

Rewrite suggested
This comment was inserted into another editor's comment above. I've moved it here for prominence and per WP:TALK. --Anthonyhcole (talk) 07:44, 27 January 2011 (UTC)

I agree with this statement. I have just completed a 2 year research project where we cataloged every single piece of research related to Fibromyalgia, Chronic Fatigue Syndrome/ME. Most of the research used in this wiki piece is horribly out of date and gives a slanted view of this illness. There is NO mention whatsoever of pediatric fibromyalgia. I am surprised to find such a low quality article on Wikipedia. —Preceding unsigned comment added by 70.26.44.92 (talk) 21:54, 26 January 2011 (UTC)
 * Congratulations! You have found a fascinating and worthwhile project, which you seem ideally suited to. Anyone can edit, so please add and subtract. An important guideline to observe is WP:MEDRS, and the folks here and at WT:MED can be very helpful. --Anthonyhcole (talk) 07:52, 27 January 2011 (UTC)

I may just take you up on that. Given the fact that the research into neuroimmune diseases has increased exponentially in the past decade there is some fascinating new research out there. My interest is primarily in junevile fibromyalgia. CAn we start a new section for this ?

Just out of curiosity, why is the section on causality so massive? The wiki entry for multiple sclerosis (also of unkown etiology), which has a much larger body of research, is far more concise than the section here. Is there a reason for fibromyalgia to have so much weight to this section ? Seems a bit like overkill. —Preceding unsigned comment added by 205.193.94.40 (talk) 21:22, 7 February 2011 (UTC)
 * Please do have a go at juvenile or pediatric fibromyalgia. Post it here first if you want help formatting. Re: the size of the causes section, I can only imagine it is a function of how little is known about the cause. There is an entire article on the causes of autism. --Anthonyhcole (talk) 20:17, 5 March 2011 (UTC)

Pharmaceutical
I have a question about this in the pharmaceutical section:

In a review in the 2009 Journal of Rheumatology, fibromyalgia researcher H.A. Smythe writes, “patients receive some benefit, but when side effects make the patient dull, lethargic, or fat, neither their goals nor those of society are satisfactorily met”.[104]

Can someone tell me what medications H.A. Smythe was writing about? This part of the quote doesn't seem to give enough detail to be useful. Spdem2 (talk) 07:23, 6 February 2011 (UTC)

Sarno again
Let's please discuss this rather than edit warring. The edit war seems to be over whether or not Sarno has sufficient weight. I said above that he doesn't seem to have many citations, but I did some more searches on google scholar and it seems that his book has 43 citations and at least one of his papers has 11 citations. Not a huge amount, but he's certainly not a 'nobody'. Probably sufficient for a short mention like we already have. --sciencewatcher (talk) 14:39, 29 April 2011 (UTC)


 * According to Wikipedia:Identifying reliable sources (medicine):


 * "Ideal sources for such content includes general or systematic reviews published in reputable medical journals, academic and professional books written by experts in a field and from a respected publisher, and medical guidelines or position statements from nationally or internationally recognised expert bodies."


 * From the Sarno page in wikipedia:


 * "Sarno's most notable (and controversial) achievement is the development, diagnosis and treatment of TMS, which is not recognized by mainstream medical science."


 * Seeing as the statement in question is not based on any scientific study, how about if I move this sentence to the controversy section? Would that work for everyone? After all, the sentence starts with "Controversial theories propose..." Spdem2 (talk) 07:46, 30 April 2011 (UTC)
 * Makes sense to me. --Anthonyhcole (talk) 08:36, 30 April 2011 (UTC)


 * Sounds reasonable. --sciencewatcher (talk) 15:48, 30 April 2011 (UTC)

External link to be added
I would like to add a link to FibromyalgiaSource.com as this site is an excellent website written by a Fibro sufferer and provides some great support. Sideline2084 (talk) 18:41, 1 May 2011 (UTC)Sideline2084


 * Sorry, that is a Link normally to be avoided. See #11. Ward20 (talk) 19:08, 1 May 2011 (UTC)

Credibility of Frederick Wolfe
I changed that part today, and I hope the change stays because there is absolutely no point in even mentioning Frederick Wolfe. Let's see what credible people have to say on the subject instead of someone (Wolfe) who either lied in 1990 or lied in 2008. If this changes back to speaking of Frederick Wolfe as though he has any credibility whatsoever and should be listened to at all, both myself and everyone else interested in the truth (whether it's the "truth" Wolfe told in 1990 or the "truth" Wolfe told in 2008) will be upset. If there is a particular IP Address that keeps adding Frederick Wolfe to the page and concealing/downplaying his questionable credibility, you should prevent that IP Address from being able to edit wikipedia because that IP Address is not interested in posting the truth on wikipedia. For the record, all I'm asserting to be the truth now is that Frederick Wolfe has no credibility because he is known to have lied at least once - either in 1990 or in 2008.

I'll come here every day and change it over and over and over again if that is what it takes, but there must be a better way to keep the truth concerning Frederick Wolfe on this wikipedia page (the truth being simply that he either lied in 1990 or lied in 2008 and thus has no credibility). —Preceding unsigned comment added by Darc0000 (talk • contribs) 07:39, 2 May 2011 (UTC)


 * Please see WP:MEDRS, WP:TRUTH and WP:NPOV. As far as I can tell (I have no idea about 'lying') Wolfe is one of the foremost authorities on fibromyalgia. If you do a search on google scholar you'll see that his first 2 articles have thousands of citations. It sounds like you just don't like some of the things that Wolfe says, but that is not a good reason to remove him. Instead you should reconsider your editing of wikipedia. If you keep trying to insert your unsourced WP:POV, you will just get banned. You're just wasting your time. --sciencewatcher (talk) 13:32, 2 May 2011 (UTC)


 * Darc0000, can you please concisely explain what you're talking about with regard to lying? Or supply a link to a credible web page that explains it? If the claim is based on conclusions you've drawn from the evidence - rather than conclusions drawn in reliable sources - it would be best to post your answer on my talk page. --Anthonyhcole (talk) 13:49, 2 May 2011 (UTC)

The last time I editted it (yesterday, I heeded sciencewatcher's advice today), all I did was add "Critics of Frederick Wolfe point out that his current stance is the opposite of his former stance." Is that really too much to ask for? I didn't use any words like lie, deceit, dishonest, etc. - I just stated the fact that his current stance is the opposite of his former stance. Needless to say, it still got deleted. (I'll head over to Anthonyhcole's talk page now.) —Preceding unsigned comment added by 68.108.158.40 (talk) 18:58, 2 May 2011 (UTC)


 * But you didn't reference it. Pretty much everything in wikipedia needs to be referenced by a reliable source - see WP:RS. --sciencewatcher (talk) 19:06, 2 May 2011 (UTC)


 * Thank you Darc0000. I'm impressed when scientists have the integrity to publicly change their view, and wouldn't call that lying. From my reading of the paragraph on Wolf, it's pretty explicit that he shifted from someone who once saw it as a unique entity and now holds a different view, so I see no need for the change you're proposing. --Anthonyhcole (talk) 09:05, 4 May 2011 (UTC)


 * Well said, Anthonyhcole. I agree. -- JTSchreiber (talk) 05:18, 5 May 2011 (UTC)


 * Does anyone know why he changed his mind? He makes a lot of statements that sound like opinion. Did he do any scientific studies? It seems like he is given a lot of weight in the controversy section. I think we should make sure it is justified. Spdem2 (talk) 07:41, 6 May 2011 (UTC)


 * We mainly go on number of citations. His papers each have thousands of citations, therefore he gets weight in the article. I would guess he evaluated the new research and came to that conclusion based on the evidence. --sciencewatcher (talk) 14:31, 6 May 2011 (UTC)

Tramadol
I think it is important to note that Tramadol is one of the few medications for Fibromyalgia that has few adverse side effects. Unfortunately, the 2004 review is silent on this, so that's why I think it's important to include the 2003 study to show where this information is coming from. If you want to remove the 2003 source, but leave in the information, that would be fine with me, but I don't think it should be taken out completely. Spdem2 (talk) 08:02, 21 May 2011 (UTC)
 * Why don't you use the information from the drugs instructions for use? It might be more informative.   Orange Marlin  Talk• Contributions 17:10, 21 May 2011 (UTC)
 * I've rewritten based on a 2006 review --Anthonyhcole (talk) 17:39, 21 May 2011 (UTC)
 * Thanks for that Anthonycole. It's always good to have more up-to-date sources. Spdem2 (talk) 21:08, 21 May 2011 (UTC)

Hyperalgesia or allodynia.
The first sentence of the section Signs and symptoms refers to "heightened pain in response to tactile pressure (allodynia)". Allodynia is actually pain resulting from a normally non-painful stimulus. An example would be pain evoked by light touch on sunburned skin. Hyperalgesia is more intense pain from a normally painful stimulus; i.e., the threshold stimulus intensity is normal but the resulting pain is more intense. I'm not sure whether the symptom being referred to here is allodynia or hyperalgesia. If anyone knows, could they clarify please. If it is allodynia, can I suggest "pain in response to normally non-painful tactile pressure"? --Anthonyhcole (talk) 06:33, 26 October 2011 (UTC)

While we're at it, "tactile pressure" makes me think the pain is evoked in the skin but isn't it supposed to be emanating from muscle? If so, what about replacing "tactile pressure" with "pressure on superficial muscles"? I don't have time to read up on this just now; if no one addresses it, I'll sort it out later. --Anthonyhcole (talk) 06:44, 26 October 2011 (UTC)


 * I think that both allodynia and hyperalgesia are present in fibromyalgia, but the former might get more attention because the tender point exam checks for allodynia. -- JTSchreiber (talk) 05:42, 27 October 2011 (UTC)

Ghrelin
Does anyone mind if I remove this "possibly linked to lower levels of ghrelin[]"from the section Signs and symptoms? It's supported by a 2007 primary study, and seems a bit WP:UNDUE. --Anthonyhcole (talk) 08:24, 27 October 2011 (UTC)

The brain
These are just thoughts that occur to me as I read this article for the first time in a long time. Please don't feel under any pressure to respond, or to respond in a hurry. I'd like to replace"Evidence from research conducted in the last three decades has revealed abnormalities within the central nervous system affecting brain regions that may be linked both to clinical symptoms and research phenomena.[] These studies show a correlation, but not causation.[] Some research suggests that alterations in the central nervous system might be the result of childhood stress, or prolonged or severe stress.[]"with something a little more detailed. Something like this The brains of fibromyalgia patients are structurally different from those of healthy individuals, exibiting a significant loss of gray matter density in the cingulate, insular and medial frontal cortices, the parahippocampal gyri, and the thalamus. The loss of grey matter density is greater the longer the person has had fibromyalgia. Fibromyalgia patients' brains exhibit heightened pain-related activity compared with healthy individuals, and they function abnormally in networks involving dopamine, serotonin and opioid neurotransmitters. The dopamine system is underactive at rest but displays higher sensitivity to dopamine. The cerebrospinal fluid of fibromyalgia patients contains higher concentrations of opioids and lower concentrations of the metabolites of serotonin, dopamine and noradrenaline. Many of these brain abnormalities are also common to chronic fatigue syndrome, posttraumatic stress disorder, irritable bowel syndrome, and depression, conditions frequently found comorbid with fibromyalgia.[]

The heightened perception of pain and other unpleasant bodily feelings experienced by fibromyalgia patients may be the product of this atrophied and dysfunctional brain, and the brain abnormalities may be the product of exposure to early or ongoing stress. Dopamine pathways play an important role in some of the cognitive functions often impaired in fibromyalgia patients.[] Thoughts and observations would be very welcome. --Anthonyhcole (talk) 11:52, 27 October 2011 (UTC) Waste of time Anthonyhcole (talk)


 * First thoughts? Far too long for a sub-section of the lead (you could cut it significantly, by saying "loss of grey matter in some parts of the brain) and based on a single study that shows only correlation, but not causation. As such, the second paragraph is mostly speculation if it came from the authors of the paper, or original research by you. Also, having reduced grey matter in some areas of the brain and not other is not the sign of an "atrophied and dysfunctional brain"! Jugglers will have differently distributed grey matter from stockbrokers, or English teachers. It's part of life. Famousdog (talk) 13:39, 27 October 2011 (UTC)


 * Darn. I got carried away and forgot I was editing the lead. I just read the pathophysiology section and it's good. The article certainly doesn't need my little effort. Sorry for having wasted your (and my) time. To be clear, I'm not pushing the causation barrow one direction or the other. The second paragraph is a paraphrase of Schweinhardt et al., 2008


 * I do have issues with the existing text, though. "Evidence from research conducted in the last three decades has revealed" seems redundant to me. Schweinhardt et al. only discusses the brain (where it mentions CSF it does so in relation to brain function not spinal cord function), so there's no need, based on that source, to mention CNS in the lead. Re: "These studies show a correlation not causation", that could be clearer for a reader unfamiliar with the formulation frequently repeated in science and medicine, "correlation is not causation". How about"The brains of fibromyalgia patients show structural and behavioral differences from those of healthy individuals, but it is unclear whether the brain anomalies cause fibromyalgia symptoms or are the product of an unknown underlying common cause. Some research suggests that these anomalies may be the result of childhood stress, or prolonged or severe stress.[]" --Anthonyhcole (talk) 14:54, 27 October 2011 (UTC)

Fibromyalgia article
Edit suggest use material from more up to date sources.Sources quoted are 19 years old! Much research has occurred since then.

' Many patients diagnosed with fibromyalgia also have psychiatric disorders.'

I have seen no evidence that suggests this. Many sufferers have attendant depression, but by no means psychiatric disorders. There is no current extant evidence to prove psychiatric disorder is any more prevalent in sufferers of FM than in other groups.

It is distressing for sufferers to read incorrect information of this nature and retrograde. It is incorrect to claim psychiatric disorder as common in fibromyalgia.

This is a common and chronically out of date misunderstanding of the condition, possibly due to the type of therapies which can help FM, which include psychoactive drugs such as Amitryptiline and Acupan. Read below from:



'Latest Treatment guidelines As previously reported in FaMily Magazine, The European League Against Rheumatism (EULAR) issued the first guidelines for the treatment of fibromyalgia syndrome (FMS) and published them in the September 17th On-line First issue of the Annals of the Rheumatic Diseases. While these guidelines are not adopted by NICE (National Institute for Health and Clinical Excellence) as yet, they can be seen as a significant step forward in medical treatment.

Specific recommendations in these guidelines regarding general considerations for management of FMS are as follows

Comprehensive evaluation of pain, function, and psychosocial context is needed to understand FMS completely, because it is a complex, heterogeneous condition involving abnormal pain processing and other secondary features. Optimal treatment of FMS mandates a multidisciplinary approach, which should include a combination of non-pharmacologic and pharmacologic interventions. After discussion with the patient, treatment modalities should be specifically tailored based on pain intensity, function, and associated features such as depression, fatigue, and sleep disturbance. Specific recommendations on non-pharmacologic management of FMS are as follows:

Heated pool treatment, with or without exercise, is effective. For some patients with FMS, individually tailored exercise programs can be helpful. These may include aerobic exercise and strength training. For certain patients with FMS, cognitive behavioral therapy may be beneficial. Based on the specific needs of the patient, relaxation, rehabilitation, physiotherapy, psychological support, and other modalities may be indicated. Specific recommendations on pharmacologic management are as follows:

Tramadol is recommended for management of pain. Although other treatment options may include simple analgesics (eg, paracetamol) and other weak opioids, corticosteroids and strong opioids are not recommended. Antidepressants are recommended for the treatment of FMS because they decrease pain and often improve function. Appropriate options may include amitriptyline, fluoxetine, duloxetine, milnacipran, moclobemide, and pirlindole. Tropisetron, pramipexole, and pregabalin are recommended for the treatment of FMS because they reduce pain.'

It is not entirely true to say that 'Many members of the medical community consider fibromyalgia a ‘non-disease’ because of a lack of abnormalities on physical examination, the absence of objective diagnostic tests etc.' I would argue that the papers on which this is based is out of date by 19 years.(1990 Frederick Wolfe)

Fibromyalgia is a recognised condition in the UK, see the NHS pages here:

As a recognised and established condition in the UK and, sufferers are recognised as being so chronically ill that they  may claim State benefits in the form of Disability Living allowance and other allowances.
 * Freud and Breuer successfully treated several "fibromyalgia" patients using a primitive form of psychotherapy way back in the 1895 (http://en.wikipedia.org/wiki/Studies_on_Hysteria). Read *On Hysteria* by Freud and Breuer if you want to see the details.  Anna O and Elizabeth Von R were obvious cases, and of course Freud had never heard of fibromyalgia--or any other euphemism for "nervous exhaustion." If he had he might not have even attempted to cure his poor miserable patients, and people like you are trying to keep good science away from desperate patients for political reasons.  Did you know that Dr. Kevorkian helped a fibromyalgia sufferer to kill herself?  People would rather die than admit they are crazy.  This is because neurotic symptoms are defenses against intolerable internal conflicts.  Oh well; as Socrates said, "an unexamined life is not worth living."  Snud (talk) 03:10, 15 January 2012 (UTC)

Somatization
4. "fibromyalgia due to somatization" (may respond to psychotherapy).

What, you mean like type 4 diabetes which is also somatization? — Preceding unsigned comment added by 2.217.136.218 (talk) 22:42, 2 December 2011 (UTC)

Blanket psychobabble about distress may not apply to a proportion of patients
This may be useful when published, there are probably similar conclusions in other studies but I came across this when looking for something else and thought that others who edit this FM article may find it interesting, I don't pay much attention to the FM article or talkpage so I probably won't remember later: http://www.ncbi.nlm.nih.gov/pubmed/22065070 - Tekaphor  ( TALK ) 02:20, 21 November 2011 (UTC)


 * "Psychobabble" is right. Any time someone uses the term "co-morbid" it's time to suspect pure psychogenesis is involved.  According to Freud, though, fibromyalgia (Freud called it "neuraesthenia" or nervous exhaustion) is a general form of hysteria, and as such always starts out as a physical condition which the unconscious finds use for in the form of a mental illness. For instance; hysterical blindness is always triggered by something like a blinding explosion or a lightning strike. So the vast list of co-morbid psychological symptoms actually are co-morbid to a physiological illness--technically speaking that is.  Snud (talk) 06:15, 15 January 2012 (UTC)

Tai chi
I restored the summary of the RCT of tai chi. This was previously removed because "One small study. Virtually meaningless". While not the best RCT in the world, it is the best RCT of tai chi for fibromylagia. I added that the RCT was small and single blinded. Please not that the edit does not recommend tai chi, it honestly notes that tai chi may help. To remove this edit, at least while there are not better trails, does not make sense. Wikipedia is full of content in medical articles that have one or no studies cited. Do we call all of that content virtually meaningless and delete? The deletion of tai chi seems capricious. If the goal of wikipedia is to provide the best knowledge available, then this edit must remain until better research emerges. - Robert Badgett 22:29, 10 December 2011 (UTC)
 * Robert, first, you can automatically sign using ~ . Makes it easy for you.  Here's my issue with your edit, and I'm reviewing the article.  It kind of fails WP:MEDRS because it seems like a primary study.  I don't think it's been repeated in larger studies.  The problem with these small prospective type of studies is that they are often overturned with future research.  They're written in a "predictive" type of language.  You even write it that way.  Also, is it tai chi?  Or is it just getting out and doing any type of stretching exercise.  Would pilates do the same thing?  Or 100 sit-ups?  That's why these studies drive me up the wall.   Orange Marlin  Talk• Contributions 23:09, 10 December 2011 (UTC)
 * I agree that the predictive wording is inappropriate for Wikipedia and I think it should be removed. As far as secondary sources are concerned, PubMed reports that this article refers to the tai chi RCT in question.  The new article appears to be a review, but I can't tell much from the abstract.  I think it would be worthwhile for someone with access to this journal to look up the article.  -- JTSchreiber (talk) 05:09, 16 December 2011 (UTC)

Natural Suggestions for Pain Relief
I would like to consider adding a portion on Natural Pain relief because there is a lot of talk right now about how patients are finding relief (not a cure) by exercise and diet. There is also a lot of talk about the idea of massage helping and I do believe this information would benefit others who are suffering from Fibromyalgia.

The site NaturalFibromyalgiaTreatments.com has a lot of really useful information and resources about not only exercise and healthy eating but also about how certain vitamins (such as Vitamin D) and superfoods can help reduce risk of further health problems.

This website has been a HUGE help to me and I'd love to be able to share it with others who are also looking for relief without pills and surgeries: http://naturalfibromyalgiatreatments.com/ — Preceding unsigned comment added by Foderak (talk • contribs) 18:37, 10 January 2012 (UTC)


 * Any information needs to comply with WP:MEDRS, so adding that website would not be acceptable. However it is certainly plausible that massage, exercise and diet (and similar) could help fibromyalgia. I would suggest finding a good review that discusses this - the easiest way to find something would be to look on either google scholar or pubmed. --sciencewatcher (talk) 19:29, 10 January 2012 (UTC)

Hello, I'd also like to continue the discussion of adding a section regarding natural treatment of pain relief. Significant advancements have been shown regarding CAM (Complementary and Alternative Therapies), and think it would be a productive and helpful addition to the page. Perhaps something like below: ''Numerous CAM options are available for treating Fibromyalgia(1-3). An integrated approach, using what has been called the SHINE protocol, treats with Sleep and Hormonal support, Infections, Nutritional support and Exercise and was shown to help 91% of patients, improving overall quality of life by an average 90%.(2) Two studies have also shown Ribose 5 gm 3 x day to be helpful (4,5), increasing energy an average of 61% in 1 multicenter study(5).''

1. J. Teitelbaum and B. Bird, “Effective Treatment of Severe Chronic Fatigue: A Report of a Series of 64 Patients,” Journal of Musculoskeletal Pain 3 (4) (1995): 91–110. http://informahealthcare.com/doi/abs/10.1300/J094v03n04_11

2. J.E. Teitelbaum, B. Bird, R.M. Greenfield, et al., “Effective Treatment of CFS and FMS: A Randomized, Double-Blind Placebo Controlled Study,” Journal of Chronic Fatigue Syndrome Vol. 8, No. 2, 2001. PP3-28 http://www.jacobteitelbaum.com/documents/The-Definitive-Study-CFS-Research-by-Jacob-Teitelbaum.pdf

3. Rakel, D ed., Integrative Medicine, third edition. Chapter 47. Chronic Fatigue Spectrum p447-455. 2012. Elsevier/Saunders. http://www.expertconsultbook.com/expertconsult/ob/book.do?method=display&decorator=none&type=bookPage&eid=4-u1.0-B978-1-4377-1793-8..00100-X&isbn=978-1-4377-1793-8&hitTerms=%221546+993x%22|%22integrative+medicine%22|1546|1546-993x|993x|teitelbaum&hitNum=2&simulateUpsell=true

4. Teitelbaum JE, JA St.Cyr, C Johnson. The use of D-ribose in chronic fatigue syndrome and fibromyalgia: a pilot study. J Alternative and Complementary Medicine 2006;12(9):857-862. http://online.liebertpub.com/doi/abs/10.1089/acm.2006.12.857

5. Jandrain J, McGrew R., Teitelbaum JE,  Effective Treatment of Chronic Fatigue Syndrome and Fibromyalgia with D-ribose—A Multicenter Study. Scripps Conference 2010 San Diego, California (full study has been accepted for publication. In Press. Open Pain Journal (A link to the study on the website should be available within the next month))

Thanks for your input! Aloha76 (talk) 20:31, 5 June 2012 (UTC)


 * Generally speaking Wikipedia articles on medical topics should use review articles published in reputable journals, not primary research papers. WP:MEDRS explains what we strive for.  The only one in your list that meets that criterion is #3. Looie496 (talk) 21:14, 5 June 2012 (UTC)

Possible bias against opiates

 * PROMINENT BIAS against opiate based medications in the treatment, opiates, section needs to be addressed. Recent NICE (UK) guidelines for pain management target this bias, which is largely baseless, and recommend more appropriate opiate prescription. This section is being used anecdotally by GP's (really!) to refuse proper pain medication. The bias against low dose opiate treatment for chronic pain needs to be removed and a better researched section put in its' place. I would suggest review of current prescribing guidelines as opposed to speculation based on outdated and opinionated meta-studies (the quality of studies included in same is dreadful and also very outdated) As Wikipedia becomes more widely trusted it is important that bias such as this is NOT included, especially in medical articles ** — Preceding unsigned comment added by Klmccaughey (talk • contribs) 18:35, 16 July 2012 (UTC)


 * Per Wikipedia's guideline on medical sources, statements about effectiveness should be based on peer-reviewed medical studies, especially high quality reviews of medical studies. What peer-reviewed medical studies do you have to support your view that the current content is outdated?  If the UK guidelines include a review of peer-reviewed medical studies, that may be usable as a reference for effectiveness.  Otherwise, the only way to use the UK guideleines as a reference would be in support of new content describing the UK guidelines.  Such a description of UK guidelines should be brief and should not replace any current article content.  -- JTSchreiber (talk) 05:06, 22 July 2012 (UTC)
 * The source for the second half of the Opioids section says there are "no randomized controlled trials addressing the short- or long-term use of opioids in FMS" If that is true, does this source fail Wikipedia's guideline on medical sources ? I can only access the abstract and don't know what the basis is for the conclusions it asserts. Spdem2 (talk) 00:47, 23 July 2012 (UTC)


 * I don't understand why the statement that you quoted may be problematic per Wikipedia's guideline on medical sources (WP:MEDRS). Please provide a quote from WP:MEDRS to show what you think the issue is.  Also, I noticed that you changed "no evidence" to "insufficient evidence" in the article.  I think that may be misleading, in that some readers may interpret this to mean that the review found some evidence, but not enough.  -- JTSchreiber (talk) 05:36, 25 July 2012 (UTC)


 * From WP:MEDRS "The best evidence comes primarily from meta-analyses of randomized controlled trials (RCTs)" This source says there aren't any, so how can it meet the guidelines? What is the basis for the opinions stated? Am I missing something? My changes to "insufficient evidence" are directly from the abstract provided by the source. I think "no evidence" is misleading. Spdem2 (talk) 08:28, 27 July 2012 (UTC)


 * The source does not fail MEDRS; describing the literature (i.e. the lack of studies) does not "fail MEDRS". That there lacks high quality studies doesn't mean we don't talk about them, it just means we have to describe the state of the literature as best we can with best available sources (in this case literature review on the topic).  By your logic, any condition that doesn't have systematic reviews of RCTs would not be able to be discussed on Wikipedia, which is clearly not correct. Yobol (talk) 13:53, 27 July 2012 (UTC)


 * OK, I missed the term "insufficient evidence" in the abstract. That wording is fine, but I think that "no randomized controlled trials" would be better, since it's more precise.  I agree with Yobol about how to interpret WP:MEDRS.  If we use an interpretation similar to yours for, say, Tramadol, then we would remove all current Tramadol content, because none of it is based on meta-analyses of RCTs.  -- JTSchreiber (talk) 05:31, 30 July 2012 (UTC)


 * Perhaps I'm not being clear. I don't have an issue with it saying there is a lack of studies. It is this statement I have an issue with: " ...are not recommended as they can worsen mood, such as depression in fibromyalgia, have abuse and dependence potential as well as have a significant adverse effect profile. Long-term use of opioids may worsen pain in some people... " This is a strong POV, but are there any RCTs that found that opioids will worsen mood, depression and pain? Was it a meta analysis of RCTs? I believe at least one of the statements on Tramadol was a meta analysis of RCTs. I am no expert, but there seems to be an inconsistent standard applied based on who is doing the changes to this article. Spdem2 (talk) 05:56, 16 September 2012 (UTC)


 * Thanks for the clarification. I don't have access to the body of the article, so I do not know what type of evidence was used.  I am going to wait a little while longer to see if anyone else comments.  If not, I will try to get some help with this.


 * As far as meta-analyses, that type of research is a statistical approach in which data from multiple similar studies are contrasted and/or combined. I see no meta-analyses of RCTs in the Tramadol section.  Note that WP:MEDRS doesn't say that meta-analyses are required.  We often use other types of reviews instead.  They can be high quality, depending on the type of evidence that is being reviewed.  -- JTSchreiber (talk) 05:23, 24 September 2012 (UTC)


 * Thanks for checking it out. As far as Tramadol, I'm happy to hear you think the evidence meets WP:MEDRS. It took a lot of effort to get this information into this page. Spdem2 (talk) 10:09, 24 September 2012 (UTC)


 * Since no one has responded on the talk page, I have requested assistance from WikiProject Medicine in this section .  -- JTSchreiber (talk) 05:51, 9 October 2012 (UTC)

(outdent) Klmccaughey, do the NICE guidelines on pain specifically mention fibromyalgia? I suspect that the NICE guidelines are not talking about a centralised pain syndrome such as fibromyaligia. Pain that originates from the nervous system, peripheral or especially central nervous system does not typically respond to opiates. There is no doubt that some patients have opiates withheld unfairly when they need them for pain that is opiate responsive, eg bone/joint/soft tissue pain.-- MrADHD  |  T@1k?  16:16, 22 July 2012 (UTC)

(outdent) The NICE guidelines are with reference to treating pain in primary care, particularly chronic pain. JTSchreiber: Just because the author of this bias hasn't seen a study does not mean there are none. I would suggest there are multitudes of studies about the efficacy of opiates and chronic pain. As Fibromyalgia is a syndrome and not a disease or specific disease process these guidelines, along with the very latest on chronic pain, are not only relevant but key to the discussion. If we are saying that Fibromyalgia should not be treated with opiates then the specifics of the evidence for this need to be cited and shown in context. Just because the person writing this bit of bias has seen no evidence that opiates are effective does not mean there is none. Either say something is so and reference it, or say nothing at all. I feel the phrase asserting that opiates are ineffective should be dropped as it does not have significant basis in fact. — Preceding unsigned comment added by Klmccaughey (talk • contribs) 20:10, 10 August 2012 (UTC)
 * Discussion of the use of opioids is already extensively and well referenced to WP:MEDRS compliant sources. I'm not sure what your suggestion is, though it appears you seem to have a personal objection to the conclusion of the sources, which does not factor into how we write articles here. We care what sources say, not what individual editors believe. Yobol (talk) 20:16, 10 August 2012 (UTC)


 * Klmccaughey, you are entitled to your opinions about what is relevant and key. However, from a Wikipedia policy perspective, it doesn't matter what the NICE guidelines say about chronic pain.  It also doesn't matter if there are "multitudes" of studies about opiates and chronic pain.  Per Wikipedia's policy on original research, the guidelines and studies need to be explicitly about fibromyalgia or they cannot be used as sources in the fibromyalgia article.  What evidence from WP:MEDRS compliant sources do you have about the effectiveness of opiates for fibromyalgia?  If you cannot provide such sources, you have very little chance of getting people here to agree with your suggested changes to the article.  -- JTSchreiber (talk) 04:46, 13 August 2012 (UTC)

Can someone please point me to the NICE guidelines? If they're a recent update, I'd like to look at them for another article. --Anthonyhcole (talk) 15:49, 11 August 2012 (UTC)

Regarding opiates, coming over from WT:MED
Having looked at the full text of, the tone of the language described at WT:MED seems consistent with the article. For example, here is the entire Discussion section of that article (extending from page 9 to page 10 of the original): DISCUSSION Despite a lack of evidence supporting the efficacy of opioids in FMS, their use remains prevalent. A small non-controlled study suggests that they are of no benefit and may actually exacerbate co-existent disturbances of mood. Impaired μ-opioid receptor binding has been demonstrated in the areas important in pain and nociception processing in the brains of patients with FMS, suggesting further that these agents are unlikely to be useful. Improvements in our understanding of the neurobiology of FMS have helped the development of pharmacotherapy targeted to the pathophysiology of the condition. Opioids can be particularly problematic in patients with FMS. Without concrete evidence of their benefit, and the availability of other medications which act on pathophysiological mechanisms, it is difficult to see a current role for opioids in a long-term FMS management program. I hope this is helpful. -- Scray (talk) 06:08, 9 October 2012 (UTC)


 * Also from page 9, a section on Tramadol:


 * "Tramadol While data for benefit of opioids in FMS is lacking, there are several randomized controlled trials that support the use of tramadol in FMS. Tramadol is a novel analgesic agent with combined μ-receptor agonist and 5-HT and NE reuptake inhibition activity. This additional action of preventing neurotransmitter reuptake is possibly the key to the superior efficacy of tramadol compared to other opioids in FMS symptom control. A double-blind, controlled trial of 12 patients with FMS demonstrated an improvement in pain, as measured by a visual analogue scale (VAS 100 mm), but no clinically important difference in terms of tenderness outcomes.41(Biasi, ) A subsequent double-blind, randomized controlled trial of 315 patients found that patients taking a 37.5 mg tramadol/325 mg acetaminophen combination tablet had improved pain scores and less discontinuation of medication than the patients in the placebo group (48% vs. 62%,P=0.004).42(Bennett, ) These patients also had better Fibromyalgia Impact Questionnaire scores, with significant improvement in physical functioning, role-physical, body pain, health transition and physical component summaries. A follow-up study examining the healthrelated quality of life (HRQOL) in these patients found that those with more severe pain had a greater impairment of HRQOL and that tramadol/acetaminophen-treated patients had a greater improvement in HRQOL compared with those who received placebo.43(Bennett, ) Tramadol is therefore included in the EULAR guidelines for the management of FMS with a level of evidence of Ib (evidence from at least one randomized controlled trial)."


 * Hope this helps as well. -- Scray (talk) 06:31, 9 October 2012 (UTC)


 * Thanks! That does help.  -- JTSchreiber (talk) 05:43, 12 October 2012 (UTC)

Fibromyalgia webcomic maybe useful
Fibromyalgia for Beginners — Preceding unsigned comment added by 27.0.81.155 (talk) 04:02, 29 October 2012 (UTC)

Tender points
Tender points seem to have been rejected by the latest guidelines. Do they belong in the infobox? I think they should be moved to the discussion of tender points --Nbauman (talk) 22:40, 9 December 2012 (UTC)

2012 Canadian Fibromyalgia Guidelines
2012 Canadian Fibromyalgia Guidelines has 60 recommendations, which should be an authoritative source on some of the issues in this article. They recommended against complementary and alternative medicine, but for cognitive behavioral therapy and lifestyle practices. I saw some drafts on the Internet, but I can't find a good authoritative link to the final version. --Nbauman (talk) 22:43, 9 December 2012 (UTC)

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. 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 . With respect to the associated psychiatric issues it is unknown which causes which.. 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.  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"  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. 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.  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 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". 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" and evidence in support is that few people are found to have organic disease after long term follow up.  It is grouped with IBS and chronic fatigue by some   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,

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

OK. I've replaced the existing text withAnthonyhcole (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)


 * I've made some changes. Now it looks like this:
 * We could add that, unlike other opioids, tramadol appears not to lower the pain threshold/induce hyperalgesia over time - though that is kind of implied in the statement about tolerance. Anything else? Feel free to edit the article directly. Every statement has to be supported by a reliable source per this guideline WP:MEDRS. Ideally that means current national/international specialist guidelines, recent systematic reviews, current graduate-level textbooks, etc. --Anthonyhcole (talk · contribs · email)  09:52, 23 April 2013 (UTC)
 * Much clearer. Thanks for making those changes. 98.207.197.166 (talk) 18:46, 24 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 (, 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)