Treatments will be fully addressed in another article of this supplement. We will however provide a brief introduction by emphasizing new concepts that apply to management of FMS. Firstly, the concept of symptom-based treatments is logical and will allow a focussed starting point for a physician. Secondly, in the setting of no single “gold standard” treatment, a multimodal approach which includes both nonpharmacologic and pharmacologic treatments is rational [75
]. In this regard, patient education with emphasis on an active role of the patients is critical. A patient-centred approach with individualization of management is very important.
Finally, as patients with FMS commonly report sensitivity to medications, clinical experience suggests that low doses of medications can be used, with gradual increase in dose depending upon efficacy and tolerability. It is the authors' experience that doses of medications used in real life clinical practices are often much lower than those reported in industry-controlled studies. It is also notable that many of the adverse effects of medications present symptoms similar to those experienced by patients with FMS. Therefore, any patient being treated with a medication should be carefully evaluated for both efficacy as well as side effects, and medications should be discontinued unless there is evidence for definite benefit. In addition, combinations of medications are also more commonly used in practice, although there is limited evidence to support this practice from randomised clinical trials.
A key principle to management of patients with FMS is to encourage a shift of locus of control towards the patient and to ensure that the patient is an active rather than a passive participant in management. Understanding and support should form the cornerstone of care for these patients, with treatment strategies directed towards psychological status and physical symptoms within the context of family and society. Most patients will eventually with time find some treatment modality which will at least somewhat modulate, but not cure symptoms, improve health status globally and improve function.
Evidence-based treatment guidelines include those developed by the American Pain Society (APS) in 2005 and the European League Against Rheumatism (EULAR) in 2008 [49
]. Recent reviews of treatment options state that there is good to moderate evidence for efficacy of over 20 treatment interventions in FMS, highlighting the uncertainty in management of these patients [79
]. Approval of several drugs by the FDA in recent years, for example, pregabalin, duloxetine, and milnacipran, has been of great help in alleviating symptoms. Other medications may also be used [77
Nonpharmacologic treatments are an important component of management and recommended in both sets of guidelines. These might include a tailored exercise program, water therapy, physiotherapy, relaxation, cognitive behavioural training, and psychological support [80