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## Complete Summary

#### GUIDELINE TITLE

Guideline for the management of fibromyalgia syndrome pain in adults and
children.

#### BIBLIOGRAPHIC SOURCE(S)

Buckhardt CS, Goldenberg D, Crofford L, Gerwin R, Gowens S, Jackson K,
Kugel P, McCarberg W, Rudin N, Schanberg L, Taylor AG, Taylor J, Turk D.
Guideline for the management of fibromyalgia syndrome pain in adults and
children. Glenview (IL): American Pain Society (APS); 2005. 109
p. (Clinical practice guideline; no. 4). \[335 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory information
has been released.

-   [May 2, 2007, Antidepressant
    drugs](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Antidepressant):
    Update to the existing black box warning on the prescribing
    information on all antidepressant medications to include warnings
    about the increased risks of suicidal thinking and behavior in young
    adults ages 18 to 24 years old during the first one to two months of
    treatment.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Fibromyalgia syndrome

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Neurology\
Nursing\
Pediatrics\
Pharmacology\
Physical Medicine and Rehabilitation\
Psychiatry\
Psychology\
Rheumatology

#### INTENDED USERS

Advanced Practice Nurses\
Nurses\
Pharmacists\
Physical Therapists\
Physician Assistants\
Physicians\
Psychologists/Non-physician Behavioral Health Clinicians

#### GUIDELINE OBJECTIVE(S)

-   To provide evidence-based guidelines for diagnosis and management of
    fibromyalgia syndrome (FMS) in children and adults

-   To improve the quality of care for children and adults

#### TARGET POPULATION

Adults and children suffering from fibromyalgia syndrome

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis/Evaluation**

1.  Complete history and differential diagnosis

2.  Pain assessment including pain intensity, pain affect, and pain
    location

3.  Physical examination including general physical examination and
    tender point examination

4.  Psychological and functional assessment

5.  Laboratory assessment including complete blood count, erythrocyte
    sedimentation rate, muscle enzymes, liver function, and thyroid
    function tests

**Management/Treatment of Fibromyalgia Syndrome in Adults**

1.  Pharmacologic therapies

    -   Antidepressant medication, such as tricyclic antidepressants
        (e.g., amitriptyline or cyclobenzaprine); selective serotonin
        reuptake inhibitors (SSRIs) (e.g., fluoxetine, alone or in
        combination with tricyclics)

    -   Analgesics, such as non-steroidal anti-inflammatory drugs
        (NSAIDs) in combination with other medication (**Note**: NSAIDs
        are [not]{.underline} recommended); tramadol, alone or in
        combination with acetaminophen; opioids

    -   Sleep and anti-anxiety medications, such as trazodone,
        benzodiazepines, nonbenzodiazepine sedatives, L-dopa and
        carbidopa

    -   Trigger point injections in patients with co-existent myofascial
        pain

> **Note**: Guideline developers considered but did not recommend
> anticonvulsant medication and hormone therapy including
> corticosteroids (unless there is concurrent joint, bursa, or tendon
> inflammation)

2.  Nonpharmacologic therapies

    -   Patient education about fibromyalgia syndrome and treatment
        options, pain management and self-management programs

    -   Cognitive-behavioral therapy

    -   Aerobic exercise

    -   Clinician-assisted treatment, such as clinical hypnosis and
        biofeedback, acupuncture, chiropractic manipulations,
        therapeutic massage, and balneotherapy

> **Note**: Guideline developers considered but did not recommend
> dietary modifications, nutritional supplements, and biologic agents
> due to lack of sufficient research

3.  Multidisciplinary treatment incorporating two or more strategies

4.  Referral to a specialist

**Evaluation/Management of Fibromyalgia Syndrome in Children and
Adolescents**

1.  Assessment of pain including pain history, behavioral observations,
    physiologic and psychosocial cues, mood disorders, and functional
    status

2.  Child and family education

3.  Cognitive-behavioral therapy

4.  Aerobic exercise and physical therapy

5.  Sleep hygiene

6.  Pharmacologic management (e.g., fluoxetine)

7.  Family involvement and school integration

#### MAJOR OUTCOMES CONSIDERED

Effect of treatment on pain relief, fatigue, sleep, function,
self-efficacy, mood, and Fibromyalgia Syndrome Impact Questionnaire
(FIQ) scores

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

A comprehensive literature review was conducted to locate recently
published systematic evidence reviews and to identify areas in which
reviews were needed. This evidence was used in the development of the
guideline.

Four sources of evidence review were used: (a) Cochrane Collaboration
Reviews, (b) other published systematic reviews, (c) reviews
commissioned by American Pain Society (APS), and (d) reviews conducted
by APS panel and staff members. The Cochrane and other published reviews
are listed in Table 1 of the original guideline document.

The reviews commissioned by APS were completed under the direction of
Linda Tyler, PharmD (Utah Drug Information Service, University of Utah
Health Sciences Center), and included use of opioids, nonsteroidal
anti-inflammatory drugs (NSAIDs), muscle relaxants, lidocaine, ketamine,
tramadol, and miscellaneous medications used to treat fibromyalgia
syndrome (FMS). The remaining 12 reviews were conducted by APS panel and
staff members and are listed in Table 2 of the original guideline
document. All reviews conducted by APS staff and by the Utah Drug
Information Service used the same protocol for reviewing individual
studies.

The databases, dates searched, and review methods used are described in
each published evidence review. For reviews conducted by the Utah Drug
Information Service and APS panel and staff members, the following
databases and dates were included: MEDLINE (1966-April 2004), CINAHL
(1982-April 2004), Embase (1988-April 2004), PubMed (1966-April 2004),
HealthStar (1997-2000), Current Contents (2000-April 2004), Web of
Science (1980-April 2004), PsycINFO (1887-April 2004), Science Citation
Indexes (1996-April 2004), and the Cochrane Database (1993-2004). The
abstracts were searched to identify research articles. Case reports,
letters to the editor, articles describing diagnostic techniques, animal
studies, and surveys reporting the incidence of pain were excluded.
Published studies were reviewed and evaluated following a specific
protocol.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus (Committee)\
Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

The type of evidence for recommendations was ranked ordinally in
categories from I to V as follows:

I.  Meta-analysis of multiple well-designed controlled studies

II. Well-designed experimental studies

III. Well-designed, quasi-experimental studies, such as nonrandomized
     controlled, single-group pre-post, cohort, time series, or
     matched-case controlled studies

IV. Well-designed nonexperimental studies, such as comparative and
    correlational descriptive and case studies

V.  Case reports and clinical examples

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

The evidence was classified by type and strength. The type of evidence
for recommendations was ranked ordinally in categories from I to V.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The fibromyalgia syndrome (FMS) guideline development process combined
the review of available scientific evidence and the judgment of pain
experts.

The interdisciplinary panel comprised 13 experts in various aspects of
the management of pain associated with FMS. The panel and American Pain
Society (APS) staff prepared multiple drafts of the document.

The panelists based recommendations labeled A or B primarily on the
evidence. For recommendations labeled C or D, the panel used the
available empiric evidence but based its recommendations primarily on
expert judgment. The term *panel consensus* was used when the
recommendation was a statement of panel opinion regarding desirable
practice.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

The evidence for the recommendations was summarized according to its
strength and consistency. Strength of evidence ranged from A (the
strongest evidence) to D (little or no evidence, or type V evidence
only). The strength and consistency of the recommendations are as
follows:

A.  There is evidence of type I or consistent findings from multiple
    studies of types II, III, or IV.

B.  There is evidence of types II, III, or IV, and findings are
    generally consistent.

C.  There is evidence of types II, III, or IV, but findings are
    inconsistent.

D.  There is little or no evidence, or there is type V evidence only.

Panel Consensus: Practice recommended based on the opinions of experts
in pain management.

#### COST ANALYSIS

Published cost analyses were reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Two drafts of the guideline underwent peer review, with 50 reviewers
participating in the first review and 9 in the second; some reviewers
read both drafts. Peer reviewers are listed in Appendix F of the
original guideline document, except for those who chose to remain
anonymous (two individuals). The questionnaire that reviewers used to
evaluate the drafts was based on the Institute of Medicine\'s
*Guidelines for Clinical Practice: From Development to Use*.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

*These recommendations are presented in abbreviated form. Readers should
refer to the text of the guideline document for a detailed discussion of
each of the following topics*.

Definitions for the type of evidence (I, II, III, IV, V) and the
strength and consistency of evidence grades (A, B, C, D, Panel
consensus) are provided at the end of the \"Major Recommendations\"
field.

**Fibromyalgia Syndrome Diagnosis and Assessment**

1.  Begin the evaluation of people with fibromyalgia syndrome (FMS) with
    a complete history and physical examination, focusing on illnesses
    that may mimic or complicate FMS, such as hypothyroidism or
    ankylosing spondylitis, or that can occur concurrently with FMS,
    such as tendonitis, systemic lupus erythematosus, rheumatoid
    arthritis, or osteoarthritis. The clinician should perform a
    complete joint examination, manual muscle strength testing, and
    neurologic examination. **(Panel consensus)**

2.  Base the clinical diagnosis of FMS on the presence of widespread
    pain, defined as pain in all four body quadrants and axial pain, for
    at least 3 consecutive months. The only physical examination
    criterion for the diagnosis of FMS is the presence of excess
    tenderness to manual palpation of at least 11 of 18 muscle-tendon
    sites obtained through the manual tender point examination. **(B)**

3.  Focus pain assessment on type and quality of pain, source, location,
    duration, time course, pain affect, and effects on quality of life.
    Use self-report as the primary source of pain assessment, and use
    the same pain measurement tool at subsequent visits. **(B)**

4.  Evaluate the severity of other FMS symptoms, including fatigue,
    sleep disturbance, and mood and cognitive disturbance. Refer people
    with suspected mood disorders for formal psychological testing.
    **(Panel consensus)**

5.  Assess functional status in the initial and subsequent patient
    visits. Measure the impact of FMS on physical and emotional function
    and overall quality of life. **(Panel consensus)**

6.  Obtain a complete blood count and conduct erythrocyte sedimentation
    rate, muscle enzymes, liver function, and thyroid function tests in
    a new patient with probable FMS. **(Panel consensus)**

**Interventions**

7.  Begin treatment of FMS by confirming the diagnosis of FMS and
    explaining what the condition is and what it is not. **(Panel
    consensus)** Patient education is critical to optimal management of
    FMS. **(B)**

8.  Use multiple strategies and include both pharmacologic and
    nonpharmacologic therapies in the management of FMS. **(A)**

**Pharmacologic Therapies**

9.  For initial treatment of FMS, prescribe a tricyclic antidepressant
    for sleep, in particular 10 to 30 mg amitriptyline or
    cyclobenzaprine at bedtime. **(A)**

10. Use selective serotonin reuptake inhibitors (SSRIs) such as
    fluoxetine, alone or in combination with tricyclics, for pain
    relief. **(B)** The doses of all antidepressants should be
    individualized and any concurrent mood disturbances treated.
    **(Panel consensus)**

11. Do not use non-steroidal anti-inflammatory drugs (NSAIDs) as the
    primary pain medication for people with FMS. **(A)** There is no
    evidence that NSAIDs are effective when used alone to treat FMS
    patients. NSAIDs, including COX-2 selective agents and
    acetaminophen, may provide some analgesia when used with other
    medications. **(C)**

12. Use tramadol (50 to 100 mg two or three times daily) for pain relief
    in people with FMS. The dose of tramadol should be increased slowly
    over time and should be tapered gradually when discontinued.
    Tramadol can be used alone or in combination with acetaminophen.
    **(B)**

13. Use opioids for management of FMS pain only after all other
    pharmacologic and nonpharmacologic therapies have been exhausted.
    **(Panel consensus)**

14. Use sleep and anti-anxiety medications such as trazodone,
    benzodiazepines, nonbenzodiazepine sedatives, or L-dopa and
    carbidopa in FMS, especially if sleep disturbances such as restless
    leg syndrome are prominent. **(A)**

15. Do not use corticosteroids in the treatment of FMS unless there is
    concurrent joint, bursa, or tendon inflammation. **(A)**

16. Ask patients about their use of complementary products and practices
    and have sufficient knowledge of them to be able to answer questions
    concerning efficacy and identify possible negative interactions with
    prescribed treatment. **(C)**

**Nonpharmacologic Therapies**

17. Provide all patients with basic information on FMS and treatment
    options, and educate them about pain management and self-management
    programs as an initial part of treatment. **(A)**

18. Incorporate cognitive-behavioral therapy into a multimodality
    treatment approach to reduce pain, enhance self-efficacy, and
    improve function. **(A)**

19. Encourage and support people with FMS to perform moderately intense
    aerobic exercise (60-75% of age-adjusted maximum heart rate \[210
    minus the person\'s age\]) two to three times per week. **(A)** In
    individuals who are deconditioned, this rate can be achieved with
    very low levels of exercise.

20. Advise people with FMS to avoid exercise-induced pain by stretching
    to the point of slight resistance, not to the point of pain. This is
    especially important in a subgroup of individuals who have joint
    hypermobility. **(B)**

21. Begin exercise programs for people with FMS at a level just below
    their capacity, and progress in frequency, duration, or intensity as
    their levels of fitness and strength increase. Exercise progression
    should be slow and gradual, or participants will experience a
    marked, exercise-induced exacerbation of pain that may lead to
    discontinuation of the exercise program. **(Panel consensus)**

22. Encourage people with FMS to perform muscle-strengthening exercise
    two times per week. **(B)**

23. Encourage ongoing exercise to maintain exercise-induced gains.
    **(B)**

24. Offer clinician-assisted treatments such as clinical hypnosis and
    biofeedback **(B)**, acupuncture **(C)**, chiropractic manipulation,
    therapeutic massage **(B)**, and balneotherapy **(A)**, which may be
    helpful for pain relief.

25. Use multidisciplinary approaches that incorporate two or more
    strategies to decrease pain and improve function in FMS, especially
    in people who have not responded to simpler approaches. **(A)**

**Fibromyalgia Syndrome in Children and Adolescents**

26. Assessment of pain in children with juvenile FMS (JFMS) should be
    developmentally based and should include both child and parent
    components. Include pain history, behavioral observation,
    physiologic cues, and evaluation of comorbid mood disorders,
    psychosocial distress, and functional status, including school
    attendance, for a comprehensive assessment. **(Panel consensus)**

27. Provide education for the child and family on the diagnosis of JFMS,
    interrelationship of symptoms, and management of symptoms. Provide
    education to the child and family on an ongoing basis to increase
    self-care skills, improve self-efficacy, and enhance understanding
    of the interrelationships between pain, mood, stress, exercise, and
    the role of factors concerning the parental and family environment.
    Include background information regarding the prevalence of pain in
    children. **(Panel consensus)**

28. Utilize pharmacologic and nonpharmacologic strategies in the
    management of JFMS. **(Panel consensus)**

29. Focus treatment on maximizing function, stressing the importance of
    regular school attendance. Set functional goals with the child and
    family. **(Panel consensus)**

30. Use cognitive-behavioral training (CBT) to reduce pain and
    psychological disability by enhancing self-efficacy,
    self-management, and skills for coping with pain. **(Panel
    consensus)**

31. Use aerobic exercise to minimize pain, improve sleep quality,
    enhance self-efficacy and increase positive mood. **(Panel
    consensus)**

32. Emphasize sleep hygiene as part of the treatment plan, using both
    pharmacologic and nonpharmacologic techniques. **(Panel consensus)**

33. Treat anxiety and depression aggressively with both pharmacologic
    and nonpharmacologic approaches. **(Panel consensus)**

34. Fluoxetine should be the first antidepressant agent used to treat
    depression in children and adolescents; however, all of these
    medications should be used only with extreme caution and extensive
    parental education. Psychiatric consultation is recommended.
    **(Panel consensus)**

35. Clinicians should focus on the goal of restoring function. The
    importance of continuing or returning to school cannot be
    overemphasized, and every effort should be made to maintain and
    maximize the child\'s ability to attend school.

**Definitions**:

**Type of Evidence**

I.  Meta-analysis of multiple well-designed controlled studies

II. Well-designed experimental studies

III. Well-designed, quasi-experimental studies, such as nonrandomized
     controlled, single-group pre-post, cohort, time series, or
     matched-case controlled studies

IV. Well-designed nonexperimental studies, such as comparative and
    correlational descriptive and case studies

V.  Case reports and clinical examples

**Strength and Consistency of Evidence**

A.  There is evidence of type I or consistent findings from multiple
    studies of types II, III, or IV.

B.  There is evidence of types II, III, or IV, and findings are
    generally consistent.

C.  There is evidence of types II, III, or IV, but findings are
    inconsistent.

D.  There is little or no evidence, or there is type V evidence only.

Panel Consensus: Practice recommended based on the opinions of experts
in pain management.

#### CLINICAL ALGORITHM(S)

The original guideline document contains algorithms for:

-   Assessment of the Patient with Widespread Pain

-   Treatment of Fibromyalgia Syndrome

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The strength and consistency of the evidence supporting the
recommendations ranges from A, which is the strongest evidence to D,
which indicates there is little or no evidence, or that only type V
(i.e., case reports and clinical examples) exists. In the absence of
level A or B evidence, the panel used the available empirical evidence,
but based its recommendation primarily on expert judgment. In these
instances, the term, \"Panel consensus,\" was used.

The type of evidence and/or expert judgment supporting each
recommendation is identified and graded in the \"Major Recommendations\"
field of this summary.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Appropriate diagnosis and management of fibromyalgia syndrome

-   Improved quality of care

#### POTENTIAL HARMS

Refer to Tables 7 and 8 in the original guideline document for potential
adverse effects of medications used to treat fibromyalgia syndrome.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

The combination of hydrocodone with aspirin (Lortab ASA) is
contraindicated in children in the presence of fever or other viral
disease, because aspirin is associated with Reye\'s Syndrome.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   Any recommendations made by the authors must be weighed against the
    clinician\'s own clinical judgement, based on but not limited to
    such factors as the patient\'s condition, the benefits versus the
    risks of suggested treatment, and comparison with recommendations of
    pharmaceutical compendia and other authorities.

-   No published reviews were found of fibromyalgia syndrome (FMS) pain
    in children and adolescents. The few published studies of FMS pain
    in children and adolescents are discussed in the section
    \"Management of Pain in Juvenile Fibromyalgia Syndrome\" of the
    original guideline document.

-   Despite recognition of FMS as one of the most common chronic pain
    conditions, FMS continues to generate controversy. As noted earlier,
    much of the controversy is related to the diagnostic challenges and
    frustrations faced by clinicians and patients when dealing with
    symptoms that lack objective physical, laboratory, or radiologic
    evidence. Although many clinicians accept FMS as a common cause of
    chronic pain, they also recognize the subjectivity and lack of
    defining precision inherent in FMS.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms\
Clinical Algorithm\
Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Buckhardt CS, Goldenberg D, Crofford L, Gerwin R, Gowens S, Jackson K,
Kugel P, McCarberg W, Rudin N, Schanberg L, Taylor AG, Taylor J, Turk D.
Guideline for the management of fibromyalgia syndrome pain in adults and
children. Glenview (IL): American Pain Society (APS); 2005. 109
p. (Clinical practice guideline; no. 4). \[335 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2005

#### GUIDELINE DEVELOPER(S)

American Pain Society - Professional Association

#### SOURCE(S) OF FUNDING

The following companies have contributed over the years to a common APS
Guidelines Program Fund that is used for the support of all APS
evidence-based clinical practice guidelines:

-   Abbott Laboratories

-   BASF

-   Endo Pharmaceuticals Inc.

-   Faulding Laboratories

-   GlaxoSmithKline

-   Hoechst Foundation

-   Janssen Pharmaceutica

-   Knoll Laboratories

-   McNeil Consumer Healthcare

-   Merck and Co., Inc.

-   Pain Therapeutics, Inc.

-   Pharmacia and Upjohn

-   Purdue Pharma L.P.

-   Roxane Laboratories, Inc.

#### GUIDELINE COMMITTEE

Fibromyalgia Syndrome Pain Management Guideline Panel (2002-2005)

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Carol S. Burckhardt, PhD RN (Co-chair) Professor,
Psychiatric Mental Health Nursing, Oregon Health & Science University,
School of Nursing, Portland Campus, Portland, OR; Don L. Goldenberg, MD
(Co-chair) Chief, Rheumatology Newton-Wellesley Hospital, Newton, MA,
Professor of Medicine, Tufts University School of Medicine; Leslie J.
Crofford, MD, Associate Professor, Internal Medicine, Rheumatology
Division, University of Michigan, School of Medicine, Ann Arbor, MI;
Robert Gerwin, MD, Assistant Professor, Neurology, The Johns Hopkins
Hospital, East Baltimore Campus, Bethesda, MD; Sue Gowans, PhD PT,
University Health Network, Department of Rehabilitation Services,
Toronto General Hospital, Toronto, Ontario, Canada; Kenneth C. Jackson
II, PharmD, Assistant Professor of Pharmacy Practice\--Pain Management,
Texas Tech University Health Sciences Center at Amarillo, School of
Pharmacy, Lubbock, TX; Pearl Kugel, BBA, Accountant, San Diego, CA;
William McCarberg, MD FABPM, Founder, Chronic Pain Management Program,
Kaiser Permanente, Escondido, CA; Nathan Jeffrey Rudin, MD, Associate
Professor (CHS), Department of Orthopedics and Rehabilitation,
University of Wisconsin Medical School Madison, WI; Laura Schanberg, MD,
Associate Professor, Pediatrics, Co-chief, Pediatric Rheumatology,
Medical Director, Pediatric Pain Evaluation Clinic, Duke University
Medical Center, Durham, NC; Ann G. Taylor, EdD RN, Betty Norman Norris
Professor of Nursing, Director, Center for the Study of Complementary
and Alternative Therapies, University of Virginia Health System,
Charlottesville, VA; Janalee Taylor, MSN RN, Clinical Nurse Specialist,
Associate Clinical Director, Children\'s Hospital Medical Center,
Cincinnati, OH; Dennis C. Turk, PhD, John and Emma Bonica Professor of
Anesthesiology and Pain Research, Department of Anesthesiology,
University of Washington, Seattle, WA

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Individuals involved in drafting clinical practice guidelines are
charged by APS with the responsibility to develop objective, complete,
and balanced guidelines. Financial relationships with commercial
companies could conflict with the responsibility when the company\'s
products or services are related to the subject of the guideline. To
ensure the integrity of APS and the Clinical Practice Guidelines
Program, all participants in the development of clinical practice
guidelines must submit a Conflict of Interest Disclosure Form to APS
prior to participation in any guideline development activity.

All members of the Fibromyalgia Syndrome Pain Management Guideline Panel
have submitted a Conflict of Interest Disclosure form, which is on file
at the APS national office. In addition, panel members disclosed
financial relationships with commercial companies to all other panel
members during panel meetings.

Individual panel members presently have or during the past 3 years have
had relationships with the following pharmaceutical or biotechnology
companies:

**Carol S. Burckhardt**. Secondary data analysis: Astra Zeneca.

**Leslie Crofford**. Consultant: Eli Lilly, Pfizer; Speakers\' Bureau:
Cypress, Forest, Pfizer, Wyeth.

**Robert Gerwin**. Research support: Allergan, Ferris Manufacturing.

**Kenneth Jackson**. Consultant: Elan Pharmaceuticals; Research support:
Elan Foundation, Merck Foundation; Speakers\' Bureau: Merck,
Ortho-McNeil, Pharmacia, Purdue Pharma L.P.

**William McCarberg**. Speakers\' Bureau: Endo, Janssen Pharmaceutica,
Ligand, Purdue Pharma L.P.

**Dennis Turk**. Advisory boards: Alpharma, Eli Lilly, Elan
Pharmaceuticals, Endo Pharmaceuticals, GlaxoSmithKline, Ligand, Merck,
Novartis, Pfizer; Consultant: aaiPharma Inc., Bayer Corporation, Omeros
Medical Systems.

**Ada Jacox and Carol Spengler, APS consultants**. Funding from the APS
Guidelines Program Fund.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: None available at this time.

Print copies: Available from for purchase (\$20 nonmembers; \$15
members) from the American Pain Society (APS), 4700 W. Lake Avenue,
Glenview, IL 60025-1485; Web site,
[www.ampainsoc.org](http://www.ampainsoc.org/). Orders can be placed via
telephone, (847) 375-4715; fax (847) 375-4777; or visit APS\'s online
store, [www.ampainsoc.org](http://www.ampainsoc.org/).

#### AVAILABILITY OF COMPANION DOCUMENTS

Implementation tools, including manual tender point diagram and survey
and examples of pain scales, are available in the original guideline
document.

Electronic copies: None available at this time.

Print copies: Available from for purchase (\$20 nonmembers; \$15
members) from the American Pain Society (APS), 4700 W. Lake Avenue,
Glenview, IL 60025-1485; Web site,
[www.ampainsoc.org](http://www.ampainsoc.org/). Orders can be placed via
telephone, (847) 375-4715; fax (847) 375-4777; or visit APS\'s online
store, [www.ampainsoc.org](http://www.ampainsoc.org/).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on July 27, 2005. The information
was verified by the guideline developer on August 31, 2005. This summary
was updated by ECRI Institute on November 9, 2007, following the U.S.
Food and Drug Administration advisory on Antidepressant drugs.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. Written requests to
reproduce any portion of this guideline may be directed to Managing
Editor at the American Pain Society (APS), 4700 W. Lake Avenue,
Glenview, IL, 60025-1485.

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Date Modified: 11/10/2008