is it and how do we treat it?
Geoff Littlejohn (reprinted with permission from
Australian Family Physician)
Summary of important points
- Fibromyalgia is a term applied to a subset of the population
[3-5%] who have pain and abnormal tenderness, which is not due
to tissue damage.
- Fibromyalgia has been subject to significant scientific scrutiny
with over 1000 publications in peer-reviewed journals published
in the last ten years
- The tender point sites are reliable and clinically useful sites
for assessment of lowered pain threshold, the key feature of
- Many fibromyalgia patients are emotionally distressed or react
to stress in an adverse way.
- Organic conditions can mimic fibromyalgia and fibromyalgia
can occur with organic conditions.
- The majority of patients are best treated with education, aerobic
exercise and stress management with an expected good outcome.
- Fibromyalgia is a relatively common
- Fibromyalgia is best managed in the
primary care setting
- Depression is
not a cause of fibromyalgia but it may be a consequence of
the chronic pain and disability that accompanies disorder
- Common musculoskeletal pain syndrome paradigms
- Overlapping syndromes
- Where does fibromyalgia fit in?
- What is a tender point?
- Symptoms and signs in fibromyalgia
Fibromyalgia is a chronic musculoskeletal disorder
that is characterised by widespread pain, exquisite tenderness
at multiple anatomical sites, and other clinical manifestations
such as fatigue and sleep disturbance. It primarily affects women.
Chronic widespread musculoskeletal pain occurs in approximately
10% of the population and chronic regional pain in about 20-25%
. Fibromyalgia is a term applied to a subset of this population
who have pain and abnormal tenderness, which is not due to tissue
pain syndrome paradigms
From a simple perspective one can specify two types of chronic musculoskeletal
pain syndromes those that involve pain generation and those that
involve pain amplification .
Myofascial pain syndrome is a term that refers to pain arising
from muscle. This syndrome is characterised by taught palpable bands
in muscle, usually around the mid-belly area, which in turn contain areas,
which are exquisitely tender to palpation. These are known as trigger
points. Pressure on this site leads to pain which is familiar to the
patient. These problems are usually related to chronic postural strain
or muscle injury and are particularly prevalent around the neck/trapezius
area and low back/ buttock region.
Segmental spinal dysfunction syndromes relate to pain generated
in deep tissues around the spine. These syndromes are characterised by
change in function of the relevant spinal segment with restriction in
range of motion, localised tenderness on deep palpation around the spine
and abnormal resistance on movement of that segment. An example is a
stiff neck, which might be present when one awakens in the morning. The
pain generated by the deep spinal tissues is referred to the surface
giving rise to pain and tenderness in the muscles and skin, which relate
to that spinal segment. The segmental symptoms and signs are due to referred
reflex mechanisms and not due to neural entrapment or dysfunction.
Pain amplification syndromes include fibromyalgia, which usually
indicates widespread pain accompanied by widespread lowering of pain
A variation on fibromyalgia is regional pain
syndrome where there is pain and abnormal tenderness typically
in a quadrant of the body, say in the neck/ shoulder/ arm area, for example.
Synonyms include localised fibromyalgia or regional fibromyalgia.
Complex regional pain syndrome indicates more significant pain
amplification, which may be segmental or affect a more limited area such
as the wrist/ hand or lower leg/foot. Synonyms include reflex dystrophy
syndrome and algodystrophy, among a host of others.
The above terms are not mutually exclusive. Patients with fibromyalgia
may have regional muscle tenderness fulfilling criteria for myofascial
pain syndrome. Patients with initial segmental spinal dysfunction may
develop amplified pain causing a regional pain syndrome. The point of
these terms is to identify predominant mechanisms, which contribute to
the patients pain and hence, hopefully, lead to appropriate management.
For instance, simple physical therapy is useful for segmental spinal
dysfunction but when significant pain amplification occurs additional
or alternative management approaches will be needed.
Unfortunately, many of these paradigms, although discussed with vigour
in the literature and acting as a base for a host of specific therapies,
from manipulative treatment through to acupuncture, do not have well
validated and reliable classification criteria. This does not mean the
relevant paradigm is not useful clinically but it does significantly
hinder appropriate evidence-based assessment.
Where does fibromyalgia
Fibromyalgia has been subject to significant scientific scrutiny with
over 1000 publications in peer-reviewed journals published in the last
ten years this term has now been accepted by peak bodies such
as the World Health Organisation, the International Association for the
Study of Pain and most national rheumatology groups . The study of
this disorder has been enhanced by development of classification criteria
by the American College of Rheumatology, which essentially link the presence
of chronic widespread pain to the presence of a large number of abnormally
tender sites at predesignated regions in the body . These are termed tender
points. Use of these classification criteria has shown that between
2-4% of people in industrial societies have fibromyalgia. However, there
is nothing magical about defining this group of individuals. Chronic
pain and tenderness occur as a continuum in the population and these
criteria merely pick out the top 2-4% of the population who have abnormal
tenderness with pain [5, 6]. Nevertheless, it is patients at this end
of the spectrum that have significant symptoms and disability associated
with their chronic disorder.
What is a tender point?
The term tender point relates to areas in the body, which have been found
by empirical observation to be more sensitive to gentle palpation than
surrounding regions . Typical examples include the mid-trapezius point,
the area adjacent to the insertion of the common extensor muscles to
the lateral epicondyle or the medial fat pad of the knee [Figure 1].
If palpation of these regions with a force of around 4kg/sq cm (equating
to blanching of the thumb or fingernail) induces pain, then this site
is called a tender point. The tender point region is histologically normal
as the problem derives from abnormal sensitivity of pain nerves in that
area. It is important to be aware that areas between the tender points
also have abnormal lowering of pain threshold and hence are abnormally
tender in those with fibromyalgia when compared to those without fibromyalgia
. The tender point sites are reliable and clinically useful sites
for assessment of lowered pain threshold, the key feature of fibromyalgia.
1: Clinically useful sites for evaluating tenderness.
sites are more sensitive to palpation than adjacent sites
in pain-free individuals and significantly more sensitive
in patients with widespread pain when they are termed tender
points. Regional pain syndromes are associated with increased
sensitivity in tender points located within the painful region.
Figure with permission G. Littlejohn.
Symptoms and signs
Most patients with fibromyalgia have a fluctuating set of symptoms occurring
over many months or years with variable degrees of pain and muscular
stiffness [7, 9]. These symptoms may vary according to weather change,
emotional distress or physical activity. Patients often feel quite fatigued,
which also varies in severity, and often sleep poorly wakening unrefreshed
in the mornings. Many are emotionally distressed or react to stress in
an adverse way. As such, fibromyalgia is often associated with other
stress-related changes in function . These are displayed in the Table
Table 1: Associated
disorders in fibromyalgia syndrome
- Cognitive dysfunction common
- Dizziness common
- Chronic fatigue syndrome common
- Irritable bowel syndrome 60%
- Irritable bladder syndrome 50%
- Multiple chemical sensitivities 50%
- Restless legs syndrome 30%
- Cold intolerance 30%
- Neurally-mediated hypotension 15%
Apart from the sign of widespread tenderness,
which affects a variety of tissues, patients will also demonstrate
the sign of dermatographia where lightly stroking the skin over
the upper back with the fingernail, will induce a very brisk wheal
and flare response, usually visualised within 10 seconds . This
reaction is mediated by release of neuropeptide chemicals from
the activated pain nerve fibres in the skin of fibromyalgia patients.
These substances cause rapid vasodilatation and localised oedema.
Patients also complain of regional swelling, perhaps with tightening
of rings in the morning or puffiness around ankle or other areas
of pain. Muscles are often quite tight and spinal examination reveals
limited range of motion of spinal segments. Importantly, examination
does not reveal evidence of inflammation, degenerative change,
abnormal neurology or a systemic process, which could explain the
distribution of symptoms and signs found. Conversely, this is not
to say that patients with other organic conditions cannot develop
fibromyalgia, as they commonly do. Where a patient presents with
a widespread pain, fatigue and abnormal tenderness through the
body a diagnosis of fibromyalgia is usually easily elicited. However
there are a number of red flags that need to be considered and
these are listed in theTable 2. If present search for other abnormalities
needs to follow.
Table 2: Red flags that might indicate a more sinister process
- Weight loss
- Night pain
- Focal pain
- Neurological signs
How is fibromyalgia
The essential features are widespread pain accompanied by widespread
abnormal tenderness. Palpation of tender point sites aids this assessment.
Careful consideration of other disorders requires a full history and
examination and careful investigation profile which might include full
blood examination, erythrocyte sedimentation rate, thyroid function,
creatine kinase, routine biochemistry, calcium, rheumatoid factor, and
antinuclear antibodies. Other tests and imaging may be required according
to the clinical features. The important points are firstly, that organic
conditions can mimic fibromyalgia and secondarily, that fibromyalgia
can occur with organic conditions . Top of Page
Current evidence indicates fibromyalgia is due to abnormal
sensitivity of the pain nerve system [7,12,13]. This sensitisation,
which enables subthreshold stimuli to induce pain nerve impulses,
occurs predominantly within the spinal cord and more proximally.
This leads to the abnormal tenderness as well as the secondary
muscular tightness in peripheral and spinal regions. In addition,
the nerves subserving proprioception, the mechanoreceptors, also
function abnormally through their interaction with the sensitised
deep pain transmission neuron system in the dorsal horn of the
spinal cord. Through this process normal movement, such as posture
and exercise will generate pain through the A-beta mechanoreceptor
fibre system. This is of course despite there being no tissue damage
in the area. This is called mechanical allodynia and is a feature
The cause for the increased central sensitisation of the pain system
is still unclear but likely relates to abnormal activation of the stress
axis with change in hypothalamic-pituitary-adrenal function, hormone
profiles, and sympathetic nervous system efferent activity.
Fibromyalgia may be triggered by a number of events, which can include
a physically mild, but frightening injury. Infection, more likely an
unusually named viral infection rather than everyday common upper respiratory
infection, may trigger fibromyalgia. Many patients identify stress as
a specific precipitator. In other cases stress is deemed to be in the
environment of patients with fibromyalgia more commonly than those without.
Importantly, stress may relate to another chronic illness such as inflammatory
joint disease, lupus or chronically painful disorders such as degenerative
neck or back pain. Pain in itself activates the stress response.
Depression is not a cause of fibromyalgia but it may be a consequence
of the chronic pain and disability that follows this disorder. There
is an increased prevalence of diagnosis of anxiety and depression in
patients who have fibromyalgia compared to persons with fibromyalgia
who are not attending doctors or therapists . Top
When considering treatment options, it is useful to think
of fibromyalgia as being either simple or complex [12, 15, 16].
Simple fibromyalgia relates to a patient with mild to moderate
symptoms usually occurring after an identifiable trigger and with
good family and emotional support and reasonably good coping skills.
There may be poor sleep, change in muscle fitness or a recent illness
triggering the problem. These patients are best treated with education
in regard to the nature of the problem, advice on aerobic exercise
program and advice regarding stress management with the expected
outcome being very good.
In contrast, complex fibromyalgia indicates patients who have persisting
stress, significant psychological trauma, those with poor coping skills
or significant lack of understanding of the nature of the problem. Onset
after injury is common and often reflects many of the previous situations.
Complex fibromyalgia patients often have a poor outcome, at least in
the short term. They may need an interdisciplinary approach with significant
psychological input. Such patients are often involved in the validation
of their symptoms, particularly where medicolegal, compensation or safety
net issues are involved.
Who should look
Fibromyalgia is best managed in the primary
care setting where the family doctor is familiar
with the patient, their family and the nature of
stressors and previous reactions to such problems
. The family doctor may be well aware of risk
factors, so-called yellow flags, for the development
of fibromyalgia (see Table 3). If such risk factors
are present the family doctor may intervene with
counselling early in the course of any new set
of symptoms, hopefully decreasing the development
of the syndrome with this approach.
Table 3: Risk factors (yellow flags) for fibromyalgia
- Positive family history
- Previous pain syndrome
- Medical condition causing prognostic concern, e.g. SLE or RA
- Current community pain epidemic with perceived environmental
- Pain - related work predicament
- Spine injury
- Poor coping skills
- Difficult life predicament
- Past or present depression/anxiety
- Persisting post-viral symptoms
- Sleep disturbance
- Significant emotional distress Top of Page
- Cognitive behavioural therapy
- Which analgesics / psychotropics are best?
- Overview of management
The role of education is to validate the patients symptoms. An
explanation as to the nature of the problem is provided. Some doctors
prefer not to use the F-word, fearing that labelling patients with fibromyalgia
may make them more prone to chronic pain behaviour. Recent studies have
shown that this is not the case. The majority of patients are empowered
with the diagnosis of fibromyalgia, assuming they understand the essential
nature of the disorder, which it is a pain sensitisation problem and
the problem is not due to tissue damage or injury. This diagnosis emphasises
the non-destructive nature of the problem, focuses on appropriate self-management
and not necessarily a magic cure of the disorder and focuses on improving
health and wellness rather than focusing on illness and disability.
Low-level aerobic exercise increasing gradually in intensity is almost
always of value in fibromyalgia. The key is to start low and built up
slowly. Perhaps taking three times longer to achieve fitness compared
to a normal non-fibromyalgic patient who is unfit. The biggest issues
remain those of exercise tolerance, compliance and adherence to prescription.
Exercise should be regarded as a drug and the doctor should be checking
on exercise participation characteristics regularly when a patient is
reviewed. Exercise is more beneficial if pain control can be introduced
some time before an exercise program starts. Stretching exercises by
themselves are also helpful and may be useful when combined with relaxation
programs such as in yoga, tai chi or more complex interactive techniques
such as Feldenkrais. Many patients with fibromyalgia develop regionalised
tightness around spinal areas, which can be helped significantly through
these techniques thus decreasing pain generation, and as well the relaxation
component of these treatments decreases pain amplification.
Other patients may gain help from more physically demanding passive physical
treatments but these should be regarded as an adjunct to the overall
program rather than being a primary program in themselves.
This type of therapy has been shown to be extremely beneficial in fibromyalgia.
It is a program designed to teach patients techniques to reduce their
symptoms, to increase coping strategies and to identify and eliminate
maladaptive illness behaviour. The benefit of this approach is seen in
many chronic illnesses. Such programs depend very much on the therapist
providing the input and just like physiotherapy there is
no one universal prescription of this type of approach.
It is recommended that the general practitioner should build a network
of health care providers who understand the concept of central sensitivity
in fibromyalgia and can provide appropriate management input. These may
be physical therapists of various types to supervise the exercise program
and provide other physical advice, occupational therapists who may provide
advice on sleep disturbance, fatigue management skills and simple relaxation
therapy or psychologists who might provide advice on cognitive-behavioural
therapy approaches. Communication is essential between therapists and
the family doctor.
Which analgesics /
psychotropics are best?
Simple analgesics are helpful in many patients, but not all. Paracetamol
up to 4 gm/day, although a recommended basic strategy, is not often followed
by the patient. In general, opioid medication is not favoured as these
drugs may aggravate the fogged thinking and bowel disturbance that many
fibromyalgia patients have and the opioids are not particularly specific
for the type of pain mechanism involved in fibromyalgia.
Fibromyalgia is not a neuropathic pain in that there is no damage to
peripheral nerves such as in diabetic neuropathy. Hence, various anti-convulsant
medications, membrane stabilisers and similar drugs are of limited use
in this disorder.
The change in central pain control associates with decreased serotonin
levels, increased substance P and other neuropeptide change.
Low dose tricyclic medication such as Amitriptyline or Nortriptyline
in 10-30 mg in the mid-evening some hours before bedtime does help around
30-40% of people, if tolerated. The key is to use very low doses and
build very slowly.
The selective serotonin re-uptake inhibitors have not proven as useful
as was hoped in this disorder . Certainly if depression is present
these drug may be required.
Some patients respond more to the centrally acting adrenergic agonists
for fatigue and pain, such as Venlafaxine.
Overview of management
Management should be flexible. Some patients will respond best to simple
physical therapy to loosen tight spinal muscles, others will require
medication for their sleep disturbance whilst others still will gain
benefit from an exercise program. Some require all of these techniques
or others again. Fibromyalgia is a syndrome and there is no one universal
management approach. All patients require an individual assessment and
treatment strategy. Top of Page
The question of management of complex fibromyalgia and
its relationship to injury and disability requires a much longer
discussion than is available here [18, 19]. Suffice to say that
exiting the safety net system as soon practical best helps many
patients with fibromyalgia in this setting. However herein lies
the problem. Although it is important to reassure such patients
that in the long run the potential for improvement remains good,
this potential may not be realised while they are still subject
to deliberations regarding causal issues. When these issues have
been finalised to the satisfaction of the patient the fibromyalgia
invariably improves. If these problems are not finalised to their
satisfaction or if significant maladaptive chronic pain behaviour
has ensued in the process then longer-term symptoms may follow.
It is important to remind patients that there are not hospitals
full of fibromyalgia sufferers and the majority of post-injury
fibromyalgia patients are able to return to viable household,
recreational and work activity, albeit sometimes modified. The
provision of disability support in such settings should be carefully
considered. It is best to know the patient and their fluctuations
in symptoms for several months before providing definitive statements
on longer-term outcome, which might dictate that patients
behaviour and symptoms for a long time to come. Top
Fibromyalgia is a relatively common disorder. It exists
on a spectrum blending with normal physiological responses on
one axis and abnormal psychological response to stressors on
another axis. Many doctors do not choose to use the F-word to
describe this clinical syndrome but it is important to recognise
the problem for what it is . The disorder is one of pain
amplification due to increased sensitivity of the pain system.
Fibromyalgia links with other sensitivity syndromes, often stress-associated,
and management needs to flexible and holistic, focussing on patients'
wellness while keeping a close eye on markers of disability. Top
Case Study 1: Simple fibromyalgia
Mary H is age 47 and presents with a history of eight years of aching
and pain around the neck/shoulder girdle area and low back/hip/buttock
region. The aching is described as deep, discomforting and burning in
quality. She has tried various physical therapies over a number of years,
with simple physiotherapy being the most helpful. She has an older husband
age 57 and a 12-year-old daughter who provide significant stress to her.
She sleeps somewhat poorly and expresses concern regarding the situation
and where she is heading. She has discussed the issue with her friends
and wonders if she has fibromyalgia.
Examination shows widespread tenderness on gentle palpation around the
neck, chest wall, upper back, upper outer buttocks, trochanteric and
inner fat pad of knee region. Other areas are also more tender than expected.
She has mild dermatographia over the upper back, some trigger points
through the mid trapezius area and tight cervical spine. General examination
is unremarkable. There is no muscle wasting, normal range of motion in
peripheral joints, no evidence of degenerative or inflammatory arthritis
and no neurological abnormality.
A diagnosis of fibromylagia is made. A routine screen of investigations,
to ensure there is no occult underlying problem, includes normal full
blood examination, ESR, liver function and routine biochemistry, thyroid
function, calcium, creatinine kinase, anti-nuclear antibody and rheumatoid
The diagnosis is confirmed. Advice is given in regard to the nature of
the problem. Simple self-help strategies are emphasised with an aerobic
exercise program, some relaxation therapy, suggestion to consider tai
chi or yoga, advise to consider the Arthritis Foundation Self-Management
Program and the suggestion of a referral to a Feldenkrais practitioner
to improve postural awareness around the neck and low back.
One month later Mary reports improvement in symptoms but she is still
sleeping poorly. A trial of low dose Amitriptyline does not help. Referral
to a clinical psychologist for some simple cognitive behavioural therapy
is followed by further improvement in symptoms.
Case Study 2: Complex fibromyalgia
Jane aged 35, presents for her monthly Workcover certificate. She has
been off for one year following pain in the neck/shoulder area, which
came on following a strain when she was doing more overtime on the checkout
machine. Her right neck/chest wall/arm remain tender and sore with restricted
movements. She is not able to do her normal job. She has tenderness in
other areas around the left shoulder girdle and arm and now also in the
low back and buttocks.
After some micromanagement problems at work she has been able to get
into a modified work situation and is feeling more satisfied and confident
about her future. She is slowly building into her aerobic exercise program
and continuing to do cognitive- behavioural work with a clinical psychologist.
Her concerns about longer-term disability are fading. The program continues
with the expectation of further improvement over time. Top
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