The fibromyalgia syndrome (FMS) is a common, chronic, widespread pain disorder that mainly affects middle-aged women. In addition to pain complaints, fatigue and disturbed sleep are symptoms frequently reported by these patients. Many FMS patients also meet diagnostic criteria for mood disorders (e.g. depression) as well as other so-called 'functional somatic syndromes', including irritable bowel syndrome, temporomandibular joint disorder, and subsets of chronic low-back pain. It is characterized by widespread muscle pain, and pain in at least 11 out of 18 defined so-called tender points. The widespread muscle pain must be present for at least 3 months. For the diagnosis of fibromyalgia many other rheumatological, neurological and psychiatric diseases have to be excluded (Schmerz. 2003 Dec; 17(6): 464-74).  The causes of fibromyalgia are still very uncertain, but it is apparently not an autoimmune disease.

A wide variety of medications are used to manage the eclectic symptomatology of FMS patients, although relatively few have been rigorously tested. (Best Pract Res Clin Rheumatol. 2003 Aug; 17(4): 611-27).

Highly addictive and expensive patented drugs are often promoted for fibromyalgia.  For instance, the date-rape drug sodium oxybate (Xyrem or GHB) was of modest benefit in a short 4-week study, but FMS is a chronic disease (J Rheumatol. 2003 May; 30(5): 1070-4). Tramadol (Ultracet and Ultram), an addictive opioid, was of modest benefit in a three month DB study (Am J Med. 2003 May; 114(7): 537-45).  Many patients get addicted to these and still more powerful narcotics none of which in my opinion should never have been given in the first place.

The best researched basic treatment is the use of certain anti-depressant medications: amitriptyline, nortriptyline or fluoxetine.  Acetaminophen (generic Tylenol) may be useful as may muscle relaxants like carisoprodol.  Folic acid might be of benefit and is a very good supplement for everyone. Some research suggests that massage therapy helps and does education on coping with chronic pain.  Light exercise for long periods, like 60-75 minutes per day, may help.  Vitamin D supplements might be a good idea. 

Exercise has been found helpful in many studies and is a standard part of therapy.  A recent study found strong evidence for small bowel bacterial overgrowth, which suggests that Yogurt or similar therapy may be successful. Six studies have found muscle relaxants to help the pain, but not the fatigue or tenderness.

The level of 5-HT (serotonin) in the masseter muscle is increased in patients with fibromyalgia as compared with healthy subjects and that high intramuscular level of 5-HT is associated with muscle pain.  5-HT(3) receptor antagonists have been found to reduce pain induced by 5-HT and abolish allodynia/hyperalgesia (Pain. 2003 Feb; 101(3): 275-82). These are still being studied.  In direct contrast, 5-HTP, which increases serotonin, helped decrease fibromyalgia pains in one study.

A fair number of very odd treatments have been reported of value in single double-blind studies, although most of these studies have been done in odd places and need independent replication in larger studies.  Some newer treatments are being studied.  A number of studies have found high placebo effects which stresses the importance of multiple double-blind studies or at least randomized studies with treatments of equal attractiveness or one of proven value.

Open trials of a number of drugs and supplements (e.g. melatonin, nefazodone, ascorbigenm capsaisin, venlafaxine) have been reported, but open trials are virtually worthless in trying to figure out what works and doesn't work for FMS.  These studies simply shouldn't be published in my opinion.  Malic acid (1200 mg b.i.d.) and magnesium (300 mg b.i.d.) was used in an open trial after half the dosage failed to have any benefit in the 4-week DB trial.  Magnesium has been recommended by some, but no good study has been done. 

Fibromyalgia Common; Very Common in Lupus Patients: Chronic widespread pain, the central symptom of fibromyalgia (FM), is common in the general population, with comparable prevalence rates of 7.3% to 12.9% across different countries. The prevalence of FM in the general population was reported to range from 0.5% to 5%. The common association of FM with other rheumatic disorders, chronic viral infections, and systemic illnesses has been well documented in several studies. Up to 65% of patients with systemic lupus erythematosus meet the criteria for FM. Epidemiology of fibromyalgia. Neumann L, Buskila D. Ben-Gurion University,  Israel. 

Spinal Cord Hypersensitivity Might be Involved: In a controlled study of 78 patients and healthy controls, researchers found evidence for spinal cord hyperexcitability in patients with chronic pain after whiplash injury and in fibromyalgia patients. This can cause exaggerated pain following low intensity nociceptive or innocuous peripheral stimulation. Spinal hypersensitivity may explain, at least in part, pain in the absence of detectable tissue damage. Evidence for spinal cord hypersensitivity in chronic pain after whiplash injury and in fibromyalgia. Banic B, Petersen-Felix S, et al. Pain. 2004 Jan; 107(1-2): 7-15

Free Radical Damage May be Involved: In a Turkish study of 85 fibromyalgia patients and 80 matched controls, malondialdehyde levels were significantly higher and superoxide dismutase levels significantly lower in fibromyalgic patients than controls. Free radicals and antioxidants in primary fibromyalgia: an oxidative stress disorder? Bagis S, Tamer L, et al. Rheumatol Int. 2003 Dec 20

Dry Mouth, Tongue and TMJ Pain, Difficulty Swallowing Common: 67 women with fibromyalgia and without

Viral: Enterovirus Infection May Explain Some Fibromyalgia and Chronic Fatigue: Enterovirus RNA has been found in specimens of muscle biopsy from patients with idiopathic dilated cardiomyopathy, chronic inflammatory muscle diseases, and fibromyalgia or chronic fatigue syndrome. Using a reverse transcription-polymerase chain reaction (RT-PCR) assay the presence of enterovirus in skeletal muscle of patients with chronic inflammatory muscle diseases or fibromyalgia/chronic fatigue syndrome, and also of healthy subjects, three of 15 (20%) patients with chronic inflammatory muscle diseases, 4 of 30 (13%) patients with fibromyalgia/chronic fatigue syndrome, and none of 29 healthy subjects was found positive. Detection of enterovirus in human skeletal muscle from patients with chronic inflammatory muscle disease or fibromyalgia and healthy subjects. Douche-Aourik F, Berlier W, Feasson L, Bourlet T, Harrath R, Omar S, Grattard F, Denis C, Pozzetto B. Saint-Etienne, France. J Med Virol. 2003 Dec;71(4):540-7

Viral: Fibromyalgia Much Higher with Hepatitis C Infection: 95 chronic HCV patients and 95 healthy controls were studied. Fibromyalgia was found in 18.9% of patients and 5.3% of healthy controls. No significant relationship was observed between the two groups regarding headache, IBS, and sicca- and Raynaud-like symptoms. Fibromyalgia syndrome in patients with hepatitis C infection. Kozanoglu E, Canataroglu A, Abayli B, Colakoglu S, Goncu K. Cukurova University, Adana, Turkey. Rheumatol Int. 2003 Sep;23(5):248-51

Vitamin D Levels Often Low: Of 40 fibromyalgia patients, 43% had low vitamin D blood levels vs. 18% of 37 normal controls. Three of the fibromyalgia patients had hyperparathyroidism. Dundee, UK. Bone health in patients with fibromyalgia. Al-Allaf AW, Mole PA, Paterson CR, Pullar T. Rheumatology (Oxford). 2003 Oct; 42(10): 1202-6. Lower bone density has also been reported.

Vitamin D Lower with Anxiety and Depression: In a study of 75 European-American fibromyalgia patients, deficient vitamin D was found in 13.3%, while 56.0% had insufficient levels and 30.7% had normal levels. Patients with vitamin D deficiency (<25 nmol/l) had higher HADS anxiety and depression scores [median 31.0] than patients with insufficient levels [25-50 nmol/l; 22.5] or than patients with normal levels [50 nmol/l or greater; HADS 23.5; p<0.05]. There was no relationship with global measures of disease impact or musculoskeletal symptoms. Vitamin D deficiency is associated with anxiety and depression in fibromyalgia. Armstrong DJ, et al. Belfast, UK, . Clin Rheumatol 2006 Jul 19.

Treatment

5-HT3 Receptor Antagonist Helped in DB: Tropisetron, a 5-HT3 receptor antagonist, was tested in a multicenter, double-blind, randomized, placebo-controlled trial including 403 patients. In those receiving 5 mg tropisetron, 39.2% fulfilled the response criterion (pain reduction 35%) as compared to 26.2% in the placebo group (p=0.033). On 10 and 15 mg, the responder rates were smaller and statistically not significant. A total of 78 responders to therapy were followed up for 12 months. After the end of treatment, pain intensity rose within one month in all 4 groups. Patients having received 5 or 10 mg showed a less pronounced increase in pain. In addition, even 12 months after stopping treatment, pain was still markedly below baseline levels in the 5 and 10 mg groups. Univ Munich, M Spath, Schmerz. 2003 Dec; 17(6): 437-40

5-Hydroxytryptophan Reported of Benefit: In a DB PC study of 50 fibromyalgia patients, significant benefit was reported in the older Italian study. Double-blind study of 5-hydroxytryptophan versus placebo in the treatment of primary fibromyalgia syndrome. Caruso I, Sarzi Puttini P, Cazzola M, Azzolini V. J Int Med Res. 1990 May-Jun; 18(3): 201-9

Acupuncture No Better than Sham in Excellent Study of Fibromyalgia: In a 12-week with 6-month follow-up DB PC study of 100 adults with fibromyalgia, patients received twice-weekly treatment of either an acupuncture program that was specifically designed to treat fibromyalgia, or 1 of 3 sham acupuncture treatments: acupuncture for an unrelated condition, needle insertion at nonacupoint locations, or noninsertive simulated acupuncture. The mean subjective pain rating among patients who received acupuncture for fibromyalgia did not differ from that in the pooled sham acupuncture group (mean between-group difference, 0.5 cm [95% CI, -0.3 cm to 1.2 cm]). Participant blinding was adequate throughout the trial. A randomized clinical trial of acupuncture compared with sham acupuncture in fibromyalgia. Assefi NP, et al. University of Washington, Seattle. Ann Intern Med. 2005 Jul 5;143(1):10-9.

Amitriptyline or Nortriptyline Helped in DB: In a 120-patient DB PC Univ Sao Paulo study, 25 mg/day of either medicine did modestly better than placebo with most differences failing to be statistically significant because of the smaller size of the study. A double-blind, randomized, controlled study of amitriptyline, nortriptyline and placebo in patients with fibromyalgia. An analysis of outcome measures. Heymann RE, Helfenstein M, Feldman D. Clin Exp Rheumatol. 2001 Nov-Dec; 19(6): 697-702

Amitriptyline or Nortriptyline Meta-Analysis: A review of 16 DB PC studies of fibromyalgia with tricyclics found nine well designed and suitable for analysis. Effect sizes were calculated for measurements of physician and patient overall assessment, pain, stiffness, tenderness, fatigue, and sleep quality. Compared with placebo, tricyclic agents were associated with effect sizes that were substantially larger than zero for all measurements. Univ Cincinnati. Antidepressant treatment of fibromyalgia. A meta-analysis and review. Arnold LM, Keck PE Jr, Welge JA. Psychosomatics. 2000 Mar-Apr; 41(2): 104-13

Anti-Viral: Valacyclovir No Benefit:  In a 6-week 52-patient DB PC study, valacyclovir had no beneficial effect on pain and tenderness in patients with the fibromyalgia (FM) syndrome. No effect of antiviral (valacyclovir) treatment in fibromyalgia: a double blind, randomized study. Kendall SA, Schaadt ML, Graff LB, Wittrup I, Malmskov H, Krogsgaard K, Bartels EM, Bliddal H, Danneskiold-Samsoe B. Frederiksberg, Denmark. J Rheumatol. 2004 Apr;31(4):783-4

Bacterial Overgrowth in Small Intestine Appears Very Common in Fibromyalgia: An association between irritable bowel syndrome (IBS) and small intestinal bacterial overgrowth (SIBO) has been found. Patients with either IBS of fibro and controls were tested. A lactulose hydrogen breath test was used to determine the presence of SIBO. 3/15 (20%) controls had an abnormal breath test compared with 93/111 (84%) subjects with IBS (p<0.01) and 42/42 (100%) with fibromyalgia (p<0.0001 v controls, p<0.05 v IBS). Subjects with fibromyalgia had higher hydrogen profiles (p<0.01), peak hydrogen (p<0.0001), and area under the curve (p<0.01) than subjects with IBS. This was not dependent on the higher prevalence of an abnormal breath test. The degree of somatic pain in fibromyalgia correlated significantly with the hydrogen level seen on the breath test (r = 0.42, p<0.01). Pimentel M, Wallace D, Hallegua D, Chow E, Kong Y, Park S, Lin HC. Department of Medicine, Cedars-Sinai Medical Center, Ann Rheum Dis. 2004 Apr;63(4):450-2. Ed: If this is true, yogurt might help.

Chlorella Reported of Benefit: At the Medical College of Virginia in a DB PC trial of 55 subjects with fibromyalgia, 33 with hypertension, and 9 with ulcerative colitis, subjects consumed 10 g of pure chlorella in tablet form and 100 mL of a liquid containing an extract of chlorella each day for 2 or 3 months. For fibromyalgia patients, assessments of pain and overall quality of life. For hypertensive patients, measurements of sitting diastolic blood pressure and serum lipid levels. For patients with ulcerative colitis, determination of state of disease using the Disease Activity Index. The authors reports that chlorella may reduce high blood pressure, lower serum cholesterol levels, accelerate wound healing, and enhance immune functions as well as relieve symptoms, improve quality of life, and normalize body functions in patients with fibromyalgia, hypertension, or ulcerative colitis. A review of recent clinical trials of the nutritional supplement Chlorella pyrenoidosa in the treatment of fibromyalgia, hypertension, and ulcerative colitis. Merchant RE, Andre CA. Altern Ther Health Med. 2001 May-Jun; 7(3): 79-91. Ed: This study is quite odd in studying three unrelated diseases and combining the results.  I am quite skeptical.

Copper Wire Bedsheet Reported Helpful: In a DB PC study of 40 fibromyalgia patients, a pure copper wire sheet ("Telo Cypro") used as bedsheet was reported as being extremely beneficial in reducing painful symptomatology at the tender point level and improving sleep quality. Univ of Siena. A new approach to the treatment of fibromyalgia syndrome. The use of Telo Cypro. Biasi G, Badii F, Magaldi M, Moltoni L, Marcolongo R. Minerva Med. 1999 Jan-Feb; 90(1-2): 39-43

Cosmetic Absence May Have Helped in Small Study: In a prospective, randomized, controlled trial of 48 women with FMS (some of whom had a rheumatic condition) who were regular users of cosmetics, after 2 years, there was significant improvement in pain (p < 0.02), sleep (p < 0.01), and stiffness (p < 0.02), together with better physical function (p < 0.01) and improved wellbeing (p < 0.01) in the make-up free group, as measured by the Fibromyalgia Impact Questionnaire (FIQ). Use less cosmetics--suffer less from fibromyalgia? Sverdrup B. Eskilstuna, Sweden. J Womens Health (Larchmt). 2004 Mar;13(2):187-94

DHEA No Benefit: In a 3-month DB PC crossover study (one month washout) of 52 adults with fibromyalgia, DHEA supplementation (50 mg/day) caused no improvement in well-being, pain, fatigue, cognitive dysfunction, functional impairment, depression, or anxiety, nor in objective measurements made by physicians. Androgenic side effects (greasy skin, acne, and increased growth of body hair) were more common during the DHEA treatment period (p = 0.02).

Duloxetine Some Benefit for Fibromyalgia: In a 12-week DB PC study of 207 fibromyalgia sufferers, duloxetine 60 mg twice a day improved slightly more (P = 0.027) on the total fibromyalgia score, but not for pain (P = 0.130). Duloxetine-treated subjects had greater reductions in Brief Pain Inventory average pain severity score (P = 0.008), Brief Pain Inventory average interference from pain score (P = 0.004), number of tender points (P = 0.002), and FIQ stiffness score (P = 0.048), and had significantly greater improvement in mean tender point pain threshold (P = 0.002), CGI-Severity (P = 0.048), PGI-Improvement (P = 0.033), and several quality-of-life measures. A double-blind, multicenter trial comparing duloxetine with placebo in the treatment of fibromyalgia patients with or without major depressive disorder. Arnold LM, Lu Y, Crofford LJ, Wohlreich M, Detke MJ, Iyengar S, Goldstein DJ. University of Cincinnati. Arthritis Rheum. 2004 Sep;50(9):2974-84. Ed: This apparently industry funded study’s abstract doesn’t give any actual figures of improvement. With large studies, small benefits can be statistically significant but less significant clinically. It is very likely that other much less expensive and better tested anti-depressants like amitriptyline and nortriptyline do as well or better.

Growth Hormone of Modest Benefit: In a 9-month DB PC trial of 50 women with fibromyalgia, daily injections of growth hormone were found modestly better than placebo. Oregon Health Sciences University. A randomized, double-blind, placebo-controlled study of growth hormone in the treatment of fibromyalgia. Bennett RM, Clark SC, Walczyk J. Am J Med. 1998 Mar; 104(3): 227-31. Ed: This appears an exceedingly expensive therapy. The benefit was also very slow to appear.

Hyperbaric Oxygen Said to Help in Small Study: In a randomized controlled study to evaluate the effect of hyperbaric oxygen (HBO) therapy in FMS (HBO group: n = 26; control group: n = 24), there was a significant reduction in tender points and a significant increase in pain threshold of the HBO group after the first and fifteenth therapy sessions. There was also a significant difference between the HBO and control groups for all parameters except the Visual Analogue Scale scores after the first session. A new treatment modality for fibromyalgia syndrome: hyperbaric oxygen therapy. Yildiz S, Kiralp MZ, Akin A, Keskin I, Ay H, Dursun H, Cimsit M. Istanbul, Turkey. J Int Med Res. 2004 May-Jun;32(3):263-7

Muscle Relaxant: Carisoprodol-Acetaminophen-Caffeine Helped: In an 8-week, 43-patient DB PC trial, patients on the active medicine did better. Many fewer of the active medicine group used additional pain medicines, tricyclics, anxiolytics or sedatives. Treatment of fibromyalgia (fibrositis syndrome): a parallel double blind trial with carisoprodol, paracetamol and caffeine (Somadril comp) versus placebo. Vaeroy H, Abrahamsen A, Forre O, Kass E. Clin Rheumatol. 1989 Jun; 8(2): 245-50. Ed: This study seems poorly designed.

Muscle Relaxant Helped Pain, Not Fatigue or Tenderness: In a review of five randomized, placebo-controlled trials, the odds ratio for global improvement with therapy was 3.0 with a pooled risk difference of 0.21, which calculates to 4.8 individuals needing treatment for 1 patient to experience symptom improvement. Pain improved early on, but there was no improvement in fatigue or tender points at any time. Treatment of fibromyalgia with cyclobenzaprine: A meta-analysis. Tofferi JK, Jackson JL, O'Malley PG. Walter Reed Army Medical Center, Arthritis Rheum. 2004 Feb 15;51(1):9-13

Pramipexole (Mirapex) Helped: In a 14-week DB PC study of 60 patients with fibromyalgia, those on 4.5 mg of pramipexole, a dopamine 3 receptor agonist, orally every evening experienced gradual and more significant improvement in measures of pain, fatigue, function, and global status. At 14 weeks, the VAS pain score decreased 36% vs. 9% for placebo. The percentages of improvement were for function (22% versus 0%), fatigue (29% versus 7%), and global (38% versus 3%) scores. There were also decreases in the MDHAQ psychiatric score (37% versus 28%), the BAI score (39% versus 27%), and the HAM-Depression score (29% versus 9%). The most common side-effects were transient anxiety and weight loss.

Pool Therapy as Good as Exercise Therapy: 50 FM female patients were randomly assigned to  pool-based exercise, or balneotherapy in the same pool without any exercise for 35 min three times a week for 12 weeks. Both groups showed equal improvements in pain, morning stiffness, sleep, tender points, global evaluation by the patient and the physician, and the fibromyalgia impact questionnaire. Neither improved in the chair test, and group 2 did not improve on the Beck depression inventory. Investigation of the effects of pool-based exercise on fibromyalgia syndrome. Altan L, Bingol U, Aykac M, Koc Z, Yurtkuran M. Uludag University, Bursa, Turkey. Rheumatol Int. 2003 Sep 24

Qigong No Better Than Education & Support: 128 individuals with FM were randomly assigned to an 8-week mind-body training program or an education support group. Both groups registered statistically significant but equal improvements across time for the Fibromyalgia Impact Questionnaire, Total Myalgic Score, Pain, and Depression, and no improvement in the number of feet traversed in the 6 minute walk. Improvements were maintained by both groups throughout the 6 month followup. The efficacy of mindfulness meditation plus Qigong movement therapy in the treatment of fibromyalgia: a randomized controlled trial. Astin JA, Berman BM, Bausell B, Lee WL, Hochberg M, Forys KL. California Pacific Medical Center Research Institute, San Francisco, J Rheumatol. 2003 Oct;30(10):2257-62

SAMe Helped in DB: In a DB PC study of 44 patients using oral SAMe 800 mg/day, improvements were seen for clinical disease activity (P = 0.04), pain experienced during the last week (P = 0.002), fatigue (P = 0.02), morning stiffness (P = 0.03) and mood evaluated by Face Scale (P = 0.006) in the actively treated group compared to placebo. The tender point score, isokinetic muscle strength, mood evaluated by Beck Depression Inventory and side effects did not differ. Denmark. Oral S-adenosylmethionine in primary fibromyalgia. Double-blind clinical evaluation. Jacobsen S, Danneskiold-Samsoe B, Andersen RB. Scand J Rheumatol. 1991; 20(4): 294-302; Similar in smaller study. Am J Med. 1987 Nov 20; 83(5A): 107-10

SAMe Trend Toward Benefit in Small Study: In a DB PC crossover 34-patient study using SAMe 600 mg i.v. daily for 10 days, there was no significant difference in improvement in the primary outcome: tender point change between the two treatment groups. There was a tendency towards statistical significance in favor of SAMe on subjective perception of pain at rest (p = 0.08), pain on movement (p = 0.11), and overall well-being (p = 0.17) and slight improvement only on fatigue, quality of sleep, morning stiffness, and on the Fibromyalgia Impact Questionnaire for pain. Copenhagen. Double-blind, placebo-controlled cross-over study of intravenous S-adenosyl-L-methionine in patients with fibromyalgia. Volkmann H, Norregaard J, Jacobsen S, Danneskiold-Samsoe B, Knoke G, Nehrdich D. Scand J Rheumatol. 1997; 26(3): 206-11. Ed: Since folic acid supplementation increases SAMe levels in the body by 43%, having patients take 1200 to 1600 mcg (1.2-1.6 mg) per day of folic acid would save a huge amount of money and should accomplish the same benefit.

SSRIs Fluoxetine (Prozac), Citalopram(Celexa) Helped in DB: In a 12-week DB PC study of 60 women 21-71 years old, those given the selective serotonin reuptake inhibitor fluoxetine 10-80 mg per day showed significantly better improvement over placebo. Univ Cincinnati. A randomized, placebo-controlled, double-blind, flexible-dose study of fluoxetine in the treatment of women with fibromyalgia. Arnold LM, Hess EV, Hudson JI, Welge JA, Berno SE, Keck PE Jr. Am J Med. 2002 Feb 15; 112(3): 191-7; Citalopram (Celexa), another SSRI, helped in another DB PC study. Eur J Pain. 2000; 4(1): 27-35

Staphlococcal Toxoid Helped in DB: In a 6-month DB PC 100-patient study of FMS/Chronic Pain Syndrome patients at the University of Goteborg, 65% of those given weekly and then monthly injections of staphlococcal toxoid vs. 18% for placebo. Treatment with staphylococcus toxoid in fibromyalgia/chronic fatigue syndrome--a randomised controlled trial. Zachrisson O, Regland B, Jahreskog M, Jonsson M, Kron M, Gottfries CG. Eur J Pain. 2002; 6(6): 455-66; Treatment led to a significantly increased capacity of serum to neutralise alpha-toxin and a significant increase in serum IgG to alpha-toxin and lipase. Furthermore, the increase in these parameters combined paralleled the improvement in clinical outcome. Eur J Clin Microbiol Infect Dis. 2004 Jan 20

Ultrasound and Electrotherapy Help in Very Small Study: In a DB PC 17-patient study of fibromyalgia, those receiving the real therapy for 12 sessions had a large decrease in pain points and intensity and sizeable improvement in sleep while patients receiving the sham therapy had no change. The effect of combined therapy (ultrasound and interferential current) on pain and sleep in fibromyalgia. Almeida TF, Roizenblatt S, Benedito-Silva AA, Tufik S. Universidade Federal de Sao Paulo, Pain. 2003 Aug;104(3):665-72

Vitamin D: Muscle Pain Linked to Low Vitamin D in Minnesota: Of 150 patients screened with persistent, nonspecific musculoskeletal pain, 140 had unrecognized and untreated severe hypovitaminosis D including 55% of those under age 30. This risk extended to those considered at low risk for vitamin D deficiency: non-elderly, non-housebound, or nonimmigrant persons of either sex. Nonimmigrant women of childbearing age with such pain appear to be at greatest risk for misdiagnosis or delayed diagnosis. Seasons of the year did not affect vitamin D levels. Because osteomalacia is a known cause of persistent, nonspecific musculoskeletal pain, screen all outpatients with such pain for hypovitaminosis D. U Minn. Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain. Plotnikoff GA, Quigley JM. Mayo Clin Proc. 2003 Dec;78(12):1463-70. Two studies of the elderly have documented reduced muscle mass in those with vitamin D deficiencies.

Vitamin D: Low Hip Bone Mass Tied to Increased Pain: 31 FM patients (20 pre- and 11 postmenopausal) and 41 healthy women (30 pre- and 10 postmenopausal) studied found BMD-lumbar spine and BMD-femoral neck did not differ significantly between FM patients and controls, though premenopausal FM patients tended to have lower BMD-femoral neck (p = 0.09). Self reported pain and FIQ-ADL among FM patients correlated with BMD-femoral neck (r(s) = -0.52, p = 0.003). Self reported pain correlated negatively to BMD. Bone mineral density in fibromyalgia patients--correlation to disease activity. Jensen B, Wittrup IH, Bliddal H, Danneskiold-Samsoe B, Faber J. Copenhagen, Denmark. Scand J Rheumatol. 2003;32(3):146-50

Vitamin D: Fibromyalgia Higher with Low Vitamin D: In a cohort of 994 healthy adult ages 16-69 (101 Germans, 327 Turkish residents of Turkey and 566 Turkish immigrants living in Germany), the Germans had a mean 25(OH)D of 68.4 nmol/l and BioPTH of 26.7 pg/ml. Turkish residents of Turkey had scores of 40.6 nmol/l and 27.5 pg/ml, whereas Turkish residents of Germany had a 25(OH)D of 38.1 nmol/l and a BioPTH of 35.6 pg/ml. Vitamin D insufficiency was common among Turkish nationals independent of whether they lived in Turkey or Germany; 75% had 25(OH)D levels of <50 nmol/l. Turkish females had a higher prevalence of 25(OH)D deficiency (<25 nmol/l) than Turkish males. The most important predictors for low 25(OH)D levels as sex, body mass index, lack of sun exposure and living at a higher latitude. There was a strong correlation between low 25(OH)D levels and higher rates and longer duration of generalized bone and/or muscle aches and pains often diagnosed as fibromyalgia. High prevalence of vitamin D deficiency, secondary hyperparathyroidism and generalized bone pain in Turkish immigrants in Germany: identification of risk factors. Erkal MZ, et al. University of Giessen, Germany. Osteoporosis Int 2006 May 23.