Fibromyalgia syndrome (FMS) is a common condition characterized by chronic widespread pain and stiffness, chronic fatigue, non-restorative sleep, cognitive dysfunction and a higher lifetime incidence of mood or anxiety disorders. FMS affects a significant segment of our population, including up to 6% of women. Onset is most common in middle age but can occur in both children and the elderly. FMS is not a type of arthritis. At this point it can not be diagnosed with a blood test, x-ray or biopsy. In our clinic the diagnosis is made by identifying the pattern and nature of widespread pain, typical risk factors, onset and symptom patterns and the documentation of tender points on the body, while carefully addressing other underlying illness that might be causing or contributing to the symptoms.  The diagnosis is most commonly made using the ACR (American College of Rheumatology) FM criteria, which require  chronic widespread pain, and tenderness at least 11 of 18 standardized tender points.  New criteria in development that will highlight the many other aspects of FMS beside pain.  There is also a pediatric version of FM criteria called Juvenile Primary Fibromyalgia Syndrome (JPFS).

The cause (or causes) of FMS are unknown, but tendency to the illness may be genetic or familial.  In my experience, the onset almost always occurs in the setting of chronic "stress," as stress is broadly defined, spanning the range from  simply being chronically overextended to more severe emotional and/or physical stressors. Onset is also associated with a variety of other co-factors (hormone dysreguation such as menopause, mechanical trauma to the head and neck, chronic spine disorders, surgeries, infections, autoimmune illness, metabolic syndrome or diabetes, primary sleep disorders, mental health conditions and others). Poor coping skills or maladaptive behaviors are clearly not necessarily present with the onset of fibromyalgia, but they can certainly compound the presentation, severity, duration, and treatment.

The term FMS probably encompasses a number of conditions characterized by widespread pain due to amplified sensory processing (or central sensitivity).  Hyperalgesia (increased response to a painful stimulus) and allodynia (the sensation of pain from a stimulus that is not normally provoke pain) are usually present.  Patients with FMS thus exhibit a lower pain threshold ---although not necessarily a lower pain tolerance--- and amplified pain response that causes not only muculoskeletal pain, but also may contribute to headaches, tingling, chest, bowel or bladder pain. Research shows nonspecific changes in autonomic nervous system function, dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, and elevation of Substance P, glutamate and other pain neurotransmitters in the cerebrospinal fluid.  Functional MRI scans demonstrate more areas of pain processing in the brain for a given stimulus compared to normal people.  Sleep studies show profound alteration of brain waves sleep stages.

Related conditions include irritable bowel syndrome, gastroesophageal reflux, irritable bladder or interstitial cystitis, endometriosis, vulvodynia, tension headaches and migraines, dry eyes and mouth, palpitations, low blood pressure, postural tachycardia and fainting, sleep disorders, allergies, and many others. Illness onset and flares of illness are often associated with both mental and physical stressors. The symptoms can become chronic and very difficult to treat, even after the "stress" is relieved and mood symptoms are well compensated. On the other hand, early intervention may lead to a better chance of complete resolution, so one should not hesitate to make the diagnosis and treat supportively in the setting of mild but suggestive symptoms.

 Treatment of FMS can be both frustrating and rewarding. As symptoms warrant, interval assessment for other disorders should be done. Otherwise, the treatment of FMS is supportive and symptomatic.  We now have several drugs approved by the FDA to treat the pain of FMS (Cymbalta, Savella and Lyrica).  These drugs that modify pain, mood and sleep, along with other related medications, have improved the symptoms of many FMS patients.

Since the exact cause and pathophysiology are not well understood, the primary approach to treatment of FMS symptoms is to relieve symptoms and improve function.  Any plan that improves pain, restorative sleep and mental health, and includes gentle physical conditioning is likely to improve FMS.

I follow a simple treatment paradigm:

1)  Identify and treat all known medical conditions.

2)  Continuously address the "4 table legs" of FM management

     ---Restorative sleep

     ---Stress management and good mental health

     ---Physical conditioning (balanced with appropriate activity pacing)

     ---Pain management (using effective pain modifiers and avoiding opioids)