Fibromyalgia

Aka: Fibromyalgia, Fibrositis

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II. Epidemiology

  1. Women account for more than 75-85% of Fibromyalgia patients (female gender RR 2-14)
  2. Peak Incidence: ages 20 to 60 years old
    1. Incidence increases with age
  3. Most common rheumatic cause of chronic diffuse pain
    1. Most common cause of Chronic Pain in women ages 20 to 55 years old
  4. Incidence
    1. Rheumatology patients: 15%
      1. Only Osteoarthritis is more common in rheumatology practice
    2. General medical patients: 5%
    3. General female population: 2-3%

III. Pathophysiology

  1. Increased central sensitivity to peripheral Sensation (as with other functional pain syndromes)
  2. Pain system dysfunction related to abnormalities in the forebrain
    1. Dysfunctional central nociceptive signal processing leading to hyperalgesia and Allodynia
    2. Imbalance between excitatory and inhibitory Neurotransmitters including within the insula

IV. Risk Factors

  1. Post-Traumatic Stress Disorder (present in up to 45% of Fibromyalgia patients)
  2. Sexual abuse or rape
  3. Family History
    1. D'Agnelli (2019) Mol Pain 15:1744806918819944 +PMID: 30486733 [PubMed]

V. Symptoms: General

  1. See Fibromyalgia Rapid Screening Tool
  2. Chronic diffuse pain (100%)
    1. Predominant, core symptom
  3. Severe Fatigue (81%)
  4. Morning stiffness longer than 15 minutes (77%)
  5. Sleep Disorder (75%)
    1. Difficulty falling asleep, staying asleep or frequent awakenings
    2. Non-restorative sleep (alpha-delta sleep)
    3. Sleep Apnea
    4. Nocturnal Myoclonus
    5. Restless Leg Syndrome
  6. Atypical Paresthesias (63%)
  7. Anxiety (48%)
  8. Dry Mouth (36%)
  9. Recurrent Headaches (53%)
  10. Dysmenorrhea (41%)
  11. Past History of Major Depression (31%)
  12. Irritable Bowel Syndrome (30-70%)
  13. Urinary urgency (26%)
  14. Cold sensitivity or Raynaud's Phenomenon (17%)
  15. Cognitive impact ("Fibro Fog)
    1. Decreased concentration and attention
    2. Mental slowing

VI. Symptoms: Exacerbating Factors

  1. Post-exertional increase in Muscle pain
  2. Emotional Stress or Abuse

VII. Signs

  1. See Diagnosis below
  2. Diffuse soft tissue Tender Points
    1. Not associated with focal or generalized findings to suggest other rheumatologic cause
    2. Joint inflammation, swelling or deformity suggests alternative diagnosis
    3. However, Fibromyalgia may coexist with other Pain Disorders (see associated comorbid conditions below)

VIII. Labs

  1. Fibromyalgia is a clinical diagnosis and labs are not required in routine causes
    1. Labs are normal in isolated Fibromyalgia
    2. Labs are often obtained to evaluate specific prominent symptoms (e.g. Fatigue)
  2. Standard Evaluation
    1. Complete Blood Count (CBC, esp. Hemoglobin)
    2. Basic Metabolic Panel (e.g. Chem8)
    3. Thyroid Stimulating Hormone (TSH)
  3. Additional tests when indicated (non-specific tests, order judiciously, when rheumatologic features are present)
    1. Erythrocyte Sedimentation Rate (ESR)
    2. C-Reactive Protein (C-RP)
    3. Antinuclear Antibody (ANA)
    4. Rheumatoid Factor (RF)
    5. Creatinine Phosphokinase (CPK)
  4. Fibromyalgia specific testing
    1. FM/a Cytokine Array-based Test
      1. May be used to confirm Fibromyalgia Diagnosis
      2. Test Sensitivity: 93%
      3. Test Specificity: 89% (70% when patient has comorbid Rheumatologic Conditions)
      4. Positive Likelihood Ratio: 3.1
      5. Negative Likelihood Ratio: 0.1
      6. Straub (2021) Am Fam Physician 103(9): 566-7 [PubMed]

IX. Diagnosis: General Criteria

  1. Fibromyalgia is a diagnosis of exclusion
  2. Widespread musculoskeletal pain ("I hurt all over")
  3. Regional: Each of 4 body quadrants involved
    1. Pain on left and right side of body
    2. Pain above and below waist
  4. Axial skeleton pain present
    1. Cervical Spine
    2. Anterior chest
    3. Thoracic Spine
    4. Low back
  5. Pain worse in the morning and at the end of the day
  6. Moderate to severe Fatigue or sleep problems
  7. Symptoms persist at least 3 months

X. Diagnosis: Specific Diagnostic Tools

  1. Screening
    1. See Fibromyalgia Rapid Screening Tool
  2. AAPT Criteria 2019 (alternative to ACR Criteria, Test Sensitivity 74%)
    1. Six of 9 painful sites (head, each arm, each leg, chest, Abdomen, upper back, lower back/buttocks)
    2. Moderate to severe sleep problems or Fatigue
    3. Pain present for 3 months or more
    4. Arnold (2019) J Pain 20(6):611-628 +PMID: 30453109 [PubMed]
  3. ACR Criteria Updates 2016 (Test Sensitivity 78-80%)
    1. Generalized pain in 4 of 5 regions for at least 3 months
    2. Simplified Part 2 of the Symptom Severity Score
    3. Incorporates Widespread Pain Index, symptom severity and Fatigue, sleep and cognitive impacts
  4. ACR Criteria Updates 2010
    1. See ACR Fibromyalgia Diagnostic Criteria (ACRFDC)
    2. Widespread Pain Index replaced Tender Points
  5. ACR Original Criteria 1990
    1. See Tender Points (11 of 18 present)
    2. Replaced by newer ACR and AAPT Criteria
  6. References
    1. Salaffi (2020) Rheumatology 59(10): 3042-9 [PubMed]

XI. Associated Conditions: Augmented Pain and Sensory Processing Disorders

  1. Chronic Fatigue Syndrome
  2. Tension Headache
  3. Migraine Headache
  4. Primary Dysmenorrhea
  5. Restless Legs Syndrome
  6. Periodic Limb Movement disorder
  7. Temporomandibular Joint pain
  8. Myofascial Pain Syndrome
  9. Interstitial Cystitis
  10. Irritable Bowel Syndrome
  11. Endometriosis
  12. Non-cardiac Chest Pain
  13. Chronic Low Back Pain
  14. Reduced functional ability
  15. Aerobic deconditioning
  16. Vulvodynia

XII. Associated Conditions: Common Comorbid Chronic Conditions

  1. Obstructive Sleep Apnea
  2. Rheumatologic Conditions (may complicate Fibromyalgia Diagnosis)
    1. Rheumatoid Arthritis
    2. Psoriatic Arthritis
    3. Osteoarthritis
    4. Lyme Disease
    5. Ankylosing Spondylitis
  3. Mental health disorders
    1. Post-Traumatic Stress Disorder
    2. Major Depression (occurs in up to 50% of Fibromyalgia patients)
    3. Bipolar Disorder
    4. Generalized Anxiety Disorder
    5. Substance Use Disorder

XIII. Differential Diagnosis

  1. Other Myofascial Conditions
    1. See Associated Conditions listed above
    2. Myofascial Pain Syndrome
    3. Chronic Fatigue Syndrome
  2. Psychiatric Conditions
    1. Masked Major Depression
    2. Somatoform Disorder
  3. Rheumatic, Endocrine and Neurologic Conditions
    1. Systemic Lupus Erythematosus (SLE)
    2. Rheumatoid Arthritis
    3. Polymyalgia Rheumatica (esp. age >60 years old)
    4. Polymyositis
    5. Diabetes Mellitus
    6. Myopathy or Neuropathy
    7. Myotonic Dystrophy
    8. Multiple Sclerosis
    9. Hypothyroidism
    10. Hyperparathyroidism
    11. Ankylosing Spondylitis or other Spondyloarthropathy
    12. Disc Herniation with radiculopathy
    13. Paraneoplastic Neuropathy
    14. Parkinson's Disease
  4. Infectious Conditions
    1. Epstein-Barr Virus (Mononucleosis)
    2. Parvovirus
    3. Q Fever
    4. Lyme Disease
    5. Viral Hepatitis
  5. Medications
    1. Statin-Induced Myopathy
    2. Bisphosphonates
    3. Aromatase Inhibitors
    4. Chronic Opioids
  6. Miscellaneous Conditions
    1. Vitamin D Deficiency
    2. Eosinophilia-Myalgia Syndrome (rare, likely toxin related, such as L-Tryptophan ingestion)

XIV. Management

  1. See Fibromyalgia Non-Pharmacologic Management
  2. See Fibromyalgia Pharmacologic Management
  3. Fibromyalgia Impact Questionnaire
    1. Assess for associated functional Impairment

XV. Resources: Patients

  1. Fransen (1997) Fibromyalgia Help Book, Smith House
    1. Paid link to Amazon.com (ISBN 0961522143)
  2. Starlanyl (1996) Fibromyalgia and Myofascial Pain, NHP
    1. Paid link to Amazon.com (ISBN 1572240466)

XVI. Resources: Organizations

  1. Arthritis Foundation
    1. http://www.arthritis.org
  2. National Fibromyalgia Research Association
    1. http://www.teleport.com/~nfra
  3. USA Fibromyalgia Association
    1. http://www.fibromyalgiaassnusa.org
  4. UK Fibromyalgia Association
    1. http://www.community-care.org.uk/charity/fmauk.html

XVII. References

  1. Money and Glauser (2017) Crit Dec Emerg Med 31(1): 15-21
  2. Klippel (1997) Primer Rheumatic Diseases, p.124-7
  3. Yunus (1996) Consultant, p. 1260-74
  4. Yunus (1996) Consultant, p. 1279-85
  5. Berman (1999) J Fam Pract 48(3):213-18 [PubMed]
  6. Gremillion (1998) Phys Sportsmed, 26(4) 55-65 [PubMed]
  7. Hadler (1997) Postgrad Med 102(2):161-77 [PubMed]
  8. Kodner (2015) Am Fam Physician 91(7): 472-8 [PubMed]
  9. Reiffenberger (1996) Am Fam Physician 53(5):1698-1704 [PubMed]
  10. Wilke (1996) Postgrad Med 100(1):153-70 [PubMed]
  11. Winslow (2023) Am Fam Physician 107(2): 137-44 [PubMed]

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Related Studies

Ontology: Fibromyalgia (C0016053)

Definition (MEDLINEPLUS)

Fibromyalgia is a disorder that causes muscle pain and fatigue. People with fibromyalgia have "tender points" on the body. Tender points are specific places on the neck, shoulders, back, hips, arms, and legs. These points hurt when pressure is put on them.

People with fibromyalgia may also have other symptoms, such as

  • Trouble sleeping
  • Morning stiffness
  • Headaches
  • Painful menstrual periods
  • Tingling or numbness in hands and feet
  • Problems with thinking and memory (sometimes called "fibro fog")

No one knows what causes fibromyalgia. Anyone can get it, but it is most common in middle-aged women. People with rheumatoid arthritis and other autoimmune diseases are particularly likely to develop fibromyalgia. There is no cure for fibromyalgia, but medicine can help you manage your symptoms. Getting enough sleep, exercising, and eating well may also help.

NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases
Definition (NCI) Inflammation and fibrous degeneration of a muscle.
Definition (NCI) A chronic disorder of unknown etiology characterized by pain, stiffness, and tenderness in the muscles of neck, shoulders, back, hips, arms, and legs. Other signs and symptoms include headaches, fatigue, sleep disturbances, and painful menstruation.
Definition (NCI_FDA) Inflammation and fibrous degeneration of a muscle.
Definition (MSH) A common nonarticular rheumatic syndrome characterized by myalgia and multiple points of focal muscle tenderness to palpation (trigger points). Muscle pain is typically aggravated by inactivity or exposure to cold. This condition is often associated with general symptoms, such as sleep disturbances, fatigue, stiffness, HEADACHES, and occasionally DEPRESSION. There is significant overlap between fibromyalgia and the chronic fatigue syndrome (FATIGUE SYNDROME, CHRONIC). Fibromyalgia may arise as a primary or secondary disease process. It is most frequent in females aged 20 to 50 years. (From Adams et al., Principles of Neurology, 6th ed, p1494-95)
Definition (PSY) A common nonarticular rheumatic condition that is characterized by muscle pain, tenderness, and stiffness.
Definition (CSP) an acute, subacute, or chronic painful state of muscles, subcutaneous tissues, ligaments, tendons, or fasciae caused by a number of agents such as trauma, strain, occupation, exposure, posture, infection, or arthritis.
Concepts Disease or Syndrome (T047)
MSH D005356
ICD10 M79.7 , M79.1
SnomedCT 1304004, 203101004, 203082005, 203111006, 247365004, 13612005, 156727006, 268107007, 203138004, 24693007, 56557000, 203102006
English Fibromyalgias, Fibrositides, Fibrositis, Muscular Rheumatism, Rheumatism, Muscular, Diffuse myofascial pain synd, Fibrositis unspecified, MPDS-Myofac pain dysfunct syn, Myofac pain dysfunct syndrome, Myofascial pain dysfunct syn, Myofascial pain dysfunction syndrome, myofascial pain dysfunction syndrome, MPD syndrome, muscular rheumatism, fibrositis, fibromyalgia (diagnosis), fibromyalgia, fibrositis (diagnosis), Fibromyalgia syndrome, Diffuse Myofascial Pain Syndrome, Myofascial Pain Syndrome, Diffuse, Fibromyalgia Fibromyositis Syndrome, Fibromyalgia-Fibromyositis Syndrome, Fibromyalgia-Fibromyositis Syndromes, Fibromyositis Fibromyalgia Syndrome, Fibromyositis-Fibromyalgia Syndrome, Fibromyositis-Fibromyalgia Syndromes, Syndrome, Fibromyalgia-Fibromyositis, Syndrome, Fibromyositis-Fibromyalgia, Syndromes, Fibromyalgia-Fibromyositis, Syndromes, Fibromyositis-Fibromyalgia, Fibromyalgia [Disease/Finding], fibromyalgia (FM), fibromyalgia syndrome, pain syndrome myofascial, syndrome fibromyalgia, fibromyalgias, fms, mpd syndrome, fibromyalgia (FMS), Fibromyalgia Syndrome, fibromyositis fibromyalgia syndrome, FMS, Fibrositis unspecified (disorder), Fibromyalgia (finding), Fibromyalgia (disorder), Fibromyositis NOS (disorder), Fibrositis NOS, FIBROMYOSITIS, Fibromyositis, Diffuse myofascial pain syndrome, MPDS - Myofacial pain dysfunction syndrome, Myofacial pain dysfunction syndrome, Myofascial pain syndrome, Muscular rheumatism, Fibromyositis (disorder), Fibrositis (disorder), Muscular rheumatism (disorder), fibromyositis, Fibromyositis, NOS, Fibrositis, NOS, Fibromyalgia, NOS, Fibromyalgia -RETIRED-, Fibromyalgia [Ambiguous], Fibromyalgia, Fibromyositis NOS
Dutch fibrositis, fibromyalgiesyndroom, fibromyositis, spier reumatisme, fibromyalgie, Fibromyalgie, Fibrositis, Myofasciaal pijnsyndroom, Spierreuma, Wekedelenreuma
French Syndrome fibromyalgique, Fibrosite, Rhumatisme musculaire, Fibromyalgie, Fibro-myosite, Fibromyosite, Polyenthésopathie, Syndrome de la douleur chronique myofasciale, Syndrome polyalgique diffus
German Fibromyalgiesyndrom, Fibromyositis, Fibromyalgie, Fibrositis, Diffuses myofasziales Schmerzsyndrom, Muskelrheumatismus, Rheumatismus, muskulärer
Italian Fibromiosite, Sindrome fibromialgica, Fibrosite, Reumatismo muscolare, Sindrome dolorosa miofasciale diffusa, Fibromialgia
Portuguese Síndrome de fibromialgia, Reumatismo muscular, Fibromiosite, Síndrome da Dor Miofascial Difusa, Fibromialgia, Fibrosite, Reumatismo Muscular
Spanish Fibromiositis, Reumatismo muscular, Síndrome de fibromialgia, Síndrome de Dolor Miofascial Difuso, fibromiositis, SAI, fibromiositis, SAI (trastorno), fibrositis, no especificada (trastorno), fibromialgia - RETIRADO - (concepto no activo), fibrositis, no especificada, fibromialgia - RETIRADO -, fibromialgia, no especificada (trastorno), fibromialgia, no especificada, fibromialgia, fibromiositis (trastorno), fibromiositis, fibrositis (trastorno), fibrositis, reumatismo muscular (trastorno), reumatismo muscular, síndrome de dolor miofascial, Fibromialgia, Fibrositis, Reumatismo Muscular
Japanese 線維筋炎, 線維筋痛, 線維筋痛症候群, 結合織炎, ｾﾝｲｷﾝﾂｳｼｮｳｺｳｸﾞﾝ, ｾﾝｲｷﾝﾂｳ, ｹﾂｺﾞｳｼｷｴﾝ, ｾﾝｲｷﾝｴﾝ, ｷﾝﾆｸﾘｳﾏﾁ, 筋肉リウマチ, 線維筋痛症, 筋リウマチ, 結合組織炎, リウマチ-筋肉
Swedish Fibromyalgi
Czech fibromyalgie, Fibrozitida, Fibromyalgie, Svalový revmatismus, Syndrom fibromyalgie, Fibromyozitida, fibrositis, fibromyalgický syndrom, svalový revmatismus, fibrozitida, myofasciální bolestivý dysfunkční syndrom
Finnish Fibromyalgia
Russian FIBROMIALGIIA, FIBROZIT, REVMATIZM MYSHECHNYI, РЕВМАТИЗМ МЫШЕЧНЫЙ, ФИБРОЗИТ, ФИБРОМИАЛГИЯ
Korean 섬유근육통
Croatian FIBROMIALGIJA
Polish Zapalenie tkanki łącznej włóknistej, Fibromialgia, Reumatyzm mięśniowy
Hungarian Fibromyalgia syndroma, Fibromyositis, Fibrositis, Muscularis rheumatismus, Fibromyalgia
Norwegian Fibromyalgi, Kronisk muskelsmerte syndrom, Fibrositt, Myofascielle smerter, Myofibrositt, Fibromyositt
Derived from the NIH UMLS (Unified Medical Language System)

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