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Fibromyalgia is a chronic pain syndrome ACR (American College of Rheumatology 1990 ) classification criteria state the presence of widespread pain in combination with 11 or more of 18 specific 
tender point sites. Widespread pain was defined as 3 out of 4 quadrant pain including left-and right and upper and lower segment pain and axial pain.

Better understanding of disease since initial ACR criteria ( 1990 ) Examination of tender point – found to be barrier in primary care Erroneous impression – that it is a peripheral musculoskeletal disease .Fibromyalgia usually diagnosed in primary care Diagnosis often not considered initially

Pain for at-least three months affecting both sides of the body , both above and below the waist Palpation of tender points not required Body divided into 19 regions and score how many regions are painful

Epidemiology-Common with a prevalence of 2 % Seen in all ethnic and socio-economic groups Prevalence ↑↑ in females Age of onset between 20-60 average age of 35 Diagnosis & management remains a challenge Often takes > 2 yrs to diagnose and an average 3.7 consultations with different physicians

Causes -Not known what exactly causes fibromyalgia – several mechanisms proposed
○ central sensitisation – maladaptive pain response
○ sleep cycle abnormalities
○ psychological and social factors
○ genetic-role of polymorphisms of genes
○ disturbances of serotonin , growth hormone , substance P & cortisol levels

Presentation-Varied and fluctuating symptoms
 Chronic widespread pain and tenderness
○ may have burning quality suggestive of neuropathic pain
○ not localised to any specific body tissue
○ tends to move from site to site
 Fatigue Unrefreshed sleep Cognitive dysfunction

Differential diagnosis -Inflammatory arthritis- including spondyloarthropathies Osteoarthritis Iron deficiency anaemia Hypermobility syndromes Chronic fatigue syndrome Polymyalgia rheumatica Polymyositis / dermatomyositis Thyroid dysfunction Multiple sclerosis Neuropathies Osteomalacia Drug related- eg statins

Investigations – ESR / CRP TFT FBC Iron studies Alkaline phosphatase Rheumatoid factor- if inflammatory cause suspected ( many false +ves ) Anti-CCP antibody – also many false + ves ANA -r/o SLE Vitamin D and B12

DiagnosisEstablish diagnosis and inform educate
 the patient / carers – inform that fibromylagia is a real disease Diagnosis does not require specialist eg Rheumatology confirmation Inform and educate- see information under links and resources Discuss treatment options and local availability Advice patients to expect exacerbation and remissions to vary over time Despite treatment with non-pharmacological measures and treatment with maximum dose of a single pharmacological agent , many patients still continue to be symptomatic – consider using combination drug therapy in such cases Consider referral to rheumatology , psychiatry , physiatrist ( physical medicine and rehabilitation physicians ) if troublesome symptoms continue despite optimum measures

Factors associated with a poor prognosis include –long duration of illness high stress levels co-morbidities like depression or anxiety which have not been treated adequately long standing avoidance of work alcohol or drug dependence moderate or severe functional impairment

Pharmacological management 

Amitriptyline –Often first-line inexpensive and can improve sleep Studies have shown patients more likely to achieve 30 % pain reduction
 ie evidence of efficacy

Gabapentinoids –Pregabalin is licensed for use
Gabapentin has shown similar efficacy Likely 30 % pain reduction and small effect on fatigue and sleep

SSRIs –Recent review of medium quality seven trials and reported a moderate
 effect on pain , sleep and no effect on fatigue- total available evidence is
 of low quality ( currently not approved for fibromyalgia by international drug agencies )

SNRIs- duloxetine Good choice for patients associated depression 
or fatigue -low to moderate quality evidence 
of efficacy

NSAIDs and Tramadol –Effective for acute pain and in chronic nocioceptive pain states and widely used -No evidence that they are effective alone in fibromyalgia

Combination –For example Tricyclics + SNRIs ( BMJ Best Practice )
Small risk serotonin syndrome but seen rarely in clinical practice

Non-pharmacological management

Acupuncture –Acupuncture significantly improved pain and symptoms of FM. although sham effect was important , real acupuncture treatment seems to be effective in treatment of FM
 ( Cochrane 2017 )

Exercise –Aerobic exercise was associated with improvements in pain and physical function. Evidence consistent for aerobic and strengthening exercises – less evidence to suggest superiority of one over another ( Cochrane )
BMJ Best Practice suggests that nearly any kind of exercise can be helpful with
 some evidence that aquatic exercise may be a good way to begin

Cognitive behaviour therapy-Cochrane review suggests that CBT in part via reductions in catastrophizing , help to normalize pain-related brain responses in FM (Clin J Pain 2017 Mar)

Biofeedback-Cochrane review from 2007 mentions – Biofeedback as a treatment modality reduces pain in patients with FM along with improvements in FIQ ( fibromyalgia impact questionnaire ) , 
SMWT ( 6 min walk test ) and the number of tender points – Indian J Med Sci 2007



Arthritis Research booklet on fibromyalgia

FMAUK org information page on fibromyalgia

NRS Healthcare – info about fibromyalgia ( has a disability aid shop ) 

Fibromyalgia Awareness Association ( Spain ) has a beginners guide which patients can download

UK Fibromyalgia com

Pain relief foundation booklet on Fibromylagia

Excellent work from HSE Ireland

A questionnaire from Fibromyalgia network can be printed for the patient to fill

This is an online calculator from The SOAP Note project which stands for subjective objective assessment plan by Mark Morgan in 2013 ( I am unsure about the validity of this questionnaire but incorporates the current ACR-FDC diagnostic criteria )

American College of Physicians on fibromyalgia 1 page ( double sided )

NHS Inform Scot

For patients in the USA

American College of Rheumatology fast facts about fibromyalgia


European League Against Rheumatism guideline Macfarlane GJKronisch CDean LE, et al EULAR revised recommendations for the management of fibromyalgia 

Another useful article Boomershine CS. A comprehensive evaluation of standardized assessment tools in the diagnosis of fibromyalgia and in the assessment of fibromyalgia severity. Pain Res Treat. 2012;2012:653714. doi:10.1155/2012/653714

Polish Archives of Internal Medicine Management of fibromyalgia: practical guides from recent evidence-based guidelines Winfried Häuser, Jacob Ablin, Serge Perrot, Mary-Ann Fitzcharles DOI: 10.20452/pamw.3877 Published online: January 04, 2017

Canadian guideline on fibromyalgia management Fitzcharles MA, Ste-Marie PA, Goldenberg DL, et al. 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summaryPain Res Manag. 2013;18(3):119–126. doi:10.1155/2013/918216

Practical pain management – Fibromyalgia what clinicians need to know by Gary W Jay MD

2016 ACR Diagnostic criteria of fibromyalgia



  1. Fibromyalgia syndrome : management in primary care by Peter Glennon GP Stafford, Arthritis Research UK Reports on the Rheumatic Diseases Series 6 Autumn 2010 Hands on No 7
  2. Macfarlane GJKronisch CDean LE, et al
    EULAR revised recommendations for the management of fibromyalgia
  3. Fibromyalgia: A Clinical Update June 2010 (Volume 18, Issue 4)
    Claudia Sommer
  4. Fibromylagia Clinical Review BMJ 2014 ; 348 :g1224
  5. Medscape CME Fibromyalgia : Diagnostic and Treatment Strategies for the Family Physicians
  6. BMJ Best Practice Fibromyalgia
  7. Fibromyalgia in Primary Care : Incorporating Patient Insights into Patient Care
  8. Angry patient with fibromyalgia: Diagnosis and
    management in primary care Teoh Soo Huat, MD1,2
    1 Department of Family Medicine, Hospital University Science Malaysia, Kubang Kerian, Kelantan, 2 Klinik Kesihatan Bakar Arang, Sungai Petani, Kedah Med J Malaysia Vol 71 No 6 December 2016
  9. Fitzcharles, M. A., Ste-Marie, P. A., Goldenberg, D. L., Pereira, J. X., Abbey, S., Choinière, M., Ko, G., Moulin, D. E., Panopalis, P., Proulx, J., Shir, Y., & National Fibromyalgia Guideline Advisory Panel (2013). 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary. Pain research & management18(3), 119–126.
  10. Australian Family Physician Fibromyalgia Emma Guymer
    Geoffrey Littlejohn Volume 42 , No 10 , October 2013
  11. New and Modified Fibromyalgia Diagnostic Criteria Neha Garg and Atul Deodhar February 9, 2012 Neha Garg, MD

  12. The effects of acupuncture versus sham
    acupuncture in the treatment of fibromyalgia:
    a randomized controlled clinical trial
    Uğurlu FG1 , Sezer N1 , Aktekin L1 , Fidan F1 , Tok F2 , Akkuş S1 2017 Jan-Mar;42(1):32-37.
  13. Bhargava J, Hurley JA. Fibromyalgia. [Updated 2019 Nov 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:



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