To the Editor:

We appreciate the comments of Dr. Logan regarding our report of pain response in patients with fibromyalgia (FM) over a 3-year period (1). This reader has highlighted the use of complementary and alternative medicine (CAM) practices in our patient cohort. It was observed that concomitant with improvement in symptoms in the entire group, use of alternative treatments increased.

Although motivation for the use of CAM in this patient group was not examined, it should be the next question investigated. Interestingly, patients seldom identified CAM as a particularly helpful treatment but continued to remain users of CAM. This curious paradox may have several explanations. There is a prevalent belief by the public in Quebec, Canada that CAM treatments are without harm, and they are identified by patients as “douce” or “gentle” medicine. Psychological distress resulting from a disease poorly responsive to conventional medicine, the ability to have personal control over illness and body, as well as cultural attitudes and philosophy are factors that likely influence the use of CAM in different diseases and societies (2–4). Our study was observational, with recording of patients' perceptions of interventions, but was not designed to test the efficacy of any specific treatment. The fact that particular interventions are used is no proof of efficacy, but should encourage further research in that area.

Although we did not specifically question patients regarding use of dietary interventions, an opportunity to report the effect of dietary manipulation was given via an open-ended question. No patient spontaneously reported the use of this intervention. In our previous study we specifically questioned patients regarding the use of diet and reported that 25% of FM patients were using diet, but without any great enthusiasm (5). It is also not known whether patients adhere to a program of dietary interventions for any duration of time. Adherence to dietary recommendations in other medical conditions which have been medically proven to be of benefit, such as lipid lowering in cardiovascular disease, are often poor (6).

We acknowledge that we are reporting on a sample of patients from a single city, seen mostly in tertiary care practice. Additionally, most CAM interventions are not reimbursed in Quebec and thus represent out-of-pocket expenses for the patient. These factors clearly have an impact upon prevalence of use of CAM treatments. It is however important to note that prevalence of use of any treatment should not be seen as a measure of success of a treatment, but should rather encourage continued study to fully test efficacy as well as safety. We believe however, that the improvement we have observed in pain in our patients is the result of a spontaneous attenuation of the pain process, rather than the result of any specific intervention, either traditional or alternative.

R. Pöyhiä MD, PhD* †, D. Da Costa PhD‡ §, M-A. Fitzcharles MB, ChB, MrCP(UK), FRCP (C)‡ §, * McGill-MGH Pain Centre McGill University Montreal, Quebec, Canada, † University of Helsinki, Helsinki, Finland, ‡ Montreal General Hospital, Montreal, Quebec, Canada, § McGill University, Montreal, Quebec, Canada