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Background: Fibromyalgia (FM) is a common soft tissue rheumatic disease. There is no established treatment plan for FM. Current treatments primarily focus on controlling symptoms and improving the quality of life. The aim of our study was to determine how connective tissue massage (CTM) and kinesiotaping (KT) affect pain and depression in patients with fibromyalgia, and to compare their effects on quality of life., Methods: Thirty-four patients diagnosed with fibromyalgia were included. Participants divided into two groups. Group 1: CTM (n = 17, mean age = 35.47 ± 6.84 years), Group 2: KT (n = 17, mean age = 34.00 ± 5.46 years). This study was initiated by obtaining sociodemographic information. Pain (Visual Analogue Scale (VAS)), pain characteristics (McGill Pain Questionnaire), disease impact on patients (Fibromyalgia Impact Questionnaire (FIQ)), depression (Beck's Depression Inventory (BDI)), and quality of life (Short Form-36 (SF-36)) were evaluated. All participants received electrotherapy (TENS and infrared treatment) for 25 min, 5 days a week for 4 weeks. CTM was applied 3 days a week, KT was applied 2 days a week for 4 weeks., Results: A significant improvement with very large effect size was found in VAS, McGill, FIQ, BDI, and SF-36 variables in both groups (p < 0.05). The change after 4 weeks of treatment was similar between groups in terms of all parameters (p > 0.05)., Conclusion: Both CTM and KT improved pain, disease effects depression, and quality of life. These two interventions, which are not superior, can be added to the treatment program for patients with fibromyalgia., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. We declare that we have no competing financial interests or personal relationships that could influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Introduction: Fibromyalgia (FM) is a multifaceted disease that is often associated with neuropsychiatric disorders and is burdened by a high degree of psychological distress. Non-pharmacological interventions, including physical exercise and complementary therapies, have shown satisfactory results for either physical or psychological FM symptoms., Methods: In this narrative review, we analyzed scientific evidence of moderate to high quality regarding the psychological and neurocognitive effects of physical therapies for FM. A total of 29 studies were selected after searching the PubMed and Google Scholar databases using the combination of terms « fibromyalgia», «psychological distress», «fibrofog», mental disorder», «aerobic exercise», «strength exercise», «Pilates», «Tai chi» and «Yoga»., Results: Aerobic exercise can improve depression, anxiety, stress, mental function and mood, thanks to the remodulation of neurotransmitters and hormones. Strength training, on the other hand, has been shown to alleviate mental confusion, anger and depression. Finally, mind-body disciplines appear to be effective for depression, anxiety, catastrophizing, memory and coping strategies. Based on these findings, we devised an ideal exercise program that could relieve the psychological distress of FM patients, thus interrupting the pathogenic neuroendocrine circuits that lead to the exacerbation of pain and other FM-related symptoms., Conclusions: Thanks to neuroendocrine remodulation, physical exercise may simultaneously improve the physical and mental health of FM patients. This narrative review collects current evidence on the effects of specific physical interventions on psychological and neurocognitive domains of FM patients and additionally provides an evidence-based training program that could be prescribed to FM patients with high psychological distress or neuropsychiatric symptoms., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Introduction: Fibromyalgia is a chronic syndrome characterized by constant and generalized pain associated with sleep disturbance, depression, muscle stiffness, fatigue and cognitive disorders. Among non-pharmacological treatments, physical exercise stands out as a low-cost approach., Aim: To summarize and analyze evidence on the effects of resistance training on pain, functionality and quality of life in women with fibromyalgia., Methods: Following the PRISMA method, this systematic review included clinical trials assessing the effects of resistance training on pain, quality of life and functionality in female patients with fibromyalgia, regardless age. The researches were conducted in April 2021 in PubMed, Cochrane, Web of Science and Scopus databases, using the search strategy: ("fibromyalgia") AND ("strength training" OR "resistance training") AND ("quality of life" OR "pain" OR "functionality"). This study was registered in PROSPERO (CRD number: 42,021,246,245), and the risk of bias was assessed using the Version 2 of the Cochrane Risk-of-Bias tool (RoB 2)., Results: The search resulted in 125 studies (760 women), of which 16 were eligible for this review. Risk of bias assessment resulted in high (n = 5), moderate (n = 6) and low (n = 5) risks. Resistance training has proven to be an important non-pharmacological treatment tool for fibromyalgia, reducing pain, and improving patients' functionality and quality of life., Conclusion: The available evidence suggests that resistance training performed twice weekly, with progressive loads ranging from 40 to 80% of one-repetition maximum and a total duration of 4-24 weeks, appears to be an effective and safe therapeutic approach., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Fibromyalgia (FM) is a common chronic pain condition for which acupuncture treatment is increasingly utilized. However, there is no universally accepted measure to predict whether a specific patient will benefit from acupuncture. This is a single-center, single-blind, sham-controlled, randomized, noncrossover, longitudinal trial of 76 subjects with FM, assigned to either electroacupuncture (EA) or a placebo control, mock laser (ML) acupuncture. Outcome measures included clinical pain severity (Brief Pain Inventory [BPI]), degree of nociplastic pain (Fibromyalgia Survey Questionnaire), and pressure pain tolerance (PPtol). Baseline measures of temporal summation of pain and expectations for treatment relief were used as predictors. Individuals in both treatment groups experienced significant reductions in BPI (EA: P < .001, ML: P = .018) and Fibromyalgia Survey Questionnaire (EA: P = .032, ML: P = .002) after treatment; however, neither group showed a significant increase in PPtol. Lower temporal summation at baseline was correlated with greater post-treatment improvement in BPI in the EA group (rho = .389, P = .025) but not in the ML group (rho = -.272, P = .109). Lower-baseline temporal summation was correlated with greater decreases in PPtol following EA (rho = .400, P = .040), whereas the opposite was seen for ML (rho = -.562, P = .001). Treatment expectancy at baseline was not correlated with any outcome after EA or ML treatments. Our results support using a quantitative sensory testing metric, temporal summation of pain, but not expectations, to predict analgesia following acupuncture treatment for pain. PERSPECTIVE: A randomized study of acupuncture in FM found baseline temporal summation, but not expectations of pain relief, to be predictive of treatment response. CLINICAL TRIAL REGISTRATION: Registered under ClinicalTrials.gov identifier NCT02064296., (Copyright © 2024. Published by Elsevier Inc.)

Fibromyalgia (FM) is a complex and poorly understood disorder characterized by chronic and widespread musculoskeletal pain, of which the etiology remains unknown. Now, the disorder of the gut microbiome is considered as one of the main causes of FM. This study aimed to investigate the potential benefits of fecal microbiota transplantation (FMT) in patients with FM. A total of 45 patients completed this open-label, randomized, nonplacebo-controlled clinical study. The numerical rating scale scores in the FMT group were slightly lower than the control group at 1 month (P > .05), and they decreased significantly at 2, 3, 6, and 12 months after treatment (P < .001). Besides, compared with the control group, the Widespread Pain Index, Symptom Severity, Hospital Anxiety and Depression Scale, and Pittsburgh Sleep Quality Index scores were significantly lower in the FMT group at different time points (P < .001). After 6 months of treatment, there was a significant increase in serotonin (5-hydroxytryptamine) and gamma-aminobutyric acid levels (P < .001), while glutamate levels significantly decreased in the FMT group (P < .001). The total effective rate was higher in the FMT group (90.9%) compared to the control group (56.5%) after 6 months of treatment (P < .05). FMT can effectively improve the clinical symptoms of FM. With the close relations between the changes in neurotransmitters and FM, certain neurotransmitters may serve as a diagnostic marker or potential target for FM patients. PERSPECTIVE: FMT is a novel therapy that aims to restore the gut microbial balance and modulate the gut-brain axis. It is valuable to further explore the therapeutic effect of FMT on FM. Furthermore, certain neurotransmitters may become a diagnostic marker or a new therapeutic target for FM patients., (Copyright © 2024. Published by Elsevier Inc.)

Persons with fibromyalgia experience a diverse set of symptoms. Recommendations for management generally focus on multidisciplinary approaches involving multiple modalities. Mobile apps can be an essential component for self-management, yet little is known about how persons with fibromyalgia use mobile apps for health-related purposes. A cross-sectional survey (N = 663) was conducted to understand the real-world use of apps among persons with fibromyalgia. The survey included 2 main foci: 1) eHealth literacy and use of information sources, and 2) mobile app use patterns and preferences for health-related purposes, including the types of apps used and usage characteristics of apps currently in use, as well as those that had been discontinued. Respondents' average eHealth literacy as measured by eHealth Literacy Scale (eHEALS) was 31.4 (SD = 7.1), and they utilized diverse information sources. Approximately two-thirds of the sample used mobile apps; the remaining one-third did not. Diverse health management needs were represented in the apps reported, including scheduling/time management, notetaking, fitness, and wellness. Compared to apps that had been discontinued, participants rated apps that they still used higher in terms of ease of use and used them more frequently. Reasons for discontinuing app use included issues with privacy, the effort required, lack of interest, and lack of perceived quality. Other reasons for app nonuse were lack of awareness and how-to knowledge, indicating that disseminating information about apps and addressing other barriers, such as providing user support, are critical to increasing uptake. These study findings can inform both app design and dissemination. PERSPECTIVE: This article presents how persons with fibromyalgia use mobile apps to manage their health. The findings could inform the development of digital interventions or programs for this population., (Copyright © 2024 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

Transcutaneous electrical nerve stimulation (TENS) effectively reduces pain in fibromyalgia (FM). The purpose of this study was to examine the influence of TENS use on pressure pain thresholds (PPT) and conditioned pain modulation (CPM) in individuals with FM using data from the Fibromyalgia Activity Study with TENS trial (NCT01888640). Individuals with FM were randomly assigned to receive active TENS, placebo TENS, or no TENS for 4 weeks. A total of 238 females satisfied the per-protocol analysis among the active TENS (n = 76), placebo TENS (n = 68), and no TENS (n = 94) groups. Following 4 weeks of group allocation, the active TENS group continued for an additional 4 weeks of active TENS totaling 8 weeks (n = 66), the placebo and no TENS groups transitioned to receive 4 weeks of active TENS (delayed TENS, n = 161). Assessment of resting pain, movement-evoked pain (MEP), PPT, and CPM occurred prior to and following active, placebo, or no TENS. There were no significant changes in PPT or CPM among the active TENS, placebo TENS, or no TENS groups after 4 weeks. Individuals who reported clinically relevant improvements in MEP (≥30% decrease) demonstrated increases in PPT (P < .001), but not CPM, when compared to MEP non-responders. There were no significant correlations among the change in PPT or CPM compared to MEP and resting pain following active TENS use (active TENS + delayed TENS). PPT and CPM may provide insight to underlying mechanisms contributing to pain; however, these measures may not relate to self-reported pain symptoms. PERSPECTIVE: Pressure pain threshold increased in individuals with clinically relevant improvement (≥30%) in MEP, indicating the clinical relevance of PPT for understanding mechanisms contributing to pain. CPM was not a reliable indicator of treatment response in MEP responders., (Copyright © 2024 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of the study was to examine the effectiveness of Clinical Pilates exercises and connective tissue massage (CTM) in individuals with Fibromyalgia (FM) on pain, disease impact, functional status, anxiety, quality of life and biopsychosocial status., Methods: 32 women were randomly divided into two groups as intervention gorup (CTM + Clinical Pilates exercises, n = 15, mean age = 48.80 ± 7.48) and control gorup (Clinical Pilates exercises, n = 17, mean age = 55.64 ± 7.87). The number of painful regions were assessed with Pain Location Inventory (PLI), disease impact with Fibromyalgia Impact Questionnare (FIQ), functional status with Health Assessment Questionnare (HAQ), anxiety with Beck Anxiety Inventory (BAI), quality of life with Short Form-36 (SF-36) and biopsychosocial status with Biopsychosocial Questionnaire (BETY-BQ) were evaluated. All evaluations were made before and after treatment. Both treatments were applied 3 times a week for 6 weeks., Results: When the pre-treatment and post-treatment results are analyzed; significant difference was observed in PLI (p = 0.007; effect size 1.273), FIQ (p = 0.004; effect size 0.987), SF-36 physical component (p = 0.025; effect size -0.496) and mental component (p = 0.017; effect size -0.761) in the intervention group while the significant difference was observed in FIQ (p = 0.001; effect size 1.096) and BAI (p = 0.043; effect size 0.392), SF-36 physical component (p = 0.008; effect size -0.507) and mental component (p = 0.024; effect size -0.507) in the control group. When the delta values of the groups are compared, the difference was determined only in the PLI (p = 0.023) in favor of the intervention group., Conclusions: CTM can be effective in reducing the number of painful areas in addition to the positive effects of clinical Pilates exercises in women with FM., Competing Interests: Declaration of competing interest The authors declare no potential conflicts of interest with respect to the authorship and/or publication of this article. The authors received no financial support for the research and/or authorship of this article. This part of the manuscript has not been submitted to or published in any journals. The manuscript, which was designed Basic Research, has been read and approved by all the authors., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Currently there is no treatment capable of significantly alleviating all the symptoms of fibromyalgia (FM), even though it is a complex syndrome with a high prevalence in the population., Design: Experimental study using a single-blind, randomised, clinical trial., Objective: To analyse the efficacy of manual lymphatic drainage (MLD) as an alternative to traditional treatment of fibromyalgia (FM) in women., Methods: This was an experimental study using a single-blind, randomised, clinical trial of 20 women between 30 and 55 years old with FM. Patients were divided into an experimental group (n = 10) and a control group (n = 10). During the study, 3 measurements of pain (visual analogue scale and algometry), FM impact (Fibromyalgia Impact Questionnaire), sleep quality (Index Pittsburgh), anxiety and depression (Hospital Anxiety and Depression Scale) were recorded. Treatment of the experimental group consisted of 2 weekly MLD sessions for 6 weeks., Results: The effect of the interaction of MLD showed statistically significant results in Right intercostal space (F 2,36  = 3.54; p = 0.04; n 2 p = 0.16). The sleep quality was significantly better favour of the treatment (F 2,36  = 4.16; p = 0.01; n 2 p = 0.20)., Conclusions: MLD therapy demonstrated effects in the experimental group in contrast to the control group across the intervention period concerning the right intercostal space and sleep-related factors. However, MLD did not result in observable alterations in pain perception., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

This randomized, double-blind, controlled clinical trial compared the effectiveness of home-based-(HB) active transcranial direct current stimulation (a-tDCS) over the left dorsolateral prefrontal cortex (l-DLPFC) or primary motor cortex (M1) with their respective sham-(s)-tDCS to determine whether a-tDCS would be more effective than s-tDCS in reducing pain and improving disability due to pain. The study included 102 patients with fibromyalgia aged 30 to 65 years old randomly assigned to 1 of 4 tDCS groups using a ratio of 2:1:2:1. The groups included l-DLPFC (a-tDCS, n = 34) and (s-tDCS, n = 17), or tDCS on the M1 (a-tDCS, n = 34) or (s-tDCS, n = 17). Patients self-administered 20 sessions of tDCS, with 2 mA for 20 minutes each day under remote supervision after in-person training. The Mixed Model for Repeated Measurements revealed that a-tDCS on DLPFC significantly reduced pain scores by 36.53% compared to 25.79% in s-tDCS. From baseline to the fourth week of treatment, a-tDCS on M1 reduced pain scores by 45.89% compared to 22.92% over s-tDCS. A generalized linear model showed a significant improvement in the disability scale in the groups that received a-tDCS compared to s-tDCS over M1 20.54% versus 2.49% (χ 2 = 11.06, df = 1, P < .001]), while on DLPFC the improvement was 14.29% and 5.77%, with a borderline significance (χ 2 = 3.19, df = 1, P = .06]), respectively. A higher reduction in serum brain-derived neurotrophic factor from baseline to treatment end was positively correlated with decreased pain scores regardless of the treatment group. The application of a-tDCS over M1 increased the heat pain threshold and the function of the descending pain inhibitory system. PERSPECTIVE: These findings provide important insights: (1) HB-tDCS has effectively reduced pain scores and improved disability due to fibromyalgia. (2) The study provides evidence that HB-a-tDCS is a viable and effective therapeutic approach. (3) HB-a-tDCS over M1 improved the function of the descending pain inhibitory system and increased the heat pain threshold. Finally, our findings also emphasize that brain-derived neurotrophic factor, as an index of neuroplasticity, may serve as a valuable marker associated with changes in clinical pain measures. TRIAL REGISTRATION: Number NCT03843203., (Copyright © 2024 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Fibromyalgia is a chronic and idiopathic condition and is among the most common causes of generalized chronic pain, even affecting psychological and cognitive aspects., Aim: To evaluate the efficacy of cupping therapy on pain, quality of life, sleep disorders, and the impact of the disease in subjects with fibromyalgia., Methods: We searched the Pubmed, CINAHL, Epistemonikos, Scopus, and Web of Science databases. Randomized controlled trials involving adults with fibromyalgia undergoing cupping were included. Pain intensity, quality of life, sleep disturbances, and the impact of fibromyalgia were assessed. We have reported the results using descriptive statistics and narrative synthesis., Results: Two articles with a total of 155 participants were included. Large effect sizes were found for pain intensity, moderate for quality of life, and low for the impact of fibromyalgia and sleep disorders. However, the certainty of the evidence is low for most outcomes except for sleep disorders., Conclusions: There is a discrepancy in the efficacy of cupping therapy in improving pain intensity, quality of life, sleep disturbances, and disease impact in people with fibromyalgia. Future high-quality randomized clinical trials are required., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Introduction: The Feldenkrais Method® is a form of awareness through movement (ATM) aimed at improving spatial and kinesthetic awareness through verbally guided movements, in order to learn more effective actions., Method: The present study, a proof-of-concept, observational, non-controlled prospective study, aims at exploring the effectiveness of ATM for fibromyalgia syndrome (FM), measuring the effect by means of multi-dimensional questionnaires, administered at baseline and after 4 months of ATM activity., Results: One hundred twenty-eight FM patients (mean age 54 years old, 2% males) participated in the study. A statistically significant improvement was found in FM-specific measures (Polysymptomatic Distress Scale, PDS) (p = 0.003) and the Pain Catastrophization Scale (PCS) (p = 0.020); coherently, the Revised Fibromyalgia Impact Questionnaire (FIQR) showed a trend in improvement after the intervention, although this improvement was not statistically significant. The logistic regression analysis found a correlation between PDS, fatigue and anxiety measures; PCS, years from diagnosis and anxiety., Conclusion: ATM could improve FM-specific measures and pain-related catastrophizing. Further studies are needed to identify FM subgroups in order to find personalized targets that can be used to guide treatments., Competing Interests: Declaration of competing interest All the Authors declare that there are no financial or other relationships that could lead to a conflict of interest., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Nocebo effects are adverse treatment outcomes that are not ascribed to active treatment components. Potentially, their magnitude might be higher in patients with chronic pain compared to healthy controls since patients likely experience treatment failure more frequently. The current study investigated group differences in the induction and extinction of nocebo effects on pressure pain at baseline (N = 69) and 1-month follow-up (N = 56) in female patients with fibromyalgia and matched healthy controls. Nocebo effects were first experimentally induced via classical conditioning combined with instructions on the pain-increasing function of a sham transcutaneous electrical nerve stimulation device, then decreased via extinction. One month later, the same procedures were repeated to explore their stability. Results suggest that nocebo effects were induced in the healthy control group during baseline and follow-up. In the patient group, nocebo effects were only induced during follow-up, without clear group differences. Extinction was only observed during baseline in the healthy control group. Further comparisons of nocebo effects and extinction indicated no significant changes across sessions, possibly suggesting their overall magnitudes were stable over time and across groups. In conclusion, contrary to our expectations, patients with fibromyalgia did not have stronger nocebo hyperalgesia; instead, they might be less responsive to nocebo manipulations than healthy controls. PERSPECTIVE: The current study is the first to investigate group differences in experimentally manipulated nocebo hyperalgesia between chronic pain and healthy populations at baseline and 1-month follow-up. Since nocebo effects are common in clinical settings, their investigation in different populations is essential to explain and minimize their adverse effects during treatment., (Copyright © 2023 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

This randomized, double-blind trial tested the hypothesis that 20 sessions of home-based anodal(a)-transcranial direct current stimulation (tDCS) (2mA for 20 minutes) bifrontal, with anodal on the left dorsolateral prefrontal cortex (l-DLPFC) would be better than sham-(s)-tDCS to reduce scores on Pain Catastrophizing Scale and disability-related to pain assessed by the Profile of Chronic Pain: Screen (primary outcomes). Secondary outcomes were depressive symptoms, sleep quality, heat pain threshold , heat pain tolerance , and serum brain-derived-neurotrophic-factor (BDNF). Forty-eight women with fibromyalgia, 30 to 65 years-old were randomized into 2:1 groups [a-tDCS (n = 32) or s-tDCS (n = 16)]. Post hoc analysis revealed that a-tDCS reduced the Pain Catastrophizing Scale total scores by 51.38% compared to 26.96% in s-tDCS, and a-tDCS reduced Profile of Chronic Pain: Screen total scores by 31.43% compared to 19.15% in s-tDCS. The a-tDCS improved depressive symptoms, sleep quality and increased the heat pain tolerance. The delta-value in the serum BDNF (mean post treatment end minus pretreatment) was conversely correlated with the a-tDCS effect in pain catastrophizing. In contrast, the a-tDCS impact on reducing the disability-related to pain at the treatment end was positively associated with a reduction in the serum BDNF and improvement of depressive symptoms, sleep quality and pain catastrophizing symptoms. PERSPECTIVE: Home-based bifrontal tDCS with a-tDCS on the l-DLPFC are associated with a moderate effect size (ES) in the following outcomes: 1) Decreased rumination and magnification of pain catastrophizing. 2) Improved the disability for daily activities due to fibromyalgia symptoms. Overall, these findings support the feasibility of self-applied home-based tDCS on DLPFC to improve fibromyalgia symptoms., (Copyright © 2022 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

In this double-blinded, sham-controlled, counterbalanced, and crossover study, we investigated the potential neuroplasticity underlying pain relief and daily function improvements following repetitive transcranial magnetic stimulation of the motor cortex (M1-rTMS) in fibromyalgia syndrome (FMS) patients. Specifically, we used magnetic resonance imaging (MRI) to examine changes in brain structural and resting-state functional connectivity (rsFC) that correlated with improvements in FMS symptomology following M1-rTMS. Twenty-seven women with FMS underwent real and sham treatment series, each consisting of 10 daily treatments of 10Hz M1-rTMS over 2 weeks, with a washout period in between. Before and after each series, participants underwent anatomical and resting-state functional MRI scans and questionnaire assessments of FMS-related clinical pain and functional and psychological burdens. The expected reductions in FMS-related symptomology following M1-rTMS occurred with the real treatment only and correlated with rsFC changes in brain areas associated with pain processing and modulation. Specifically, between the ventromedial prefrontal cortex and the M1 (t = -5.54, corrected P = .002), the amygdala and the posterior insula (t = 5.81, corrected P = .044), and the anterior and posterior insula (t = 6.01, corrected P = .029). Neither treatment significantly changed brain structure. Therefore, we provide the first evidence of an association between the acute clinical effects of M1-rTMS in FMS and functional alterations of brain areas that have a significant role in the experience of chronic pain. Structural changes could potentially occur over a more extended treatment period. PERSPECTIVE: We show that the neurophysiological mechanism of the improvement in fibromyalgia symptoms following active, but not sham, rTMS applied to M1 involves changes in resting-state functional connectivity in sensory, affective and cognitive pain processing brain areas, thus substantiating the essence of fibromyalgia syndrome as a treatable brain-based disorder., (Copyright © 2021 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Fibromyalgia is a debilitating condition characterized by chronic widespread pain. It is believed to be caused by dysfunction of the central nervous system (CNS) but current treatments are largely ineffective. Transcranial direct current stimulation (tDCS), a neuromodulation technique that targets the CNS, may offer a new line of treatment., Objective: To systematically review the most up-to-date literature and perform a meta-analysis of the effects of tDCS on pain intensity in fibromyalgia., Methods: The following databases were searched from inception: Medline (Ovid), PsychInfo, CINAHL, Cochrane Library, and Web of Science. Studies were eligible if they were randomized controlled trials, quasi-randomized trials, and nonrandomized. Crossover and parallel-group design studies were included. Risk of bias was assessed for all included studies. Meta-analysis was conducted on studies investigating pain intensity after tDCS in participants with fibromyalgia and analyzed using standardized mean difference and 95% confidence intervals., Results: Fourteen clinical studies were included. Ten were controlled trials and 4 were within-subjects crossover studies. Meta-analysis of data from 8 controlled trials provides tentative evidence of pain reduction when active tDCS is delivered compared to sham. However, substantial statistical heterogeneity and high risk of bias of primary studies prevent more conclusive recommendations being made., Conclusions: tDCS is a safe intervention with the potential to lower pain intensity in fibromyalgia. However, there is a need for more empirical research of the neural target sites and optimum stimulation parameters to achieve the greatest effects before conducting further clinical studies., Perspective: This systematic review and meta-analysis synthesizes current evidence for the clinical effectiveness of tDCS in the treatment of fibromyalgia pain. There is only tentative evidence of pain reduction when active tDCS is compared to sham. High heterogeneity and risk of bias across studies suggest a need for further empirical research., (Copyright © 2020 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Current clinical guidelines do not support the use of manual therapy (MT) interventions for Fibromyalgia (FM) patients, despite evidence of positive biochemical, mechanical and psychological effects, and the popularity of hands-on treatments amongst patients. An optimal dose for MT has not been established; this may explain the discrepancies found within the published literature. The aim of this systematic review was to determine whether there is a dose response relationship for MT leading to improvements in core domains of FM symptomology; Pain, Mood, Sleep, Global Measure of Impact (Functional Status & Quality of Life)., Methods: We searched six databases from 1990 to January 2018; studies were evaluated using the PEDro scale. Within-group (ESd) and between-group (ESg) Effect Sizes were calculated., Results: We identified and screened 4012 articles, 12 articles were critically appraised. Overall, there is moderate evidence that MT has positive effects on the four clinical outcomes investigated. However, there was no consistent dose response relationship observed across all studies., Conclusions: A dose of approximately 45 min MT, three to five times per week, for three to five weeks, totalling 11 h 15 min, should be considered a baseline generic protocol for treatment delivery and research trials. Further research is necessary to confirm domain specific, or patient specific optimal doses. Moderator variables such as treatment time, frequency, duration; and MT type also need to be explored to ensure optimal delivery of MT in future research and clinical care provision., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

This randomized, double-blind controlled trial tested the hypothesis that 60 sessions of home-based anodal (a)-transcranial direct current stimulation (tDCS) over dorsolateral prefrontal cortex (DLPFC) would be better than home-based sham-tDCS to improve the widespread pain and the disability-related to pain. The anodal-tDCS (2 mA for 30 minutes) over the left DLPFC was self-administered with a specially developed device following in-person training. Twenty women, 18 to 65 years old were randomized into 2 groups [active-(a)-tDCS (n = 10) or sham-(s)-tDCS (n = 10)]. Post hoc analysis revealed that after the first 20 sessions of a-tDCS, the cumulative pain scores reduced by 45.65% [7.25 (1.43) vs 3.94 (1.14), active vs sham tDCS, respectively]. After 60 sessions, during the 12-week assessment, pain scores reduced by 62.06% in the actively group [visual analogue scale reduction, 7.25 (1.43) to 2.75 (.85)] compared to 24.92% in the s-tDCS group, [mean (SD) 7.10 (1.81) vs 5.33 (.90)], respectively. It reduced the risk for analgesic use in 55%. Higher serum levels of the brain-derived neurotrophic factor predicted higher decreases on the pain scores across of treatment. PERSPECTIVE: These findings bring 3 important insights: 1) show that an extended period of treatment (60 sessions, to date the largest number of tDCS sessions tested) for fibromyalgia induces large pain decreases (a large effect size of 1.59) and 2) support the feasibility of home-based tDCS as a method of intervention; 3) provide additional data on DLPFC target for the treatment of fibromyalgia. Finally, our findings also highlight that brain-derived neurotrophic factor to index neuroplasticity may be a valuable predictor of the tDCS effect on pain scores decreases across the treatment., (Copyright © 2019 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

This study's aim was to assess the efficacy of 2 forms of activity pacing in patients with fibromyalgia syndrome (FMS). Treatment-related changes in activity management patterns were also examined. Patients with FMS (n = 178) were randomly assigned to an operant learning (OL; delayed [n = 36] or immediate [n = 54] groups) or an energy conservation (EC; delayed [n = 35] or immediate [n = 53] groups) treatment condition. Of these, 32 OL and 37 EC patients completed treatment. Forty-three patients were allocated to the delayed treatment condition (control group). Repeated measures analyses of variance were used to examine the effects of OL and EC treatments on primary (average pain and usual fatigue), secondary (pain and fatigue interference, physical and psychological function, sleep quality, depressive symptoms, and anxiety symptoms), and tertiary (pain-related activity patterns) outcomes. Neither treatment was effective in reducing average pain or usual fatigue symptoms. Relative to EC, OL patients showed greater improvements in depressive symptoms, whereas nonsignificant trends (P values ranging between .05 and .06) were observed for pain interference, fatigue interference, and psychological function. Both treatments were associated with improvements in sleep quality and physical function, increases in pacing, and decreases in overdoing activity patterns. Reductions in activity avoidance were only found in OL. These findings suggest that OL may be more beneficial than EC and that it could potentially be viewed as an effective stand-alone activity pacing treatment for patients with FMS. Research to determine the extent to which these preliminary findings replicate is warranted. PERSPECTIVE: This article examines the efficacy of 2 forms of activity pacing in patients with fibromyalgia syndrome. The results suggest the possibility that operant learning may be more beneficial than energy conservation and could potentially be viewed as an effective stand-alone activity pacing treatment for patients with fibromyalgia syndrome., (Copyright © 2019. Published by Elsevier Inc.)

Introduction: Physical training has been recommended to improve overall well-being in patients with fibromyalgia. Body relaxation exercises also seem to have some beneficial effect, however there is no consensus regarding this modality., Objective: Comparing the effectiveness of sophrology and resistance training in improving the pain of women with fibromyalgia., Method: A randomized controlled clinical trial with a blind evaluator. Sixty (60) women with a medical diagnosis of fibromyalgia were randomized and included in two groups: sophrology group (SG) who participated in a relaxation program based on sophrology (n = 30), and resistance group (RG) (n = 30) who participated in a resistance training program for biceps, pectoral, triceps, knee extensors, trapezius, knee flexors, hip abductors. Both groups were treated twice a week for 12 weeks and reevaluated every 4 weeks. The assessment instruments used were the Visual Analog Scale for Pain (VAS), the one-repetition maximum test (1 RM), the overall quality of life (SF-36), the 6-min walk test (6MWT), the Timed Up and Go test (TUG) and the Fibromyalgia Impact Questionnaire (FIQ)., Results: We found that the RG presented statistically significant decreases in pain (VAS) during the evaluations (p < 0.05) and increased strength of the evaluated muscles (p < 0.05). A statistically significant decrease in pain (p < 0.05) was observed in the SG compared to T0, with no significant differences in muscle strength. Differences between groups were observed, with better indices only for 6MWT and functional capacity domain of the SF36 for the RG (p < 0.05)., Conclusion: No differences in pain were found between the groups. Resistance training was more effective than sophrology in improving strength and functional capacity of women with fibromyalgia., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Fibromyalgia (FM) is a prevalent and debilitating chronic pain disorder associated with a substantial economic burden. Although there are several studies investigating the effectiveness of psychological treatments such as cognitive-behavioral therapy for FM, studies on cost-effectiveness are scarce. The aim of the present study was to investigate the cost-effectiveness of Internet-delivered exposure therapy (iExp) for FM. We used health economic data from a recently conducted randomized, controlled trial, where 140 participants were randomized to either iExp or a waitlist control (WLC) condition. Economic data were collected at pre-treatment, post-treatment, and at the 1-year follow-up. Treatment effectiveness in relation to costs were analyzed using both a societal perspective (including all direct and indirect costs) and a health care unit perspective (including only the direct treatment costs). Bootstrapped net benefit regression analyses were also conducted, comparing the difference in costs and effects between iExp and WLC, within different willingness-to-pay scenarios. Results showed that the incremental cost-effectiveness ratio was -$15,295, indicating that iExp was highly cost-effective as each successfully treated case (treatment responder) was associated with a substantial net reduction in costs. The robustness of the results was tested in 2 different sensitivity analyses, where iExp remained cost-effective, even in a willingness-to-pay-scenario of $0. We conclude that iExp is a cost-effective treatment that generates large societal cost savings. PERSPECTIVE: Health-economic evaluations of psychological interventions for FM are scarce. This study is a cost-effectiveness analysis of Internet-delivered exposure therapy for patients with FM. Results showed that iExp was highly cost-effective compared with no treatment, where each successfully treated case generated a substantial societal cost saving., (Copyright © 2018 the American Pain Society. Published by Elsevier Inc. All rights reserved.)

Cognitive-behavioral therapy (CBT) improves coping and daily functioning in adolescents with juvenile fibromyalgia (JFM), but is less effective in reducing pain. This pilot trial evaluated the efficacy of a novel intervention (Fibromyalgia Integrative Training for Teens; FIT Teens) which integrates CBT with specialized neuromuscular exercise training to enhance the effect of treatment on reducing pain and disability. Forty adolescents with JFM (12-18 years) were randomized to CBT-only or FIT Teens. Treatment was conducted in group-based sessions over 8 weeks with assessments at baseline, post-treatment, and 3-month follow-up (primary end point). Primary outcomes were pain intensity and functional disability. Secondary outcomes were depressive symptoms, fear of movement, and pain catastrophizing. Thirty-six participants (mean age=15.33 years; 90% female) completed the program. Intent to treat analysis was conducted to evaluate differences between the FIT Teens and CBT groups from baseline to 3-month follow-up, controlling for baseline group differences. Participants in the FIT Teens group showed significantly greater decreases in pain than the CBT group. FIT Teens participants also showed significant improvements in disability, but did not differ from CBT-only at the 3-month end point. Results provide preliminary evidence that the FIT Teens intervention provides added benefits beyond CBT in the treatment of JFM, particularly in pain reduction., Perspective: Results from this pilot randomized controlled trial of a new combined CBT and specialized neuromuscular exercise intervention (FIT Teens), compared with CBT alone suggested that FIT Teens offers stronger treatment benefits than CBT alone at initial treatment follow-up, especially with respect to the outcome of pain reduction., (Copyright © 2018 The American Pain Society. Published by Elsevier Inc. All rights reserved.)

In this study, 67 participants (95% female) with fibromyalgia (FM) were randomly assigned to an online acceptance and commitment therapy (online ACT) and treatment as usual (TAU; ACT + TAU) protocol or a TAU control condition. Online ACT + TAU participants were asked to complete 7 modules over an 8-week period. Assessments were completed at pre-treatment, post-treatment, and 3-month follow-up periods and included measures of FM impact (primary outcome), depression, pain, sleep, 6-minute walk, sit to stand, pain acceptance (primary process variable), mindfulness, cognitive fusion, valued living, kinesiophobia, and pain catastrophizing. The results indicated that online ACT + TAU participants significantly improved in FM impact, relative to TAU (P <.001), with large between condition effect sizes at post-treatment (1.26) and follow-up (1.59). Increases in pain acceptance significantly mediated these improvements (P = .005). Significant improvements in favor of online ACT + TAU were also found on measures of depression (P = .02), pain (P = .01), and kinesiophobia (P = .001). Although preliminary, this study highlights the potential for online ACT to be an efficacious, accessible, and cost-effective treatment for people with FM and other chronic pain conditions., Perspective: Online ACT reduced FM impact relative to a TAU control condition in this randomized controlled trial. Reductions in FM impact were mediated by improvements in pain acceptance. Online ACT appears to be a promising intervention for FM., (Copyright © 2018 The American Pain Society. Published by Elsevier Inc. All rights reserved.)

Introduction: The importance of physical exercise for patients with fibromyalgia (FM) is very clear in the literature. Dancing is a type of aerobic exercise that has great acceptance. In addition to the beneficial effects of aerobic exercise, Zumba works on motor coordination and also has socializing as a part that should be included in patients with fibromyalgia., Objectives: To evaluate the effectiveness of Zumba dancing in improving pain, functional capacity, quality of sleep and quality of life of women with fibromyalgia., Design: A pre-post treatment design., Methods: We evaluated 19 women with fibromyalgia, selected by convenience. Data were collected in the second half of 2016. Zumba dancing was performed twice a week for 12 weeks. Patients were evaluated at week 0 (T0) and at week 12 (T12), by the following instruments: VAS (Visual Analogic Scale), Likert Scale, TUG (Timed Up an Go Test), 6MWT (Six-minute Walk Test), FIQ (Fibromyalgia Impact Questionnaire), PSQI (Pittsburgh Sleep Quality Index), ESS (Epworth Sleepiness Scale) and SF-36 quality of life., Results: We found differences in pain (VAS T0  = 6.21 and VAS T12  = 4.53) with p = 0.001 and in the domain physical functioning of SF36 (T0 = 42.37 and T12 = 52.11) with p = 0.04. No differences were found for the other variables between the times., Conclusion: Zumba dancing as a form of treatment for three months for patients with fibromyalgia was effective in improving pain and physical functioning. Future controlled and randomized clinical trials should be performed to improve the evidence of Zumba dancing in women with fibromyalgia., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

The heterogeneity of the clinical presentation and the pathophysiologic mechanisms associated with fibromyalgia (FM), and the modest results on average for any therapy, call for a more individualized management strategy. Individualized treatment can be on the basis of subgrouping of patients according to associated conditions (mental health problems, chronic overlapping pain conditions, other somatic diseases) or on disease severity. Categorizing FM as mild, moderate, or severe can be on the basis of clinical assessment (eg, degree of daily functioning) or on questionnaires. Shared decision-making regarding treatment options can be directed according to patient preferences, comorbidities, and availability in various health care settings. The European League Against Rheumatism guidelines recommend a tailored approach directed by FM key symptoms (pain, sleep disorders, fatigue, depression, disability), whereas the German guidelines recommend management tailored to disease severity, with mild disease not requiring any specific treatment, and more severe disease requiring multicomponent therapy (combination of drug treatment with aerobic exercise and psychological treatments). When indicated, treatments should follow a stepwise approach beginning with easily available therapies such as aerobic exercise and amitriptyline. Successful application of a tailored treatment approach that is informed by individual patient characteristics should improve outcome of FM., Perspective: This article presents suggestions for an individualized treatment strategy for FM patients on the basis of subgroups and disease severity. Categorizing FM as mild, moderate, or severe can be on the basis of clinical assessment (eg, degree of daily functioning) or questionnaires. Subgroups can be defined according to mental health and somatic comorbidities., (Copyright © 2017 The American Pain Society. Published by Elsevier Inc. All rights reserved.)

We compared the recommendations and methodology of several recent evidence-based guidelines for the management of patients with fibromyalgia published by professional organizations: 1) American Pain Society (APS; 2005), 2) Association of the Scientific Medical Societies in Germany (AWMF; 2012), 3) Canadian Pain Society (CPS; 2013; also used in the United Kingdom), and 4) European League Against Rheumatism (EULAR; 2016). Each guideline used systematic reviews and meta-analyses as highest level of evidence; APS, CPS, and AWMF also included individual randomized clinical trials. The APS, CPS, and AWMF assigned the highest ranking of recommendation to aerobic exercise, cognitive-behavioral therapy, amitriptyline, and multicomponent treatment. In contrast, the most recent EULAR guidelines assign the highest level of recommendation to exercise, contrary to the 2008 EULAR guidelines, which recommended pharmacotherapy. Although there was some consistency for pharmacological treatment recommendations among the 4 guidelines, APS, CPS, and AWMF guidelines gave the higher ranking to cognitive-behavioral therapy and multicomponent treatments. The inconsistencies across guidelines can be attributed to the criteria used for study inclusion, outcome measures used, weighting systems, and composition of the review panels. A guideline consensus is needed to harmonize the discrepancies., Perspective: This article presents an overview and highlights the inconsistencies of 4 recent clinical practice guidelines for treatment of fibromyalgia patients related to study inclusion criteria, outcome measures used, ranking system used, and composition of the review panels. The discrepancies suggest a need to create a guideline consensus to synthesize guidelines., (Copyright © 2016 American Pain Society. Published by Elsevier Inc. All rights reserved.)

The aim of this study was to analyze the cost utility of a group-based form of acceptance and commitment therapy (GACT) in patients with fibromyalgia (FM) compared with patients receiving recommended pharmacological treatment (RPT) or on a waiting list (WL). The data were derived from a previously published study, a randomized controlled trial that focused on clinical outcomes. Health economic outcomes included health-related quality of life and health care use at baseline and at 6-month follow-up using the EuroQoL and the Client Service Receipt Inventory, respectively. Analyses included quality-adjusted life years, direct and indirect cost differences, and incremental cost effectiveness ratios. A total of 156 FM patients were randomized (51 GACT, 52 RPT, 53 WL). GACT was related to significantly less direct costs over the 6-month study period compared with both control arms (GACT €824.2 ± 1,062.7 vs RPT €1,730.7 ± 1,656.8 vs WL €2,462.7 ± 2,822.0). Lower direct costs for GACT compared with RPT were due to lower costs from primary care visits and FM-related medications. The incremental cost effectiveness ratios were dominant in the completers' analysis and remained robust in the sensitivity analyses. In conclusion, acceptance and commitment therapy appears to be a cost-effective treatment compared with RPT in patients with FM., Perspective: Decision-makers have to prioritize their budget on the treatment option that is the most cost effective for the management of a specific patient group. From government as well as health care perspectives, this study shows that a GACT is more cost effective than pharmacological treatment in management of FM., (Copyright © 2017 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Despite promising preliminary results in treating fibromyalgia (FM) pain, no neuromodulation technique has been adopted in clinical practice because of limited efficacy, low response rate, or poor tolerability. This phase II open-label trial aims to define a methodology for a clinically effective treatment of pain in FM by establishing treatment protocols and screening procedures to maximize efficacy and response rate. High-definition transcranial direct current stimulation (HD-tDCS) provides targeted subthreshold brain stimulation, combining tolerability with specificity. We aimed to establish the number of HD-tDCS sessions required to achieve a 50% FM pain reduction, and to characterize the biometrics of the response, including brain network activation pain scores of contact heat-evoked potentials. We report a clinically significant benefit of a 50% pain reduction in half (n = 7) of the patients (N = 14), with responders and nonresponders alike benefiting from a cumulative effect of treatment, reflected in significant pain reduction (P = .035) as well as improved quality of life (P = .001) over time. We also report an aggregate 6-week response rate of 50% of patients and estimate 15 as the median number of HD-tDCS sessions to reach clinically meaningful outcomes. The methodology for a pivotal FM neuromodulation clinical trial with individualized treatment is thus supported., Online Registration: Registered in Clinicaltrials.gov under registry number NCT01842009., Perspective: In this article, an optimized protocol for the treatment of fibromyalgia pain with targeted subthreshold brain stimulation using high-definition transcranial direct current stimulation is outlined., (Copyright © 2016 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Objectives: Patients with long-lasting pain problems often complain of lack of confidence and trust in their body. Through physical experiences and reflections they can develop a more positive body- and self-experience. Body awareness has been suggested as an approach for treating patients with chronic pain and other psychosomatic conditions. The aim of this systematic review is to assess the effectiveness of body awareness interventions (BAI) in fibromyalgia (FM) and chronic fatigue syndrome (CFS)., Methods: Two independent readers conducted a search on Medline, Cochrane Central, PsycINFO, Web of knowledge, PEDro and Cinahl for randomized controlled trials., Results: We identified and screened 7.107 records of which 29 articles met the inclusion criteria. Overall, there is evidence that BAI has positive effects on the Fibromyalgia Impact Questionnaire (FIQ) (MD -5.55; CI -8.71 to -2.40), pain (SMD -0.39, CI -0.75 to -0.02), depression (SMD -0.23, CI -0.39 to -0.06), anxiety (SMD -0.23, CI -0.44 to -0.02) and Health Related Quality of Life (HRQoL) (SMD 0.62, CI 0.35-0.90) when compared with control conditions. The overall heterogeneity is very strong for FIQ (I(2) 92%) and pain (I(2) 97%), which cannot be explained by differences in control condition or type of BAI (hands-on/hands-off). The overall heterogeneity for anxiety, depression and HRQoL ranges from low to moderate (I(2) 0%-37%)., Conclusions: Body awareness seems to play an important role in anxiety, depression and HRQoL. Still, interpretations have to be done carefully since the lack of high quality studies., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Unlabelled: Acceptance and commitment therapy (ACT) is a developing approach for chronic pain. The current study was designed to pilot test a brief, widely inclusive, local access format of ACT in a UK primary care setting. Seventy-three participants (68.5% women) were randomized to either ACT or treatment as usual (TAU). Many of the participants were aged 65 years or older (27.6%), were diagnosed with fibromyalgia (30.2%) and depression (40.3%), and had longstanding pain (median = 10 years). Standard clinical outcome measures included disability, depression, physical functioning, emotional functioning, and rated improvement. Process measures included pain-related and general psychological acceptance. The recruitment target was met within 6 months, and 72.9% of those allocated to ACT completed treatment. Immediately post treatment, relative to TAU, participants in ACT demonstrated lower depression and higher ratings of overall improvement. At a 3-month follow-up, again relative to TAU, those in ACT demonstrated lower disability, less depression, and significantly higher pain acceptance; d = .58, .59, and .64, respectively. Analyses based on intention-to-treat and on treatment "completers," perhaps predictably, revealed more sobering and more encouraging results, respectively. A larger trial of ACT delivered in primary care, in the format employed here, appears feasible with some recommended adjustments in the methods used here (Trial registration: ISRCTN49827391)., Perspective: This article presents a pilot randomized controlled trial of ACT for chronic pain in a primary care setting in the United Kingdom. Both positive clinical outcomes and ways to improve future trials are reported., (Copyright © 2013 American Pain Society. All rights reserved.)

Unlabelled: Fibromyalgia is a prevalent chronic pain syndrome characterized by altered pain and sensory processing in the central nervous system, which is often refractory to multiple therapeutic approaches. Given previous evidence supporting analgesic properties of noninvasive brain stimulation techniques in this condition, this study examined the effects of a novel, more focal method of transcranial direct current stimulation (tDCS), using the 4×1-ring configuration of high-definition (HD)-tDCS, on overall perceived pain in fibromyalgia patients. In this patient- and assessor-blind, sham-controlled, crossover trial, 18 patients were randomized to undergo single 20-minute sessions of anodal, cathodal, and sham HD-tDCS at 2.0 mA in a counterbalanced fashion. The center electrode was positioned over the left primary motor cortex. Pain scales and sensory testing were assessed before and after each intervention. A finite element method brain model was generated to predict electric field distribution. We found that both active stimulation conditions led to significant reduction in overall perceived pain as compared to sham. This effect occurred immediately after cathodal HD-tDCS and was evident for both anodal and cathodal HD-tDCS 30 minutes after stimulation. Furthermore, active anodal stimulation induced a significant bilateral increase in mechanical detection thresholds. These interventions proved well tolerated in our patient population., Perspective: 4×1-ring HD-tDCS, a novel noninvasive brain stimulation technique capable of more focal and targeted stimulation, provides significant reduction in overall perceived pain in fibromyalgia patients as compared to sham stimulation, irrespective of current polarity. This technique may have other applications in research and clinical settings, which should be further explored., (Copyright © 2013 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Unlabelled: This study compared the efficacy of 2 psychological treatments for fibromyalgia with each other and with standard care. Ninety-three patients with fibromyalgia (FM) were randomly assigned to 1 of the 3 experimental conditions: 1) multicomponent cognitive-behavioral therapy (CBT); 2) multicomponent CBT with hypnosis; and 3) pharmacological treatment (standard care control group). The outcome measures of pain intensity, catastrophizing, psychological distress, functionality, and sleep disturbances were assessed before treatment, immediately after treatment, and at 3- and 6-month follow-up visits. CBT and CBT with hypnosis participants received the standard pharmacological management plus 14 weekly, 120-minute-long sessions of psychological treatment. All but 1 session followed a group format; the remaining session was individual. The analyses indicated that: 1) patients with FM who received multicomponent CBT alone or multicomponent CBT with hypnosis showed greater improvements than patients who received only standard care; and 2) adding hypnosis enhanced the effectiveness of multicomponent CBT. This study presents new evidence about the efficacy of multicomponent CBT for FM and about the additional effects of hypnosis as a complement to CBT. The relevance and implications of the obtained results are discussed., Perspective: This article highlights the beneficial effects of adding hypnosis in a multicomponent cognitive-behavioral group treatment of fibromyalgia patients. Also, this research showed that by adding hypnosis the length of treatment did not increase., (Copyright © 2012 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Fibromyalgia (FM) has been conceptualized as a disorder of the central nervous system, characterized by augmented sensory processing and an inability to effectively modulate pain. We previously reported that physical activity is related to brain processing of pain, providing evidence for a potential mechanism of pain management. The purpose of this study was to extend our work by manipulating pain modulation and determining relationships to both physical activity and sustained sedentary behavior. Eleven women with FM completed accelerometer measures of physical activity and underwent functional magnetic resonance imaging of painful heat, administered alone and during distracting cognitive tasks. Results showed that physical activity was significantly (P < .005) and positively related to brain responses during distraction from pain in regions implicated in pain modulation including the dorsolateral prefrontal cortex (DLPFC), the dorsal posterior cingulate, and the periaqueductal grey. A significant negative relationship occurred in the left anterior insula. For sedentary time, significant negative relationships were observed in areas involved in both pain modulation and the sensory-discriminative aspects of pain including the DLPFC, thalamus, and superior frontal and pre- and post-central gyri. These results suggest that physical activity and sedentary behaviors are related to central nervous system regulation of pain in FM., Perspective: Our results support a promising benefit of physical activity and highlight the potentially deleterious effects of sustained sedentary behavior for pain regulation in FM. Studies aimed at increasing physical activity or reducing sedentary behavior and determining the impact of these on pain regulation are warranted., (Published by Elsevier Inc.)

Unlabelled: The relationship between physical activity and central nervous system mechanisms of pain in fibromyalgia (FM) is unknown. This study determined whether physical activity was predictive of brain responses to experimental pain in FM using functional magnetic resonance imaging (fMRI). Thirty-four participants (n = 16 FM; n = 18 Control) completed self-report and accelerometer measures of physical activity and underwent fMRI of painful heat stimuli. In FM patients, positive relationships (P < .005) between physical activity and brain responses to pain were observed in the dorsolateral prefrontal cortex, posterior cingulate cortex, and the posterior insula, regions implicated in pain regulation. Negative relationships (P < .005) were found for the primary sensory and superior parietal cortices, regions implicated in the sensory aspects of pain. Greater physical activity was significantly (P < .05) associated with decreased pain ratings to repeated heat stimuli for FM patients. A similar nonsignificant trend was observed in controls. In addition, brain responses to pain were significantly (P < .005) different between FM patients categorized as low active and those categorized as high active. In controls, positive relationships (P < .005) were observed in the lateral prefrontal, anterior cingulate, and superior temporal cortices and the posterior insula. Our results suggest an association between measures of physical activity and central nervous system processing of pain., Perspective: Our data suggest that brain responses to pain represent a dynamic process where perception and modulation co-occur and that physical activity plays a role in balancing these processes. Physically active FM patients appear to maintain their ability to modulate pain while those who are less active do not., (Copyright © 2011 American Pain Society. All rights reserved.)

Unlabelled: In this study we aimed to determine current distribution and short-term analgesic effects of transcranial direct current stimulation (tDCS) in fibromyalgia using different electrode montages. For each electrode montage, clinical effects were correlated with predictions of induced cortical current flow using magnetic resonance imaging-derived finite element method head model. Thirty patients were randomized into 5 groups (Cathodal-M1 [primary motor cortex], Cathodal-SO [supra-orbital area], Anodal-M1, Anodal-SO, and Sham) to receive tDCS application (2 mA, 20 minutes) using an extracephalic montage. Pain was measured using a visual numerical scale (VNS), pressure pain threshold (PPT), and a body diagram (BD) evaluating pain area. There was significant pain reduction in cathodal-SO and anodal-SO groups indexed by VNS. For PPT there was a trend for a similar effect in anodal-SO group. Computer simulation indicated that the M1-extracephalic montage produced dominantly temporo-parietal current flow, consistent with lack of clinical effects with this montage. Conversely, the SO-extracephalic montage produced current flow across anterior prefrontal structures, thus supporting the observed analgesic effects. Our clinical and modeling findings suggest that electrode montage, considering both electrodes, is critical for the clinical effects of M1-tDCS as electric current needs to be induced in areas associated with the pain matrix. These results should be taken into consideration for the design of pain tDCS studies., Perspective: Results in this article support that electrode montage is a critical factor to consider for the clinical application of tDCS for pain control, as there is an important correlation between the location of induced electrical current and tDCS-induced analgesic effects., (Copyright © 2011 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Although most cases of temporomandibular muscle and joint disorders (TMJD) are mild and self-limiting, about 10% of TMJD patients develop severe disorders associated with chronic pain and disability. It has been suggested that fibromyalgia and widespread pain play a significant role in TMJD chronicity. This paper assessed the effects of fibromyalgia and widespread pain on clinically significant TMJD pain (GCPS II-IV). Four hundred eighty-five participants recruited from the Minneapolis/St. Paul area through media advertisements and local dentists received examinations and completed the Graded Chronic Pain Scale (GCPS) at baseline and at 18 months. Baseline widespread pain (OR: 2.53, P = .04) and depression (OR: 5.30, P = .005) were associated with onset of clinically significant pain (GCPS II-IV) within 18 months after baseline. The risk associated with baseline fibromyalgia was moderate, but not significant (OR: 2.74, P = .09). Persistence of clinically significant pain was related to fibromyalgia (OR: 2.48, P = .02) and depression (OR: 2.48, P = .02). These results indicate that these centrally generated pain conditions play a role in the onset and persistence of clinically significant TMJD., Perspective: Fibromyalgia and widespread pain should receive important consideration when evaluating and developing a treatment plan for patients with TMJD., (Copyright © 2010 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Significant evidence exists for central sensitization in fibromyalgia, however the cause of this process in fibromyalgia-and how it relates to other known abnormalities in fibromyalgia-remains unclear. Central sensitization occurs when persistent nociceptive input leads to increased excitability in the dorsal horn neurons of the spinal cord. In this hyperexcited state, spinal cord neurons produce an enhanced responsiveness to noxious stimulation, and even to formerly innocuous stimulation. No definite evidence of muscle pathology in fibromyalgia has been found. However, there is some evidence for dysfunction of the intramuscular connective tissue, or fascia, in fibromyalgia. This paper proposes that inflammation of the fascia is the source of peripheral nociceptive input that leads to central sensitization in fibromyalgia. The fascial dysfunction is proposed to be due to inadequate growth hormone production and HPA axis dysfunction in fibromyalgia. Fascia is richly innervated, and the major cell of the fascia, the fibroblast, has been shown to secrete pro-inflammatory cytokines, particularly IL-6, in response to strain. Recent biopsy studies using immuno-histochemical staining techniques have found increased levels of collagen and inflammatory mediators in the connective tissue surrounding the muscle cells in fibromyalgia patients. The inflammation of the fascia is similar to that described in conditions such as plantar fasciitis and lateral epicondylitis, and may be better described as a dysfunctional healing response. This may explain why NSAIDs and oral steroids have not been found effective in fibromyalgia. Inflammation and dysfunction of the fascia may lead to central sensitization in fibromyalgia. If this hypothesis is confirmed, it could significantly expand treatment options to include manual therapies directed at the fascia such as Rolfing and myofascial release, and direct further research on the peripheral pathology in fibromyalgia to the fascia.

Unlabelled: In 2004, the American Pain Society (APS) issued evidence-based fibromyalgia treatment recommendations. The objective of this claims database analysis is to describe prescription and medical use in patients with newly diagnosed and established fibromyalgia. Privately insured patients with 2+ myalgia/myositis claims (1999 to 2005) were categorized as newly diagnosed or established; this dichotomy involves comparisons between prediagnosis (S1) and postdiagnosis (S2) stages in the newly diagnosed and between newly diagnosed (S2) and established patients (S3). Use of APS guideline medications increased across stages: selective serotonin reuptake inhibitors (SSRIs) (S1, S2, S3: 20.6%, 22.9%, 25.3%), serotonin norepinephrine reuptake inhibitors (SNRIs) (4.5%, 6.4%, 8.9%), pregabalin/gabapentin (5.4%, 7.4%, 8.8%), benzodiazepines (19.0%, 21.1%, 24.2%), non-benzodiazepine sedatives (9.1%, 11.5%, 13.7%) (all P < .0001), and opioids (39.5%, 43.3%, 43.9%; S1 vs S2, P < .0001; S2 vs S3, P = .2835). Use of multiple therapeutic classes also increased across stages: 3+ classes (7.1%, 9.6%, 11.8%) (all P < .0001). Office visits to providers increased, on average, after diagnosis: primary care (70.9%, 78.3%, 76.3%; all P < .0001), chiropractors (28.8%, 51.1%, 53.3%; all P < .0001), rheumatologists (4.2%, 9.9%, 10.5%; S1 vs S2, P < .0001; S2 vs S3, P = .0595), mental health (6.4%, 7.3%, 8.3%; S1 vs S2, P < .0001, S2 vs S3, P = .0003). Average health care costs rose after diagnosis in the newly diagnosed group (S1: $6555 vs S2: $8654, P < .0001)., Perspective: This paper investigates prescription drug and medical care use with respect to stages of fibromyalgia diagnosis. Established fibromyalgia patients use more medical resources and have higher rates of concomitant medication use than newly diagnosed fibromyalgia patients. Findings can help educate providers regarding optimal drug treatment patterns in this population.

Unlabelled: Fibromyalgia (FM) is a chronic pain condition marked by centrally mediated augmentation of pain and sensory processes. Skepticism has marked the history of this condition, but more recent study has identified neurobiological underpinnings supporting many of the symptoms associated with this condition. Early research in FM had unprecedented latitude within the rheumatology community to borrow heavily from theory and methods being applied in chronic pain research more generally. These insights facilitated rapid advances in FM research, not the least of which was the abandonment of a peripheral focus in favor of studying central mechanisms associated with central augmentation. Currently, rapid-paced discovery is taking place in FM genetics, patient assessment, new therapeutic targets, and novel methods of treatment delivery. Such insights are not likely to be limited in application just to FM and could have relevance to the broader field of pain research as well., Perspective: This manuscript reviews the history of FM and its diagnosis, evidence supporting central augmentation of pain in FM, potential mechanisms of central augmentation, current approaches to integrated care of FM, and areas of active collaboration between FM research and other chronic pain conditions.

Unlabelled: Evoked pain measures such as tender point count and dolorimetry are often used to determine tenderness in studies of fibromyalgia (FM). However, these measures frequently do not improve in clinical trials and are known to be influenced by factors other than pain such as distress and expectancy. The purpose of this investigation was to determine whether evoked pain paradigms that present pressure stimuli in a random fashion (eg, Multiple Random Staircase [MRS]) would track with clinical pain improvement in patients with FM better than traditional measures. Sixty-five subjects enrolled in a randomized clinical trial of acupuncture were observed longitudinally. Clinical pain was measured on a 101-point numerical rating scale (NRS) and the Short Form McGill Pain Questionnaire (SF-MPQ), whereas evoked pressure sensitivity was assessed via manual tender point count, dolorimetry, and MRS methods. Improvements in clinical pain and evoked pain were assessed irrespective of group assignment. Improvement was seen in clinical pain during the course of the trial as measured by both NRS (P = .032) and SF-MPQ (P = .001). The MRS was the only evoked pain measure to improve correspondingly with treatment (MRS, P = .001; tender point count and dolorimeter, P > .05). MRS change scores were correlated with changes in NRS pain ratings (P = .003); however, this association was not stronger than tender point or dolorimetry correlations with clinical pain improvement (P > .05). Pain sensitivity as assessed by random paradigms was associated with improvements in clinical FM pain. Sophisticated pain testing paradigms might be responsive to change in clinical trials., Perspective: Trials in fibromyalgia often use both clinical and experimental methods of pain assessment; however, these two outcomes are often poorly correlated. We explore the relationship between changes in clinical and experimental pain within FM patients. Pressure pain testing that applies stimuli in a random order is associated with improvements in clinical pain, but this association was not stronger than other experimental techniques.

Unlabelled: Results from modified Stroop and dot-probe tasks have provided mixed evidence regarding attentional biases for sensory and affect pain stimuli in chronic pain patients. No studies have compared the same groups of chronic pain and healthy control participants on both tasks. We tested 36 patients with chronic musculoskeletal pain and 29 healthy control subjects on the modified Stroop and dot-probe tasks. Stimuli comprised affect pain, sensory pain, physical catastrophe, and neutral words. There was no evidence to suggest differential processing of threat cues by patients and control subjects on the modified Stroop task. All participants did, however, show differential processing of affect pain words. This was evident on both masked and unmasked presentation formats. There were no significant interactions between clinical status and threat word type observed for any of the indices of selective attention derived from the dot-probe task, but all participants had difficulty disengaging attention from affective pain and health catastrophe words. Findings were not influenced by individual differences in mood, anxiety, or fear of pain. Correlational analyses of the standard (unmasked) Stroop interference index and dot-probe indices of selective attention revealed a consistent lack of significant association, suggesting that the 2 tasks might be measuring different phenomena. Taken together, these findings provide evidence that chronic pain patients and healthy control participants do not differ in the way they attend to threatening linguistic stimuli., Perspective: Some patients with chronic pain might have trouble paying attention to anything other than the affective components of pain and associated catastrophic health consequences. Interventions that specifically target this attentional fixedness might facilitate shifting attention to other targets and thereby reduce pain-specific anxiety and fear.

Fibromyalgia syndrome (FMS) is a common, chronic musculoskeletal pain disorder of unknown etiology seen predominately in women. It is recognized as an important clinical problem associated with high levels of functional disability, emotional distress, and utilization of several types of medical services. While widespread pain and the presence of multiple tender points characterize the dominating features, there are a large number of nonrheumatic symptoms and associated conditions that occur in a high frequency in this disorder. When the characteristic pattern of symptoms is recognized, FMS can be successfully managed by nurse practitioners with expectation of some improvement. The mainstays of management include patient education, medication, aerobic exercise, and physical therapy. An ongoing relationship with the patient and periodic follow-up are mandatory.