Fibromyalgia syndrome (FMS)
You hurt all over, and you frequently feel exhausted. Even after numerous tests,
your doctor can't find anything specifically wrong with you. If this sounds familiar,
you may have fibromyalgia.
Fibromyalgia is a chronic condition characterized by widespread pain in your
muscles, ligaments and tendons, as well as fatigue and multiple tender points —
places on your body where slight pressure causes pain. Fibromyalgia is more
common in women than in men. Previously, fibromyalgia was known by other
names such as fibrositis, chronic muscle pain syndrome, psychogenic
rheumatism and tension myalgias.
Although the intensity of your symptoms may vary, they'll probably never
disappear completely. It may be reassuring to know, however, that fibromyalgia
isn't progressive or life-threatening. Treatments and self-care steps can improve
fibromyalgia symptoms and your general health.
Signs and symptoms of fibromyalgia can vary, depending on the weather, stress,
physical activity or even the time of day. Common signs and symptoms include:
Widespread pain. Fibromyalgia is characterized by pain in specific areas
of your body when pressure is applied, including the back of your head,
upper back and neck, upper chest, elbows, hips and knees. The pain
generally persists for months at a time and is often accompanied by
Fatigue and sleep disturbances. People with fibromyalgia often wake up
tired and unrefreshed even though they seem to get plenty of sleep. Some
studies suggest that this sleep problem is the result of a sleep disorder
called alpha wave interrupted sleep pattern, a condition in which deep
sleep is frequently interrupted by bursts of brain activity similar to
wakefulness. So people with fibromyalgia miss the deep restorative stage
of sleep. Nighttime muscle spasms in your legs and restless legs
syndrome also may be associated with fibromyalgia.
Irritable bowel syndrome (IBS). The constipation, diarrhea, abdominal
pain and bloating associated with IBS are common in people with
Headaches and facial pain. Many people who have fibromyalgia also
have headaches and facial pain that may be related to tenderness or
stiffness in their neck and shoulders. Temporomandibular joint (TMJ)
dysfunction, which affects the jaw joints and surrounding muscles, also is
common in people with fibromyalgia.
Heightened sensitivity. It's common for people with fibromyalgia to report
being sensitive to odors, noises, bright lights and touch.
Other common signs and symptoms include:
Numbness or tingling sensations in the hands and feet (paresthesia)
Dry eyes, skin and mouth
Painful menstrual periods
Doctors don't know what causes fibromyalgia. Current thinking centers around a
theory called quot;central sensitization.quot; This theory states that people with
fibromyalgia have a lower threshold for pain because of increased sensitivity in
the brain to pain signals. Researchers believe repeated nerve stimulation causes
the brains of people with fibromyalgia to change. This change involves an
abnormal increase in levels of certain chemicals in the brain that signal pain
(neurotransmitters). In addition, the brain's pain receptors (neurons) — which
receive signals from the neurotransmitters — seem to develop a sort of memory
of the pain and become more sensitive, meaning they can overreact to pain
signals. In this way, pressure on a spot on the body that wouldn't hurt someone
without fibromyalgia can be very painful to someone who has the condition. But
what initiates this process of central sensitization isn't known.
It's likely that a number of factors contribute to the development of fibromyalgia.
Other theories as to the cause of fibromyalgia include:
Sleep disturbances. Some researchers theorize that disturbed sleep
patterns may be a cause rather than just a symptom of fibromyalgia.
Injury. An injury or trauma, particularly in the upper spinal region, may
trigger the development of fibromyalgia in some people. An injury may
affect your central nervous system, which may trigger fibromyalgia.
Infection. Some researchers believe that a viral or bacterial infection may
Abnormalities of the autonomic (sympathetic) nervous system. Part
of your autonomic nervous system — the sympathetic, or involuntary,
system — controls bodily functions that you don't consciously control,
such as heart rate, blood vessel contraction, sweating, salivary flow and
intestinal movements. It’s thought that sympathetic nervous system
dysfunction occurs in people with fibromyalgia, particularly at night, which
leads to fatigue, stiffness, dizziness and other signs and symptoms
associated with the condition.
Changes in muscle metabolism. For example, deconditioning and
decreased blood flow to muscles may contribute to decreased strength
and fatigue. Differences in metabolism and abnormalities in the hormonal
substance that influences the activity of nerves may play a role.
Psychological stress and hormonal changes also may be possible causes of
Risk factors for fibromyalgia include:
Your sex. Fibromyalgia occurs more often in women than in men.
Age. Fibromyalgia tends to develop during early and middle adulthood.
But it can also occur in children and older adults.
Disturbed sleep patterns. It's unclear whether sleeping difficulties are a
cause or a result of fibromyalgia — but people with sleep disorders, such
as nighttime muscle spasms in the legs, restless legs syndrome or sleep
apnea, can also develop fibromyalgia.
Family history. You may be more likely to develop fibromyalgia if a
relative also has the condition.
Rheumatic disease. If you have a rheumatic disease, such as
rheumatoid arthritis, lupus or ankylosing spondylitis, you may be more
likely to have fibromyalgia.
When to seek medical advice
See your doctor if you experience general aching or widespread pain that lasts
several months and is accompanied by fatigue. Many of the symptoms of
fibromyalgia mimic those of other diseases, such as low thyroid hormone
production (hypothyroidism), polymyalgia rheumatica, neuropathies, lupus,
multiple sclerosis and rheumatoid arthritis. Your doctor can help determine if one
of these other conditions may be causing your symptoms.
Tests and diagnosis
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Diagnosing fibromyalgia is difficult because there isn't a single, specific
diagnostic laboratory test. In fact, before receiving a diagnosis of fibromyalgia,
you may go through several medical tests, such as blood tests and X-rays, only
to have the results come back normal. Although these tests may rule out other
conditions, such as rheumatoid arthritis, lupus and multiple sclerosis, they can't
The American College of Rheumatology has established general classification
guidelines for fibromyalgia, to help in the assessment and study of the condition.
According to these guidelines, to be diagnosed with fibromyalgia you must have
experienced widespread aching pain for at least three months and have a
minimum of 11 locations on your body that are abnormally tender under relatively
mild, firm pressure. In addition to taking your medical history, a doctor checking
for fibromyalgia will likely press firmly on specific points on your head, upper
body and certain joints so that you can confirm which cause pain.
Not all doctors agree with these guidelines. Some believe that the criteria are too
rigid and that you can have fibromyalgia even if you don't meet the required
number of tender points. Others question how reliable and valid tender points are
as a diagnostic tool.
Fibromyalgia isn't progressive and generally doesn't lead to other conditions or
diseases. It can, however, cause pain, depression and lack of sleep. These
problems can then interfere with your ability to function at home or on the job, or
maintain close family or personal relationships. The frustration of dealing with an
often-misunderstood condition also can be a complication of the condition.
Treatments and drugs
In general, treatment for fibromyalgia includes both medication and self-care. The
emphasis is on minimizing symptoms and improving general health.
Medications can help reduce the pain of fibromyalgia and improve sleep.
Common choices include:
Analgesics. Acetaminophen (Tylenol, others) may ease the pain and
stiffness caused by fibromyalgia. However, its effectiveness varies.
Tramadol (Ultram) is a prescription pain reliever that may be taken with or
without acetaminophen. Your doctor may recommend nonsteroidal anti-
inflammatory drugs (NSAIDs) — such as aspirin, ibuprofen (Advil, Motrin,
others) or naproxen sodium (Anaprox, Aleve) — in conjunction with other
medications. NSAIDs haven't proved to be effective in managing the pain
in fibromyalgia when taken by themselves.
Antidepressants. Your doctor may prescribe antidepressant medications
such as amitriptyline, nortriptyline (Pamelor) or doxepin (Sinequan) to help
promote sleep. Fluoxetine (Prozac) in combination with amitriptyline has
also been found effective. Sertraline (Zoloft) and paroxetine (Paxil) may
help if you're experiencing depression.
Some evidence exists for a newer class of antidepressants known as
serotonin and norepinephrine reuptake inhibitors or dual uptake inhibitors,
which regulate two brain chemicals that may transmit pain signals. Studies
have found that duloxetine (Cymbalta) may help control pain better than
placebo in people with fibromyalgia. Small trials of venlafaxine (Effexor)
suggest the same, though more study is needed to confirm these findings.
Muscle relaxants. Taking the medication cyclobenzaprine (Flexeril) at
bedtime may help treat muscle pain and spasms. Muscle relaxants are
generally limited to short-term use.
Pregabalin (Lyrica). Pregabalin may reduce pain and improve function in
people with fibromyalgia. Pregabalin, an anti-seizure medication that's
also used to treat some types of pain, is the first drug approved by the
Food and Drug Administration to treat fibromyalgia. Studies show
pregabalin reduced signs and symptoms of fibromyalgia in some people.
In one study, about half of the participants taking the highest doses of the
drug reported at least a 30 percent improvement. Side effects of
pregabalin include dizziness, sleepiness, difficulty concentrating, blurred
vision, weight gain, dry mouth, and swelling in the hands and feet.
Prescription sleeping pills, such as zolpidem (Ambien), may provide short-term
benefits for some people with fibromyalgia, but doctors usually advise against
long-term use of these drugs. These medications tend to work for only a short
time, after which your body becomes resistant to their effects. Ultimately, using
sleeping pills tends to create even more sleeping problems in many people.
Benzodiazepines may help relax muscles and promote sleep, but doctors often
avoid these drugs in treating fibromyalgia. Benzodiazepines can become habit-
forming, and they haven't been shown to provide long-term benefits.
Doctors don't usually recommend narcotics for treating fibromyalgia because of
the potential for dependence and addiction. Corticosteroids, such as prednisone,
haven't been shown to be effective in treating fibromyalgia.
Cognitive behavior therapy
Cognitive behavior therapy seeks to strengthen your belief in your abilities and
teaches you methods for dealing with stressful situations. Therapy is provided
through individual counseling, classes, and with tapes, CDs or DVDs, and may
help you manage your fibromyalgia.
Programs that combine a variety of treatments may be effective in improving your
symptoms, including relieving pain. These interdisciplinary programs can
combine relaxation techniques, biofeedback and receiving information about
chronic pain. There isn't one combination that works best for everybody. Your
doctor can create a program based on what works best for you.
Lifestyle and home remedies
Self-care is critical in the management of fibromyalgia.
Reduce stress. Develop a plan to avoid or limit overexertion and
emotional stress. Allow yourself time each day to relax. That may mean
learning how to say no without guilt. But try not to change your routine
completely. People who quit work or drop all activity tend to do worse than
those who remain active. Try stress management techniques, such as
deep-breathing exercises or meditation.
Get enough sleep. Because fatigue is one of the main characteristics of
fibromyalgia, getting sufficient sleep is essential. In addition to allotting
enough time for sleep, practice good sleep habits, such as going to bed
and getting up at the same time each day and limiting daytime napping.
Exercise regularly. At first, exercise may increase your pain. But doing it
regularly often decreases symptoms. Appropriate exercises may include
walking, swimming, biking and water aerobics. A physical therapist can
help you develop a home exercise program. Stretching, good posture and
relaxation exercises also are helpful.
Pace yourself. Keep your activity on an even level. If you do too much on
your good days, you may have more bad days.
Maintain a healthy lifestyle. Eat healthy foods. Limit your caffeine intake.
Do something that you find enjoyable and fulfilling every day.
Coping and support
Besides dealing with the pain and fatigue of fibromyalgia, you may also have to
deal with the frustration of having a condition that's often misunderstood. In
addition to educating yourself about fibromyalgia, you may find it helpful to
provide your family, friends and co-workers with information.
It's also helpful to know that you're not alone. Organizations such as the Arthritis
Foundation and the American Chronic Pain Association provide educational
classes and support groups. These groups can often provide a level of help and
advice that you might not find anywhere else. They can also help put you in
touch with others who have had similar experiences and can understand what
you're going through.
Complementary and alternative therapies for pain and stress management aren't
new. Some, such as meditation and yoga, have been practiced for thousands of
years. But their use has become more popular in recent years, especially with
people who have chronic illnesses, such as fibromyalgia.
Several of these treatments do appear to safely relieve stress and reduce pain,
and some are gaining acceptance in mainstream medicine. But many practices
remain unproved because they haven't been adequately studied. Some of the
more common complementary and alternative treatments promoted for pain
Acupuncture. Acupuncture is a Chinese medical system based on
restoring normal balance of life forces by inserting very fine needles
through the skin to various depths. According to Western theories of
acupuncture, the needles cause changes in blood flow and levels of
neurotransmitters in the brain and spinal cord. In a 2006 Mayo Clinic
study, acupuncture significantly improved symptoms of fibromyalgia.
Research on the benefits of acupressure — a similar practice that uses
finger pressure on the skin rather than needles — is inconclusive.
Chiropractic care. This treatment is based on the philosophy that
restricted movement in the spine may lead to pain and reduced function.
Spinal adjustment (manipulation) is one form of therapy chiropractors use
to treat restricted spinal mobility. The goal is to restore spinal movement
and, as a result, improve function and decrease pain. Chiropractors
manipulate the spine from different positions using varying degrees of
force. Manipulation doesn't need to be forceful to be effective.
Chiropractors may also use massage and stretching to relax muscles that
are shortened or in spasm. Because manipulation has risks, always go to
properly trained and licensed practitioners.
Massage therapy. This is one of the oldest methods of health care still in
practice. It involves use of different manipulative techniques to move your
body's muscles and soft tissues. The therapy aims to improve blood
circulation in the muscle, increasing the flow of nutrients and eliminating
waste products. Massage can reduce your heart rate, relax your muscles,
improve range of motion in your joints and increase production of your
body's natural painkillers. It often helps relieve stress and anxiety.
Although massage is almost always safe, avoid it if you have open sores,
acute inflammation or circulatory problems.
Osteopathy. Doctors of osteopathy go through rigorous and lengthy
training in academic and clinical settings, equivalent to medical doctors.
They're licensed to perform many of the same therapies and procedures
as conventional doctors. One area where osteopathy differs from
conventional medicine — but is similar to chiropractic medicine — is in the
use of manipulation to address joint and spinal problems.
Fibromyalgia symptoms treatment
The primary symptoms of fibromyalgia include widespread musculoskeletal pain, severe
fatigue, and disturbed sleep. Fibromyalgia means pain in the muscles, ligaments, and
tendons – the soft fibrous tissues in the body.
Most patients with fibromyalgia say that they ache all over. Their muscles may feel like
they were pulled or overworked. Sometimes fibromyalgia symptoms include muscle
twitches and burning sensations. More women than men are afflicted with fibromyalgia,
and it shows up in people of all ages. A conservative estimate of its prevalence is 2% of
the general population, but it may be as high as 3-5%.
To help your family and friends relate to your fibromyalgia symptoms, have them think
back to the last time they had a bad flu. Every muscle in their body shouted out in pain.
In addition, they felt devoid of energy as though someone had unplugged their power
supply. While the severity of symptoms fluctuates from person to person, fibromyalgia
may resemble a post-viral state. This similarity is the reason experts believe that
fibromyalgia syndrome (FMS) and chronic fatigue syndrome (CFS) may actually be the
same condition. Gulf War syndrome also overlaps with FMS/CFS.
Common symptoms of fibromyalgia and chronic fatigue
Pain - The pain of fibromyalgia has no boundaries. People describe the pain as
deep muscular aching, throbbing, shooting, and stabbing. Intense burning may
also be present. Quite often, the pain and stiffness are worse in the morning and
you may hurt more in muscle groups that are used repetitively.
Fatigue - This symptom can be mild in some fibromyalgia patients and yet
incapacitating in others. The fatigue has been described as quot;brain fatiguequot; in
which patients feel totally drained of energy. Many patients depict this situation
by saying that they feel as though their arms and legs are tied to concrete blocks,
and they have difficulty concentrating, e.g., brain fog.
Sleep disorder - Most fibromyalgia patients have an associated sleep disorder
called the alpha-EEG anomaly. This condition was uncovered in a sleep lab with
the aid of a machine that recorded the brain waves of patients during sleep.
Researchers found that the majority of fibromyalgia patients could fall asleep
without much trouble, but their deep level (or stage 4) sleep was constantly
interrupted by bursts of awake-like brain activity. Patients appeared to spend the
night with one foot in sleep and the other one out of it.
Sleep lab tests may not be necessary to determine if you have disturbed sleep. If
you wake up feeling as though you've just been run over by a Mack truck—what
doctors refer to as unrefreshing sleep—it is reasonable for your physician to
assume that you have a sleep disorder. Many fibromyalgia patients have been
found to have other sleep disorders in addition to the alpha-EEG, such as sleep
apnea (as well as the newly discovered form of interrupted breathing called upper
airway resistance syndrome, or UARS), bruxism (teeth grinding), periodic limb
movement during sleep (jerking of arms and legs), and restless legs syndrome
(difficulty sitting still in the evenings).
Irritable Bowel Syndrome - Constipation, diarrhea, frequent abdominal pain,
abdominal gas, and nausea represent symptoms frequently found in roughly 40 to
70% of fibromyalgia patients. Acid reflux or gastroesophageal reflux disease
(GERD) also occurs with the same high frequency.
Chronic headaches - Recurrent migraine or tension-type headaches are seen in
about 70% of fibromyalgia patients and can pose a major problem in coping for
this patient group.
Temporomandibular Joint Dysfunction Syndrome - This syndrome,
sometimes referred to as TMJ or TMD, causes tremendous jaw-related face and
head pain in one-quarter of fibromyalgia patients. However, a 1997 published
report indicated that close to 75% of fibromyalgia patients have a varying degree
of jaw discomfort. Typically, the problems are related to the muscles and
ligaments surrounding the jaw joint and not necessarily the joint itself.
Other common symptoms - Premenstrual syndrome and painful periods, chest
pain, morning stiffness, cognitive or memory impairment, numbness and tingling
sensations, muscle twitching, irritable bladder, the feeling of swollen extremities,
skin sensitivities, dry eyes and mouth, dizziness, and impaired coordination can
occur. Fibromyalgia patients are often sensitive to odors, loud noises, bright
lights, and sometimes even the medications they are prescribed.
Aggravating factors - Changes in weather, cold or drafty environments,
infections, allergies, hormonal fluctuations (premenstrual and menopausal states),
stress, depression, anxiety and over-exertion may all contribute to fibromyalgia
Criteria for Diagnosis
If you are devastated by symptoms of severe widespread pain and daytime exhaustion,
yet your blood tests are normal, you may have fibromyalgia syndrome or chronic fatigue
syndrome. Both are serious chronic illnesses that have specific criteria for diagnosis, but
may be overlooked. Also, you should be aware that the distinction between fibromyalgia
and chronic fatigue syndrome is quot;very fuzzy rather than sharp,quot; and up to 70% of
fibromyalgia patients meet the diagnosis for chronic fatigue syndrome.*
Fibromyalgia Syndrome (FMS)
Routine lab tests do not detect the widespread pain of fibromyalgia. Instead,
the diagnosis is made by a physical exam that takes about five minutes.
When light pressure is applied to the surface of the muscles throughout the
body, patients with fibromyalgia find this painful, especially at the tender
points used for diagnosis.
To meet the fibromyalgia criteria for diagnosis,
patients must have:
A. Widespread pain in all four quadrants of their body for a minimum
of three months
B. At least 11 of the 18 specified tender points (see diagram**)
The 18 sites used for the fibromyalgia diagnosis cluster around the neck,
shoulder, chest, hip, knee, and elbow regions. The finger pressure that must be applied to
these areas during a quot;palpationquot; exam is roughly equivalent to the amount that causes the
finger nail bed to blanch or start to become white. Over 75 other tender points have been
found to exist, but are not used for diagnostic purposes.
While many chronic pain syndromes display symptoms that overlap with fibromyalgia,
the 1990 American College of Rheumatology (ACR) multi-center criteria study
(published in the February 1990 issue of Arthritis and Rheumatism) evaluated a total of
558 patients, of which 265 were classified as controls. These control individuals weren't
your typical healthy quot;normals.quot; They were age and sex matched patients with neck pain
syndrome, low back pain, local tendonitis, trauma-related pain syndromes, rheumatoid
arthritis, lupus, osteoarthritis of the knee or hand, and other painful disorders. These
patients all had some symptoms that mimic fibromyalgia, but the trained examiners were
not foiled—they hand-picked the fibromyalgia patients out of the quot;chronically illquot;
melting pot with an accuracy of 88%. Fibromyalgia is not a wastebasket diagnosis!
Although the above diagnosis focuses on tender point count, a consensus of 35
fibromyalgia experts published a report in 1996 saying that a person does not need to
have the required 11 tender points to be diagnosed and treated for fibromyalgia (Wolfe F,
et al. J Rheumatology 23(3):534-9, 1996). This criteria was created for research purposes
and many people may still have fibromyalgia with less than 11 of the required tender
points as long as they have widespread pain and many of the commonly associated
irritable bowel (e.g., diarrhea, constipation, etc.)
sleep disorder (or sleep that is unrefreshing)
chronic headaches (tension-type or migraines)
jaw pain (including TMJ dysfunction)
cognitive or memory impairment
post-exertional malaise and muscle pain
morning stiffness (waking up stiff and achy)
numbness and tingling sensations
dizziness or lightheadedness
skin and chemical sensitivities
Overlaps with Fibromyalgia
Fibromyalgia syndrome (FMS), chronic fatigue syndrome (CFS), multiple chemical
sensitivity syndrome (MCS), myofascial pain syndrome (MPS), and other conditions
form a family of overlapping syndromes. In fact, researcher Muhammad Yunus, M.D.,
of the University of Illinois College of Medicine, claims, most patients have more than
one syndrome. Thus, he views FMS and CFS as being part of a larger spectrum of
conditions, which he calls Dysregulation Spectrum Syndrome or DSS (see diagram
below). Dr. Yunus uses the term dysregulation to mean biophysiological abnormalities,
possibly in the body's neurological, hormonal and chemical systems.
Backing up Dr. Yunus’ commentary are studies by Dedra Buchwald, M.D., of the
University of Washington, Anthony Komaroff, M.D., of Brigham and Women’s
Hospital and Don Goldenberg, M.D., of Newton-Wellesley Hospital. It is always
important to keep these overlapping syndromes in mind because the presence of one or
more syndromes could impact your treatment. These three researchers have shown that
CFS and FMS overlap in patients by as much as 75%. When it comes to MCS, this
syndrome is present in roughly 50% of FMS- and CFS-diagnosed patients.
Most practicing physicians and researchers alike will tell you that the chronic pain
diagnosis a person first receives is often colored by their chief symptom complaint. For
example, widespread muscular pain is often diagnosed by rheumatologists as
fibromyalgia syndrome. A person who is overcome by extreme fatigue and flu-like
symptoms might consult an infectious disease expert and receive the diagnosis of chronic
fatigue syndrome. A person who has severe jaw pain might see a dentist and be told that
they have temporomandibular joint dysfunction (TMJD). People who appear to have
allergic-type symptoms to a number of chemicals, foods, or odors may be informed by an
allergist that they have MCS. Similar situations occur with the other conditions in the
family of Dysregulation Spectrum Syndrome.
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Sleep Disorders in Fibromyalgia
Two common sleep disorders that may be present in fibromyalgia patients are: restless
leg syndrome (RLS) and periodic limb movement during sleep (PLMS). According to
sleep researcher Harvey Moldofsky, M.D., of the University of Toronto, RLS has been
described as someone playing soccer all night long. The patient’s arms and legs just
cannot stay still. PLMS may feel like a startling response that occurs when you think you
have reached the last step going down a flight of stairs and you fling your limbs to catch
your balance as you discover that there is one step remaining. Both RLS and PLMS can
cause continuous arousal movements during sleep and impede your ability to wake up
Referring to the specific sleep disorders of RLS and PLMS, Dr. Yunus comments that a
sleep study might be helpful if a physician suspects either condition. First of all, it may
offer an objective test finding that is lacking for most fibromyalgia patients. Secondly,
the treatment for RLS or PLMS is a benzodiazepine with anti-seizure properties such as
Klonopin (clonazepam), or a dopamine-like drug such as Mirapex or Requip. The most
commonly used medications for fibromyalgia, such as tricyclics like Elavil and
trazodone, can actually make this subgroup (30%) of patients worse. Therefore, it is
important that you assist your physician by providing accurate symptom information
regarding your sleep to help identify related syndromes. This can aid in the development
of appropriate treatment strategies.