Fibromyalgia: Assessment and Treatment Guidelines

Fibromyalgia is a chronic generalized musculoskeletal pain disorder characterized by widespread pain and tenderness to palpation. It mostly presents in women, with those aged 35 to 50 years old most at risk. This condition is two to five times more prevalent than rheumatoid arthritis, affecting 2 to 4 percent of the U.S. population—yet the etiology and pathogenesis of fibromyalgia remains relatively unknown, making it difficult to successfully treat.

In this article, we’ll take a look at the primary symptoms and diagnosis methodology of fibromyalgia, along with best practices for helping patients manage it.

Primary Fibromyalgia Symptoms

People with fibromyalgia typically experience:

Chronic Widespread Pain

Patients typically describe their pain as a constant dull ache that has lasted for at least three months on both sides of the body, above and below the waist, and accompanied by pain in the cervical spine, anterior chest, thoracic spine, or low back. This widespread pain is often diagnosed in fibromyalgia patients as nociplastic pain, but might also have a burning quality suggestive of neuropathic pain.

Fatigue

People with fibromyalgia often awaken tired, even though they report sleeping for long periods of time. Fibromyalgia can co-exist with chronic fatigue syndrome or myalgic encephalomyelitis. Even though an overlap exists between the two syndromes, studies have shown biochemical, physiological, and genetic differences between the two.¹

Cognitive Difficulties

A symptom commonly referred to as “fibro fog” impairs the ability to focus, pay attention and concentrate on mental tasks.

Non-Restorative Sleep Patterns

Sleep is often disrupted by pain. People could have other sleep disorders such as insomnia, restless leg syndrome, and sleep apnea.

Other Coexisting Conditions

Patients with fibromyalgia often live with other conditions such as irritable bowel syndrome, migraine or other types of headache, interstitial cystitis or painful bladder syndrome, TMJ disorders, anxiety, depression, and postural tachycardia syndrome.

How Is Fibromyalgia Diagnosed?

Diagnosis is entirely dependent on patient reports of symptoms and functional impairment, without any defining physical or laboratory abnormality. The American College of Rheumatology does not require a tender point exam to confirm diagnosis. Tender point exam is not supported by sound scientific basis and has been fraught with controversy.

Blood tests may be ordered to rule out other conditions that may have similar symptoms such as hypothyroidism, rheumatic conditions like early inflammatory arthritis or polymyalgia rheumatica, and neurological conditions like myopathy or multiple sclerosis.

These blood tests include:

• Complete blood count
• Erythrocyte sedimentation rate
• Cyclic citrullinated peptide test
• Rheumatoid factor
• Thyroid function tests
• Antinuclear antibody
• Celiac serology
• Vitamin D level

The cause of fibromyalgia is unknown. Familial studies have identified the possibility of genetic predisposition. While no individual gene has been associated with fibromyalgia, there is increasing evidence of a polygenic effect, with genes affecting serotonergic, catecholaminergic, and dopaminergic systems likely playing a role. Psychosocial distress, as well as early life adversity including abuse, have been shown to predict the onset of chronic widespread pain.

Treatment for Fibromyalgia

Fibromyalgia treatment and management strategies should be directed towards addressing symptoms and fostering optimum function.

Exercise and Physical Activity

The Ottawa Panel has produced two evidence-based clinical practice guidelines for fibromyalgia: one for aerobic fitness and one for strengthening exercises.^2,3

Aerobic fitness exercises have been found to greatly increase endurance, which, in turn, improves everyday functional mobility in patients.⁴ Research shows that the majority of women with fibromyalgia are aerobically unfit. Deconditioned muscles are more prone to muscle damage with activity. One third of women diagnosed with fibromyalgia do not have the upper body strength or flexibility to carry out routine activities like reaching high shelves or washing their hair. Exercise has the potential to decrease inactivity and deconditioning, a common cause of pain associated with fibromyalgia and to provide multiple beneficial physical and psychological outcomes.

Transcutaneous Electrical Stimulation (TENS)

TENS devices are sometimes used to help fibromyalgia patients manage chronic pain; however, their effectiveness in this area is controversial. Cochrane systematic reviews for fibromyalgia or chronic pain show low quality or insufficient evidence to support that TENS is effective for pain reduction.⁵

Psychological Interventions

Pharmacological management may include tricyclic antidepressants, gabapentinoids, dopaminergic agents, and sleep modifiers. Attention should be paid to the efficacy of drugs and development of side effects.

Psychological interventions that improve self efficacy should be encouraged to help patients cope with symptoms of fibromyalgia. Cognitive behavioral therapy can help alleviate fear of pain and fear of activity. Patients who have experienced previous adverse lifetime events that have impacted their psychological well being, should be offered support to facilitate attaining health-related outcome goals.

Work Recommendations

Patients who have been on prolonged sick leave secondary to experiencing symptoms of fibromyalgia should be encouraged to participate in appropriate rehabilitation programs with the focus on improving function, including return to work if possible. Every effort should be made to maintain individuals in the workforce.

The healthcare community should discourage passive health-related practices and excessive dependence on healthcare professionals. Access to a healthcare team member who is knowledgeable about fibromyalgia can provide support and may help the patient develop coping strategies.

References

1. Fatigue Syndrome and Fibromyalgia: Definitions, Similarities, and Differences. Clin Ther. 2019 Apr;41(4):612-618. doi: 10.1016/j.clinthera.2018.12.016. Epub 2019 Feb 20. PMID: 30795933; PMCID: PMC6589349.
2. Brosseau L, Wells GA, Tugwell P, Egan M, Wilson KG, Dubouloz CJ, Casimiro L, Robinson VA, McGowan J, Busch A, Poitras S, Moldofsky H, Harth M, Finestone HM, Nielson W, Haines-Wangda A, Russell-Doreleyers M, Lambert K, Marshall AD, Veilleux L; Ottawa Panel Members. Ottawa Panel evidence-based clinical practice guidelines for aerobic fitness exercises in the management of fibromyalgia: part 1. Phys Ther. 2008 Jul;88(7):857-71. doi: 10.2522/ptj.20070200. Epub 2008 May 22. PMID: 18497301.
3. Fitzcharles MA, Ste-Marie PA, Goldenberg DL, Pereira JX, Abbey S, Choinière M, Ko G, Moulin DE, Panopalis P, Proulx J, Shir Y; National Fibromyalgia Guideline Advisory Panel. 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary. Pain Res Manag. 2013 May-Jun;18(3):119-26. doi: 10.1155/2013/918216. PMID: 23748251; PMCID: PMC3673928.
4. Álvarez-Gallardo IC, Soriano-Maldonado A, Segura-Jiménez V, Estévez-López F, Camiletti-Moirón D, Aparicio VA, Herrador-Colmenero M, Castro-Piñero J, Ortega FB, Delgado-Fernández M, Carbonell-Baeza A. High Levels of Physical Fitness Are Associated With Better Health-Related Quality of Life in Women With Fibromyalgia: The al-Ándalus Project. Phys Ther. 2019 Nov 25;99(11):1481-1494. doi: 10.1093/ptj/pzz113. PMID: 31392995.
5. Arienti C. Is transcutaneous electrical nerve stimulation (TENS) effective in adults with fibromyalgia? A Cochrane Review summary with commentary. J Musculoskelet Neuronal Interact. 2019 Sep 1;19(3):250-252. PMID: 31475930; PMCID: PMC6737548.