Fibromyalgia

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[[Category: from 2019]]Fibromyalgia (FM/FMS) is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and tenderness in localized areas. Muscle pain is widespread, on both sides of the body, and above and below the waist.[1][2][3][4]

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 (RLS).[5][6][7]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".[8][5][6][7] 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).[5][6][7]

Other pain conditions are associated with FM, such as rheumatoid arthritis (RA), Lupus, ankylosing spondylitis, interstitial cystitis, and more.[9][10][11]

The United Kingdom (UK) National Health Service (NHS) lists FM as one of 20 most painful conditions.[12][13] The NHS describes the pain as diffuse aching or burning, head to toe, and can be worse at some times than at others. The pain can change location. "The fatigue ranges from feeling tired, to the exhaustion of a flu-like illness."[13] The United States (US) Centers for Disease Control and Prevention (CDC) states FM "can cause pain, disability, and lower quality of life."[14]

The American College of Rheumatology (ACR) created and updates the diagnostic criteria for FM.[15][16][1][2][3][4]See: Fibromyalgia (Diagnosis section).

1990 ACR Diagnostic Criteria: 18 Tender Points[1][2]
2010 ACR Preliminatry Diagnostic Criteria: Wisedpread Pain Index (WPI), 19 Tender Point Areas[3][4]

Prevalence[edit | edit source]

FM is the second most common rheumatic disorder behind osteoarthritis and is "now considered to be a lifelong central nervous system disorder."[17] An estimated 10 million people in the US and 3-6% of the world population have FM. 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.[18]

FM has a female:male 7:1 ratio under the American College of Rheumatology (ACR) 1990 Diagnostic Criteria[1][2] and 2:1 when the ACR 2010 Preliminary Diagnostic Criteria[3][4] is used.[19]See: Fibromyalgia (American College of Rheumatology (ACR) Criteria section). A September 2018, Wolfe et al study Fibromyalgia diagnosis and biased assessment: Sex, prevalence and bias[20] found fewer women and more men are diagnosed under the 2010/11 criteria (this criterion further updated in 2016[21]). They found the ratio is F/M 1.5:1.[20]
What we did not find in our unbiased CritFM samples was 9:1 female to male fibromyalgia ratios that are widely described by expert sources [11–13]. We believe that such findings only occur in the presence of selection bias or biased ascertainment.[20]
As unbiased epidemiological studies show only a small increase in the female to male sex ratio (~1.5:1) as opposed to the observed ratio in clinical studies of 9:1, we believe that the over-identification of fibromyalgia in women and the consequent under-identification of men is the result of bias.[20]

Fibromyalgia in ME/CFS[edit | edit source]

"The most common overlapping condition with ME/CFS is fibromyalgia."[22][23] While some have posited ME/CFS and FM are variants of the same illness, Benjamin Natelson, MD summoned considerable amounts of data that suggest the two illnesses differ with different pathophysiologic processes leading to different treatments.[24]

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.[25] However, the Canadian Consensus Criteria (CCC) requires the symptom of pain to diagnose ME/CFS.[26] It is the pattern (on both sides of the body, and above and below the waist) of chronic widespread musculoskeletal pain (involving muscle, cartilage, ligaments, and connective tissue) in FM that sets it apart from other diseases that have pain; it also causes cognitive symptoms and unrefreshing sleep.[8][5][6]

Health complications[edit | edit source]

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."[27]

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.[28]
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.[29]

Risk factors[edit | edit source]

Lupus and rheumatoid arthritis (RA) are risk factors in developing FM. Car accidents, post-traumatic stress disorder (PTSD), [[carpal tunnel syndrome|repetitive injuries], illness such as a viral infection, family history, and obesity have all been linked to FM.[7][30][31]

Diagnosis[edit | edit source]

Tender points, not trigger points, are used to diagnose FM.[32] 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, RA or lupus, osteoarthritis, ankylosing spondylitis, and polymyalgia rheumatica.[33]

United States[edit | edit source]

Blood test [edit | edit source]

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.[34][35] Most insurance companies will cover the test.[36][37] EpicGenetics offers help to determine if your insurance will cover their test.[35]

American College of Rheumatology (ACR) Criteria[edit | edit source]

1990 ACR criteria[edit | edit source]
2010 ACR criteria[edit | edit source]
Men do not seem to form the tender points needed for diagnosis under the 1990 criteria,[43] the 2010 proposed criteria diagnoses more men with a F/M ratio of 2:1.[44]
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."[45]
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[45]

There are 19 tender point areas in the widespread pain index (WPI), whereas the 1990 criteria had 18 tender points.[45][46]

Widespread pain index and Symptom severity[edit | edit source]

The Widespread Pain Index (WPI) and Symptom Severity (SS) is explained in the study Fibromyalgia Syndrome: An Overview of Pathophysiology, Diagnosis and Management.[47]

WPI 19 areas of pain. Count 1 point for each area of pain[47][3][4]
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 lossdry eyesRaynaud's phenomenon, painful urination, and more).[47][48] 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[42] and SS scale score of at least 9.[47]
Table 2: SS scale score. Add a 4th column for Somatic (physical) symptoms in general (such as Headache, weakness, bowel problems, nausea, dizziness, numbness/tingling, hair loss, dry eyes, Raynaud's phenomenon, painful urination, and more).[47][48] The patient ranks specific symptoms on a scale of 0-3. The numbers assigned to each column are added up, for a total of 0-12.[47]


The Social Security Administration (SSA) accepts a diagnosis of FM with the 1990[1][2] or 2010[3][4] ACR criteria.[49] See the Fibromyalgia disability process page.

Sleep study[edit | edit source]

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

ICD Diagnostic code[edit | edit source]

ICD-10

The World Health Organization (WHO) International Classification of Diseases (ICD) lists FM as a "disease of the musculoskeletal system and connective tissue", under the code M79.7 (WHO ICD-10 Version: 2016).[53] The WHO's ICD-10 does not refer to FM as a syndrome and it is not classified in the category for medically unexplained symptoms.[54][53]

  • M79.7 Fibromyalgia
Fibromyositis
Fibrositis
Myofibrositis[53]

In 2015, the US finally adopted ICD-10 and FM as a diagnosis.[54][55]

ICD-11 (2019)

ICD-11 (2019) has diagnostic code MG30.1 Chronic widespread pain, and changed the category from a Musculoskeletal disease, to the General signs and symptoms category, sometimes referred to as Medically unexplained physical symptoms.[56]

  • 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.[56]

Inclusions

  • Fibromyalgia

Exclusions

  • Acute pain (MG31)[56]

Pathophysiology[edit | edit source]

"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."[57] The widespread pain is severe, debilitating, and abnormal in processing its pain. There is also sleep disturbance and fatigue. Cause or causes are unproven.[58]

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.[47]
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.[47]
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.
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.[62]

Immune system research[edit | edit source]

Dr. Jarred Younger believes an overactive immune system is the cause and will be conducting a study to test this hypothesis.[63][64] An overactive immune system can cause inflammation and chronic pain.[65][66]

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).[67]

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.[68][69][70][71][72]

Recognizing FM may involve activation of the immune system researchers performed exome sequencing on chemokine genes in a region of chromosome 17 identified in a genome-wide family association study. Their conclusion: "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."[73]

Brain and spinal cord research[edit | edit source]

A 2004 study by Heffez et al. studied 270 patients with FM and found that 46% had cervical spinal stenosis and 20% chiari malformation.[74] In 2007, Heffez et al. saw significant improvement in physical and mental well-being was found in patients with cervical stenosis who received surgery.[75] A second study in 2007 by Andrew Holman found that 71% had cervical spinal cord compression.[76] It is important to note that in the past many patients were misdiagnosed with FM when further testing would have revealed the true source of their pain; the 2010 (updated in 2016) ACR criteria has helped curb misdiagnoses.[77][78][79][20]

Various types of brain imaging are being used to research FM. (See: Fibromyalgia notable studies for images.)

In 2002, an fMRI study conducted by Richard Gracely and Daniel Claw found people with FM "have measurable pain signals in their brains, from a gentle finger squeeze that barely feels unpleasant to people without the disease."[80] A 2007 study by Borsook et al., Neuroimaging revolutionizes therapeutic approaches to chronic pain found decreased gray matter density relative to controls in cingulate cortex (CC), medial prefrontal cortex (Med. PFC), parahippocampal gyrus (PHG) and insula.[81] In 2015, Loggia et al. imaged neuroinflammation due to glial activation using MR/PET imaging[82].[83] In 2017, López-Solà et al. identified three brain patterns based on fMRI responses to pressure pain and non-painful multisensory stimulation. "These patterns, taken together, discriminate FM from matched healthy controls with 92% sensitivity and 94% specificity."[84] In 2018, Albrecht et al used PET scans to document glial activation.[85] Also in 2018, Martucci et al. found unbalanced activity between the ventral and dorsal cervical spinal cord. Ventral neural processes were increased and dorsal neural processes were decreased which may reflect the presence of central sensitization contributing to fatigue and other bodily symptoms in FM.[86]

Insulin resistance research[edit | edit source]

Age-normalized data was found to show a relationship between insulin resistance/pre-diabetes and Fibromyalgia. In a preliminary study, Fibromyalgia patients were treated with metformin, a common medication for diabetes, and showed a large improvement in myofascial pain.

Fibromyalgia is not depression[edit | edit source]

Depression doesn't cause the pain of fibromyalgia, a new study shows.[88]
"People still doubt fibromyalgia is a disease," Giesecke tells WebMD. "Previously, we found that fibromyalgia patients really do have increased central pain processing. Now we can show this is not affected by depression. Something is wrong here, and it is not at all connected with depression."[88]
"Giesecke's group looked at brain responses to painful stimuli, and then checked to see if there was any difference between depressed and nondepressed fibromyalgia patients. They showed the activation of areas of the brain related to pain were not different in patients with and without depression." But there is a difference between people with and without fibromyalgia, he says.[88]
The researchers use an imaging device called functional magnetic resonance imaging, or fMRI, to look at how the brain responds to pain. Study participants get a mildly painful pressure on their thumb, which makes the brain's pain centers "light up" on the image. Thumb pressure -- at a level healthy people hardly feel -- sets off a firestorm in the pain centers of fibromyalgia patients' brains.[89]
The study the APA referred to was published in the June issue of Brain, a journal of neurology. The researchers investigated the function and structure of small nerve fibers in 25 FM patients, 10 patients with monopolar depression without pain and with healthy control subjects. Using three different methods of testing, the researchers found that compared with control subjects, patients with fibromyalgia, but not patients with depression, had impaired small fiber function.[90]
The Psychiatric News alert quoted the study authors saying, "This strengthens the notion that fibromyalgia syndrome is not a variant of depression, but rather represents an independent entity that may be associated with depressive symptoms," the researchers said. Furthermore, the findings point "towards a neuropathic nature of pain in fibromyalgia syndrome."[90]
Fibromyalgia is often misdiagnosed as a number of other illnesses. Though fibro has its own unique set of diagnostic criteria, many of its symptoms can mimic symptoms of other conditions – both physical and mental, acute and chronic.[91]
One of the most common conditions fibromyalgia gets mistaken for is depression. While each condition causes a unique set of symptoms, many of them may overlap. Like fibro, depression can cause physical symptoms such as pain, fatigue and brain fog. And living with a chronic physical symptoms can have significant effects on your mood, sometimes causing feelings of hopelessness, anxiety or general discontent – which are also symptoms of depression.[91]

Comorbidities, overlapping conditions, and common symptoms[edit | edit source]

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?[100]
Costochondritis is inflammation of the costal cartilages (shown in red) causing chest and ribcage pain
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.[101]


Fibromyalgia sufferers are "up to three times more likely to have depression at the time of their diagnosis than someone without fibromyalgia."[103] Up to 20 percent of FM patients will have either depression or anxiety.[104]

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.[109]
  • "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"[115] but with dysphasia you will have those symptoms and trouble listening and doing numeral calculations.[116]See also: Dyscalculia.
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.[118]
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.[121]
  • Raynaud's Syndrome
    • Raynaud's Syndrome in Fibromyalgia & Chronic Fatigue Syndrome[124]
      In Raynaud's syndrome, the blood vessels constrict more than they should, which allows less blood to get through. That not only makes your extremities cold, it makes them extremely difficult to warm up. The most commonly affected body parts are the fingers and toes, but your lips, nose, ear lobes, knees, and nipples may also be involved.
      Raynaud's isn't all about the cold, though. The diminished blood flow can cause pain in the affected areas, and it may also cause the skin there to turn blue. Skin ulcers (sores) are possible, since prolonged episodes of low blood flow can damage your tissues.[124]
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.[125]
  • Fibromyalgia and Sleep[126] "Most people with fibromyalgia have an associated sleep disorder that makes it difficult for them to get the deep, restorative sleep they need."[126]
The temporomandibular joint is the joint between the mandible (light blue) and the temporal bone (orange) of the skull
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[129]


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.[130]

Treatment[edit | edit source]

United States[edit | edit source]

Rheumatology and primary care providers: Diagnosing and treatment

Drugs (See main article link below)[edit | edit source]


Therapies[edit | edit source]

Exercise[edit | edit source]

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

Warm water exercise is best for fibromyalgia. Start slow and don't push through the pain[133]
Several studies have found that warm-water pool exercise is a beneficial treatment for fibromyalgia. A very large survey of patients found that 26% have used pool therapy, rating it as very effective.[137] The same survey found 74% of patients found heat helpful - either warm water or heat packs.[137] Warm water 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.[133]
  • 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.[138]

Massage[edit | edit source]

Acupuncture[edit | edit source]

Disability: SSI/SSD and LTD (See main article link below)[edit | edit source]


Notable studies (See main article link below)[edit | edit source]


Controversy[edit | edit source]

Dr. Frederick Wolfe[edit | edit source]

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.[147][148][149]

Fibromyalgia vs Chiari malformation[edit | edit source]

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.

Conclusion: Most patients with FM do not have CIM pathology. Future studies should focus on dynamic neuroimaging of craniocervical neuroanatomy in patients with FM.

See also[edit | edit source]

Learn more[edit | edit source]

Ongoing process of diagnosing and categorizing[edit | edit source]

Blood tests[edit | edit source]

Brain scans[edit | edit source]

References[edit | edit source]

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  2. 2.02.12.22.32.42.5 Wolfe; et al. (1990). "1990 Fibromyalgia Excerpt" (PDF). rheumatology.org. 
  3. 3.03.13.23.33.43.53.6 . Muhammad Yunus. "The American College of RheumatologyPreliminary Diagnostic Criteria for Fibromyalgiaand Measurement of Symptom Severity" (PDF). Arthritis Care & Research. American College of Rheumatology. 62 (5): 600–610. 2010. 
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  17. [citation needed]"Fibromyalgia now considered as a lifelong central nervous system disorder". NAIDW.org®. Retrieved Aug 9, 2018. 
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  21. "2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria". Seminars in Arthritis and Rheumatism. 46 (3): 319–329. Dec 1, 2016. doi:10.1016/j.semarthrit.2016.08.012. ISSN 0049-0172. 
  22. 22.022.122.222.322.4 "Overlapping Conditions - American Myalgic Encephalomyelitis and Chronic Fatigue Syndrome Society". ammes.org. Retrieved Aug 12, 2018. 
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Myalgic encephalomyelitis or chronic fatigue syndrome


The information provided at this site is not intended to diagnose or treat any illness.

From MEpedia, a crowd-sourced encyclopedia of ME and CFS science and history