Fibromyalgia

Fibromyalgia (FM/FMS) is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and tenderness in localized areas. Pain is widespread, on both sides of the body, and above and below the waist.

Sufferers are fatigued and tired even when sleeping for long periods of time, and sleep is often disrupted by pain. Many FM sufferers have sleep disorders like sleep apnea and restless legs syndrome. Cognitive impairment, when one cannot focus or pay attention and the patient has difficulty concentrating on mental tasks, is known by FM sufferers as "fibro fog". Some experience depression, headaches, and lower abdominal pain or cramping. Other symptoms include tingling or numbness in hands and feet, pain in jaw and disorders of the jaw such as temporomandibular joint disorder (TMJ/TMD), menstrual cycle cramps, and digestive problems like irritable bowel syndrome (IBS).

The American College of Rheumatology (ACR) created and updates the diagnostic criteria for fibromyalgia. See: Fibromyalgia (Diagnosis section).



Prevalence
FM is the second most common rheumatic disorder behind osteoarthritis and is "now considered to be a lifelong central nervous system disorder." An estimated 10 million people in the US and 3-6% of the world population have fibromyalgia. It is seen in women, men, children, and all ethnic groups. It is often seen in families and diagnosed between the ages of 20 to 50 years; incidence increases with age.

FM has a female:male 7:1 ratio under the American College of Rheumatology (ACR) 1990 Diagnostic Criteria and 2:1 when the ACR 2010 Preliminary Diagnostic Criteria is used. See: Fibromyalgia (American College of Rheumatology (ACR) Criteria section).

Fibromyalgia in ME/CFS
Dr. Jarred Younger has said that many patients that meet the criteria for FM also meet criteria for chronic fatigue syndrome (CFS) but the reverse is not necessarily true as a lot of people with CFS do not have chronic pain. However, the Canadian Consensus Criteria (CCC) requires the symptom of pain to diagnose Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). It is the pattern and significant degree of chronic pain in FM that sets it apart from other diseases that have pain.

"The most common overlapping condition with ME/CFS is fibromyalgia."

Health complications
FM is not a progressive disease but according to Dr. Dan Clauw the "slow gradual worsening of chronic pain patients over time is due to downstream consequences of poorly controlled pain and other symptoms, wherein individuals then progressively get less active, sleep worse, are under more stress and unknowingly develop bad habits which worsen pain and other symptoms."


 * Fibromyalgia Complications


 * "People who have fibromyalgia frequently complain of a variety of symptoms that affect other parts of the body. Many people complain of gastrointestinal issues and restless legs syndrome (RLS). Additionally, the chronic pain and discomfort of fibromyalgia may lead to depression."


 * Can fibromyalgia cause other medical conditions?


 * "Fibromyalgia is not known to cause other medical conditions. However, people who have fibromyalgia seem to be at high risk for developing other painful conditions, including osteoarthritis (the common type of arthritis caused by wear and tear on the joints) as well as other related conditions, such as rheumatoid arthritis, lupus, and ankylosing spondylitis. Also, people with fibromyalgia are frequently diagnosed with chronic fatigue syndrome, irritable bowel syndrome (IBS), and temporomandibular joint (TMJ) disorder."

Risk factors
Lupus and rheumatoid arthritis (RA) are risk factors in developing FM. Car accidents, post-traumatic stress disorder (PTSD), repetitive injuries, illness such as a viral infection, family history, and obesity have all been linked to FM.

Diagnosis
Tender points, not trigger points, are used to diagnose fibromyalgia. Tender points will be above and below the waist and on both sides of the body. (See: Illustrations of the 1990 and 2010 American College of Rheumatology (ACR) Criteria depicting tender points near the top of this page.) It is important to check for other conditions that could be causing pain such as hypothyroidism, rheumatoid arthritis or lupus, osteoarthritis, ankylosing spondylitis, and polymyalgia rheumatica.

1990 ACR criteria

 * 1990, The American College Of Rheumatology 1990 Criteria For The Classification Of Fibromyalgia "American College of Rheumatology guidelines suggest that people with fibromyalgia have pain in at least 11 of these tender points when a doctor applies a certain amount of pressure."

2010 ACR criteria

 * 2010, The 2010 American College of Rheumatology (ACR) Preliminary Diagnostic Criteria for Fibromyalgia: Overview was proposed and modified in 2011 with the modification being validated in 2013 and published in 2014. September of 2016, another revision has been made.


 * Men do not seem to form the tender points needed for diagnosis under the 1990 criteria, the 2010 proposed criteria diagnoses more men with a F/M ratio of 2:1.
 * Tender points were used to diagnose with the 1990 criteria, however "considerable skill is needed to correctly check for a patient’s tender points (i.e., digital palpation that is done with certain amount of applied pressure), yet this technique is not typically taught at most medical schools."
 * The new standards were designed to:
 * eliminate the use of a tender point examination
 * include a severity scale by which to identify and measure characteristic FM symptoms
 * utilize an index by which to rate pain
 * There are 19 tender point areas in the widespread pain index (WPI), whereas the 1990 criteria had 18 tender points.

Widespread pain index and Symptom severity
The Widespread Pain Index (WPI) and Symptom Severity (SS) is explained in the study Fibromyalgia Syndrome: An Overview of Pathophysiology, Diagnosis and Management. "In place of the tender point count, patients (or their physician) may endorse 19 body regions in which pain has been experienced during the past week. One point is given for each area, so the score is between 0-19. This number is referred to as the Widespread Pain Index (WPI) and it is one of the two required scores needed for a doctor to make a diagnosis of fibromyalgia.""The second part of the score required to assess the diagnosis of fibromyalgia involves the evaluation of a person's symptoms. The patient ranks specific symptoms on a scale of 0-3. These symptoms include: Fatigue, Waking unrefreshed, Cognitive symptoms, Somatic (physical) symptoms in general (such as headache, weakness, bowel problems, nausea, dizziness, numbness / tingling, hair loss). The numbers assigned to each are added up, for a total of 0-12.""The diagnosis is based on both the WPI score and the SS score either:"
 * "WPI of at least 7 and SS scale score of at least 5, OR"
 * "WPI of 4-6 and SS scale score of at least 9."



The Social Security Administration (SSA) accepts a diagnosis of fibromyalgia with the 1990 or 2010 ACR criteria. See the Fibromyalgia disability process page.

Sleep study
Sleep dysfunction is often involved in fibromyalgia. Treating a sleep disorder can help with fibromyalgia symptoms. A diagnosed sleep disorder is also helpful if one needs to file for disability.


 * Getting a Sleep Study with Fibromyalgia or Chronic Fatigue Syndrome


 * What A Sleep Study Can Reveal About Fibromyalgia


 * Fibromyalgia Sufferers Have Difficulty Maintaining Continuous Sleep, Study Says

ICD Diagnostic code
ICD-10

The World Health Organization (WHO) International Classification of Diseases (ICD) lists fibromyalgia as a "disease of the musculoskeletal system and connective tissue", under the code M79.7 (WHO ICD-10 Version: 016).


 * M79.7 Fibromyalgia
 * Fibromyositis
 * Fibrositis
 * Myofibrositis

In 2015, the United States finally adopted ICD-10 and Fibromyalgia as a diagnosis.

ICD-11 (2019)

ICD-11 (2019) has diagnostic code MG30.1 Chronic widespread pain.


 * MG30.01 Chronic widespread pain

Parent
 * MG30.0 Chronic primary pain

Description "Chronic widespread pain (CWP) is diffuse pain in at least 4 of 5 body regions and is associated with significant emotional distress (anxiety, anger/frustration or depressed mood) or functional disability (interference in daily life activities and reduced participation in social roles) [1]. CWP is multifactorial: biological, psychological and social factors contribute to the pain syndrome. The diagnosis is appropriate when the pain is not directly attributable to a nociceptive process in these regions and there are features consistent with nociplastic pain [2] and identified psychological and social contributors."

Inclusions
 * Fibromyalgia

Exclusions
 * Acute pain (MG31)

Pathophysiology
"Fibromyalgia (FM) is a chronic pain disorder with unknown etiology and unclear pathophysiology. There is no evidence that a single event “causes” FM. Rather, many physical and/or emotional stressors may trigger or aggravate symptoms. These have included certain infections, such as a viral illness or Lyme disease, as well as emotional or physical trauma." The widespread pain is severe, debilitating, and abnormal in processing its pain. There is also sleep disturbance and fatigue. Cause or causes are unproven.


 * May 2012, Fibromyalgia Syndrome: An Overview of Pathophysiology, Diagnosis and Management See Table 1: "Conditions associated with fibromyalgia." Musculoskeletal, genitourianry, gastro intestinal, and miscellaneous conditions often exist among fibromyalgia patients.

"Pathophysiology: Although the etiology remains unclear, characteristic alterations in the pattern of sleep and changes in neuroendocrine transmitters such as serotonin, substance P, growth hormone and cortisol suggest that regulation of the autonomic and neuro-endocrine system appears to be the basis of the syndrome. Fibromyalgia is not a life-threatening, deforming, or progressive disease. Anxiety and depression are the most common association. Aberrant pain processing, which can result in chronic pain, may be the result of several interplaying mechanisms. Central sensitization, blunting of inhibitory pain pathways and alterations in neurotransmitters lead to aberrant neuro-chemical processing of sensory signals in the CNS, thus lowering the threshold of pain and amplification of normal sensory signals causing constant pain."

"The frequent co-morbidity of fibromyalgia with mood disorders suggests a major role for the stress response and for neuroendocrine abnormalities. The hypothalamic pituitary axis (HPA) is a critical component of the stress-adaptation response. In FMS, stress adaptation response is disturbed leading to stress induce symptoms. Psychiatric co-morbidity has been associated with FMS and needs to be identified during the consultation process, as this requires special consideration during treatment."


 * May 2018, A comparison of the clinical manifestation and pathophysiology of myofascial pain syndrome and fibromyalgia: implications for differential diagnosis and management See Table 1 "Summary of the pathophysiology of fibromyalgia and myofascial pain syndrome." pg. 29 (pg. 4 of PDF)


 * Jun 2018, SNPs in inflammatory genes CCL11, CCL4 and MEFV in a fibromyalgia family study

"SNPs with significant TDTs were found in 36% of the cohort for CCL11 and 12% for MEFV, along with a protein variant in CCL4 (41%) that affects CCR5 down-regulation, supporting an immune involvement for FM."


 * Jul 2018, Primary and Secondary Fibromyalgia Share Same Symptom Burden, Study Suggests

"Fibromyalgia can be considered either primary, or dominant, also known as idiopathic fibromyalgia, or secondary. In the primary form, the causes of the disorder are unknown, but in secondary fibromyalgia, the disorder usually occurs alongside other debilitating medical conditions, such as rheumatoid arthritis (RA), lupus, and multiple sclerosis."

Immune system research
Dr. Jarred Younger believes an overactive immune system is the cause and will be conducting a study to test this hypothesis. An overactive immune system is responsible for inflammation which causes chronic pain.

Dr. William Pridgen's research of HSV-1 (cold sore virus) as being involved in FM has conducted a successful Phase III clinical trial, which had been fast-tracked by the Food and Drug Administration (FDA), of a combination drug that suppresses this virus and also helps with pain. See: Fibromyalgia drugs (Drug trials: IMC-1).

EpicGenetics has a blood test that is identifying the presence of specific white blood cell abnormalities of patients diagnosed with FM and has partnered with two universities to offer whole exome sequencing free of charge to those who test positive with their FM/a® test. Concerns have been raised in regards to the FM/a® EpicGenetics Blood Test.

On September 5th, 2018, EpicGenetics announced that Massachusetts General Hospital received approval from the FDA to test the Bacille Calmette-Guerin (BCG) vaccine (an old Tuberculosis vaccine) on patients that tested positive with its FM/a® test.

Comorbidities, overlapping conditions, and common symptoms



 * Allodynia
 * Allodynia: A Rare & Distinct Type of Pain in Fibromyalgia & ME/CFS Types of Allodynia: Tactile; Mechanical; and Thermal. "Type of pain, generally on the skin, that's caused by something that wouldn't normally cause pain."
 * Autoimmune disease s "Research suggests that RA and other inflammatory diseases may somehow increase the risk for fibromyalgia."


 * Body temperature
 * Temperature Sensitivity in Fibromyalgia & Chronic Fatigue Syndrome

"When you're exposed to heat, does it feel like you're burning up? Does it seem impossible for you to cool off? Or maybe it's cold that bothers you, chilling you to the bone, leaving you unable to warm up? Or are you one of those people with fibromyalgia (FMS) and chronic fatigue syndrome (ME/CFS) who is cold all the time, or hot all the time, or alternately hot or cold while out of sync with the environment?"




 * Costochondritis in Fibromyalgia

"Costochondritis is inflammation of the cartilage that connects your ribs to your breastbone. Depending on how much inflammation there is, it can range from mildly annoying to intensely painful. People sometimes describe the pain as stabbing, aching, or burning."

"Costochondritis can make you think you're having heart problems, which is a scary thing. Even though costochondritis is common, you should get medical attention if you have unexplained chest pain. You don't want to assume that it's FMS-related and end up with permanent heart damage or worse."

"The pain can radiate to your shoulder and arms as well (another way the condition mimics a heart attack). Sometimes the pain is accompanied by redness and/or swelling in the most painful areas. When that's the case, it's called Tietze's Syndrome."


 * Depression and Anxiety

Fibromyalgia sufferers are "up to three times more likely to have depression at the time of their diagnosis than someone without fibromyalgia." Up to 20 percent of Fibromyalgia patients will have either depression or anxiety.


 * Fibro fog and Cognitive dysfunction


 * What is Fibro Fog? - Fibromyalgia and Cognitive Dysfunction 'Mental confusion along with difficulty in concentration and loss of memory is often termed “fibro fog"'.


 * What Is Fibro Fog and ME/CFS Brain Fog?
 * Study Identifies the Types of Cognitive Dysfunction That Are Most Prevalent in Fibromyalgia


 * Gastrointestinal system
 * Irritable bowel syndrome: Irritable Bowel Syndrome in Fibromyalgia & Chronic Fatigue Syndrome - Why Do They Go Together?


 * "Fibromyalgia, chronic fatigue syndrome and irritable bowel syndrome (IBS) frequently go together. No one really knows why, but we do know that all three conditions can include imbalances of serotonin -- although in fibromyalgia (FMS) and Chronic Fatigue Syndrome (CFS or ME/CFS) it's an imbalance in the brain, while with IBS it's in the gut."


 * Gulf War Illness
 * Fibromyalgia in Gulf War Veterans GWI increases risk of developing fibromyalgia.


 * Interstitial Cystitis (Painful bladder)
 * Fibromyalgia, Chronic Fatigue Syndrome & Interstitial Cystitis "Fibromyalgia, chronic fatigue syndrome and interstitial cystitis (IC) -- a painful bladder condition -- frequently occur together. Women may be up to 10 times more likely than men to develop it."
 * Interstitial cystitis/painful bladder syndrome and associated medical conditions with an emphasis on irritable bowel syndrome, fibromyalgia and chronic fatigue syndrome.


 * Language Impairment
 * Word-finding problems
 * Language Impairment in Fibromyalgia and Chronic Fatigue Syndrome Impaired Language in Fibromyalgia & Chronic Fatigue Syndrome "Searching their brains for simple words that they just can't remember. On other occasions, individuals with these diagnoses may find it hard to write or even understand language."


 * "The diagnosis of Aphasia is a condition that robs you of the ability to communicate. It can affect your ability to speak, write and understand language, both verbal and written" but with dysphasia you will have those symptoms and trouble listening and doing numeral calculations. See also: Dyscalculia.


 * ME/CFS
 * Comorbid Conditions in Fibromyalgia & Chronic Fatigue Syndrome


 * Migraine
 * Migraines and Fibromyalgia

"Both fibromyalgia and migraine may reflect problems in the brain’s pain processing center. It is believed that both conditions are caused by excitation of the nervous system or an over-response to stimuli. Stress is usually cited as a trigger for both migraine and fibromyalgia attacks."
 * Multiple Chemical Sensitivity (MCS) It is thought that both Fibromyalgia and MCS are central sensitivity syndromes.


 * OBGYN
 * Menstrual Periods with Fibromyalgia: Personal Stories
 * Fibromyalgia Tied to Hysterectomy, Gynecologic Disease.
 * "You may have heard about a possible link between gynecologic surgery (such as a hysterectomy) and the development of fibromyalgia, and doctors have long suspected that fibromyalgia has strong hormonal ties and triggers. This does not seem surprising as we've long suspected a link between endocrine disorders, gynecological conditions, and autoimmune conditions."


 * Orthostatic intolerance (OI) and Postural orthostatic tachycardia syndrome (POTS)


 * Symptoms Predict the Outcome of Tilt Table Testing in CFS/ME/FM (PDF) Symptoms can include low blood pressure and/or sudden high blood pressure, dizziness, fainting.


 * An Overlooked Issue in Fibromyalgia? Study Highlights Problems Standing (Orthostatic Intolerance)


 * Sleep dysfunction
 * Sleep is associated with task-negative brain activity in fibromyalgia participants with comorbid chronic insomnia


 * "The present results of this study suggest that long-term, comorbid pain and sleep disturbance may be associated with increased activation in core default mode brain areas that is above and beyond long-term pain disturbance alone."


 * Fibromyalgia and Sleep "Most people with fibromyalgia have an associated sleep disorder that makes it difficult for them to get the deep, restorative sleep they need."


 * Temporomandibular joint disorder (TMJ/TMD)


 * Temporomandibular disorders in fibromyalgia syndrome: a short-communication


 * Other than headaches, the symptoms are quite distinct from symptoms of FMS and ME/CFS.


 * They include:
 * Jaw pain
 * Discomfort or difficulty chewing
 * Painful clicking in the jaw
 * Difficulty opening or closing the mouth
 * Headaches
 * Locking jaw
 * Teeth that don't come together properly


 * Thyroid disease
 * Chronic Fatigue Syndrome, Fibromyalgia, and Autoimmune Thyroid Disease


 * "People with Hashimoto's autoimmune thyroid disease often experience significant fatigue and body aches. While these symptoms are common in Hashimoto's, they can also be markers of other diseases, like chronic fatigue syndrome or fibromyalgia."


 * Other symptoms
 * Symptoms of Fibromyalgia (On all the many symptoms and conditions of and related to fibromyalgia.)
 * Fibromyalgia Syndrome: An Overview of Pathophysiology, Diagnosis and Management Conditions associated with fibromyalgia. (Table 1)

United States
Rheumatology and primary care providers: Diagnosing and treatment


 * 2012, A Framework for Fibromyalgia Management for Primary Care Providers Rheumatologists stopped treating fibromyalgia patients and primary care providers began treatment managment although rheumatologists are most often the specialist to diagnose. (Please see disability heading about primary provider and specialists for disability cases.)

Exercise
Please Note: These recommendations are for fibromyalgia patients and not ME/CFS sufferers due to it's hallmark symptom of post-exertional malaise.


 * Warm Water Exercise for Fibromyalgia

"A warm-water pool is good for therapy because cold water can make muscles tense up. It's especially important in FMS because many people with the condition are intolerant of cold. A warm-water pool is one that's kept around 89.6 degrees Fahrenheit (32 Celsius), which is several degrees warmer than most heated pools."


 * Moderate aerobic exercise and weights with six to eight reps and then a day or two of rest in between. Do not start a program if you are in a flare.


 * Easy fibromyalgia exercises and motivation to keep you healthy! Video


 * Fibromyalgia Myth vs. Fact Heading: Myth #3: People With Fibromyalgia Need More Exercise. Appropriate exercise, which each patient needs to gauge for themselves.

Massage

 * 2014, Massage Therapy for Fibromyalgia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials


 * 2016, Massage, Rolfing & Other Bodywork - Are They Effective Fibromyalgia & Chronic Fatigue Syndrome Treatments?

Acupuncture

 * 2004, U.S. Department of Health and Human Services (HHS) and Centers for Medicare and Medicaid Services (CMS) ruled April 16, 2004, a noncoverage determination for acupuncture.


 * 2005, Acupuncture Good for Fibromyalgia? "Acupuncture gave no significant pain relief to fibromyalgia patients."


 * 2016, Short-term complementary and alternative medicine on quality of life in women with fibromyalgia "There was no significant improvement in pain or reduction of tender points in any of the groups studied, at the end of the 8th session."


 * 2016, Acupuncture Does Not Appear to Relieve Pain in Fibromyalgia Patients

Dr. Frederick Wolfe
Dr. Frederick Wolfe, the director of the National Databank for Rheumatic Diseases and the lead author of the 1990 paper that first defined the diagnostic guidelines for fibromyalgia, says he has become cynical and discouraged about the diagnosis. He now considers the condition a physical response to stress, depression, and economic and social anxiety.

Fibromyalgia vs Chiari malformation
Some individuals diagnosed with FMS were undergoing surgery for Chiari malformation (CM). These are two separate conditions; FMS cannot be resolved by undergoing a risky CM surgery.


 * 2011, Is Chiari I malformation associated with fibromyalgia?
 * Conclusion: Most patients with FM do not have CIM pathology. Future studies should focus on dynamic neuroimaging of craniocervical neuroanatomy in patients with FM.


 * 2015, CFS/FM and Chiari Malformation Surgery

Learn more

 * Forum: Fibromyalgia and Connective Tissue Disorders at Science for ME
 * Verywell FMS/CFS

Ongoing process of diagnosing and categorizing

 * 2014, Lyme Disease, Fibromyalgia Link Evaporates (See also: Chronic lyme disease)


 * 2015, Fibromyalgia now considered as a lifelong central nervous system disorder


 * 2015, Foundation of Fibromyalgia Is Altered Central Nervous System, New Study Validates


 * 2015, Question: 'Is Fibromyalgia a Psychosomatic Illness?' Answer: "Fibromyalgia is NOT a psychosomatic illness."


 * 2016, Diagnosing Fibromyalgia May Be Possible Using Noninvasive Eye Examination


 * 2016, Microglia in Fibromyalgia & Chronic Fatigue Syndrome


 * 2016, Are Chronic Fatigue Syndrome (ME/CFS) and Fibromyalgia Immune Exhaustion Disorders?


 * 2016, Why Fibromyalgia Is Neuropathic


 * 2017, Study Reveals New Treatment Target for Fibromyalgia: Inflammation in the Brain
 * 2017, AI can spot the pain from a disease some doctors still think is fake
 * 2018, Understanding the Pathophysiology of Fibromyalgia

Blood tests

 * 2013, New Fibromyalgia Blood Test is 99% Accurate


 * 2014, Pridgen Reports Fibromyalgia Antiviral Trial Results “Very Positive”: Predicts New Approach Will Be “Game-Changer”


 * 2016, Blood Test for Fibromyalgia: FM/a Test Ⓡ is now available, Q&A


 * 2016, Fibromyalgia blood testing covered by rising number of insurance companies


 * 2017, EpicGenetics, with the Assistance of Leading Medical Centers, Expands Clinical Study of FM/a® Test to Diagnose Fibromyalgia, Identify Genetic Markers Unique to the Disorder and Explore Direct Treatment Approaches

Brain scans

 * 2002, Fibromyalgia Pain Isn't All In Patient's Heads, New Brain Study Finds


 * 2012, Fibromyalgia and the brain: New clues reveal how pain and therapies are processed


 * 2015, How Lyrica Changes the Fibromyalgia Brain