Fibromyalgia syndrome (FMS) is a common rheumatological condition characterized by chronic widespread pain and reduced pain threshold, with hyperalgesia (increased sense of pain) and allodynia (pain from a non-noxious stimulus) .
Diagnosis of fibromyalgia is made primarily from the patient’s history and physical exam. The American College of Rheumatology have produced classification criteria for fibromyalgia including widespread pain involving both sides of the body, above and below the waist for at least three months and the presence of 11 out of 18 possible pre-specified tender points .
Evidence based summary for manual therapy 
Schneider et al  conclude there is moderate level evidence from several RCTs and a systematic review  that massage is helpful in improving sleep and reducing anxiety in chronic pain; however, few of the studies included in the systematic review specifically investigated fibromyalgia. There is also moderate evidence for the benefits of acupuncture .
The evidence supporting spinal manipulation, movement/ body awareness, vitamins, herbs and dietary modification is limited (inconclusive but favourable)  and therefore is not supported as a valid treatment option.
Other effective non-invasive physical treatments or patient education
There is strong evidence for the benefits of aerobic exercise [50,48,52] and for Cognitive Behavioural Therapy (CBT) . There is moderate evidence for muscle strength training and heated pool treatment with or without exercise .
Back-in-Action clinical comment
In addition to recommending massage, acupuncture (dry needling), Cognitive Behavioural Therapy (CBT) for patients who appear to have fibromyalgia and recommending aerobic exercise, strengthening exercises and using a heated pool, we have also found clinically that a holistic approach aimed at helping relieve other problems presenting concurrently with the Fibromyalgia symptoms, can be beneficial for some patients. In order to help optimise and balance the body structure and function a combination of chiropractic adjustments, muscle release techniques, cranial work, exercise, functional neurological approaches, postural balancing, ergonomic improvement, lifestyle advice, relaxation, breathing techniques and nutritional advice may also be useful.
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