Fibromyalgia

What is it?

Fibromyalgia is a long-term condition in which widespread pain lasting at least three months comes with tiredness, unrefreshing sleep and problems with concentration and memory. People often describe it as "hurting all over". Where the pain is felt and how strong it is can change during the day and from one day to the next.

Fibromyalgia is not an inflammatory rheumatic disease, and it does not damage the muscles, joints or internal organs. The pain is nevertheless real and can have a major impact on daily life. Fibromyalgia is now understood to involve changes in the way the nervous system processes pain signals. The International Association for the Study of Pain (IASP) uses the term nociplastic pain for pain of this kind, which arises from altered pain processing without clear evidence of tissue damage or nerve disease.

Fibromyalgia is more common in women and usually starts between early adulthood and middle age, although it can develop at any age.

What causes it?

The exact cause of fibromyalgia is not known. The underlying mechanism is thought to be central sensitisation, in which the brain and spinal cord respond more strongly than usual to pain signals. Factors that may play a part include:

• A family tendency
• A triggering event such as a physical injury, an operation or an infection
• Long-term stress or traumatic life events
• Sleep disorders
• Another rheumatic condition, such as rheumatoid arthritis or lupus

Inactivity, poor sleep and anxiety can make pain worse, and worsening pain in turn limits activity and sleep, creating a vicious circle. Breaking this circle is one of the main aims of treatment.

How is it diagnosed?

There is no blood test or scan that confirms fibromyalgia. Diagnosis is based on a detailed history and examination, and on ruling out other conditions that can cause similar symptoms. Current diagnostic criteria look at how widespread the pain is, together with the severity of fatigue, sleep problems and cognitive symptoms. The old tender point count is no longer needed for diagnosis.

An underactive thyroid, anaemia, inflammatory rheumatic diseases, muscle disorders and the side effects of some medicines, such as cholesterol-lowering drugs, can cause similar complaints, so basic blood tests may be requested to rule them out. Fibromyalgia can also coexist with another problem, such as a herniated disc or rheumatoid arthritis; in that case each needs to be addressed in its own right.

A timely diagnosis that is clearly explained is an important part of treatment. Knowing what the symptoms are and why they happen reduces anxiety and makes it easier to take an active part in treatment.

Treatment options

There is not yet a treatment that makes fibromyalgia go away completely, but symptoms can be eased and daily life made easier. International guidelines recommend starting with education and non-drug approaches, then adding other options step by step, tailored to the individual, if the response is not enough. Most treatments have a modest effect on their own, so several approaches are usually combined.

Conservative care

• Education: understanding what fibromyalgia is, and why it does not damage the body's tissues, is the starting point of treatment.
• Exercise: exercise is the approach that guidelines recommend most firmly. Low-intensity aerobic exercise such as walking, swimming or cycling, together with gentle strengthening, is started in short sessions and built up gradually over weeks.
• Sleep habits: regular sleeping and waking times, avoiding caffeine and alcohol before bed and a calm sleeping environment can help to ease symptoms.
• Psychological approaches: cognitive behavioural therapy and acceptance and commitment therapy can make pain easier to manage and support daily functioning.
• Movement-based therapies: tai chi, yoga and mindfulness-based programmes may help some people.
• Medication: for severe pain or sleep problems, medicines such as low-dose amitriptyline or duloxetine may be considered. They can help with pain and sleep even when there is no depression, and are used with their side effects in mind. Strong opioid painkillers are not recommended for fibromyalgia.

Interventional pain treatments

Because the pain in fibromyalgia does not come from one specific nerve, joint or muscle, interventional treatments have a limited role. The evidence that injections help in fibromyalgia is weak; they do not treat the condition itself and are not routinely recommended for widespread pain.

Some people with fibromyalgia also have distinct trigger points in particular muscles (myofascial pain syndrome). In that situation, a trigger point injection may be considered as a limited, supportive option to ease local pain and make it easier to take part in an exercise programme. Its effect is usually temporary, and it does not replace exercise.

A team approach

Fibromyalgia care often involves several specialties working together. Specialists in physical medicine and rehabilitation, rheumatology, psychiatry or psychology, and algology may share the work of the exercise programme, treatment of associated conditions, and support for sleep and mental health. An algology assessment reviews the diagnosis, looks for other sources of pain in the back, neck or muscles that may be adding to the problem, and tailors medication to the individual.

When should you see a doctor?

See a doctor if you have had pain in many parts of your body for some time, together with unrefreshing sleep and marked tiredness. A correct diagnosis helps you avoid unnecessary tests and treatments and is the starting point for a plan that suits you. An algology (pain medicine) specialist will assess your symptoms in detail; you can request an appointment through our contact page.