Fibromyalgia www.arthritis.org 800-283-7800 - Robin K Dore MD, Inc.
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P R A C T I C A L H E L P F R O M T H E A R T H R I T I S F O U N D AT I O N
www.arthritis.org
800-283-7800
Fibromyalgia
WHAT IS FIBROMYALGIA? ACR classification, a person has fibromyalgia if
Fibromyalgia is a common condition associ- he or she has a history of widespread, allover
ated with muscular pain, fatigue and mood pain of at least three months’ duration and
changes. Fibromyalgia affects about two per- abnormal pain sensitivity in at least 11 of 18
cent of the U.S. population, and it occurs more specific sites on the body that are called “tender
commonly in women than in men. The cause points” (see page 2). Tender points are areas of
of fibromyalgia is unknown. the body that are painful when pressed.
Fibromyalgia is a form of chronic pain syn-
drome or soft-tissue rheumatism, which are SYMPTOMS AND SIGNS
broad terms used to describe a group of disor- Pain
ders that cause pain and stiffness around the Widespread musculoskeletal pain is the most
joints and in muscles and bones. However, common symptom of fibromyalgia. It generally
fibromyalgia can also occur in people with var- occurs at multiple sites throughout the body,
ious forms of arthritis or related diseases such as although it may start in one region, such as the
rheumatoid arthritis or lupus. neck and shoulders, and spread to other loca-
Fibromyalgia cannot be diagnosed with labo- tions over a period of time.
ratory tests. The results of X-rays and blood tests Fibromyalgia pain has been described in a
are normal. Therefore, the diagnosis is based on variety of ways, such as burning, gnawing,
a careful history and physical examination. aching, stiffness or soreness. It often varies
In 1990, the American College of Rheuma- according to time of the day, activity level,
tology (ACR), an organization of approximately weather, sleep patterns and stress. Most people
7,000 rheumatologists (specialists in muscu- with fibromyalgia say that some degree of pain
loskeletal diseases and immune disorders) and always is present. They feel the pain mainly in
other arthritis health professionals, developed a their muscles. For some people the pain may be
definition of fibromyalgia. According to the quite severe.
© 2003. Arthritis Foundation, Inc., Atlanta, GA. All rights reserved. For individual use only. Material in this
publication may not be reprinted without permission. Send requests for reprint permissions in writing to
1330 W. Peachtree St., Suite 100, Atlanta, GA 30309. For more information about arthritis, call 800/283-7800.
Page 1 of 7P R A C T I C A L H E L P F R O M T H E A R T H R I T I S F O U N D AT I O N
Although the results of a general physical exam- of soft tissue can be painful as well. People
ination usually are normal and individuals may often are not aware of the presence of many of
look healthy, a specific examination for tender- these tender points until a doctor performs a
ness reveals pain in response to low levels (less tender point evaluation.
than 4 kilograms) of pressure at a number of ten-
der points. However, many people with this con- Fatigue and Sleep Disturbances
dition have tenderness throughout their body. Most people with fibromyalgia have fatigue,
The tender points associated with fibromyal- decreased endurance or the kind of exhaustion
gia are similar in location to the tender areas felt with the flu or lack of sleep. Sometimes the
fatigue is severe and a much greater problem
than the pain.
People with fibromyalgia may have fatigue that
is similar to another condition called chronic
fatigue syndrome (CFS). The Centers for Disease
Control and Prevention developed criteria for
diagnosing CFS. To be diagnosed with CFS, a per-
son must experience at least six months of severe
fatigue that is not produced by other medical con-
ditions, plus four of the eight following symptoms:
• difficulty thinking clearly
• sore throat
• tender lymph nodes
• muscle aches
• joint aches
• headache
• sleep disorders
• malaise lasting more than 24 hours after
The dots in this figure indicate the various locations of exertion
tender points. People who have fibromyalgia experience
undue tenderness when pressure is applied to many of
these locations. You can see how some people with fibromyal-
gia also may fit the definition of CFS and vice
present in other common types of muscle and versa. Because of the similar symptoms of these
bone pain, such as tennis elbow (lateral epi- two conditions, some experts think they are
condylitis). A tender point on one side of the either related or variations of the same disorder.
body usually has a matching tender point in the Most people with fibromyalgia experience sleep-
same place on the opposite side of the body. ing problems. Although they typically are able to
Although the tender points illustrated are fall asleep without much difficulty, they sleep
common ones, many other muscles and areas lightly and wake up frequently during the night.
© 2003. Arthritis Foundation, Inc., Atlanta, GA. All rights reserved. For individual use only. Material in this www.arthritis.org
publication may not be reprinted without permission. Send requests for reprint permissions in writing to
1330 W. Peachtree St., Suite 100, Atlanta, GA 30309. For more information about arthritis, call 800/283-7800. 800-283-7800
Page 2 of 7P R A C T I C A L H E L P F R O M T H E A R T H R I T I S F O U N D AT I O N
They often wake up feeling tired, even after sleep- also may feel anxious. Some researchers think
ing through the night. The tiredness can range there is a link between fibromyalgia and certain
from listlessness and decreased endurance to forms of depression and chronic anxiety. How-
exhaustion and can vary from one day to the next. ever, any person with a chronic illness – not
Research has shown that a disruption of a phase just fibromyalgia – may feel depressed at times
of sleep called “deep” sleep alters many crucial while struggling with their pain and fatigue.
body functions, such as the production of chemi- People with fibromyalgia may have difficulty
cals needed by muscle tissue, as well as how a per- concentrating or performing simple mental
son perceives pain. Some researchers think sleep tasks. These problems tend to come and go and
problems may be a cause of fibromyalgia. This are often most prominent at times of extreme
theory needs more study, but it is clear that sleep fatigue or anxiety. Similar problems have been
problems can aggravate fibromyalgia symptoms. noted in many people with mood changes,
sleep disturbances or other chronic illnesses.
Tips for Improving Your Sleep
Other Problems
• Make your bedroom as comfortable and as Headaches, especially tension headaches and
quiet as possible. Invest in a good mattress. migraine headaches, are common in people
Maintain a comfortable room temperature. with fibromyalgia. Fibromyalgia may also be
• Use your bedroom only for sleeping and for associated with pain of the jaw muscles and
being physically close to your partner. face (called temporomandibular disorder).
• Avoid caffeine or alcohol before bedtime. Abdominal pain, bloating and alternating con-
• Take a warm bath before going to bed. stipation and diarrhea (called irritable bowel
• Avoid long naps. If a nap is needed to get you syndrome or spastic colon) also are common.
through the day, keep it short and schedule it Bladder spasms and irritability may cause fre-
well in advance of your bedtime. quent urination or the urge to urinate.
• Read before bedtime if you like, but avoid sus- Additional problems that may be associated
penseful, action-filled novels or work-related with fibromyalgia include dizziness, restless
material that can preoccupy your thoughts legs, endometriosis and numbness or tingling
and cause a poor night’s sleep. of the hands and feet.
• Eat a light snack before bedtime.You should not
go to bed hungry, nor should you feel too full. HOW IS FIBROMYALGIA DIAGNOSED?
• Set aside time before bed for relaxation. Fibromyalgia is diagnosed by the presence of
widespread muscle pain in combination with
tenderness (abnormal pain sensitivity) in
Mood and Concentration Symptoms response to low levels of pressure stimulation at
Changes in mood are a common symptom of most of the specific locations shown on page 2.
fibromyalgia. Feelings of sadness or being down There is no laboratory test or X-ray that can
are common, and some people with fibromyal- help a doctor diagnose fibromyalgia. But labo-
gia have depression. People with fibromyalgia ratory tests can help to diagnose other medical
© 2003. Arthritis Foundation, Inc., Atlanta, GA. All rights reserved. For individual use only. Material in this www.arthritis.org
publication may not be reprinted without permission. Send requests for reprint permissions in writing to
1330 W. Peachtree St., Suite 100, Atlanta, GA 30309. For more information about arthritis, call 800/283-7800. 800-283-7800
Page 3 of 7P R A C T I C A L H E L P F R O M T H E A R T H R I T I S F O U N D AT I O N
problems that can mimic fibromyalgia. For fibromyalgia have mild symptoms, and need
example, an underactive thyroid (hypothy- very little treatment once they understand what
roidism) causes many of the same symptoms as fibromyalgia is and how to avoid what worsens
fibromyalgia. A doctor can order a simple blood their condition. Other people, however, require
test, however, to determine if a person has this a comprehensive care program, involving med-
thyroid problem. A physical examination can ication, exercise and pain coping skills training.
rule out other conditions that may cause Treatment options for fibromyalgia include:
chronic pain and fatigue.
Because the symptoms of fibromyalgia are so • medications to diminish pain and improve sleep;
general and often bring to mind other medical • exercise programs that stretch muscles and
disorders, many people undergo complicated improve cardiovascular fitness;
and often repeated evaluations before they are • relaxation techniques to ease muscle tension
diagnosed with fibromyalgia. It is important to and anxiety; and
see a physician or rheumatologist who knows • educational programs to help you under-
how to diagnose and treat the condition. stand and better manage the symptoms of
fibromyalgia.
WHAT CAUSES FIBROMYALGIA?
No one knows what causes fibromyalgia. Medications
Researchers suspect that many different factors, Modest doses of nonsteroidal anti-inflam-
alone or in combination, may contribute to the matory drugs (NSAIDs), such as aspirin or
development of fibromyalgia. For example, fac- ibuprofen, or of analgesics, such as aceta-
tors such as an infectious illness, physical trau- minophen or tramadol (Ultram), may provide
ma, emotional trauma or hormonal changes some pain relief.
may trigger the development of generalized A subcategory of NSAIDs called COX-2
pain, fatigue and sleep disturbances that char- inhibitors, such as celecoxib (Celebrex) and
acterize the condition. rofecoxib (Vioxx), also may provide pain relief
Studies have suggested that people with fibro- but with fewer stomach side effects than tradi-
myalgia have abnormal levels of several differ- tional NSAIDs.
ent chemicals in their blood or cerebrospinal Severe pain can sometimes be treated with
fluid that help transmit and amplify pain sig- anticonvulsant medications such as gabapentin
nals to and from the brain. There also is evi- (Neurontin). Most doctors do not prescribe
dence that the central nervous system’s ability narcotic pain relievers or tranquilizers except
to inhibit pain is impaired in these people. for the most severe cases of fibromyalgia.
Whether these abnormalities are a cause or a Medications that promote sleep and relax
result of fibromyalgia is unknown. muscles help many people with fibromyalgia
get more rest.
HOW IS FIBROMYALGIA TREATED? Doctors also may prescribe medications com-
Your doctor can create a treatment plan monly known as antidepressants to treat fibro-
specifically for you. Some people with myalgia. These drugs work by elevating the lev-
© 2003. Arthritis Foundation, Inc., Atlanta, GA. All rights reserved. For individual use only. Material in this www.arthritis.org
publication may not be reprinted without permission. Send requests for reprint permissions in writing to
1330 W. Peachtree St., Suite 100, Atlanta, GA 30309. For more information about arthritis, call 800/283-7800. 800-283-7800
Page 4 of 7P R A C T I C A L H E L P F R O M T H E A R T H R I T I S F O U N D AT I O N
els of serotonin and norepinephrine in the drug while the side effects of each drug cancel
brain and spinal cord. Low levels of serotonin each other out.
and norepinephrine are linked not only to clin-
ical depression but also to the pain sensitivity Exercise and Physical Therapy
and sleeping problems associated with Exercise is an extremely important aspect of
fibromyalgia. These antidepressants, which are the management of fibromyalgia. Exercises help
typically prescribed at lower doses than those to stretch tight, sore muscles and to increase car-
used to treat major depression, have been diovascular (aerobic) fitness. Studies show cer-
shown to reduce pain in people with fibromyal- tain aerobic exercise programs give people with
gia and thereby may improve the chance of a fibromyalgia an improved sense of well-being,
good night’s sleep. increased endurance and decreased pain.
There are two major classes of antidepressants: Pilates, stretching and isometric exercises
tricyclics, such as amitriptyline (Elavil ), nor- (exercises in which you tighten your muscles
triptyline (Pamelor) and doxepin (Sinequan); without moving your joints) are good exercises
and selective serotonin reuptake inhibitors, or for people with fibromyalgia.
SSRIs, such as fluoxetine (Prozac), paroxetine Isotonic exercises (exercises in which you
(Paxil ) and sertraline (Zoloft ). A drug called strengthen muscles through resistance) work-
cyclobenzaprine (Flexeril ), classified as a muscle ing the upper extremities, particularly weight
relaxant but similar to an antidepressant, some- lifting and rowing, are not recommended.
times is prescribed. You may be reluctant to exercise if you are
There also is a new class of dual-acting reup- already tired and in pain. Low- or non-impact
take inhibitors, such as venlafaxine and nefa- aerobic exercises, such as walking, biking, water
zodone, that act on two neurotransmitters aerobics or swimming, generally are the best
involved in pain inhibition, serotonin and nore- ways to start such a program. However, it is
pinephrine. These medications have not been important to begin exercising at a level that you
studied as extensively as the tricyclics and SSRIs; can tolerate without a substantial increase in
however, studies of these medications have pro- pain. Many people with fibromyalgia find it
duced positive results in people with CFS. necessary to consult with an experienced phys-
Although many people sleep better and have ical therapist for best results.
less discomfort when they take antidepressants, Begin slowly. You can start by exercising five
the degree of improvement varies greatly from minutes, three times a day, to get a total of 15
person to person. These medications may have minutes for that day. Over a period of time, try
side effects such as daytime drowsiness, consti- to extend the endurance part of your exercise
pation, dry mouth and increased appetite. program to get a total of 30 minutes each day
Some SSRIs may actually make sleeping diffi- you exercise. Exercise every other day, if possi-
cult. These side effects rarely are severe, but ble, and gradually increase your activity to
they can be disturbing. Some studies have sug- reach a better level of fitness.
gested that combining tricyclic antidepressants Gently stretch your muscles and move your
with SSRIs may increase the benefits of each joints through their range of motion daily, and
© 2003. Arthritis Foundation, Inc., Atlanta, GA. All rights reserved. For individual use only. Material in this www.arthritis.org
publication may not be reprinted without permission. Send requests for reprint permissions in writing to
1330 W. Peachtree St., Suite 100, Atlanta, GA 30309. For more information about arthritis, call 800/283-7800. 800-283-7800
Page 5 of 7P R A C T I C A L H E L P F R O M T H E A R T H R I T I S F O U N D AT I O N
before and after exercise. Physical therapists can fibromyalgia by exercising regularly, educating
help you by designing a specific exercise pro- yourself about your condition and learning
gram to improve posture, flexibility and fitness. how to implement relaxation techniques and
stress management strategies.
Coping Skills Fortunately, fibromyalgia is not life threaten-
Many people can benefit from learning how ing and does not lead to muscle or joint dam-
to better cope with and gain control over pain. age. Although symptoms may vary in intensity,
Pain coping strategies include learning muscle the overall condition rarely worsens over time.
relaxation, meditation or biofeedback skills. In In a small study that traced how people with
addition, some cognitive coping strategies can fibromyalgia felt 10 years after diagnosis, the
help you better control feelings of being over- study authors found that although symptoms
whelmed by the pain and the stress associated may persist, many people felt better with treat-
with fibromyalgia. ment and time.
Stress management techniques, such as alter- While nine out of 10 people with fibromyalgia
nating periods of activity with periods of rest work full-time, 30 percent have had to change
and breathing exercises, can help you control jobs, and 30 percent have changed their job
the feelings of anger, sadness and panic that description. Some people with fibromyalgia have
often overwhelm people living with frequent such severe symptoms that they are unable to
pain and fatigue. function well at work or socially. These individ-
Learning pain control and stress management uals may require greater attention in a program,
techniques often requires help from health pro- such as a multi-disciplinary pain center, that uti-
fessionals. The research studies published thus lizes physical or occupational therapists, social
far on pain coping skills for fibromyalgia sug- workers, nurses, mental health professionals,
gest that the strategies may work best if they are rehabilitation counselors and sleep specialists.
tailored to fit the needs of individual patients. Your primary care doctor or rheumatologist can
refer you to a pain center or similar program.
MANAGING FIBROMYALGIA
Frequently, people with fibromyalgia have RESEARCH
undergone many tests and have seen several Arthritis Foundation-funded research is help-
specialists in their search for answers. They ing to increase understanding of the role of
often are told that because they look well and neurological and psychological factors in fibro-
their tests are normal, there is nothing wrong myalgia, which could help lead to advances in
with them. Their family and friends, as well as treatment. Studies funded by the Arthritis
physicians, may doubt the reality of their com- Foundation are also evaluating coping inter-
plaints, increasing their feelings of isolation, ventions to help people with fibromyalgia take
guilt and anger. control of their disease as well as evaluating the
You and your family should understand that role of treatment options including exercise,
fibromyalgia causes chronic pain and fatigue. medications, and complementary and alterna-
You must take an active role in managing your tive therapies in fibromyalgia.
© 2003. Arthritis Foundation, Inc., Atlanta, GA. All rights reserved. For individual use only. Material in this www.arthritis.org
publication may not be reprinted without permission. Send requests for reprint permissions in writing to
1330 W. Peachtree St., Suite 100, Atlanta, GA 30309. For more information about arthritis, call 800/283-7800. 800-283-7800
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THE ARTHRITIS FOUNDATION painful and to help you become an active part-
The mission of the Arthritis Foundation is to ner in your own health care.
improve lives through leadership in the prevention, Contact us at (800) 283-7800 or visit us on
control and cure of arthritis and related diseases. the Web at www.arthritis.org to become an
The Arthritis Foundation supports research Arthritis Advocate or to find out how you can
with the greatest potential for advances and has become involved.
invested more than $320 million in these efforts
since its inception in 1948. Additionally, the The Arthritis Foundation acknowledges with appre-
Arthritis Foundation supports key public policy ciation Laurence A.Bradley,PhD,Professor of Medicine,
and advocacy efforts at a local and national level University of Alabama at Birmingham; Daniel J. Clauw,
in order to make a difference on behalf of 70 MD, Professor of Medicine, University of Michigan, Ann
million people living with arthritis. Arbor; Leslie J. Crofford, MD, University of Michigan,
As your partner in taking greater control of Ann Arbor; Alverna Jenkins, MSW, MEd, Childrens
arthritis, the Arthritis Foundation also offers a Hospital Medical Center, Cincinnati; and Daniel Wallace,
large number of programs and services nation- MD, Cedars-Sinai/UCLA School of Medicine, Los
wide to make life with arthritis easier and less Angeles, for their assistance with this booklet.
For more information: The Arthritis Foundation offers a wide variety of books, brochures and videos about dif-
ferent forms of arthritis, treatment and self-management techniques to help you take control of your arthritis.
To order any of these products, become an Arthritis Foundation member or to subscribe to the Arthritis
Foundation's award-winning consumer health magazine, Arthritis Today, call (800) 283-7800. Call or visit our
Web site (www.arthritis.org) to find out how you can take control of your arthritis and start living better today!
This brochure has been reviewed by the
AMERICAN COLLEGE OF RHEUMATOLOGY.
MISSION STATEMENT:
The mission of the Arthritis Foundation
is to improve lives through leadership
in the prevention, control and cure
of arthritis and related diseases.
© 2003. Arthritis Foundation, Inc., Atlanta, GA. All rights reserved. For individual use only. Material in this www.arthritis.org
publication may not be reprinted without permission. Send requests for reprint permissions in writing to
1330 W. Peachtree St., Suite 100, Atlanta, GA 30309. For more information about arthritis, call 800/283-7800. 800-283-7800
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