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Dr. Maria Michailidou



Essentials of Diagnosis

Consider fibromyalgia when a patient complains of the following: Widespread pain for longer than 3 months Fatigue associated with usual daily activities Sleep disturbances Changes in personality and mood Multiple symptoms that cannot be easily explained Consider alternative explanations to a diagnosis of fibromyalgia. Conversely, if an alternate diagnosis is present, ask: "which symptoms are due to concomitant fibromyalgia?" Specifically, assess the following: Onset, location, and nature of pain, together with ameliorating and exacerbating factors Sleep quality Current and past stressors Adverse experiences during childhood, such as physical, emotional, or sexual abuse How the patient deals with the usual stresses of daily life, feelings of anxiety, and feelings of depression Presence of regional pain syndromes, such as temporomandibular joint pain, irritable bowel syndrome, and chronic pelvic pain. These disorders overlap with fibromyalgia and very frequently coexist in the same patient. Physical and neurologic examinations will be normal unless there are coexisting diagnoses.

General Considerations

Chronic pain and fatigue are extremely prevalent in the general population, especially among women and persons of lower socioeconomic status: regional pain, 20%; widespread pain, 11%; fibromyalgia by American College of Rheumatology (ACR) criteria, 3–5% in females and 0.5–1.6% in males; and chronic fatigue, ~ 20%. Fibromyalgia may develop in both children and older persons. Although there is debate about whether fibromyalgia is a discrete illness or simply the extreme end of a spectrum of pain and distress in the general population, abnormal central nociceptive processing appears to be the basis for a generalized decrease in thresholds for pain perception and pain tolerance.

The 1990 ACR classification criteria for fibromyalgia specify that widespread pain be present for longer than 3 months and that pain can be elicited by manual pressure at 11 or more defined tender points (). Not all patients have tenderness at all 11 points. Fibromyalgia frequently coexists with systemic lupus erythematosus, rheumatoid arthritis, and other systemic disorders. In addition, fibromyalgia overlaps with chronic fatigue syndrome, irritable bowel syndrome, and multiple other regional pain syndromes. Associated psychiatric conditions, especially depression, anxiety, and personality disorders, are prevalent.  

In assessing patients with fibromyalgia, a detailed social and behavioral history, identification of current and past stressors, and recognition of depression are essential. The physician should validate the patient's complaints. Therapy combines pharmacologic treatment of pain, depression, and sleep disturbances with nonpharmacologic approaches, including education, graded aerobic exercise, and promotion of self-efficacy for control of pain through self-management, rather than health care–seeking behavior. The therapeutic goal is care not cure.


The precise etiology and pathogenesis of pain in fibromyalgia is currently unknown. Nevertheless, a clinically useful conceptual basis for understanding the nature of pain is provided by the International Association for the Study of Pain definition: pain is "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." The pain experience involves simultaneous parallel processing of sensory-discriminative elements of nociception (twisting your ankle), afferent input from somatic reflexes (sweating, heart rate acceleration), and major contributions from pathways and regions of the brain concerned with cognitive (is my ankle broken?) and emotional aspects of pain. Collectively, these determine the subjective intensity of pain. Negative psychological factors (depression and anxiety, loss of control, unpredictability in one's environment) and certain cognitive aspects (negative beliefs and attributions, catastrophizing) amplify perceived pain. The principal effectors of the stress response system (hypothalamic-pituitary-adrenocortical axis and the sympathetic nervous system) become activated in pain states, as well. Normally adaptive, the stress response may become maladaptive in chronic pain syndromes, thereby contributing to diffuse aching pain, fatigue, poor sleep, low mood and anxiety, and "flu-like" illness.

Psychological variables clearly operative in fibromyalgia include pain beliefs and attributions; hypervigilance (expectancy); active and passive coping strategies; perceived self-efficacy for pain control; mood, depression, and anxiety; personality traits and disorders; and pain behaviors. Certain environmental and sociocultural variables also contribute to chronic diffuse pain, such as a history of poor health in parents; parental pain history; poor family environment; and childhood abuse, particularly sexual abuse. Other environmental and sociocultural variables that can serve to perpetuate symptoms in fibromyalgia include lack of spousal and family support, poor work environment and job dissatisfaction, focus on definable causes, media hype, primary and secondary gain, diagnostic "waffling" and inappropriate diagnostic testing, and prescription of long courses of physical therapy by well-meaning physicians.

Clinical Findings

Symptoms and Signs

The hallmark of fibromyalgia is widespread pain (above and below the waist, both sides of the body) for longer than 3 months. Pain is described as "exhausting,""miserable," or "unbearable" and diffusely radiates from the axial skeleton over large areas of the body, primarily in muscles. Arthralgias may be present together with a subjective sense of joint swelling, which is not confirmed by physical examination unless another coexisting rheumatic disease is present. Morning stiffness may be prominent. The patient may complain that a light touch by the spouse or even a breeze is unpleasant (allodynia, defined as pain with stimulation that should not be painful). The skin may "burn." Nondermatomal paresthesiaes are common.

Regional pain syndromes, such as headache, temporomandibular joint pain, irritable bowel syndrome, and chronic pelvic pain overlap with fibromyalgia and very frequently coexist in the same patient. Indeed, the diagnostic label applied often is determined by which specialist the patient sees first.

Marked fatigue with usual activities is almost universal and may dominate the clinical picture. As with diffuse pain, physical and laboratory examinations fail to define abnormal findings other than deconditioning. Associated symptoms are subjective muscle weakness not confirmed by loss of muscle power or elevated creatinine kinase levels, hypersomnolence during the day, and exhaustion after mild exercise. Pain and fatigue may be intermittent, with "good days and bad days." On good days, the patient may overexert herself or himself, for example, with an exercise routine, with consequent flare in pain and fatigue. Exercise often is feared and avoided.

Poor sleep almost always is present, and the patient awakens unrefreshed. Specific sleep abnormalities may be demonstrable, particularly -wave intrusion into slow -wave non-REM sleep, restless legs syndrome, and sleep apnea. Formal sleep testing should be sought in patients whose sleep does not improve with hypnotics and proper sleep hygiene.

Current and past stressors and adverse experiences should be explored. Persons with fibromyalgia often carry a huge psychological burden of stress and distress that may precede chronic pain.

Patients often report difficulty dealing with the usual stresses of daily life, feelings of anxiety, and feelings of depression. A majority of patients have current or lifetime depression. Recognition of mood disorders, anxiety, and insomnia is the essential first step in developing approaches for improving chronic pain and fatigue.

Reporting of multiple symptoms that cannot be explained ("diffusely positive" review of systems) is very common. Many patients meet the criteria established in the fourth edition of the Diagnostic and Statistical Manual for Mental Disorders for somatoform disorder (When physical and neurologic examinations are normal, it is important that the physician not pursue unnecessary diagnostic laboratory or imaging evaluations for each symptom. Conversely, it should be recognized that fibromyalgia and somatiform disorders are extremely common in primary care, and therefore frequently coexist with other significant illnesses. Optimum care requires recognition and treatment of both fibromyalgia and any comorbid illnesses present.  

Cognitive impairment ("fibro-fog") manifests as difficulty finding the right word, decreased short-term memory, forgetting names, or difficulty concentrating and is extremely common. In some cases, this is exacerbated by central effects of psychotropic medications.

Many patients exhibit functional impairment in multiple activities of daily living, such as performing household chores, shopping, or working an 8-hour day.

Patients with fibromyalgia suffer frustration with respect to their perceived poor states of health and the apparent inability of the medical profession to help them.

Patients with fibromyalgia often have fixed beliefs that minor traumatic events, viruses (Epstein-Barr), chemical sensitivities ("sick building syndrome"), or other physical agents (silicone breast implants, "black mold") caused their illness. Such false beliefs not infrequently lead to litigation and can be a barrier to recovery.

The physician should be aware of pending litigation regarding causation of fibromyalgia, disability determination, or worker's compensation claims because therapy will be fruitless until such issues are resolved.

Laboratory Findings

There are no characteristic laboratory findings in fibromyalgia. The results of routine testing are normal unless a coexisting or alternative diagnosis is present. Additional laboratory tests are unnecessary unless there is a specific indication from the history and physical examination. Antinuclear antibodies, complete blood cell count, erythrocyte sedimentation rate, C-reactive protein levels, urine dipstick, thyroid-stimulating hormone levels, creatine kinase, aspartate aminotransferase, and alanine aminotransferase are useful screening tests for autoimmune diseases, hematologic problems, systemic inflammatory states, hypothyroidism, myopathies, and occult liver disease. Illnesses in these categories can present with chronic pain and fatigue.


Much of the current treatment of fibromyalgia is empiric, based on proposed rather than on established models of pathophysiology. Pain, poor sleep, low mood and depression, anxiety, and fatigue usually are amenable to pharmacologic therapy, but the treatment plan should be multifaceted, incorporating pharmacologic, physical, psychological, and behavioral approaches. The goal is palliation of symptoms, not cure.

Special approaches are required for treatment of diffuse pain in older persons and in children. Most common in preadolescent to adolescent girls, unexplained diffuse or localized pain is associated with incongruent affect disproportional dysfunction. Psychological distress in the child or the family is common. Elements of therapy include discontinuation of all medications, a psychological evaluation and psychotherapy if necessary, and a program of intense exercise. Most children do well.