Chronic musculoskeletal pain is highly prevalent in the United States and includes inflammatory and non-inflammatory syndromes, such as low back pain (reported by 59 million Americans in the past 3 months), neck pain (reported by 30.1 million Americans in the past 3 months), clinical osteoarthritis (reported by 27 million Americans in the past 3 months), and fibromyalgia (FM). FM affects between 2% to 4% of the US population or 12 million people. Inflammatory pain conditions commonly reported by patients include rheumatoid arthritis (2.5 million) and gout (3 million), among others. This article will focus primarily on FM, which is a chronic pain condition that predominately affects women.

The current diagnostic criteria for FM include chronic widespread pain for at least 3 months and the presence of widespread mechanical tenderness. A patient with suspected FM must report pain in all four body quadrants and have at least 11 of 18 tender points for a positive diagnosis to be made. Tender points are areas of the body where pressure is applied until pain threshold is achieved. In addition to pain and tenderness, FM patients very frequently describe widespread stiffness and fatigue, disrupted or poor sleep, dyscognition, and mild soft tissue swelling. Patients often also report symptoms of anxiety and depression.

In discussion of the best practices for patients with fibromyalgia (FM), it is key to Introduce commentary about what FM is as a clinical condition, how clinicians should assess for FM, and the pharmacologic approaches to management.

The first widely accepted criteria for the classification for FM were published in 1990 as the American College of Rheumatology criteria for FM. However, the condition has long been described in medical history. In the 1800s, a condition similar to FM was labeled “neurasthenia” and was further defined by researchers in the medical literature. During the early 1900s, symptoms associated with FM were labeled “fibrositis,” which was based on the mistaken idea that there were inflammatory changes in peripheral connective tissue. It was not until the mid-1970s when pioneering work by Smythe and Moldofsky defined central nervous system abnormalities, including significant sleep pathology, in patients with this condition that led to the increased recognition by researchers and clinicians that FM was a central pain phenomenon.

Following this critical development, use of the term “fibromyalgia” began and was codified in the 1990 criteria, intended for use in research settings to standardize classification of FM. The 1990 criteria classify the condition as involving chronic widespread pain for at least 3 months. Patients must also exhibit tenderness of at least 11 of 18 tender points.

The optimal management of fibromyalgia (FM) is comprised of both pharmacologic and nonpharmacologic approaches. This multidimensional approach is preferred given that FM is not only a pain condition, but involves a number of other symptoms as is reflected in the new clinical criteria being developed by Wolfe and colleagues. Proper management of FM should be informed through multidimensional assessment of the clinically relevant domains described previously in this supplement. Pharmacologic and nonpharmacologic approaches work together to provide the broadest possible coverage of these domains, minimize the impact of each domain on functioning and well-being, and facilitate long-term adaptations to one's lifestyle.

The use of nonpharmacologic strategies in the management of FM has varying levels of evidence. The strongest evidence currently exists for aerobic exercise, cognitive-behavioral therapy (CBT), and for patient education or self-management. Moderate evidence exists for strength training, acupuncture, hypnotherapy, and biofeedback modalities. Weaker evidence exists for manual massage therapy. Currently, there is no evidence of long-term benefit for tender point injections or flexibility exercise modalities, although these options may be beneficial in the short term. This article will focus on the three areas that have the strongest evidence base: patient education, exercise, and CBT.

Educational programs are typically offered in the context of primary care or in specialty practices. In their simplest form, these programs try to dispel myths about FM and provide patients with the most up-to-date knowledge about the condition.