A stepwise treatment approach to FMS

A graded treatment approach to functional somatic syndromes is recommended [10]. The American Pain Society (APS) [1] and the German Interdisciplinary Guideline Group [24] both recommend a stepwise treatment approach.

Treatment should begin with confirming the diagnosis and patient education. Self-management and patient-centered communication are regarded as key principles of FMS therapy. Both guidelines recommended first, second and third lines of therapy depending on the course of symptoms, the existence of relevant restrictions of daily activities and the response to different treatment modalities. The APS recommended individualized exercise and CBT as first-line therapy. The German guideline recommended aerobic exercise, CBT, amitriptyline and treatment of physical and mental co-morbidities as single interventions or combined as first-line therapies.

In cases of persisting symptoms after first-line treatment, the APS recommended tender point injections, local manual therapies and acupuncture for focal pain, tramadol, SNRI, anticonvulsants for generalized pain, and psychiatric treatment in cases of major mood disorder as second-line therapy. The German guideline recommended multicomponent therapy in cases of persisting restrictions of daily activities as second-line therapy.

Multidisciplinary pain management, psychopharma-cology, opioids, experimental therapies and combinations is the third-line therapy recommended by the APS in cases of persisting symptoms. In cases lacking adaptation to symptoms or persistent restrictions of daily functioning, the German guideline recommended either no therapy or self-management (aerobic exercise, stress management, pool-based exercise), or booster multi-component therapy, or psychotherapy (hypnotherapy, written emotional disclosure), or pharmacologic therapy (duloxetine or fluoxetine or paroxetin or prega-balin, or tramadol with or without acetaminophen), or complementary/alternative therapies (homeopathy, vegetarian diet) as third-line therapy. The choice of treatment options should be based on informed patient consent, the patient's preferences and co-morbidities, and the treatment options locally available [24].

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