February 2013 References  Devin J. Starlanyl   for http://www.sover.net/~devstar

Abramowicz S, Kim S, Susarla HK et al. 2013. Differentiating Arthritic from Myofascial Pain in Children with Juvenile Idiopathic Arthritis: Preliminary Report. J Oral Maxillofac Surg. S0278-2391(12)01617-5. To differentiate between temporomandibular joint (TMJ) inflammation and myofascial pain (MPD) in children with juvenile idiopathic arthritis (JIA). “The results of this study indicate that in patients with JIA and jaw signs/symptoms, there is an overlap in diagnoses between arthritis and MPD. This has considerable implications for patient management.” [Patients with jaw pain must be assessed for the presence of myofascial pain due to trigger points, and these TrPs treated ASAP. This may prevent or slow the progress of the OA. DJS]

Alburquerque-Sendín F, Camargo PR, Vieira A et al. 2013. Bilateral myofascial trigger points and pressure pain thresholds in the shoulder muscles in patients with unilateral shoulder impingement syndrome: A Blinded, Controlled Study. Clin J Pain. [Jan 16 Epub ahead of print]. “To identify the presence of myofascial trigger points (TrPs) and pressure pain threshold (PPT) levels in the shoulder muscles of both involved and uninvolved sides in patients with unilateral shoulder impingement syndrome (SIS)... SIS group showed a greater number of TrPs…than the control group. The muscles of the uninvolved side of the SIS group also presented some active TrPs…. The muscle PPTs of the patients presenting TrPs in each muscle of the involved side were lower than the PPTs of the patients without TrPs in the same muscle for both involved and uninvolved sides with few significant differences….The high number of TrPs in the involved side of patients with SIS suggests the presence of peripheral sensitization. The results reject the presence of central alterations. Finally, the patients with unilateral SIS may present bilateral deficits related to myofascial pain.”

Chou LW, Kao MJ, Lin JG. 2012. Probable mechanisms of needling therapies for myofascial pain control. Evid Based Complement Alternat Med. 2012:705327.

“Myofascial pain syndrome (MPS) has been defined as a regional pain syndrome characterized by muscle pain caused by myofascial trigger points (MTrPs) clinically.

MTrP is defined as the hyperirritable spot in a palpable taut band of skeletal muscle fibers.

Appropriate treatment to MTrPs can effectively relieve the clinical pain of MPS. Needling therapies, such as MTrP injection, dry needling, or acupuncture (AcP) can effectively eliminate pain immediately. AcP is probably the first reported technique in treating MPS patients with dry needling based on the Traditional Chinese Medicine (TCM) theory….   There are several principles for selection of acupoints based on the TCM principles: "Ah-Shi" point, proximal or remote acupoints on the meridian, and extra-meridian acupoints. Correlations between acupoints and MTrPs are discussed. Some clinical and animal studies of remote AcP for MTrPs and the possible mechanisms of remote effectiveness are reviewed and discussed.”

Dennis NL, Larkin M, Derbyshire SW. 2013. 'A giant mess' - making sense of complexity in the accounts of people with fibromyalgia. Br J Health Psychol. [Jan 24 Epub ahead of print]. “Twenty people with fibromyalgia participated in email interviews exploring their experiences, history and diagnosis…. Participants described enduring the course of a 'giant mess' of unpleasant symptoms, some of which were understood to be symptoms of fibromyalgia and some the interactive or parallel effects of comorbid illness. The respondents also demonstrated their considerable efforts at imposing order and sense on complexity and multiplicity, in terms of the instability of their symptoms. They expressed ambivalence towards diagnosis, doctors and medication, and we noted that each of the above areas appeared to come together to create a context of relational uncertainty, which undermined the security of connections to family, friends, colleagues and the workplace….Three key issues were discussed. First, there was not one overall symptom (e.g., pain) driving the unpleasantness of fibromyalgia; second, participants spent excessive time and energy trying to manage forces outside their control; third, because there is no definitive 'fibromyalgia experience', each diagnosis is unique, and our participants often appeared to be struggling to understand the course of their illness.  [While I disagree with the authors’ contention that FM is a diagnosis of exclusion, I agree that co-existing conditions cause a lot of the confusion concerning FM, and there are many interesting points in this paper. DJS]

Erdem HR, Cakit BD, Ozdemirel AE et al. 2012. Fear of falling in patients with cervical myofascial pain syndrome.  J Musculoskel Pain. 20(4):257-262. “Patients with cervical MPS suffer from FOF (fear of falling) probably due to balance problems and dizziness.”  Fear of falling is common in the elderly, and can cause limitations and psychological stress.  Vestibular rehabilitation and balance exercises are recommended in myofascial pain patients. [Falling can have serious consequences.  TrPs in the cervical area can adversely affect balance and proprioception, so are important to assess and treat, especially in the elderly, as well as possible co-existing vestibular and  ocular dysfunctions. DJS]

Fernandez-de-las-Penas C, Grobli C, Ortega-Santiago R et al. 2012. Referred pain from myofascial trigger points in head, neck, shoulder, and arm muscles reproduces pain symptoms in blue-collar (manual) and white-collar (office) workers. Clin J Pain. 28(6):511-518. “Blue-collar and white-collar workers exhibited a similar number of TrPs in the upper quadrant musculature. The referred pain elicited by active TrPs reproduced the overall pain pattern. The distribution of TrPs was not significantly different between groups. Clinicians should examine for the presence of muscle TrPs in blue-collar and white-collar workers.” [TrPs are common in people no matter what type of work they do. DJS]

Geletka BJ, O'Hearn MA, Courtney CA. 2012. Quantitative sensory testing changes in the successful management of chronic low back pain. J Man Manip Ther. 20(1):16-22.

“Individuals with chronic low back pain (LBP) represent a significant percentage of patients in physical therapy practice. The clinical pattern often includes diffuse pain and a variety of sensory complaints, making categorization difficult and leading to diagnoses such as non-specific LBP. Objective measures of sensory changes through quantitative sensory testing may help identify central sensitization of nociceptive pathways in this population. Identification of these somatosensory changes may contribute to clinical decision making and patient management. The purpose of this case report is to present objective evaluation findings, including altered somatosensation, in a patient with a 2-year history of LBP, and to describe changes in function and quantitative sensory testing with successful management.”

Gerbershagen HJ. 2013. [Transition from acute to chronic postsurgical pain: Physiology, risk factors and prevention.] Schmerz. [Feb 2 Epub ahead of print]. [Article in German]

“Chronic postsurgical pain (CPSP) is defined as pain persisting for longer than 3 months postoperatively. The frequency of occurrence ranges from 5 % to 60 % in all types of surgery and 1-3 % of patients with CPSP will suffer from severe pain and pain-related interference with daily activities. The pathological mechanisms which lead to the development of CPSP are complex and have not yet been analyzed. Neuropathic pain after surgical nerve lesions has been reported. Many patients with CPSP, however, do not present with any neuropathic pain characteristics. Peripheral and central sensitization are the essential mechanisms of the development of pain chronicity in the postoperative period. As treatment of CPSP is demanding it is attempted to prevent central sensitization before CPSP develops.” [It would be wise to assess each post-surgical patient for developing TrPs in a follow-up exam at least a month after surgery.  DJS]

Gerdle B, Forsgren MF, Bengtsson A et al. 2013. Decreased muscle concentrations of ATP and PCR in the quadriceps muscle of fibromyalgia patients – A (31) P-MRS study. Eur J Pain. [Jan 30 Epub ahead of print]. “Alterations in intramuscular ATP, PCr and fat content in FMS probably reflect a combination of inactivity related to pain and dysfunction of muscle mitochondria.” [OR, they may reflect the presence of co-existing TrPs. DJS]

Gonzalez B, Baptista TM, Branco JC et al. 2013. Fibromyalgia: antecedent life events, disability, and causal attribution. Psychol Health Med. [Jan 17 Epub ahead of print].

“This study aimed to evaluate the relation of disability and physical and mental health status with potentially traumatic life events (PTLE) before the onset of fibromyalgia in women diagnosed with this syndrome. We also investigated causal attribution of fibromyalgia to a triggering event, physical or psychological in nature, and its relation with the health measures and the adverse life events….There were no statistically significant relations between the health measures (disability, physical and mental health, and pain) and the PTLE. The predominant attribution was to a physical event. There were no significant differences neither in the health measures across causal attribution status….nor in the PTLE not in childhood….There were significant differences across causal attribution status in the PTLE in childhood…., specifically between the group that made a psychological attribution and the group that made no attribution….with the former having a higher score of PTLE in childhood. The results raise questions about the importance of psychological aspects in the appraisal of the adverse events and its possible relation to the psychological functioning in women with fibromyalgia.” [Many symptoms now attributed to FM may be due to co-existing conditions.  FM is heterogeneous. DJS]

Heredia-Jimenez JM, Soto-Hermoso VM. 2013. Kinematics gait disorder in men with fibromyalgia. Rheumatol Int. [Jan 5 Epub ahead of print]. “We studied 12 male with fibromyalgia and 14 healthy men. Each participant of the study walked five trials along a 18.6-m walkway. Fibromyalgia patients completed a Spanish version of Fibromyalgia Impact Questionnaire. Significant differences between fibromyalgia and control groups were found in velocity, stride length, and cadence. Gait parameters of men affected by fibromyalgia were impaired when compared to those of healthy group due to bradykinesia. According to previous studies to assess gait variables in female patients, the male with fibromyalgia also showed lower values of velocity, cadence, and stride length than healthy group but not reported significant differences in swing, stance, single, or double support phase.” [It would be interesting to check these men for co-existing TrPs, as TrPs usually co-exist with FM and some TrPs influence gait profoundly. DJS]

Hsieh YL, Yang SA, Yang CC et al. 2012. Dry needling at myofascial trigger spots of rabbit skeletal muscles modulates the biochemicals associated with pain, inflammation, and hypoxia. Evid Based Complement Alternat Med. 2012:342165. “Dry needling at the MTrSs modulates various biochemicals associated with pain, inflammation, and hypoxia in a dose-dependent manner.”  

Kuan TS, Hong CZ, Chen SM et al. 2012. Myofascial pain syndrome: correlation between the irritability of trigger points and the prevalence of local twitch responses during trigger point injection. J Musculoskel Pain. 20(4):250-256. The local twitch response appears to be a reflex contraction of muscle fiber within the TrP taut band.  The LTR occurs when the nociceptors in the taut band are stimulated, such as during TrP injection or dry needling “This study supports the hypothesis that in MPS there are multiple sensitized loci nociceptors in TrP regions and that the Local Twitch Response is related to the irritability of the TrP.”  This study found a high correlation of LTR during injection and intensity of pain or pressure pain threshold before injection. We don’t yet know why it is so critical for pain relief to elicit an LTR during injection.  The prevalence of LTR seems to be highly associated with the LTR. The amount of pain relief was in proportion to the LTR only when the mean intensity of pain was very high before injection.

Lee YC. 2013. Effect and treatment of chronic pain in inflammatory arthritis. Curr Rheumatol Rep.15(1):300. “Pain is the most common reason patients with inflammatory arthritis see a rheumatologist. Patients consistently rate pain as one of their highest priorities, and pain is the single most important determinant of patient global assessment of disease activity. Although pain is commonly interpreted as a marker of inflammation, the correlation between pain intensity and measures of peripheral inflammation is imperfect. The prevalence of chronic, non-inflammatory pain syndromes such as fibromyalgia is higher among patients with inflammatory arthritis than in the general population. Inflammatory arthritis patients with fibromyalgia have higher measures of disease activity and lower quality of life than inflammatory patients who do not have fibromyalgia. This review article focuses on current literature involving the effects of pain on disease assessment and quality of life for patients with inflammatory arthritis. It also reviews non-pharmacologic and pharmacologic options for treatment of pain for patients with inflammatory arthritis, focusing on the implications of comorbidities and concurrent disease-modifying antirheumatic drug therapy.”

Liu J, Wang XQ, Zheng JJ et al. 2012. Effects of Tai Chi versus Proprioception Exercise Program on Neuromuscular Function of the Ankle in Elderly People: A Randomized Controlled Trial. Evid Based Complement Alternat Med. 2012:265486. “Tai Chi is a traditional Chinese medicine exercise used for improving neuromuscular function. This study aimed to investigate the effects of Tai Chi versus proprioception exercise program on neuromuscular function of the ankle in elderly people...Sixty elderly subjects were randomly allocated into three groups of 20 subjects per group. For 16 consecutive weeks, subjects participated in Tai Chi, proprioception exercise, or no structured exercise. Primary outcome measures included joint position sense and muscle strength of ankle…Results: (1) Both Tai Chi group and proprioception exercise group were significantly better than control group in joint position sense of ankle, and there were no significant differences in joint position sense of ankle between TC group and PE group. (2) There were no significant differences in muscle strength of ankle among groups. (3) Subjects expressed more satisfaction with Tai Chi than with proprioception exercise program…. None of the outcome measures on neuromuscular function at the ankle showed significant change post training in the two structured exercise groups. However, the subjects expressed more interest in and satisfaction with Tai Chi than proprioception exercise.”

Lorduy KM, Liegey-Dougall A, Haggard R et al. 2013. The Prevalence of Comorbid Symptoms of Central Sensitization Syndrome among Three Different Groups of Temporomandibular Disorder Patients. Pain Pract. [Jan 22 Epub ahead of print].

“Myofascial TMD is characterized by a high degree of comorbidity of symptoms of CSS and associated emotional distress.” [Patients with TMD should be assessed for myofascial pain due to trigger points, fibromyalgia, and other possible co-existing conditions, and distinction must be made between a general use of the term “myofascial pain” to mean TMJ and myofascial pain due to trigger points.  DJS]

Mander BA, Rao V, Lu B et al. 2013. Prefrontal atrophy, disrupted NREM slow waves and impaired hippocampal-dependent memory in aging. Nat Neurosci. [Jan 27 Epub ahead of print]. “…findings suggest that sleep disruption in the elderly, mediated by structural brain changes, represents a contributing factor to age-related cognitive decline in later life.”  It is critical that quality as well a quantity of sleep be monitored in older adults, as quality of sleep directly relates to cognitive function.  [A sleep study may uncover hidden reasons for (or contributions to) cognitive decline that may be treatable. DJS]

Markotic F, Cerni Obrdalj E, Zalihic A et al. 2013. Adherence to pharmacological treatment of chronic nonmalignant pain in individuals aged 65 and older. Pain Med. [Jan 31 Epub ahead of print]. “According to their own statements, 57% of the patients were nonadherent, while 84% exhibited some form of nonadherence …The most common deviation from the prescribed therapy was self-adjustment of the dose and medical regimen based on the severity of pain. Polymedication correlated positively with nonadherence. Nonsteroidal anti-inflammatory drugs were the most frequently prescribed medications. The majority of the participants (59%) believed that higher pain intensity indicates progression of the disease, and half of the participants believed that one can easily become addicted to pain medications. Nonadherence was associated with patient attitudes about addiction to analgesics and ability of analgesics to control pain….High pain intensity and nonadherence found in this study suggest that physicians should monitor older patients with chronic nonmalignant pain more closely and pay more attention to patients' beliefs regarding analgesics to ensure better adherence to pharmacological therapy.” [Many patients have incorrect understanding of medications, and may fail to use sufficient medication to control their symptoms due to fear of addiction  DJS]

Menant JC, Wong A, Sturnieks DL et al. 2013. Pain and Anxiety Mediate the Relationship Between Dizziness and Falls in Older People. J Am Geriatr Soc. [Jan 25 Epub ahead of print]. “Suffering from neck and back pain and anxiety were mediators of the relationship between dizziness and falls after controlling for poor sensorimotor function and balance. Older people with dizziness might benefit from interventions targeting these mediators such as pain management and cognitive behavioral therapy.” [This should include an assessment for TrPs. DJS]

Miernik M, Wieckiewicz M, Paradowska A. 2012. Massage therapy in myofascial TMD pain management. Adv Clin Exp Med. 21(5):681-685. Myofascial pain located in the area of the head is a very common disease of the stomatognathic system. The fact that the mechanism of its development is very complex may cause a variety of problems in diagnosis and therapy. Patients diagnosed with this type of affliction usually need a variety of different therapies. Massage therapy can be a significant method of treatment of myofascial pain. That kind of therapy is clinically useful as it improves the subjective and objective health status of the patient and is easy to follow. The aim of this paper is to show the physiological effect and different massage techniques applied in myofascial pain treatment. The authors would also like to present the protocol for dealing with patients who demand that kind of therapy for masseter and temporal muscles.

Palstam A, Gard G, Mannerkorpi K. 2013. Factors promoting sustainable work in women with fibromyalgia. Disabil Rehabil. [Jan 22 Epub ahead of print]. “Promoting factors for work were identified, involving individual and environmental factors. These working women with FM had developed advanced well-functioning strategies to enhance their work ability. The development of such strategies should be supported by health-care professionals as well as employers to promote sustainable work in women with FM… Working women with FM appear to have developed advanced well-functioning individual strategies to enhance their work ability. The development of individual strategies should be supported by health-care professionals as well as employers to promote sustainable work and health in women with FM.”

Perez-de-Heredia-Torres M, Martínez-Piedrola RM et al. 2013. Bilateral deficits in fine motor control ability and manual dexterity in women with fibromyalgia syndrome. Exp Brain Res. [Jan 26 Epub ahead of print]. “Our findings revealed bilateral deficits in fine motor control ability and manual dexterity in patients with FMS without symptoms in the upper extremity. These deficits are not related to the clinical features of the symptoms

supporting an underlying central mechanism of altered motor control.” [These patients should be assessed for the presence of latent TrPs, as they are known (or should be) to co-exist with FM, and can cause deficits in fine motor control and manual dexterity. DJS]

Puretic MB, Demarin V. 2012. Neuroplasticity mechanisms in the pathophysiology of chronic pain. Clin Croat. 51(3):425-429. “Chronic pain is a widespread healthcare problem with great impact on mental health, professional and family life of the patient. It can be a consequence of many disorders; however, its pathogenesis has not yet been fully understood. Neuroplasticity is the ability of the nervous system to adapt to different changes and it is present throughout life, not only in prenatal period, infancy and childhood. However, in the pathophysiology of chronic pain, neuroplasticity shows its ‘dark side’. Due to the central sensitization process, noxious stimuli can produce chronic pain or misinterpretation of non-noxious stimuli (secondary hyperalgesia and allodynia). These changes occur at the level of brain cortex as well at peripheral nerves and receptors. This review summarizes a significant portion of literature dealing with neuroplasticity processes in well known chronic pain conditions such as migraine, chronic posttraumatic headache, low back pain, fibromyalgia, and others.” [This review from Croatia is well-thought-out and well-done. It is to be hoped that in the future, these researchers will include papers dealing with central sensitization generating TrPs in their research. DJS]

Rocha CB, Sanchez TG. 2012. [Efficacy of myofascial trigger point deactivation for tinnitus control]. Braz J Otorhinolaryngol. 78(6):21-26. [Article in Portuguese]

“Besides medical and audiological investigation, patients with tinnitus should also be checked for: 1) presence of myofascial pain surrounding the ear; 2) laterality between both symptoms; 3) initial decrease of tinnitus during muscle palpation. Treating this specific subgroup of tinnitus patients with myofascial trigger point release may provide better results than others described so far.”

Sales Pinto LM, de Carvalho JJ, Cunha CO et al. 2013. Influence of Myofascial Pain on the Pressure Pain Threshold of Masticatory Muscles in Women with Migraine. Clin J Pain. [Jan 16 Epub ahead of print]. “We found that all groups had significantly lower PPT values compared with asymptomatic women, with lower values seen in group II (women with migraine and myofascial pain). Women with a migraine and myofascial pain showed significantly lower PPT values compared with women with a migraine only, and also when compared with women with myofascial pain only …Migraine, especially when accompanied by myofascial pain, reduces the PPT of masticatory muscles, suggesting the importance of masticatory muscle palpation during examination of patients with migraine.”

Sanchez del Río-Gonzalez M. 2012. [Chronic migraine: pathophysiology]. Rev Neurol. 54 Suppl 2:S13-19 [Article in Spanish]. “Chronic migraine is considered a complication of episodic migraine. Several risk factors, which may be modifiable or non-modifiable, make varying contributions to the progression towards chronification. Every year 2.5% of patients with episodic migraine go on to suffer chronic migraine. Experimental studies point to a dysfunction in the descending pain modulatory system that would facilitate nociceptive afferents, in the absence of damage to tissues, and so chronic migraine would share a pathogenesis that is similar to that of fibromyalgia, irritable bowel syndrome or chronic tension-type headache (conditions that frequently coexist). This paper reviews the risk factors and the scientific evidence of the possible pathogenic mechanisms involved in the progression towards chronification.”

Seok J, Warren HS, Cuenca AG et al. 2013. Genomic responses in mouse models poorly mimic human inflammatory diseases. Proc Natl Acad Sci USA. [Feb 11 Epub ahead of print].  This study shows that the commonly used mouse as an experimental model does not translate well to human applications in the context of inflammatory disease.  How a mouse responds in an experiment does not indicate how a human will respond. [One very small step for mouse-kind. DJS]

Stryła W, Pogorzała AM, Stępień J. 2013. Proprioception exercises in medical rehabilitation. Pol Orthop Traumatol. 78:5-27. “Proprioception, or kinesthesia, is the sense of orientation responsible for perception of body and relative position of its parts. Kinesthesia is received by receptors located in muscles and tendons. In this study a set of proprioception developing exercises was presented. Proprioception should be restored in case of musculoskeletal and neurological disorders. Proprioception training can also be used as a prophylaxis before starting various sporting activities. Proprioception developing exercises have significant meaning for the elderly, who are at risk of balance disorders. These exercises help developing motor memory and at the same time protect from falls.” [All care providers must understand that myofascial TrPs can have associated proprioceptive and/or autonomic dysfunction. DJS]

Tagoe CE, Zezon A, Khattri S et al. 2013. Rheumatic manifestations of euthyroid, anti-thyroid antibody-positive patients. Rheumatol Int. [Jan 5 Epub ahead of print]. The aim of this study is to define the rheumatic manifestations of euthyroid patients with chronic lymphocytic thyroiditis (CLT) but without a well-defined connective tissue disease…..[This study found that] Rheumatic manifestations frequently occur in patients with CLT in the absence of overt thyroid dysfunction and mimic the presentation of the well-defined connective tissue diseases.”

Taylor AG, Anderson JG, Riedel SL et al. 2013. A randomized, controlled, double-blind pilot study of the effects of cranial electrical stimulation on activity in brain pain processing regions in individuals with fibromyalgia. Explore (NY). 9(1):32-40. “The observed decrease in activation in the pain processing regions may indicate a decrease in neural activity in these regions that may be related to decreased pain. This is the first randomized, controlled trial of CES in patients diagnosed with fibromyalgia to report functional magnetic resonance imaging data.”

Turo D, Otto P, Shah JP et al. 2012. Ultrasonic tissue characterization of the upper trapezius muscle in patients with myofascial pain syndrome. Conf Proc IEEE Eng Med Biol Soc. 2012:4386-4389. Myofascial trigger points (MTrPs) are palpable, tender nodules in skeletal muscle that produce symptomatic referred pain when palpated…. Objective characterization and quantitative measurement of the properties of MTrPs can improve their localization and diagnosis, as well as lead to clinical outcome measures. MTrPs associated with soft tissue neck pain are often found in the upper trapezius muscle. We have previously demonstrated that MTrPs can be visualized using ultrasound imaging. The goal of this study was to evaluate whether texture-based image analysis can differentiate structural heterogeneity of symptomatic MTrPs and normal muscle.

Valrie CR, Bromberg MH, Palermo T et al. 2013. A systematic review of sleep in pediatric pain populations. J Dev Behav Pediatr. 34(2):120-128. “Findings from this review highlight the need to assess and treat sleep problems in children presenting with persistent pain. Health care providers should consider conducting routine sleep screenings, including a comprehensive description of sleep patterns and behaviors obtained through clinical interview, sleep diaries, and/or the use of standardized measures of sleep. Future research focusing on investigating the mechanisms associating sleep and pediatric persistent pain and on functional outcomes of poor sleep in pediatric pain populations is needed.”

van Oosterwijck J, Meeus M, Paul L et al. 2013. Pain physiology education improves health status and endogenous pain Inhibition in fibromyalgia: A double-blind randomized controlled trial. Clin J Pain. [Jan 30 Epub ahead of print]. “These results suggest that FM patients are able to understand and remember the complex material about pain physiology. Pain physiology education seems to be a useful component in the treatment of FM patients as it improves health status and endogenous pain inhibition in the long term.”

Younger J, Noor N, McCue R et al. 2013. Low-dose naltrexone for the treatment of fibromyalgia: Findings of a small, randomized, double-blind, placebo-controlled, counterbalanced, crossover trial assessing daily pain levels. Arthritis Rheum. 65(2):529-538. “The preliminary evidence continues to show that low-dose naltrexone has a specific and clinically beneficial impact on fibromyalgia pain. The medication is widely available, inexpensive, safe, and well-tolerated. Parallel-group randomized controlled trials are needed to fully determine the efficacy of the medication.”

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