The Pharmacotherapy of Common Functional Syndromes: Evidence-Based Guidelines for Primary Care Practice.

The Pharmacotherapy of Common Functional Syndromes: Evidence-Based Guidelines for Primary Care Practice Manu P. Binghamton, NY 13904, The Haworth Medical Press, 2000, paperback, 320 pp, ISBN: 0-7890-0589-1, $39.95.

The purpose of this book is to provide a research perspective on 4 common functional disorders (ie, chronic fatigue syndrome [CFS], fibromyalgia, irritable bowel syndrome [IBS], and premenstrual syndrome [PMS]). The author defines a functional somatic syndrome as an "illness characterized by a constellation of symptoms, suffering, and disability that lack demonstrable structural abnormalities and cannot be explained by an evidence-based pathophysiologic mechanism." The author argues that at least 10% of the adult population in the United States has symptoms compatible with 1 of these 4 syndromes, costing billions of dollars annually. The information in this text is organized into 4 major categories with topical chapters that cover (1) definition and methodological issues, (2) controversial treatments, (3) ineffective therapies, (4) unreplicated trials, and (5) evidence-based therapy. Most of the text reads as a summary of studies investigating different pharmaceuticals and some neutraceutical formulations (natural supplements) for these functional syndromes. The author critiques each study and comments on its relative merits.

Section I is devoted to CFS and examines therapies--such as immunoglobulin infusions, hydrocortisone, and fish and plant oils--that are considered to be controversial treatments. Another 12 pharmaceuticals are examined individually in the unreplicated clinical trials chapter. The author concludes this chapter by stating that all of the therapeutic agents he listed have not demonstrated their efficacy in replicated clinical trials to date. This failure has stimulated efforts to conduct controlled trials of nonpharmacological interventions (ie, cognitive-behavioral and exercise therapy). The graded aerobic exercise studies consistently showed positive results, leading the author to conclude that a "prudent program of graded aerobic exercise ... is the only evidence-based acceptable treatment for CFS."

Section II deals with fibromyalgia syndrome and its clinical presentation. The author critically appraises a substantial list of pharmaceutical trials, including both controversial and ineffective drug regimens. The chapter on effective therapy focuses on the tricyclic antidepressants, specifically amitriptyline. According to the author, these drugs provide a clinically significant improvement in the main characteristics of this condition over the use of a placebo. The author discourages exercise as a stand-alone treatment based on contradictory reports, and he states that "given its mostly negative results and potential for adverse effects (D.O.M.S. [delayed onset muscle soreness]), a prescription for exercise does not appear justified for most patients with fibromyalgia." However, exercise given as part of an integrated therapeutic program that includes cognitive-behavioral strategies and relaxation seemed to be more effective than any single therapy.

Section III focuses on IBS, and here the author expands his pharmaceutical focus to include research on neutraceuticals as well. In the chapters on controversial and ineffective therapies, substances--such as bulking agents, calcium channel blockers, smooth muscle relaxants, dietary fiber, and various Chinese and Indian herbs--are discussed in terms of their scientific support. Ultimately, the author settles on a more eclectic formula for the treatment of IBS and its 5 subtypes, pointing to a study that recommends treating each symptom separately rather than treating the entire syndrome. Studies examining cognitive-behavioral therapy did not inspire the author's confidence because of contradictory findings and methodological flaws in the study design. No studies involving exercise therapy were mentioned in this section dealing with IBS.

The fourth and final section discusses PMS, using the 1994 definition of the American Psychiatric Association. There are 11 symptom clusters, 5 of which must be present during a premenstrual week of most menstrual cycles of the preceding year. This section reviews a multitude of drug formulations, including estrogens, progesterones, nonsteroidal anti-inflammatory agents, beta blockers, magnesium, primrose oil, and vitamin E, and all of these formulations fell into the controversial or ineffective therapies designation. The author states that, based on rigorous clinical trials, the only effective therapy was the selective serotonin reuptake inhibitors (SSRIs) or serotonergic antidepressants. The author goes on to describe the clinical research that supports his assertion of which drug is most effective.

This book has essentially 2 parts: (1) the clinical descriptions and the manifestations of the functional syndromes, and (2) descriptions of the various therapeutic drug trials that are used in the effort to ameliorate the condition. Because the majority of the studies concern medications, this book would naturally find an interested readership among physicians. Physical therapists may find those sections describing diagnostic criteria of functional syndromes interesting; however, I do not believe this book would be useful as a textbook in a physical therapist education program.

Tiziano Marovino, PT
Preferred Medicine, Inc
Spine, Sports and Occupational Medicine
Allen Park, Mich

Mr Marovino is Director of Rehabilitation Services at a private outpatient facility. His clinical interests are in orthopedic physical therapy with pain management as a subspecialty. He holds board certifications in pain management, disability analysis, and forensic examination.