To the Editor:

I read with great interest the recent article by Dr. Pöyhiä et al concerning the observed improvement in pain among fibromyalgia (FM) patients over 3 years (1). The findings are encouraging in this understudied area of FM research. However, there are some areas of the study that need to be addressed.

Current research indicates that FM patients resort to complementary and alternative medicine (CAM) when they experience higher pain and disability in the hope that CAM will provide some relief (2, 3). Pöyhiä's research shows a correlation between decreased pain and concurrent increased use of CAM therapies by patients with FM. This is an interesting finding, and one that conflicts with expected results. Without further explanation, discussion, or evaluation, however, the issue is dismissed in one sentence, “alternative treatments … were seldom identified as being of value in the control of symptoms.” The question remains, why would patients increase their use of CAM modalities as their pain attenuates?

Pöyhiä et al neglected one of the most common CAM interventions in FM, dietary modification. Investigators have found that between 26% and 40% of FM patients attempt dietary changes—the addition and/or elimination of foods (3, 4). Similar findings have been observed in the related disorder chronic fatigue syndrome (CFS), in which 54% of patients attempt dietary modifications and of these individuals, 73% reported it to be the most helpful CAM therapy (5). Although not particularly robust, there is evidence to suggest that dietary modifications may be beneficial in some FM patients, as measured both subjectively and objectively (6–11). A review of this literature is beyond the scope of this letter, but it has been previously reported in this journal that FM patients claim dietary changes are moderately helpful (4).

The third issue is the sampling of patients from only one locality and how this relates to CAM use. In this current article and in previous work on CAM and FM by McGill University investigators (4, 12) the patient sample was taken from Montreal, Quebec, Canada. This province is one where naturopathic medicine is not legislated for primary care, therefore any statistics related to CAM use, and naturopathic medicine in particular, derived from these studies pertains to this local area only. In the present study, Pöyhiä et al report that 1 patient out of 59 visited a naturopathic doctor (ND) in a 3 year period. In a previous study published in this journal, investigators, again from Montreal, reported 1 FM patient out of 46 visited an ND in the previous year (4). These statistics are in sharp contrast to visits made by FM patients to NDs in jurisdictions where naturopathic medicine is licensed for primary care. When examining a licensed jurisdiction, investigators from the University of Washington found that 25% of FM patients visit NDs, and 44% of those who meet the criteria of having both CFS and FM visit NDs (13). It is important to note that licensed NDs have 4 years of full-time, post-secondary education in most major CAM modalities (14) and may be most suited, through education and legislation, to address the concerns of FM patients related to CAM. When Pöyhiä and others produce articles related to CAM use and draw from only one locality, they should note this as a limitation due to local regulation or more importantly in this case, the lack thereof.


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Alan C. Logan ND, FRSH*, * CFS/FM Integrative Care Centre, Toronto, Ontario, Canada.