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{{Fibromyalgia}}
{{Fibromyalgia}}
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{{CMG}} ; {{AE}} {{ADG}}


==Overview==
==Overview==
There is no universally accepted treatment for fibromyalgia. Treatment typically consists of symptomic management and the treatment options include [[medications]] and [[cognitive behavioral therapy]], which has been shown to be effective in alleviating [[pain]] and other fibromyalgia-related symptoms.
==Medical Therapy==
==Medical Therapy==
As with many other syndromes, there is no universally accepted cure for fibromyalgia, though some physicians claim to have found cures.<ref>{{cite book |author=Selfridge, Dr. Nancy, and Peterson, Franklynn|title=Freedom from Fibromyalgia: The 5-Week Program Proven to Conquer Pain |year=2001| isbn=0-8129-3375-3 }}</ref> However, a steady interest in the disorder on the part of academic researchers as well as pharmaceutical interests has led to improvements in its treatment, which ranges from symptomatic prescription medication to [[alternative medicine|alternative]] and [[complementary medicine]].
The medical therapy for fibromyalgia includes [[analgesics]], [[antidepressants]], such as [[Tricyclic antidepressant|TCA]]<nowiki/>s or [[Serotonin-norepinephrine reuptake inhibitor|SNRI]]<nowiki/>s, skeletal [[muscle relaxants]], [[anticonvulsants]], and [[Anti-anxiety drugs|anti-anxiety medications.]]<ref>{{cite book |author=Selfridge, Dr. Nancy, and Peterson, Franklynn|title=Freedom from Fibromyalgia: The 5-Week Program Proven to Conquer Pain |year=2001| isbn=0-8129-3375-3 }}</ref>  
 
===Single agent therapy===
The European League Against Rheumatism (EULAR) issued the first guidelines for the treatment of fibromyalgia syndrome (FMS) and published them in the September 17th On-line First issue of the Annals of the Rheumatic Diseases.
*Preferred regimen (1): [[Amitriptyline]] 10-70 mg orally once daily at bedtime
 
*Preferred regimen (2): [[Cyclobenzaprine]] 5-30 mg orally once daily at bedtime
===Medications===
*Preferred regimen (3): [[Duloxetine]] 30-60 mg orally once daily
Many medications are used to treat specific symptoms of fibromyalgia, such as muscle pain and insomnia.
*Preferred regimen (4): [[Milnacipran]] 12.5 mg orally once daily initially, followed by 12.5 mg twice daily for 2 days, followed by 25 mg twice daily for 4 days, then 50-100 mg twice daily thereafter
 
*Preferred regimen (5): [[Pregabalin]] 75-225 mg orally twice daily, maximum 450 mg/day
==== Pain Relief ====
===Combination Therapy===
 
*Preferred regimen (1): [[Amitriptyline]] 10-70 mg orally once daily at bedtime '''(OR)'''
A number of pain relievers have been prescribed for fibromyalgia.  This includes [[NSAID]] medications over the counter, COX-2 inhibitors, and [[tramadol]] in prescription form for more advanced cases. Recently, [[pregabalin]] (marketed as Lyrica) has been given FDA approval for the treatment of diagnosed Fibromyalgia.
*Preferred regimen (2): [[Cyclobenzaprine]] 5-30 mg orally once daily at bedtime
 
'''AND'''
====Muscle Relaxants====
*Preferred regimen (3): [[Duloxetine]] 30-60 mg orally once daily; higher doses have been used, consult a specialist for guidance '''(OR)'''
 
*Preferred regimen (4): [[Milnacipran]] 12.5 mg orally once daily initially, followed by 12.5 mg twice daily for 2 days, followed by 25 mg twice daily for 4 days, then 50-100 mg twice daily thereafter
Muscle relaxants, such as [[cyclobenzaprine]] (Flexeril) or [[tizanidine]] (Zanaflex), may be used to treat the muscle pain associated with the disorder.
'''AND'''
 
*Preferred regimen (5): [[Pregabalin]] 75-225 mg orally twice daily, maximum 450 mg/day '''(OR)'''
====Tricyclic antidepressants (TCAs)====
*Preferred regimen (6): [[Gabapentin]] 300 mg orally once daily on the first day, followed by 300 mg twice daily on the second day, followed by 300 mg three times daily on the third day, then [[titrate]] dose according to response up to 1800-2400 mg/day given in 3 divided doses
Traditionally, low doses of sedating antidepressants (e.g. [[amitriptyline]] and [[trazodone]]) have been used to reduce the sleep disturbances that are associated with fibromyalgia and are believed by some practitioners to alleviate the symptoms of the disorder. Because depression often accompanies chronic illness, these antidepressants may provide additional benefits to patients suffering from depression. [[Amitriptyline]] is often favoured as it can also have the effect of providing relief from neuralgenic or [[Neuropathy|neuropathic pain]]. It is to be noted that Fibromyalgia is not considered a depressive disorder; antidepressants are used for their sedating effect to aid in sleep.
 
====Selective serotonin reuptake inhibitors (SSRIs)====
Research data consistently contradict the utility of agents with specificity as serotonin reuptake inhibitors for the treatment of core symptoms of fibromyalgia. <ref>[http://www.ncbi.nlm.nih.gov/pubmed/7478688?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum A randomized controlled trial of citalopram in the...[Pain. 1995&#93; - PubMed Result<!-- Bot generated title -->]</ref><ref>[http://www.ncbi.nlm.nih.gov/pubmed/10833553?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus Citalopram in patients with fibromyalgia-a random...[Eur J Pain. 2000&#93; - PubMed Result<!-- Bot generated title -->]</ref><ref>[http://www.ncbi.nlm.nih.gov/pubmed/17466657?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum A randomized, controlled, trial of controlled rele...[Am J Med. 2007&#93; - PubMed Result<!-- Bot generated title -->]</ref>  Moreover, SSRIs are known to aggravate many of the comorbidities that commonly affect patients with fibromyalgia including restless legs syndrome and sleep bruxism<ref>[http://www.ncbi.nlm.nih.gov/pubmed/9416386?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Extrapyramidal reactions and the selective seroton...[Ann Pharmacother. 1997&#93; - PubMed Result<!-- Bot generated title -->]</ref><ref>[http://www.ncbi.nlm.nih.gov/pubmed/8909330?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Movement disorders associated with the serotonin s...[J Clin Psychiatry. 1996&#93; - PubMed Result<!-- Bot generated title -->]</ref><ref>[http://www.ncbi.nlm.nih.gov/pubmed/9640489?ordinalpos=5&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Selective serotonin-reuptake inhibitor-induced mov...[Ann Pharmacother. 1998&#93; - PubMed Result<!-- Bot generated title -->]</ref>.
 
====Anti-seizure drugs====
Anti-seizure drugs are also sometimes used, such as [[gabapentin]]<ref>Arnold LM, Goldenberg DL, Stanford SB, et. al. Gabapentin in the treatment of fibromyalgia: a randomized, double-blind, placebo-controlled, multicenter trial.
Arthritis Rheum. 2007 Apr;56(4):1336-44</ref> and [[pregabalin]] (Lyrica). [[Pregabalin]], originally used for the nerve pain suffered by diabetics, has been approved by the American [[Food and Drug Administration]] for treatment of fibromyalgia. A [[randomized controlled trial]] of [[pregabalin]] 450 mg/day found that a [[number needed to treat]] of 6 patients for one patient to have 50% reduction in pain.<ref name="pmid15818684">{{cite journal |author=Crofford LJ, Rowbotham MC, Mease PJ, ''et al'' |title=Pregabalin for the treatment of fibromyalgia syndrome: results of a randomized, double-blind, placebo-controlled trial |journal=Arthritis Rheum. |volume=52 |issue=4 |pages=1264-73 |year=2005 |pmid=15818684 |doi=10.1002/art.20983}}</ref>
 
====Dopamine agonists====
[[Dopamine agonists]] (e.g. [[pramipexole]] (Mirapex) and [[ropinirole]](ReQuip)) have been studied for use in the treatment of fibromyalgia with good results. <ref>{{cite journal |author=Andrew J. Holman and Robin R. Myers |title=A Randomized, Double-Blind, Placebo-Controlled Trial of Pramipexole, a Dopamine Agonist, in Patients With Fibromyalgia Receiving Concomitant Medications |journal=Arthritis and Rheumatism |volume=52 |issue=8 |pages=2495-2505 |year=2005}}</ref>  A trial of transdermal [[rotigotine]] is currently on going <ref>[http://clinicaltrials.gov/ct2/show/NCT00464737 A Double-Blind Multicenter Proof of Concept Trial to Assess the Efficacy and Safety of Rotigotine in Subjects With Fibromyalgia Syndrome - Full Text View - ClinicalTrials.gov<!-- Bot generated title -->]</ref>. 


====Combination therapy====
==Underlying randomized studies of treatment==
A controlled clinical trial of [[amitriptyline]] and [[fluoxetine]] demonstrated utility when used in combination.<ref name="pmid8912507">{{cite journal |author=Goldenberg D, Mayskiy M, Mossey C, Ruthazer R, Schmid C |title=A randomized, double-blind crossover trial of fluoxetine and amitriptyline in the treatment of fibromyalgia |journal=Arthritis Rheum. |volume=39 |issue=11 |pages=1852-9 |year=1996 |pmid=8912507 |doi=}}</ref>
===Vitamin D===
Although initial studies suggest that low [[vitamin D]] levels may be associated with nonspecific musculoskeletal pain<ref name="pmid14661675">{{cite journal|author=Plotnikoff GA, Quigley JM |title=Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain |journal=Mayo Clin. Proc.|volume=78 |issue=12 |pages=1463–70 |year=2003 |pmid=14661675 |doi=}}</ref>; more recent studies make this doubtful.<ref name="pmid18431091">{{cite journal|author=Warner AE, Arnspiger SA |title=Diffuse musculoskeletal pain is not associated with low vitamin D levels or improved by treatment with vitamin D |journal=J Clin Rheumatol |volume=14 |issue=1 |pages=12–6 |year=2008 |month=February |pmid=18431091 |doi=10.1097/RHU.0b013e31816356a9 |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?an=00124743-200802000-00003 |issn=}}</ref><ref name="pmid19364687">{{cite journal| author=Arvold DS, Odean MJ, Dornfeld MP, Regal RR, Arvold JG, Karwoski GC et al.| title=Correlation of symptoms with vitamin D deficiency and symptom response to cholecalciferol treatment: a randomized controlled trial. | journal=Endocr Pract | year= 2009 | volume= 15 | issue= 3 | pages= 203-12 | pmid=19364687 | doi= | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19364687  }} </ref>


====Cannabis and cannabinoids====
Trials conflict whether Vitamin D is beneficial.<ref name="pmid19364687">{{cite journal| author=Arvold DS, Odean MJ, Dornfeld MP, Regal RR, Arvold JG, Karwoski GC et al.| title=Correlation of symptoms with vitamin D deficiency and symptom response to cholecalciferol treatment: a randomized controlled trial. | journal=Endocr Pract | year= 2009 | volume= 15 | issue= 3 | pages= 203-12 | pmid=19364687 | doi=10.4158/EP.15.3.203 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19364687  }} </ref><ref name="pmid18431091">{{cite journal| author=Warner AE, Arnspiger SA| title=Diffuse musculoskeletal pain is not associated with low vitamin D levels or improved by treatment with vitamin D. | journal=J Clin Rheumatol | year= 2008 | volume= 14 | issue= 1 | pages= 12-6 | pmid=18431091 | doi=10.1097/RHU.0b013e31816356a9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18431091  }} </ref>
Fibromyalgia patients frequently self-report using [[cannabis (drug)|cannabis]] therapeutically to treat symptoms of the disorder.<ref name="pmid16202145">{{cite journal |author=Swift W, Gates P, Dillon P |title=Survey of Australians using cannabis for medical purposes |journal=Harm reduction journal |volume=2 |issue= |pages=18 |year=2005 |pmid=16202145 |doi=10.1186/1477-7517-2-18 |url=http://www.biomedcentral.com/content/pdf/1477-7517-2-18.pdf |format=PDF}}</ref> Writing in the July 2006 issue of the journal Current Medical Research and Opinion, investigators at Germany's University of Heidelberg evaluated the analgesic effects of oral THC ([[tetrahydrocannabinol|∆<sup>9</sup>-tetrahydrocannabinol]]) in nine patients with fibromyalgia over a 3-month period. Subjects in the trial were administered daily doses of 2.5 to 15 mg of THC, but received no other pain medication during the trial. Among those participants who completed the trial, all reported a significant reduction in daily recorded pain and electronically induced pain.<ref name="pmid16834825">{{cite journal |author=Schley M, Legler A, Skopp G, Schmelz M, Konrad C, Rukwied R |title=Delta-9-THC based monotherapy in fibromyalgia patients on experimentally induced pain, axon reflex flare, and pain relief |journal=Current medical research and opinion |volume=22 |issue=7 |pages=1269–76 |year=2006 |pmid=16834825 |doi=10.1185/030079906X112651}}</ref> Previous clinical and preclinical trials have shown that both naturally occurring and endogenous cannabinoids hold analgesic qualities,<ref>{{cite journal |author=Burnes TL, Ineck JR |title=Cannabinoid Analgesia as a Potential New Therapeutic Option in the Treatment of Chronic Pain  |journal=Annals of Pharmacotherapy |year= |volume=40 |issue=2 |pages=251-60 |doi=10.1345/aph.1G217 |url=http://www.theannals.com/cgi/content/full/40/2/251}}</ref> particularly in the treatment of cancer pain and neuropathic pain,<ref name="pmid15757410">{{cite journal |author=Radbruch L, Elsner F |title=Emerging analgesics in cancer pain management |journal=Expert opinion on emerging drugs |volume=10 |issue=1 |pages=151–71 |year=2005 |pmid=15757410 |doi=}}</ref><ref name="pmid15096238">{{cite journal |author=Notcutt W, Price M, Miller R, ''et al'' |title=Initial experiences with medicinal extracts of cannabis for chronic pain: results from 34 'N of 1' studies |journal=Anaesthesia |volume=59 |issue=5 |pages=440–52 |year=2004 |pmid=15096238 |doi=10.1111/j.1365-2044.2004.03674.x}}</ref> both of which are poorly treated by conventional opioids. As a result, some experts have suggested that cannabinoid agonists would be applicable for the treatment of chronic pain conditions unresponsive to opioid analgesics such as fibromyalgia, and they propose that the disorder may be associated with an underlying clinical deficiency of the [[endocannabinoid system]].<ref name="pmid15159679">{{cite journal |author=Russo EB |title=Clinical endocannabinoid deficiency (CECD): can this concept explain therapeutic benefits of cannabis in migraine, fibromyalgia, irritable bowel syndrome and other treatment-resistant conditions? |journal=Neuro Endocrinol. Lett. |volume=25 |issue=1-2 |pages=31–9 |year=2004 |pmid=15159679 |doi=}}</ref>
* Benefit was found in trials that were not prospectively registered.<ref name="pmid19364687">{{cite journal| author=Arvold DS, Odean MJ, Dornfeld MP, Regal RR, Arvold JG, Karwoski GC et al.| title=Correlation of symptoms with vitamin D deficiency and symptom response to cholecalciferol treatment: a randomized controlled trial. | journal=Endocr Pract | year= 2009 | volume= 15 | issue= 3 | pages= 203-12 | pmid=19364687 | doi=10.4158/EP.15.3.203 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19364687  }} </ref><ref name="pmid24438771">{{cite journal| author=Wepner F, Scheuer R, Schuetz-Wieser B, Machacek P, Pieler-Bruha E, Cross HS et al.| title=Effects of vitamin D on patients with fibromyalgia syndrome: a randomized placebo-controlled trial. | journal=Pain | year= 2014 | volume= 155 | issue= 2 | pages= 261-8 | pmid=24438771 | doi=10.1016/j.pain.2013.10.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24438771  }} </ref>
===Topical Remedies===
* Benefit was found in a case series.<ref name="pmid27860257">{{cite journal| author=Yilmaz R, Salli A, Cingoz HT, Kucuksen S, Ugurlu H| title=Efficacy of vitamin D replacement therapy on patients with chronic nonspecific widespread musculoskeletal pain with vitamin D deficiency. | journal=Int J Rheum Dis | year= 2016 | volume= 19 | issue= 12 | pages= 1255-1262 | pmid=27860257 | doi=10.1111/1756-185X.12960 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27860257  }} </ref>


Users of Epsom Salts in the gel form ([[Magnesium Sulfate]]), have reported significant and lasting relief from pain associated with fibromyalgia. Epsom Salts have long been touted for its ability to reduce pain and swelling.
A [[meta-analysis]] concludes that Vitamin D reduces pain.<ref name="pmid28812209">{{cite journal| author=Yong WC, Sanguankeo A, Upala S| title=Effect of vitamin D supplementation in chronic widespread pain: a systematic review and meta-analysis. | journal=Clin Rheumatol | year= 2017 | volume= 36 | issue= 12 | pages= 2825-2833 | pmid=28812209 | doi=10.1007/s10067-017-3754-y | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28812209  }} </ref>
==Injection Therapy==
Interventional therapy can ease pain by blocking nerve conduction between specific areas of the body and the brain. Approaches range from injections of local anesthetics, steroids, proliferative agents ([[Prolotherapy]]) into affected soft tissues, joints, or nerve roots to more complex nerve blocks. Chronic use of steroid injections may lead to increased functional impairment.


==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{WH}}
{{WS}}
[[Category:Rheumatology]]
[[Category:Diseases involving the fasciae]]
[[Category:Syndromes]]
[[Category:Ailments of unknown etiology]]
[[Category:Needs Overview]]

Latest revision as of 20:08, 17 April 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Overview

There is no universally accepted treatment for fibromyalgia. Treatment typically consists of symptomic management and the treatment options include medications and cognitive behavioral therapy, which has been shown to be effective in alleviating pain and other fibromyalgia-related symptoms.

Medical Therapy

The medical therapy for fibromyalgia includes analgesics, antidepressants, such as TCAs or SNRIs, skeletal muscle relaxants, anticonvulsants, and anti-anxiety medications.[1]

Single agent therapy

  • Preferred regimen (1): Amitriptyline 10-70 mg orally once daily at bedtime
  • Preferred regimen (2): Cyclobenzaprine 5-30 mg orally once daily at bedtime
  • Preferred regimen (3): Duloxetine 30-60 mg orally once daily
  • Preferred regimen (4): Milnacipran 12.5 mg orally once daily initially, followed by 12.5 mg twice daily for 2 days, followed by 25 mg twice daily for 4 days, then 50-100 mg twice daily thereafter
  • Preferred regimen (5): Pregabalin 75-225 mg orally twice daily, maximum 450 mg/day

Combination Therapy

  • Preferred regimen (1): Amitriptyline 10-70 mg orally once daily at bedtime (OR)
  • Preferred regimen (2): Cyclobenzaprine 5-30 mg orally once daily at bedtime

AND

  • Preferred regimen (3): Duloxetine 30-60 mg orally once daily; higher doses have been used, consult a specialist for guidance (OR)
  • Preferred regimen (4): Milnacipran 12.5 mg orally once daily initially, followed by 12.5 mg twice daily for 2 days, followed by 25 mg twice daily for 4 days, then 50-100 mg twice daily thereafter

AND

  • Preferred regimen (5): Pregabalin 75-225 mg orally twice daily, maximum 450 mg/day (OR)
  • Preferred regimen (6): Gabapentin 300 mg orally once daily on the first day, followed by 300 mg twice daily on the second day, followed by 300 mg three times daily on the third day, then titrate dose according to response up to 1800-2400 mg/day given in 3 divided doses

Underlying randomized studies of treatment

Vitamin D

Although initial studies suggest that low vitamin D levels may be associated with nonspecific musculoskeletal pain[2]; more recent studies make this doubtful.[3][4]

Trials conflict whether Vitamin D is beneficial.[4][3]

  • Benefit was found in trials that were not prospectively registered.[4][5]
  • Benefit was found in a case series.[6]

A meta-analysis concludes that Vitamin D reduces pain.[7]

References

  1. ↑ Selfridge, Dr. Nancy, and Peterson, Franklynn (2001). Freedom from Fibromyalgia: The 5-Week Program Proven to Conquer Pain. ISBN 0-8129-3375-3.
  2. ↑ Plotnikoff GA, Quigley JM (2003). "Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain". Mayo Clin. Proc. 78 (12): 1463–70. PMID 14661675.
  3. ↑ 3.0 3.1 Warner AE, Arnspiger SA (2008). "Diffuse musculoskeletal pain is not associated with low vitamin D levels or improved by treatment with vitamin D". J Clin Rheumatol. 14 (1): 12–6. doi:10.1097/RHU.0b013e31816356a9. PMID 18431091. Unknown parameter |month= ignored (help)
  4. ↑ 4.0 4.1 4.2 Arvold DS, Odean MJ, Dornfeld MP, Regal RR, Arvold JG, Karwoski GC; et al. (2009). "Correlation of symptoms with vitamin D deficiency and symptom response to cholecalciferol treatment: a randomized controlled trial". Endocr Pract. 15 (3): 203–12. PMID 19364687.
  5. ↑ Wepner F, Scheuer R, Schuetz-Wieser B, Machacek P, Pieler-Bruha E, Cross HS; et al. (2014). "Effects of vitamin D on patients with fibromyalgia syndrome: a randomized placebo-controlled trial". Pain. 155 (2): 261–8. doi:10.1016/j.pain.2013.10.002. PMID 24438771.
  6. ↑ Yilmaz R, Salli A, Cingoz HT, Kucuksen S, Ugurlu H (2016). "Efficacy of vitamin D replacement therapy on patients with chronic nonspecific widespread musculoskeletal pain with vitamin D deficiency". Int J Rheum Dis. 19 (12): 1255–1262. doi:10.1111/1756-185X.12960. PMID 27860257.
  7. ↑ Yong WC, Sanguankeo A, Upala S (2017). "Effect of vitamin D supplementation in chronic widespread pain: a systematic review and meta-analysis". Clin Rheumatol. 36 (12): 2825–2833. doi:10.1007/s10067-017-3754-y. PMID 28812209.
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