Synonyms: FM, fibromyalgia syndrome (FMS), fibrositis
Fibromyalgia is a chronic pain disorder. The cause of fibromyalgia is unknown, but there is some evidence for a genetic predisposition, abnormalities in the stress response system or hypothalamic-pituitary axis, and possible triggering events.
- It is thought that the condition is common and underdiagnosed.
- The estimated prevalence in North America and Europe is as high as 5.8%.
- Women are 10 times more commonly affected than men.
- Usual age of presentation is 20-50 years but it has been diagnosed in children, adolescents and older people.
- There is a link to failing to complete education, low income, female sex and being divorced.
- The exact pathophysiology is not known. Hypotheses include:
- Peripheral and central hyperexcitability at spinal or brainstem level.
- Altered pain perception.
- The nociceptive system has links with the stress regulating, immune and sleep systems which may explain some of the clinical features.
- Genetic and environmental factors may play a role in fibromyalgia as it is more common in the relatives of affected patients.
Symptoms of fibromyalgia are chronic widespread pain associated with unrefreshing sleep and tiredness. Fibromyalgia is not a diagnosis of exclusion and often occurs in patients with other conditions, such as inflammatory arthritis and osteoarthritis.The patient may complain of:
- Pain at multiple sites. Low back pain with/without radiation to the buttocks and legs and pain in the neck and across the shoulders are common complaints.Patients may complain of "pain all over".
- Sleep disturbance (sleep may exacerbate symptoms and contribute to depression).
- Morning stiffness.
- Feeling of swollen joints (with no objective swelling).
- Problems with cognition (eg, memory disturbance, difficulty with word finding).
- Headaches (may be migrainous).
- Light-headedness or dizziness.
- Fluctuations in weight.
- Anxiety and depression.
Symptoms are generally reported as worse in cold, humid weather and under times of stress.
- This is clinical. The American College of Rheumatology has produced classification criteria for fibromyalgia. However, these criteria are not meant to be used for diagnosis. Features include:
- Widespread pain involving both sides of the body, above and below the waist as well as the axial skeletal system, for at least three months; AND
- The presence of 11 tender points among the nine pairs of specified sites (18 points) as shown in the diagram.
- Digital palpation using the thumb should be carried out to assess tenderness at these sites. The pressure applied should be just enough to blanch the examiner's thumbnail (approximately 4 kg/cm2). In someone without fibromyalgia, this would not be enough pressure to cause pain.
- Routine blood testing can help to exclude other differential diagnoses: eg, ESR, TFTs, antinuclear antibodies. However, be careful not to over-investigate.
- The Fibromyalgia Impact Questionnaire can be used to assess function (see link in 'Further reading & references' at the end of this article). It also has a role in review and assessment of treatment interventions.
- A full social, personal, family and psychological history should be taken. There may be an interplay with stress, psychosocial experiences, the psychosocial situation and sociocultural factors.
- Generalised anxiety.
- Irritable bowel syndrome.
- Irritable bladder.
- Premenstrual syndrome.
- Restless legs syndrome.
- Non-cardiac chest pain.
- Temporomandibular joint pain.
- Raynaud's phenomenon.
- Sicca syndrome (dryness of the eyes, mouth and other body parts).
- Rheumatoid arthritis: approximately 25% of patients with rheumatoid arthritis also have fibromyalgia.
- Systemic lupus erythematosus (SLE): approximately 50% of patients with SLE also have fibromyalgia.
- Chronic fatigue syndrome.
- Polymyalgia rheumatica.
- Inflammatory and metabolic myopathies.
The aim of treatment is not to cure fibromyalgia but to reduce symptoms and improve quality of life. Individual drugs are often ineffective or cause side-effects so it is important to consider a change in drug or a switch to non-drug approaches - eg, cognitive behavioural therapy or exercise.
- Pain and function should be assessed in a psychosocial context.
- A multidisciplinary approach to treatment should be used. GPs, rheumatologists, physicians experienced in dealing with chronic pain, psychologists, psychiatrists, physiotherapists, etc, may all need to be involved.
- Treatments should be discussed with the patient and tailored to their individual needs, including pain levels, function and associated features such as depression, fatigue and sleep disturbance.
- Exercise programmes including aerobic exercise and strength training may help some patients with fibromyalgia. The programmes should be tailored to the individual. (This recommendation is mostly based on expert opinion in the EULAR guidelines due to poor-quality trials.) The Ottawa Panel also recommends aerobic fitness and strengthening exercise for the management of fibromyalgia.[9, 10]
- A Cochrane review reports 'gold-level evidence' that moderate-intensity supervised aerobic exercise improves overall well-being and physical function in fibromyalgia.From a practical point of view, they recommend:
- Slowly increasing the intensity of exercise.
- If symptoms worsen, cutting back on exercise until symptoms improve.
- There is some evidence that aquatic training is beneficial for improving wellness, symptoms, and fitness in adults with fibromyalgia.
- Moderate to high intensity resistance training may improve function, pain, tenderness, and muscle strength in women with fibromyalgia.
- Cognitive behavioural therapy may help some patients with fibromyalgia.
- Therapies including relaxation, rehabilitation, physiotherapy and psychological support may help some people with fibromyalgia.
- There is some evidence that acupuncture improves pain and stiffness and that the effect of acupuncture does not differ from sham acupuncture in reducing pain or fatigue, or improving sleep or global well-being.
- Paracetamol, weak opioids and tramadol can be used for the management of pain.However, care should be taken with tramadol because of possible opiate withdrawal symptoms and the potential for abuse and dependance.
- Corticosteroids and strong opioids are not recommended. This is due to the lack of evidence from clinical trials and the long-term side-effects.
- Can help to reduce pain and improve function.
- A meta-analysis in 2009 reported strong evidence for the effectiveness of antidepressants for pain, depressed mood, sleep disturbance and 'quality of life' scores in mainly short-term studies.The tricyclics were best for pain and selective serotonin reuptake inhibitors (SSRIs) for low mood. Although the evidence is strong, the effect of antidepressants is quite small. There was no effect on fatigue.
- Venlafaxine appears to be at least modestly effective in treating fibromyalgia.
- The serotonin and norepinephrine reuptake inhibitors (SNRIs) duloxetine and milnacipran may provide a small benefit in reducing pain.
- Pregabalin and gabapentin have shown a small benefit in reducing pain and sleep problems.[19, 20]
Other points concerning treatment
- Acupuncture has not been shown to be of benefit in a systematic review.
- Patient education is also thought to be important.
- Awareness surrounding fibromyalgia has risen in recent years.
- Fibromyalgia continues to be associated with substantial socio-economic loss.
- It is difficult to predict the prognosis of fibromyalgia, due to the complex interplay of the social and psychological factors in the pathophysiology and symptomology of this condition.
Further reading and references
EULAR revised recommendations for the management of fibromyalgia; European League Against Rheumatism (2017)
Fibromyalgia Impact Questionnaire; Fibromyalgia Information Foundation
Fitzcharles MA, Ste-Marie PA, Pereira JX; Fibromyalgia: evolving concepts over the past 2 decades. CMAJ. 2013 Sep 17185(13):E645-51. doi: 10.1503/cmaj.121414. Epub 2013 May 6.
Chakrabarty S, Zoorob R; Fibromyalgia. Am Fam Physician. 2007 Jul 1576(2):247-54.
Hauser W, Bernardy K, Uceyler N, et al; Treatment of fibromyalgia syndrome with antidepressants: a meta-analysis. JAMA. 2009 Jan 14301(2):198-209.
Buskila D, Sarzi-Puttini P; Biology and therapy of fibromyalgia. Genetic aspects of fibromyalgia syndrome. Arthritis Res Ther. 20068(5):218.
Rahman A, Underwood M, Carnes D; Fibromyalgia. BMJ. 2014 Feb 24348:g1224. doi: 10.1136/bmj.g1224.
Bigatti SM, Hernandez AM, Cronan TA, et al; Sleep disturbances in fibromyalgia syndrome: relationship to pain and depression. Arthritis Rheum. 2008 Jul 1559(7):961-7.
Hauser W, Bernardy K, Arnold B, et al; Efficacy of multicomponent treatment in fibromyalgia syndrome: a meta-analysis of Arthritis Rheum. 2009 Feb 1561(2):216-24.
Brosseau L, Wells GA, Tugwell P, et al; Ottawa Panel evidence-based clinical practice guidelines for aerobic fitness exercises in the management of fibromyalgia: part 1. Phys Ther. 2008 Jul88(7):857-71. Epub 2008 May 22.
Brosseau L, Wells GA, Tugwell P, et al; Ottawa Panel evidence-based clinical practice guidelines for strengthening exercises in the management of fibromyalgia: part 2. Phys Ther. 2008 Jul88(7):873-86. Epub 2008 May 22.
Busch AJ, Barber KA, Overend TJ, et al; Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev. 2007 Oct 17(4):CD003786.
Bidonde J, Busch AJ, Webber SC, et al; Aquatic exercise training for fibromyalgia. Cochrane Database Syst Rev. 2014 Oct 2810:CD011336. doi: 10.1002/14651858.CD011336.
Busch AJ, Webber SC, Richards RS, et al; Resistance exercise training for fibromyalgia. Cochrane Database Syst Rev. 2013 Dec 2012:CD010884. doi: 10.1002/14651858.CD010884.
Bennett R, Nelson D; Cognitive behavioral therapy for fibromyalgia. Nat Clin Pract Rheumatol. 2006 Aug2(8):416-24.
Deare JC, Zheng Z, Xue CC, et al; Acupuncture for treating fibromyalgia. Cochrane Database Syst Rev. 2013 May 315:CD007070. doi: 10.1002/14651858.CD007070.pub2.
Uceyler N, Hauser W, Sommer C; A systematic review on the effectiveness of treatment with antidepressants in fibromyalgia syndrome. Arthritis Rheum. 2008 Sep 1559(9):1279-98.
VanderWeide LA, Smith SM, Trinkley KE; A systematic review of the efficacy of venlafaxine for the treatment of fibromyalgia. J Clin Pharm Ther. 2014 Oct 8. doi: 10.1111/jcpt.12216.
Hauser W, Urrutia G, Tort S, et al; Serotonin and noradrenaline reuptake inhibitors (SNRIs) for fibromyalgia syndrome. Cochrane Database Syst Rev. 2013 Jan 311:CD010292. doi: 10.1002/14651858.CD010292.
Uceyler N, Sommer C, Walitt B, et al; Anticonvulsants for fibromyalgia. Cochrane Database Syst Rev. 2013 Oct 1610:CD010782. doi: 10.1002/14651858.CD010782.
Wiffen PJ, Derry S, Moore RA, et al; Antiepileptic drugs for neuropathic pain and fibromyalgia - an overview of Cochrane reviews. Cochrane Database Syst Rev. 2013 Nov 1111:CD010567. doi: 10.1002/14651858.CD010567.pub2.
Mayhew E, Ernst E; Acupuncture for fibromyalgia--a systematic review of randomized clinical trials. Rheumatology (Oxford). 2007 May46(5):801-4. Epub 2006 Dec 19.
Rooks DS, Gautam S, Romeling M, et al; Group exercise, education, and combination self-management in women with fibromyalgia: a randomized trial. Arch Intern Med. 2007 Nov 12167(20):2192-200.
Busse JW, Ebrahim S, Connell G, et al; Systematic review and network meta-analysis of interventions for fibromyalgia: a protocol. Syst Rev. 2013 Mar 132:18. doi: 10.1186/2046-4053-2-18.