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{{Infobox_Disease
__NOTOC__
| Name          = Fibromyalgia
'''For patient information page click [[{{PAGENAME}} (patient information)|here]]'''
| Image          =
{{Fibromyalgia}}
| Caption        =
{{CMG}} {{AE}} [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], {{ADG}}
| DiseasesDB    = <!-- no entry -->
| ICD10          = {{ICD10|M|79|7|m|70}}
| ICD9          = {{ICD9|729.1}}
| ICDO          =
| OMIM          =
| MedlinePlus    = 000427
| MeshID        = D005356
}}


{{SI}}
{{SK}} Fibromyositis; fibrositis; fibromyalgia primary; fibromyalgia secondary; fibromyalgia-fibromyositis syndrome; fibrositis.
'''Editor(s)-in-Chief:''' [[C. Michael Gibson]], M.S.,M.D. [mailto:mgibson@perfuse.org] Phone:617-632-7753; [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]  
==[[Fibromyalgia overview|Overview]]==
==[[Fibromyalgia historical perspective|Historical Perspective]]==
==[[Fibromyalgia pathophysiology|Pathophysiology]]==


==Overview==
==[[Fibromyalgia causes|Causes]]==
'''Fibromyalgia''' (FM) is a disorder classified by the presence of chronic widespread [[pain]] and tactile [[allodynia]].<ref name="Wolfe">{{cite journal | last=Wolfe | first=F | coauthors=Smythe HA, Yunus MB et al. | title=The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee | journal=Arthritis and Rheumatism | volume=33 | issue=2 | pages=160–172 |date=February 1990 | pmid=2306288 }}</ref> While the [[criteria]] for such an entity have not yet been thoroughly developed, the recognition that fibromyalgia involves more than just pain has led to the frequent use of the term "fibromyalgia [[syndrome]]".  It is not [[Infectious disease|contagious]], and recent studies suggest that some people with  fibromyalgia may be [[genetics|genetically]] predisposed.<ref>[http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16887010 Biology and therapy of fibromyalgia. Genetic aspects of fibromyalgia syndrome<!-- Bot generated title -->]</ref> The disorder is not directly life-threatening.  The degree of symptoms may vary greatly from day to day with periods of flares (severe worsening of symptoms) or remission; however, the disorder is generally perceived as [[non-progressive]].<ref>{{cite web | author=McBride CR |title=Fibromyalgia |work=Clinical Vignette |date=03 Jul 2000 |url=http://www.med.ucla.edu/modules/wfsection/article.php?articleid=141 |publisher=UCLA Department of Medicine}}</ref>


==History==
==[[Differentiating Fibromyalgia from other diseases|Differentiating Fibromyalgia from other Diseases]]==
Fibromyalgia has been studied since the early 1800s and referred to by a variety of former names, including '''muscular rheumatism''' and fibrositis.<ref>{{cite web |author=Health Information Team |title=Fibromyalgia |url=http://hcd2.bupa.co.uk/fact_sheets/mosby_factsheets/fibromyalgia.html |date=February 2004 |Publisher=BUPA insurance}}</ref> The term ''fibromyalgia'' was coined in 1976 to more accurately describe the symptoms, from the [[Latin]] ''fibra'' (fiber)<ref>[http://www.bartleby.com/61/14/F0101400.html Meaning of fibra]</ref> and the [[Greek language|Greek]] words ''myo'' (muscle)<ref>[http://www.bartleby.com/61/94/M0509400.html Meaning of myo]</ref> and ''algos'' (pain).<ref>[http://www.bartleby.com/61/59/A0195900.html Meaning of algos]</ref>


In 1981, Dr. Muhammad B. Yunus published the "first controlled study of the clinical characteristics" of the fibromyalgia syndrome, for which he is considered "the father of our modern view of fibromyalgia."<ref name=Winfield>John B. Winfield (2007), "Fibromyalgia and Related Central Sensitivity Syndromes: Twenty-five Years of Progress", ''Seminars in Arthritis and Rheumatism'' '''36''' (6): 335-338.</ref><ref name=sciencedaily>[http://www.sciencedaily.com/releases/2007/06/070625095756.htm Further Legitimization Of Fibromyalgia As A True Medical Condition], ''[[Science Daily]]'', June 25, 2007.</ref> His work was the "first controlled [[Clinical trial|clinical study]]" of fibromyalgia with validation of known [[symptom]]s and tender points, and he also proposed "the first data-based criteria." In 1984, he proposed the important concept that the fibromyalgia syndrome and other similar conditions are interconnected. In 1986, he showed [[serotonergic]] and norepinephric [[drug]]s to be effective.<ref name=Inanici>F. Fatma Inanici and Muhammad B. Yunus (2004), "History of fibromyalgia: Past to present", '''8''' (5): 369-378.</ref>
==[[Fibromyalgia epidemiology and demographics|Epidemiology and Demographics]]==


Yunus later emphasized a "[[Biopsychosocial model|biopsychosocial perspective]]" of fibromyalgia, which is considered the "only way to synthesize the disparate contributions of such variables as genes and adverse childhood experiences, life stress and distress, posttraumatic stress disorder, mood disorders, self-efficacy for pain control, catastrophizing, coping style, and social support into the evolving picture of central nervous system dysfunction vis-a-vis chronic pain and fatigue."<ref name=Winfield/><ref name=sciencedaily/>
==[[Fibromyalgia risk factors|Risk Factors]]==


Fibromyalgia was recognized by the American Medical Association as an illness and a cause of disability in 1987. In an article the same year, in the [[Journal of the American Medical Association]], a physician named Dr. Don Goldenberg also called the disorder fibromyalgia. The ACR published a criteria for fibromyalgia in 1990, and developed [[Neurohormone|neurohormonal]] mechanisms with central [[sensitization]] in the 1990s.<ref name=Inanici/>
==[[Fibromyalgia screening|Screening]]==


==Incidence==
==[[Fibromyalgia natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
It affects more females than males, with a ratio of 9:1 by American College of Rheumatology (ACR)criteria.<ref>Fibromyalgia {{eMedicine|med|790}}</ref> Fibromyalgia is seen in about 2% of the general population.<ref name="Chakrabarty">{{cite journal | last=Chakrabarty | first=S | coauthors=Zoorob R | title=Fibromyalgia | journal=American Family Physician | volume=76 | issue=2 | pages=247–254 |date=July 2007 | url=http://www.aafp.org/afp/20070715/247.html | pmid=17695569 | accessdate=2008-01-06 }}</ref> It is most commonly diagnosed in individuals between the ages of 20 and 50, though onset can occur in childhood.
 
==Symptoms==
The defining symptoms of fibromyalgia are chronic, widespread pain and tenderness to light touch.  There is also typically moderate to severe fatigue.  Those affected may also experience heightened [[Sensitivity (human)|sensitivity]] of the skin (also called [[allodynia]]), tingling of the skin (often needle-like), achiness in the muscle tissues, prolonged muscle spasms, weakness in the limbs, and [[Neuropathy|nerve pain]].  Chronic sleep disturbances are also characteristic of fibromyalgia.  Indeed, studies suggest that  sleep disturbance are related to a phenomenon called ''alpha-delta sleep'', a condition in which deep sleep (associated with delta EEG waves) is frequently interrupted by bursts of brain activity similar to wakefulness (i.e. alpha waves). Deeper stages of sleep (stages 3 & 4) are often dramatically reduced.
 
An example of tactile allodynia is when a person perceives light pressure or the movement of clothes over the skin as painful, whereas a healthy individual would not feel pain. Fibromyalgia patients are often affected by a number of symptoms other than pain, including debilitating fatigue, abnormal sleep architecture, <ref>[http://www.ncbi.nlm.nih.gov/pubmed/169541?ordinalpos=40&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Musculosketal symptoms and non-REM sleep disturban...[Psychosom Med. 1975 Jul-Aug&#93; - PubMed Result<!-- Bot generated title -->]</ref> (meaning the brain does not reach all the restorative levels of sleep necessary for overall health), functional bowel disturbances,<ref>[http://www.ncbi.nlm.nih.gov/pubmed/15361320?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Fibromyalgia: the gastrointestinal link. [Curr Pain Headache Rep. 2004&#93; - PubMed Result<!-- Bot generated title -->]</ref> and a variety of neuropsychiatric problems including cognitive dysfunction, <ref>[http://www.ncbi.nlm.nih.gov/pubmed/17092441?ordinalpos=7&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Cognitive dysfunction in fibromyalgia and chronic ...[Curr Rheumatol Rep. 2006&#93; - PubMed Result<!-- Bot generated title -->]</ref> which can mean short and/or long term memory problems, slowed information processing ability, diminished attention span and anxiety and depressive symptoms.<ref>[http://www.ncbi.nlm.nih.gov/pubmed/17894922?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Comorbidity of fibromyalgia and psychiatric disord...[Curr Pain Headache Rep. 2007&#93; - PubMed Result<!-- Bot generated title -->]</ref>
 
In addition, many patients experience cognitive dysfunction (known as "brain fog" or "fibrofog"), which may be characterized by impaired concentration and short-term memory consolidation, impaired speed of performance, inability to multi-task, and cognitive overload.<ref name="pmid17041327">{{cite journal |author=Leavitt F, Katz RS, Mills M, Heard AR |title=Cognitive and Dissociative Manifestations in Fibromyalgia |journal=J Clin Rheumatol. |volume=8 |issue=2 |pages=77-84 |year=2002 |pmid=17041327 |doi=}}</ref><ref>{{cite web |author=Frank Leavitt |title=Fibrofog, Fibromyalgia and Dissociation -- Understanding why some memory-impaired patients with fibromyalgia score normally on neuropsychological testing |url=http://www.webspawner.com/users/frankleavitt/}}</ref> Many experts suspect that "brain fog" is directly related to the sleep disturbances experienced by sufferers of fibromyalgia.
 
Other symptoms often attributed to fibromyalgia that may possibly be due to a [[comorbidity|comorbid]] disorder include [[myofascial pain syndrome]], diffuse non-dermatomal [[paresthesia]]s, functional bowel disturbances and [[irritable bowel syndrome]] (possibly linked to lower levels of [[ghrelin]][http://www.ncbi.nlm.nih.gov/pubmed/17689128?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum], [[Urinary system|genitourinary]] symptoms and [[interstitial cystitis]]), [[Dermatology|dermatological]] disorders, [[headache]]s, [[Myoclonus|myoclonic twitches]], and symptomatic [[hypoglycemia]]. Although fibromyalgia is classified based on the presence of chronic widespread pain, pain may also be localized in areas such as the [[shoulder]]s, [[neck]], low [[back]], [[hip]]s, or other areas. Many sufferers also experience varying degrees of facial pain and have high rates of comorbid [[temporomandibular joint disorder]]. Weather sensitive pain is common (see [[RSD]], [[CRPS]], [[Thermography]]). Not all patients have all symptoms.
 
Symptoms can have a slow onset, and many patients have mild symptoms beginning in childhood, that are often misdiagnosed as [[growing pains]]. Symptoms are often aggravated by unrelated illness or changes in the weather. They can become more tolerable or less tolerable throughout daily or yearly cycles; however, many people with fibromyalgia find that, at least some of the time, the condition prevents them from performing normal activities such as driving a car or walking up stairs. The disorder does not cause [[inflammation]] as is characteristic of [[rheumatoid arthritis]], although some [[NSAID]]s may temporarily reduce pain symptoms in some patients. <ref name="Yahoo health">{{cite web |author=Shannon Erstad | title=Nonsteroidal anti-inflammatory drugs for fibromyalgia |url=http://health.yahoo.com/topic/pain/resources/article/healthwise/hw196001 |date=November 10, 2005 |publisher=Health Yahoo |accessdate=2007-10-25}}</ref>
 
===Variability of symptoms===
The following factors have been proposed to exacerbate symptoms of pain in patients:
 
* Increased [[psychosocial]] [[Stress (medicine)|stress]]
* Excessive physical exertion (exercise seems to decrease the pain threshold of people with fibromyalgia but increase it in healthy individuals)<ref>{{cite journal | author = Staud R, Robinson ME, Price DD | title = Isometric exercise has opposite effects on central pain mechanisms in fibromyalgia patients compared to normal controls. | journal = Pain | volume = 118 | issue = 1-2 | pages = 176-84 | year = 2005 | id = PMID 16154700}}</ref>
* Lack of [[slow-wave sleep]]
* Changes in humidity and barometric pressure (see[[RSD]], [[CRPS]], [[Thermography]])
 
==Proposed causes and pathophysiology==
The cause of fibromyalgia is unknown. In fact it may not be due to a singular cause at all, but rather due to a multiplicity of causes [http://wehelpwhathurts.homestead.com/fibromyalgia.html].  Fibromyalgia can, but most often does not, start as a result of some [[Physical trauma|trauma]] such as a traffic accident, major surgery, or disease. Some evidence shows that [[Lyme Disease]] may be a trigger of fibromyalgia symptoms.<ref>{{cite web | url = http://www.immunesupport.com/library/showarticle.cfm/ID/3579 | title = Late and Chronic Lyme Disease: Symptom Overlap with Chronic Fatigue Syndrome & Fibromyalgia}}</ref> Another study suggests that more than one clinical entity may be involved, ranging from a mild, idiopathic [[inflammation|inflammatory]] process to [[clinical depression]]<ref>http://www.springerlink.com/content/1271314042w8405g/  Mueller W, et al.  The classification of fibromyalgia syndrome.  Rheumatol Int. 2007 Jul 25</ref> 
 
=== Genetics ===
By using self-reported "Chronic Widespread Pain" (CWP) as a surrogate marker for fibromyalgia, the [http://www.meb.ki.se/twinreg/index_en.html Swedish Twin Registry] found that a modest genetic contribution may exist:<ref name="PMID16646040">{{cite journal |author=Kato K, Sullivan P, Evengård B, Pedersen N |title=Importance of genetic influences on chronic widespread pain |journal=Arthritis Rheum. |volume=54 |issue=5 |pages=1682-6 |year=2006 | doi=10.1002/art.21798 |pmid=16646040}}</ref><ref name="PMID16908799">{{cite journal |author=Kato K, Sullivan P, Evengård B, Pedersen N |title=Chronic widespread pain and its comorbidities: a population-based study |journal=Arch. Intern. Med. |volume=166 |issue=15 |pages=1649-54 |year=2006 | url=http://archinte.ama-assn.org/cgi/content/full/166/15/1649 |pmid=16908799}}</ref>
 
* [[Monozygotic twins]] with CWP have a 15% chance that their twin sibling has CWP
* Dizygotic [[twins]] with CWP have a 7% chance that their twin sibling has CWP
 
=== Stress ===
Studies have shown that [[Stress (medicine)|stress]] is a significant precipitating factor in the development of fibromyalgia,<ref>{{cite journal | author = Anderberg UM, Marteinsdottir I, Theorell T, von Knorring L | title=The impact of life events in female patients with fibromyalgia and in female healthy controls. | journal=Eur Psychiatry | month=Aug| year=2000 | pages=33-41 | volume=15 | issue=5 | id=PMID 10954873 }}</ref> and that [[PTSD]] is linked with fibromyalgia.<ref>{{cite journal | author= Amital D, Fostick L, Polliack ML, Segev S, Zohar J, Rubinow A, Amital H | title=Posttraumatic stress disorder, tenderness, and fibromyalgia syndrome: are they different entities? | journal=J Psychosom Res | month=Nov | year=2006 | pages=663-9 | volume=61 | issue=5 | id=PMID 17084145}}</ref><ref>{{cite journal | author= Raphael KG, Janal MN, Nayak S | title=Comorbidity of fibromyalgia and posttraumatic stress disorder symptoms in a community sample of women. | journal=Pain Med. | month=Mar| year=2004 | pages=33-41 | volume=5 | issue=1 | id=PMID 14996235}}</ref> The Amital study found that 49% of PTSD patients fulfilled the criteria for FMS, compared with none of the controls.
 
A non-mainstream hypothesis that fibromyalgia may be a [[psychosomatic illness]] has been described by John E. Sarno's "[[tension myositis syndrome]]". He believes many cases of [[chronic pain]] result from changes in the body caused by the mind's subconscious strategy of distracting painful or dangerous emotions. Education, attitude change, (and in some cases, psychotherapy) are treatments proposed to stop the brain from using that strategy.<ref>{{cite book |last=Sarno|first=Dr. John E,|authorlink=John E. Sarno|title=The Mindbody Prescription: Healing the Body, Healing the Pain |year=1998 |isbn=0-446-67515-6 |pages=76-78}}</ref><ref>{{cite book |last=Sarno|first=Dr. John E. et al,| title=The Divided Mind: The Epidemic of Mindbody Disorders |year=2006 |isbn=0-06-085178-3 |pages=21-22,235-237,294-298}}</ref><ref>{{cite book |author=Selfridge, Dr. Nancy, and Peterson, Franklynn|title=Freedom from Fibromyalgia: The 5-Week Program Proven to Conquer Pain |year=2001| isbn=0-8129-3375-3 |pages=56-57}}</ref><ref name="20-20">{{cite episode |title=Dr. Sarno's Cure|series=20/20|serieslink=20/20|network=[[American Broadcasting Company|ABC]]|airdate=1999-07-25|url = http://video.google.com/videoplay?docid=-6660313127569317147 | accessdate = 2008-04-02}}</ref>  Robert G. Schwartz, MD has proposed an alternative view where in mind-body connections may play an important role in chronic disease (not just fibromyalgia) [http://rgsmedicalinsight.homestead.com/hometutorialp1.html]. Through his [http://rgsmedicalinsight.homestead.com/introtochallengeandchoice.html Challenge and Choice] program strategies to align incentives are offered.
 
===Dopamine abnormality===
[[Dopamine]] is a [[catecholamine]] [[neurotransmitter]] perhaps best known for its role in the pathology of [[schizophrenia]], [[Parkinson's disease]] and [[addiction]].  As is the case with several of the neurotransmitters, there is evidence for a role of dopamine in [[restless leg syndrome]] <ref>[http://www.ncbi.nlm.nih.gov/pubmed/16816393?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Support for dopaminergic hypoactivity in restless ...[Brain. 2006&#93; - PubMed Result<!-- Bot generated title -->]</ref>, which is a common co-morbid condition in patients with fibromyalgia. <ref>[http://www.bmj.com/cgi/content/full/312/7042/1339 Restless legs syndrome and leg cramps in fibromyalgia syndrome: a controlled study - Yunus and Aldag 312 (7042): 1339 - BMJ<!-- Bot generated title -->]</ref>  Interestingly, patients with restless legs syndrome have also been demonstrated to have [[hyperalgesia]] to static mechanical stimulation.<ref>[http://brain.oxfordjournals.org/cgi/content/full/127/4/773 Static mechanical hyperalgesia without dynamic tactile allodynia in patients with restless legs syndrome - Stiasny-Kolster et al. 127 (4): 773 - Brain<!-- Bot generated title -->]</ref>
 
Fibromyalgia has been commonly referred to as a "stress-related disorder" due to its frequent onset and worsening of symptoms in the context of stressful events.<ref>[http://www.ncbi.nlm.nih.gov/pubmed/16174484?ordinalpos=18&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum The role of life stress in fibromyalgia. [Curr Rheumatol Rep. 2005&#93; - PubMed Result<!-- Bot generated title -->]</ref><ref>[http://www.ncbi.nlm.nih.gov/pubmed/12849719?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Chronic widespread pain and fibromyalgia: what we ...[Best Pract Res Clin Rheumatol. 2003&#93; - PubMed Result<!-- Bot generated title -->]</ref>  It was therefore proposed that fibromyalgia may represent a condition characterized by low levels of central dopamine  that likely results from a combination of genetic factors and exposure to environmental stressors, including psychosocial distress, physical trauma, systemic viral infections or inflammatory disorders (e.g. [[rheumatoid arthritis]], systemic [[lupus erythematosus]]).<ref>[http://www.ncbi.nlm.nih.gov/pubmed/14975515?ordinalpos=10&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Stress and dopamine: implications for the pathophy...[Med Hypotheses. 2004&#93; - PubMed Result<!-- Bot generated title -->]</ref> This conclusion was based on three key observations:  (1) fibromyalgia is associated with stress; (2) chronic exposure to stress results in a disruption of dopamine-related neurotransmission<ref>[http://www.ncbi.nlm.nih.gov/pubmed/9355111?ordinalpos=27&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum The effects of stress on central dopaminergic neur...[Neurochem Res. 1997&#93; - PubMed Result<!-- Bot generated title -->]</ref>; and (3) dopamine plays a critical role in modulating pain perception and central [[analgesia]] in such areas as the [[basal ganglia]]<ref>[http://www.ncbi.nlm.nih.gov/pubmed/7715939?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum The role of the basal ganglia in nociception and p...[Pain. 1995&#93; - PubMed Result<!-- Bot generated title -->]</ref> including the [[nucleus accumbens]]<ref>[http://www.ncbi.nlm.nih.gov/pubmed/10597883?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum The role of dopamine in the nucleus accumbens in a...[Life Sci. 1999&#93; - PubMed Result<!-- Bot generated title -->]</ref>, [[insular cortex]]<ref>[http://www.jneurosci.org/cgi/content/full/19/10/4169 Dopamine Reuptake Inhibition in the Rostral Agranular Insular Cortex Produces Antinociception - Burkey et al. 19 (10): 4169 - Journal of Neuroscience<!-- Bot generated title -->]</ref>, [[anterior cingulate cortex]]<ref>[http://www.ncbi.nlm.nih.gov/pubmed/15327817?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Dopamine and NMDA systems modulate long-term nocic...[Pain. 2004&#93; - PubMed Result<!-- Bot generated title -->]</ref>, [[thalamus]]<ref>[http://www.ncbi.nlm.nih.gov/pubmed/1611515?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Neurophysiological, pharmacological and behavioral...[Brain Res. 1992&#93; - PubMed Result<!-- Bot generated title -->]</ref>, [[periaqueductal gray]]<ref>[http://www.ncbi.nlm.nih.gov/pubmed/15275769?ordinalpos=6&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Opiate anti-nociception is attenuated following le...[Pain. 2004&#93; - PubMed Result<!-- Bot generated title -->]</ref>, and [[spinal cord]]<ref>[http://www.ncbi.nlm.nih.gov/pubmed/6314870?ordinalpos=113&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Dopamine-containing neurons in the spinal cord: an...[Ann Neurol. 1983&#93; - PubMed Result<!-- Bot generated title -->]</ref> <ref>[http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15975975 Direct inhibition of substantia gelatinosa neurones in the rat spinal cord by activation of dopamine D2-like receptors<!-- Bot generated title -->]</ref>. 
 
===Serotonin===
[[Serotonin]] is a [[neurotransmitter]] that is known to play a role in regulating sleep patterns, mood, feelings of well-being, concentration and descending inhibition of pain.  Accordingly, it has been hypothesized that the [[pathophysiology]] underlying the symptoms of fibromyalgia may be a dysregulation of serotonin metabolism, which may explain (in part) many of the symptoms associated with the disorder.  This [[hypothesis]] is derived in part by the observation of decreased serotonin metabolites in patient [[plasma]] <ref>[http://www.ncbi.nlm.nih.gov/pubmed/1313504?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Platelet 3H-imipramine uptake receptor density and...[J Rheumatol. 1992&#93; - PubMed Result<!-- Bot generated title -->]</ref> and [[cerebrospinal fluid]].<ref>[http://www.ncbi.nlm.nih.gov/pubmed/1374252?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Cerebrospinal fluid biogenic amine metabolites in ...[Arthritis Rheum. 1992&#93; - PubMed Result<!-- Bot generated title -->]</ref>  However, [[selective serotonin reuptake inhibitors]] (SSRIs) have met with limited success in alleviating the symptoms of the disorder, while drugs with activity as mixed [[serotonin-norepinephrine reuptake inhibitor]]s (SNRIs) have been more successful<ref>[http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16762044 Biology and therapy of fibromyalgia. New therapies in fibromyalgia<!-- Bot generated title -->]</ref>.  Accordingly, [[duloxetine]] ([[Cymbalta]]), a SNRI originally used to treat depression and painful [[diabetic neuropathy]], has been demonstrated by controlled trials to relieve symptoms of some patients.  Eli Lilly and Company, the manufacturer of duloxetine has submitted a supplementary new drug application (sNDA) to the [[FDA]] for approval of it use in the treatment of FM.  The relevance of dysregulated serotonin metabolism to the pathophysiology is a matter of debate.<ref>[http://www.ncbi.nlm.nih.gov/pubmed/17693607?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Serum serotonin levels are not useful in diagnosin...[Ann Rheum Dis. 2007&#93; - PubMed Result<!-- Bot generated title -->]</ref>  Ironically, one of the more effective types of medication for the treatment of the disorder (i.e. serotonin [[5-HT3 antagonist]]s) actually block some of the effects of serotonin.<ref>[http://www.ncbi.nlm.nih.gov/pubmed/12122920?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Current experience with 5-HT3 receptor antagonists...[Rheum Dis Clin North Am. 2002&#93; - PubMed Result<!-- Bot generated title -->]</ref>
 
===Sleep disturbance===
[[Electroencephalography]] studies have shown that people with fibromyalgia lack [[slow-wave sleep]] and circumstances that interfere with stage four sleep (pain, depression, serotonin deficiency, certain medications or [[anxiety]]) may cause or worsen the condition.<ref>{{cite web |title=Fibromyalgia -- An Information Booklet |url=http://www.arc.org.uk/arthinfo/patpubs/6013/6013.asp |date=October 2004 |publisher=[[Arthritis Research Campaign]]}}</ref> According to the sleep disturbance hypothesis, an event such as a trauma or illness causes sleep disturbance and possibly initial chronic pain that may initiate the disorder.  The hypothesis supposes that stage 4 sleep is critical to the function of the [[nervous system]], as it is during that stage that certain neurochemical processes in the body 'reset'.  In particular, pain causes the release of the [[neuropeptide]] [[substance P]] in the [[spinal cord]] which has the effect of amplifying pain and causing nerves near the initiating ones to become more sensitive to pain. Under normal circumstances, areas around a wound to become more sensitive to pain but if pain becomes chronic and body-wide this process can run out of control. The sleep disturbance hypothesis holds that deep sleep is critical to reset the substance P mechanism and prevent this out-of-control effect.
 
The sleep disturbance/substance P hypothesis could explain "tender points" that are characteristic of fibromyalgia but which are otherwise enigmatic, since their positions don't correspond to any particular set of nerve junctions or other obvious body structures. The hypothesis proposes that these locations are more sensitive because the sensory nerves that serve them are positioned in the spinal cord to be most strongly affected by substance P. This hypothesis could also explain some of more general neurological features of fibromyalgia, since substance P is active in many other areas of the nervous system.  The sleep disturbance hypothesis could also provide a possible connection between fibromyalgia, [[chronic fatigue syndrome]] (CFS) and [[post-polio syndrome]] through damage to the ascending reticular activating system of the [[reticular formation]].  This area of the brain, in addition to apparently controlling the sensation of fatigue, is known to control sleep behaviors and is also believed to produce some neuropeptides, and thus injury or imbalance in this area could cause both CFS and sleep-related fibromyalgia.
 
Critics of the hypothesis argue that it does not explain slow-onset fibromyalgia, fibromyalgia present without tender points, or patients without heightened pain symptoms, and a number of the non-pain symptoms present in the disorder.
 
===Human growth hormone===
An alternate hypothesis suggests that stress-induced problems in the [[hypothalamus]] may lead to reduced sleep and reduced production of [[human growth hormone]] (HGH) during [[slow-wave sleep]]. People with fibromyalgia tend to produce inadequate levels of HGH. Most patients with FM with low IGF-I levels failed to secrete HGH after stimulation with clonidine and l-dopa.
 
This view is supported by the fact that those hormones under the direct or indirect control of HGH, including [[IGF-1]], [[cortisol]], [[leptin]] and [[neuropeptide Y]] are abnormal in people with fibromyalgia,<ref>{{cite journal | last = Anderberg  | first = UM | coauthors = Liu Z, Berglund L, Nyberg F | pmid = 10700334 | title = Elevated plasma levels of neuropeptide Y in female fibromyalgia patients. | journal = European Journal of Pain | volume = 3 | issue = 1 | year = 1999 | pages = 19-30}}</ref>  In addition, treatment with exogenous HGH or growth hormone secretagogue reduces fibromyalgia related pain and restores slow wave sleep<ref> {{ cite journal | last = Jones  | first = KD | coauthors = Deodhar P, Lorentzen A, Bennett RM, Deodhar AA | title = Growth hormone perturbations in fibromyalgia: a review. | journal = Seminars in Arthritis and Rheumatism | year =  2007 | volume  = 36 | issue = 6 | pages = 357-79 | pmid = 17224178 }}</ref><ref>{{cite journal | last = Shuer | first = ML | title = Fibromyalgia: symptom constellation and potential therapeutic options | journal = Endocrine | volume = 22 | issue = 1 | pages = 67-76 | pmid = 14610300 }}</ref><ref>{{cite journal | last = Yuen | first = KC | coauthors =  Bennett RM, Hryciw CA, Cook MB, Rhoads SA, Cook DM | journal = Growth hormone & IGF research | title = Is further evaluation for growth hormone (GH) deficiency necessary in fibromyalgia patients with low serum insulin-like growth factor (IGF)-I levels? | volume = 17 | issue = 1  | year = 2007 | pages = 82-8 | pmid = 17289417 }}</ref><ref>{{cite journal | last = Bennett  | first = RM | coauthors =  Cook DM, Clark SR, Burckhardt CS, Campbell SM. | pmid = 9228141  | title = Hypothalamic-pituitary-insulin-like growth factor-I axis dysfunction in patients with fibromyalgia | | Journal of Rheumatology | volume = 24 | issue = 7 | pages = 1384-9 }}</ref> though there is disagreement about the proposition.<ref>{{cite journal | last = McCall-Hosenfeld | first = JS | coauthors = Goldenberg DL, Hurwitz S, Adler GK. | title = Growth hormone and insulin-like growth factor-1 concentrations in women with fibromyalgia | journal = Journal of Rheumatology | volume = 30 | issues = 4 | pages = 809-14 | pmid = 12672204 }}</ref>
 
===Deposition disease===
The 'deposition hypothesis of fibromyaglia' poses that fibromyalgia is due to intracellular [[phosphate]] and [[calcium]] accumulations that eventually reaches levels sufficient to impede the [[Adenosine triphosphate|ATP]] process, possibly caused by a [[kidney]] defect or missing [[enzyme]] that prevents the removal of excess phosphates from the blood stream. Accordingly, proponents of this hypothesis suggest that fibromyalgia may be an inherited disorder, and that phosphate build-up in cells is gradual but can be accelerated by trauma or illness. Calcium is required for the excess phosphate to enter the cells. The additional phosphate slows down the ATP process; however the excess calcium prods the cell to continue producing ATP.<ref name="Longley">{{cite web | title=Are phosphates the hidden enemy? |author=Kathy Longley |year=2004 |url=http://www.fibromyalgia-associationuk.org/component/option,com_docman/task,doc_download/gid,4/Itemid,40/ |format=PDF |publisher=Fibromyalgia Association UK}} - sets out Dr St Amand's ideas</ref>
 
The phosphate build-up hypothesis explains many of the symptoms present in fibromyalgiaand proposes an underlying cause. The guaifenesin treatment, based on this hypothesis, has received mixed reviews, with some practitioners claiming many near-universal successes and others reporting no success. Of note, guaifenesin is also a central acting [[muscle relaxant]] used in veterinary anaesthesia<ref>[http://www.ncbi.nlm.nih.gov/pubmed/2282545?ordinalpos=13&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Intravenous anesthesia. [Vet Clin North Am Equine Pract. 1990&#93; - PubMed Result<!-- Bot generated title -->]</ref> that is structurally related to [[methocarbamol]], a property that might explain its utility in some fibromyalgia patients.  A controlled trial of guaifenesin  for the treatment of fibromyalgia demonstrated no evidence for efficacy of this medication. <ref name="Bennett">{{cite journal |author=Bennett RM, De Garmo P, Clark SR |title=A Randomized, Prospective, 12 Month Study To Compare The Efficacy Of Guaifenesin Versus Placebo In The Management Of Fibromyalgia |journal=Arthritis and Rheumatism |volume=39 |pages=S212 |year=1996 |url=http://www.myalgia.com/guaif2.htm |format=reprint}}<br/>Lay summary and report:
* {{cite web |author=Kristin Thorson |work=Fibromyalgia Network |title=Is One Placebo Better Than Another? -- The Guaifenesin Story
|url=http://www.fmnetnews.com/resources-alert-product6.php |date=1997 |publisher=Fibromyalgia Network}}</ref>  However, this study has been criticized by the chief proponent of the deposition hypothesis for not limiting salicylic acid exposure in patients, and for studying the effectiveness of only guaifenesin, not the entire treatment method.<ref>{{cite journal | url = http://www.fibromyalgiatreatment.com/Research_Oregon.htm | title = A Response To The Oregon Study's Implication | accessdate = 2007-06-23 | first = R. Paul | last = St. Amand | journal = Clinical Bulletin of Myofascial Therapy | volume = 2 | issue = 4 | year = 1997 }}</ref> As of 2005, further studies to test the protocol's effectiveness are in the planning stages, with funding for independent studies largely collected from groups which advocate the hypothesis.  It should be noted that ''nothing'' in the scientific literature supports the proposition that fibromyalgia patients have excessive levels of phosphate in their tissues.
 
===Other hypotheses===
Other hypotheses have been proposed related to various [[toxin]]s from the patient's environment, [[virus|viral]] causes such as the [[Epstein-Barr Virus]], [[growth hormone]] deficiencies possibly related to an underlying (maybe autoimmune) disease affecting the hypothalamus gland, an aberrant immune response to [[intestinal bacteria]],<ref name="ClinExpDermatol2004-KendallSN">{{cite journal | author=Kendall SN | title=Remission of rosacea induced by reduction of gut transit time. | journal=Clin Exp dermatol. | month=May | year=2004 | pages=297-9 | volume=29 | issue=3 | pmid=15115515}}</ref><ref name="AnnRheumDis2004-PimentalM">{{cite journal | author=Pimental M, Wallace D, Hallegua D et .al | title=A link between irritable bowel syndrome and fibromyalgia may be related to findings on lactulose breath testing. | journal=Ann Rheum Dis. | month=April | year=2004 | pages=450-2 | volume=63 | issue=4 |pmid=15020342}}</ref> [[neurotransmitter]] disruptions in the [[central nervous system]], and erosion of the protective chemical coating around sensory nerves. A 2001 study suggested an increase in fibromyalgia among women with extracapsular silicone gel leakage, compared to women whose implants were not broken or leaking outside the capsule.<ref name="Brown2001">{{cite journal | author=Brown SL, Pennello G, Berg WA, Soo MS, Middleton MS | title=Silicone gel breast implant rupture, extracapsular silicone, and health status in a population of women | journal=J Rheumatol | year=2001 | pages=996-1003 | volume=28 | issue=5 | pmid=11361228}}</ref><ref>{{cite web |title=Study of Silicone Gel Breast Implant Rupture, Extracapsular Silicone, and Health Status in a Population of Women |url=http://www.fda.gov/cdrh/breastimplants/extracapstudy.html |date=May 29, 2001 |publisher=FDA}}</ref> This association has not repeated in a number of related studies,<ref name=Lipworth>{{cite journal | author=Lipworth L, Tarone RE, McLaughlin JK.| title=Breast implants and fibromyalgia: a review of the epidemiological evidence.| journal=Ann Plast Surg. | year=2004 | pages=284-7| volume=52 | issue=3 |pmid=15156983}}</ref> and the US-FDA concluded "the weight of the epidemiological evidence published in the literature does not support an association between fibromyalgia and breast implants."<ref>{{cite web |title=FDA Breast Implant Consumer Handbook 2004 |url=http://www.fda.gov/cdrh/breastimplants/handbook2004/diseases.html#1 |date=June 8, 2004 |publisher=FDA}}</ref> Due to the multi-systemic nature of illnesses such as fibromyalgia and [[chronic fatigue syndrome]] (CFS/ME), an emerging branch of medical science called [[psychoneuroimmunology]] (PNI) is looking into how the various hypotheses fit together.
 
Another hypothesis on the cause of symptoms in fibromyalgia states that patients suffer from [[vasomotor]] dysregulation causing improper [[Blood vessel|vascular]]flow and [[hypoperfusion]] (decreased blood flow to a given tissue or organ).<ref name="pmid17376601">{{cite journal |author=Katz DL, Greene L, Ali A, Faridi Z |title=The pain of fibromyalgia syndrome is due to muscle hypoperfusion induced by regional vasomotor dysregulation |journal=Med Hypotheses. |volume=(Epub ahead of print) |issue= |pages= |year=2007 |month=19 Mar |pmid=17376601 |doi=10.1016/j.mehy.2005.10.037}}</ref>
 
===Always a comorbid disease?===
Cutting across several of the above hypotheses is the proposition that fibromyalgia is almost always a [[comorbidity|comorbid]] disorder, occurring in combination with some other disorder that likely served to "trigger" the fibromyalgia in the first place. Two possible triggers are [[gluten sensitivity]] and/or irritable bowel. Irritable bowel is found at high frequency in fibromyalgia,<ref name="pmid16042909">{{cite journal | author = Frissora CL, Koch KL | title = Symptom overlap and comorbidity of irritable bowel syndrome with other conditions | journal = Current gastroenterology reports | volume = 7 | issue = 4 | pages = 264-71 | year = 2005 | pmid = 16042909 | doi = }}</ref> and a large coeliac
support group survey of adult celiacs revealed that 7% had fibromyalgia and also has a co-occurrence with chronic fatique.<ref name="pmid12741468">{{cite journal | author = Zipser RD, Patel S, Yahya KZ, Baisch DW, Monarch E | title = Presentations of adult celiac disease in a nationwide patient support group | journal = Dig. Dis. Sci. | volume = 48 | issue = 4 | pages = 761-4 | year = 2003 | pmid = 12741468 | doi = }}</ref>
 
According to this hypothesis, some other disorder (or trauma) occurs first, and fibromyalgia follows as a result.  In some cases, the original disorder abates on its own or is separately treated and cured, but the fibromyalgia remains. This is especially apparent when fibromyalgia seems triggered by major surgery.  In other cases the two disorders coexist. Since it can be extremely complex to treat the source of fibromyalgia, and since it is most probably a multifactoral disorder that is different from one afflicted patient to the next, the concept of [http://wehelpwhathurts.homestead.com/diseasemanagement.html Reducing Total Load] has been proposed. In this instance the total number of things that does not allow a patient to get well is treated, one at a time, taking into consideration the unique conditions of that individual patient.


==Diagnosis==
==Diagnosis==
There is still debate over what should be considered essential diagnostic criteria.  The most widely accepted set of classification criteria for research purposes were elaborated in 1990 by the Multicenter Criteria Committee of the [http://www.rheumatology.org/ the American College of Rheumatology].  These criteria, which are known informally as "the ACR 1990" define fibromyalgia according to the presence of the following criteria:
[[Fibromyalgia diagnostic criteria|Diagnostic Criteria]] | [[Fibromyalgia history and symptoms|History and Symptoms]] | [[Fibromyalgia physical examination|Physical Examination]] | [[Fibromyalgia laboratory findings|Laboratory Findings]] | [[Fibromyalgia other diagnostic studies|Other Diagnostic Studies]]
 
*A history of widespread pain lasting more than three months—affecting all four quadrants of the body, i.e., both sides, and above and below the waist.
*Tender points—there are 18 designated possible tender or trigger points (although a person with the disorder may feel pain in other areas as well). During diagnosis, four [[kilogram-force|kilograms-force]] (39 [[newton]]s) of [[force]] is exerted at each of the 18 points; the patient must feel pain at 11 or more of these points for fibromyalgia to be considered.<ref>{{cite web |author=National Institute of Arthritis and Musculoskeletal and Skin Diseases |title=Questions and Answers About Fibromyalgia -- How Is Fibromyalgia Diagnosed? |url=http://www.niams.nih.gov/hi/topics/fibromyalgia/fibrofs.htm#fib_d |date=June 2004 |publisher=National Institutes for Health}}</ref> Four kilograms of force is about the amount of pressure required to blanch the thumbnail when applying pressure. This set of criteria was developed by the American College of Rheumatology as a means of classifying an individual as having fibromyalgia for both clinical and research purposes.  While these criteria for classification of patients were originally established as inclusion criteria for research purposes and were not intended for clinical diagnosis, they have become the ''de facto'' diagnostic criteria in the clinical setting.  It should be noted that the number of tender points that may be active at any one time may vary with time and circumstance.
 
*It is important not to make fibromyalgia a diagnosis of inclusion (anyone with complex or chronic pain is given the diagnosis).  Very often if routine blood work including a rheumatic profile, [[X-Ray]], [[MRI]], Electrodiagnostics ([[EMG]]), [[Diagnostic musculoskeletal ultrasound]] or [[Thermography]] (for patients with weather sensitive pain) is obtained the root cause can be discovered.
 
===Differentials===
A number of other disorders can produce similar symptoms to fibromyalgia:
 
{{MultiCol}}
* [[Chronic fatigue syndrome]]
* [[clinical depression|Depression]]
* [[Ehlers-Danlos syndrome]]
* [[Gulf War syndrome]]
* [[Influenza]]
* [[Lead poisoning]]
{{ColBreak}}
* [[Lupus erythematosus]]
* [[Lyme disease]]
* [[Mercury poisoning]]
* [[Myofascial pain syndrome]]
*Sympathetic pain sydromes ([[RSD]], [[CRPS]])
* [[Tendinitis]]
{{ColBreak}}
* [[Thyroid disease]]
* [[Vitamin B12 deficiency]]
* [[Vitamin D]] deficiency
* [[Whiplash (medicine)|Whiplash-associated disorder]]
* [[Multiple chemical sensitivity]]
{{EndMultiCol}}


==Treatment==
==Treatment==
As with many other syndromes, there is no universally accepted cure for fibromyalgia, though some physicians claim to have found cures.<ref>{{cite book |author=Selfridge, Dr. Nancy, and Peterson, Franklynn|title=Freedom from Fibromyalgia: The 5-Week Program Proven to Conquer Pain |year=2001| isbn=0-8129-3375-3 }}</ref> However, a steady interest in the disorder on the part of academic researchers as well as pharmaceutical interests has led to improvements in its treatment, which ranges from symptomatic prescription medication to [[alternative medicine|alternative]] and [[complementary medicine]].
[[Fibromyalgia medical therapy|Medical Therapy]] | [[Fibromyalgia exercise |Exercise]] | [[Fibromyalgia weight loss|Weight loss]] |  [[Fibromyalgia psychotherapy|Psychotherapy]] | [[Fibromyalgia future or investigational therapies|Future or Investigational Therapies]] | [http://piedmontpmr.com/disease-management-reducing-total-load/ Reducing Total Load]
 
The European League Against Rheumatism (EULAR) issued the first guidelines<ref>EULAR 9 Point Treatment plan [url=http://www.fibromyalgia-associationuk.org/content/view/220/1/]</ref> for the treatment of fibromyalgia syndrome (FMS) and published them in the September 17th On-line First issue of the Annals of the Rheumatic Diseases.
 
===Medications===
Many medications are used to treat specific symptoms of fibromyalgia, such as muscle pain and insomnia.
 
==== Pain Relief ====
 
A number of pain relievers have been prescribed for fibromyalgia.  This includes [[NSAID]] medications over the counter, COX-2 inhibitors, and [[tramadol]] in prescription form for more advanced cases. Recently, [[pregabalin]] (marketed as Lyrica) has been given FDA approval for the treatment of diagnosed Fibromyalgia.<ref name="NYTimes" />
 
====Muscle Relaxants====
 
Muscle relaxants, such as [[cyclobenzaprine]] (Flexeril) or [[tizanidine]] (Zanaflex), may be used to treat the muscle pain associated with the disorder.<ref>[http://www.webmd.com/fibromyalgia/Cyclobenzaprine-hydrochloride-for-fibromyalgia Cyclobenzaprine hydrochloride for fibromyalgia<!-- Bot generated title -->]</ref><ref>[http://www.fibromyalgia-reviews.com/Drg_Zanaflex.cfm Zanaflex for Fibromyalgia<!-- Bot generated title -->]</ref><ref>[http://www.intelihealth.com/IH/ihtIH/WSIHW000/8310/8310.html InteliHealth:<!-- Bot generated title -->]</ref>
 
====Tricyclic antidepressants (TCAs)====
Traditionally, low doses of sedating antidepressants (e.g. [[amitriptyline]] and [[trazodone]]) have been used to reduce the sleep disturbances that are associated with fibromyalgia and are believed by some practitioners to alleviate the symptoms of the disorder. Because depression often accompanies chronic illness, these antidepressants may provide additional benefits to patients suffering from depression. [[Amitriptyline]] is often favoured as it can also have the effect of providing relief from neuralgenic or [[Neuropathy|neuropathic pain]]. It is to be noted that Fibromyalgia is not considered a depressive disorder; antidepressants are used for their sedating effect to aid in sleep.
 
====Selective serotonin reuptake inhibitors (SSRIs)====
Research data consistently contradict the utility of agents with specificity as serotonin reuptake inhibitors for the treatment of core symptoms of fibromyalgia. <ref>[http://www.ncbi.nlm.nih.gov/pubmed/7478688?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum A randomized controlled trial of citalopram in the...[Pain. 1995&#93; - PubMed Result<!-- Bot generated title -->]</ref><ref>[http://www.ncbi.nlm.nih.gov/pubmed/10833553?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus Citalopram in patients with fibromyalgia-a random...[Eur J Pain. 2000&#93; - PubMed Result<!-- Bot generated title -->]</ref><ref>[http://www.ncbi.nlm.nih.gov/pubmed/17466657?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum A randomized, controlled, trial of controlled rele...[Am J Med. 2007&#93; - PubMed Result<!-- Bot generated title -->]</ref>  Moreover, SSRIs are known to aggravate many of the comorbidities that commonly affect patients with fibromyalgia including restless legs syndrome and sleep bruxism<ref>[http://www.ncbi.nlm.nih.gov/pubmed/9416386?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Extrapyramidal reactions and the selective seroton...[Ann Pharmacother. 1997&#93; - PubMed Result<!-- Bot generated title -->]</ref><ref>[http://www.ncbi.nlm.nih.gov/pubmed/8909330?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Movement disorders associated with the serotonin s...[J Clin Psychiatry. 1996&#93; - PubMed Result<!-- Bot generated title -->]</ref><ref>[http://www.ncbi.nlm.nih.gov/pubmed/9640489?ordinalpos=5&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Selective serotonin-reuptake inhibitor-induced mov...[Ann Pharmacother. 1998&#93; - PubMed Result<!-- Bot generated title -->]</ref>.
 
====Anti-seizure drugs====
Anti-seizure drugs are also sometimes used, such as [[gabapentin]]<ref>Arnold LM, Goldenberg DL, Stanford SB, et. al. Gabapentin in the treatment of fibromyalgia: a randomized, double-blind, placebo-controlled, multicenter trial.
Arthritis Rheum. 2007 Apr;56(4):1336-44</ref> and [[pregabalin]] (Lyrica). [[Pregabalin]], originally used for the nerve pain suffered by diabetics, has been approved by the American [[Food and Drug Administration]] for treatment of fibromyalgia. A [[randomized controlled trial]] of [[pregabalin]] 450 mg/day found that a [[number needed to treat]] of 6 patients for one patient to have 50% reduction in pain.<ref name="pmid15818684">{{cite journal |author=Crofford LJ, Rowbotham MC, Mease PJ, ''et al'' |title=Pregabalin for the treatment of fibromyalgia syndrome: results of a randomized, double-blind, placebo-controlled trial |journal=Arthritis Rheum. |volume=52 |issue=4 |pages=1264-73 |year=2005 |pmid=15818684 |doi=10.1002/art.20983}}</ref>
 
====Dopamine agonists====
[[Dopamine agonists]] (e.g. [[pramipexole]] (Mirapex) and [[ropinirole]](ReQuip)) have been studied for use in the treatment of fibromyalgia with good results. <ref>{{cite journal |author=Andrew J. Holman and Robin R. Myers |title=A Randomized, Double-Blind, Placebo-Controlled Trial of Pramipexole, a Dopamine Agonist, in Patients With Fibromyalgia Receiving Concomitant Medications |journal=Arthritis and Rheumatism |volume=52 |issue=8 |pages=2495-2505 |year=2005}}</ref>  A trial of transdermal [[rotigotine]] is currently on going <ref>[http://clinicaltrials.gov/ct2/show/NCT00464737 A Double-Blind Multicenter Proof of Concept Trial to Assess the Efficacy and Safety of Rotigotine in Subjects With Fibromyalgia Syndrome - Full Text View - ClinicalTrials.gov<!-- Bot generated title -->]</ref>. 
 
====Combination therapy====
A controlled clinical trial of [[amitriptyline]] and [[fluoxetine]] demonstrated utility when used in combination.<ref name="pmid8912507">{{cite journal |author=Goldenberg D, Mayskiy M, Mossey C, Ruthazer R, Schmid C |title=A randomized, double-blind crossover trial of fluoxetine and amitriptyline in the treatment of fibromyalgia |journal=Arthritis Rheum. |volume=39 |issue=11 |pages=1852-9 |year=1996 |pmid=8912507 |doi=}}</ref>
 
====Cannabis and cannabinoids====
Fibromyalgia patients frequently self-report using [[cannabis (drug)|cannabis]] therapeutically to treat symptoms of the disorder.<ref name="pmid16202145">{{cite journal |author=Swift W, Gates P, Dillon P |title=Survey of Australians using cannabis for medical purposes |journal=Harm reduction journal |volume=2 |issue= |pages=18 |year=2005 |pmid=16202145 |doi=10.1186/1477-7517-2-18 |url=http://www.biomedcentral.com/content/pdf/1477-7517-2-18.pdf |format=PDF}}</ref> Writing in the July 2006 issue of the journal Current Medical Research and Opinion, investigators at Germany's University of Heidelberg evaluated the analgesic effects of oral THC ([[tetrahydrocannabinol|∆<sup>9</sup>-tetrahydrocannabinol]]) in nine patients with fibromyalgia over a 3-month period. Subjects in the trial were administered daily doses of 2.5 to 15 mg of THC, but received no other pain medication during the trial. Among those participants who completed the trial, all reported a significant reduction in daily recorded pain and electronically induced pain.<ref name="pmid16834825">{{cite journal |author=Schley M, Legler A, Skopp G, Schmelz M, Konrad C, Rukwied R |title=Delta-9-THC based monotherapy in fibromyalgia patients on experimentally induced pain, axon reflex flare, and pain relief |journal=Current medical research and opinion |volume=22 |issue=7 |pages=1269–76 |year=2006 |pmid=16834825 |doi=10.1185/030079906X112651}}</ref> Previous clinical and preclinical trials have shown that both naturally occurring and endogenous cannabinoids hold analgesic qualities,<ref>{{cite journal |author=Burnes TL, Ineck JR |title=Cannabinoid Analgesia as a Potential New Therapeutic Option in the Treatment of Chronic Pain  |journal=Annals of Pharmacotherapy |year= |volume=40 |issue=2 |pages=251-60 |doi=10.1345/aph.1G217 |url=http://www.theannals.com/cgi/content/full/40/2/251}}</ref> particularly in the treatment of cancer pain and neuropathic pain,<ref name="pmid15757410">{{cite journal |author=Radbruch L, Elsner F |title=Emerging analgesics in cancer pain management |journal=Expert opinion on emerging drugs |volume=10 |issue=1 |pages=151–71 |year=2005 |pmid=15757410 |doi=}}</ref><ref name="pmid15096238">{{cite journal |author=Notcutt W, Price M, Miller R, ''et al'' |title=Initial experiences with medicinal extracts of cannabis for chronic pain: results from 34 'N of 1' studies |journal=Anaesthesia |volume=59 |issue=5 |pages=440–52 |year=2004 |pmid=15096238 |doi=10.1111/j.1365-2044.2004.03674.x}}</ref> both of which are poorly treated by conventional opioids. As a result, some experts have suggested that cannabinoid agonists would be applicable for the treatment of chronic pain conditions unresponsive to opioid analgesics such as fibromyalgia, and they propose that the disorder may be associated with an underlying clinical deficiency of the [[endocannabinoid system]].<ref name="pmid15159679">{{cite journal |author=Russo EB |title=Clinical endocannabinoid deficiency (CECD): can this concept explain therapeutic benefits of cannabis in migraine, fibromyalgia, irritable bowel syndrome and other treatment-resistant conditions? |journal=Neuro Endocrinol. Lett. |volume=25 |issue=1-2 |pages=31–9 |year=2004 |pmid=15159679 |doi=}}</ref><ref>{{cite web |title=Fibromyalgia |url=http://norml.org/index.cfm?Group_ID=7007 |publisher=NORML (The National Organization for the Reform of Marijuana Laws) |accessdate=2007-10-25}}</ref>
 
===Topical Remedies===
 
Users of Epsom Salts in the gel form ([[Magnesium Sulfate]]), have reported significant and lasting relief from pain associated with fibromyalgia.  Epsom Salts have long been touted for its ability to reduce pain and swelling.  <ref>  Epsom Salts Industry Council [http://www.epsomsaltcouncil.org/health_why_it_works.htm] </ref>
 
==Injection Therapy==
Interventional therapy can ease pain by blocking nerve conduction between specific areas of the body and the brain. Approaches range from injections of local anesthetics, steroids, proliferative agents ([[Prolotherapy]]) into affected soft tissues, joints, or nerve roots to more complex nerve blocks. Chronic use of steroid injections may lead to increased functional impairment.
 
===Non-drug treatment===
====Physical treatments====
Studies have found exercise improves fitness and sleep and may reduce pain and fatigue in some people with fibromyalgia.<ref name="pmid12137713">{{cite journal |author=Busch A, Schachter CL, Peloso PM, Bombardier C |title=Exercise for treating fibromyalgia syndrome |journal=Cochrane database of systematic reviews (Online) |volume= |issue=3 |pages=CD003786 |year=2002 |pmid=12137713 |doi=}}</ref>    Many patients find temporary relief by applying heat to painful areas. Those with access to [[physical therapy]], [[massage]], or acupuncture may find them beneficial.<ref name="pmid10086765">{{cite journal |author=Berman BM, Ezzo J, Hadhazy V, Swyers JP |title=Is acupuncture effective in the treatment of fibromyalgia? |journal=The Journal of family practice |volume=48 |issue=3 |pages=213–8 |year=1999 |pmid=10086765 |doi=}}</ref> Most patients find exercise, even low intensity exercise to be extremely helpful.<ref name="pmid14770100">{{cite journal |author=Gowans SE, deHueck A |title=Effectiveness of exercise in management of fibromyalgia |journal=Current opinion in rheumatology |volume=16 |issue=2 |pages=138–42 |year=2004 |pmid=14770100 |doi=}}</ref> [[Osteopathic Manipulative Medicine|Osteopathic manipulative therapy]] can also temporarily relieve pain due to fibromyalgia.<ref name="pmid12090649">{{cite journal |author=Gamber RG, Shores JH, Russo DP, Jimenez C, Rubin BR |title=Osteopathic manipulative treatment in conjunction with medication relieves pain associated with fibromyalgia syndrome: results of a randomized clinical pilot project |journal=The Journal of the American Osteopathic Association |volume=102 |issue=6 |pages=321–5 |year=2002 |pmid=12090649 |doi= |url=http://www.jaoa.org/cgi/reprint/102/6/321.pdf |format=PDF}}</ref>
 
Transcutaneous electrical nerve stimulation (TENS) is administered by a battery-powered device that sends mild electric pulses along nerve fibers to block pain signals to the brain. Small electrodes placed on the skin at or near the site of pain generate nerve impulses that block incoming pain signals from the peripheral nerves. TENS may also help stimulate the brain’s production of endorphins (chemicals that have pain-relieving properties).
 
A holistic approach—including managing diet, sleep, stress, activity, and pain—is used by many patients. Dietary supplements, massage, chiropractic care, managing blood sugar levels, and avoiding known triggers when possible means living as well as it is in the patient's power to do.
 
====Psychological/Behavioral Therapies====
 
As the nature of fibromyalgia is not well understood, some physicians believe that it may be [[Psychosomatic illness|psychosomatic]] or [[Psychogenic disease|psychogenic]].<ref>{{cite book |last=Sarno|first=Dr. John E, et al|authorlink=John E. Sarno| title=The Divided Mind: The Epidemic of Mindbody Disorders|publisher=ReganBooks|year=2006 |isbn=0-06-085178-3 |pages=21-22, 235-237, 264-265, 294-298, 315, 319-320, 363}}</ref> Although there is no universally accepted cure, some doctors have claimed to have successfully treated fibromyalgia when a psychological cause is accepted.<ref>{{cite book |last=Leonard-Segal|first=Dr. Andrea| title=The Divided Mind: The Epidemic of Mindbody Disorders|chapter=A Rheumatologist's Experience With Psychosomatic Disorders|publisher=ReganBooks|year=2006 |isbn=0-06-085178-3 |pages=264-265 }}</ref>
 
[[Cognitive behavioral therapy]] has been shown to improve quality of life and coping in fibromyalgia patients and other sufferers of chronic pain.<ref name="Chakrabarty"/> [[Neurofeedback]] has also shown to provide temporary and long-term relief.
 
Treatment for the "brain fog" has not yet been developed, however biofeedback and self-management techniques such as pacing and stress management may be helpful for some patients. The use of medication to improve sleep helps some patients, as does supplementation with [[folic acid]] and [[ginkgo biloba]].
 
====Dietary treatment====
In a 2001 review of four case studies, symptom alleviation was found by minimizing consumption of [[monosodium glutamate]].<ref>Smith et al, Relief of fibromyalgia symptoms following discontinuation of dietary excitotoxins, Ann Pharmacother. 2001 Jun;35(6):702-6.</ref>
 
===Investigational treatments===
 
[[Milnacipran]], a  [[serotonin-norepinephrine reuptake inhibitor]] (SNRI), is available in parts of Europe where it has been safely prescribed for other disorders. On May 22nd, 2007,  a Phase III study demonstrated statistically significant therapeutic effects of [[Milnacipran]] as a treatment of fibromyalgia syndrome. At this time, only initial top-line results are available and further analyses will be completed in the coming weeks.  If ultimately approved by the [[FDA]], [[Milnacipran]] could be distributed in the United States as early as summer, 2008.<ref>{{cite web |author=Forest Laboratories |title=Forest Laboratories, Inc. and Cypress Bioscience, Inc. Announce Positive Results of Phase III Study for Milnacipran as a Treatment for Fibromyalgia Syndrome |url=http://www.frx.com/news/PressRelease.aspx?ID=1005671 |date=May 22, 2007}}</ref>
 
Among the more controversial therapies involves the use of [[guaifenesin]]; called St. Amand's protocol or the [[guaifenesin protocol]]<ref name="Longley">{{cite web | title=Are phosphates the hidden enemy? |author=Kathy Longley |year=2004 |url=http://www.fibromyalgia-associationuk.org/component/option,com_docman/task,doc_download/gid,4/Itemid,40/ |format=PDF |publisher=Fibromyalgia Association UK}}</ref> the efficacy of guaifenesin in treating fibromyalgia has not been proven in properly designed research studies.  Indeed, a controlled study conducted by researchers at Oregon Health Science University in Portland failed to demonstrate any benefits from this treatment,<ref name="Bennett">{{cite journal |author=Bennett RM, De Garmo P, Clark SR |title=A Randomized, Prospective, 12 Month Study To Compare The Efficacy Of Guaifenesin Versus Placebo In The Management Of Fibromyalgia |journal=Arthritis and Rheumatism |volume=39 |pages=S212 |year=1996 |url=http://www.myalgia.com/guaif2.htm |format=reprint}}<br/>Lay summary and report:
* {{cite web |author=Kristin Thorson |work=Fibromyalgia Network |title=Is One Placebo Better Than Another? -- The Guaifenesin Story
|url=http://www.fmnetnews.com/resources-alert-product6.php |date=1997 |publisher=Fibromyalgia Network}}</ref> and the lead researcher has suggested that the annecdotaly reported benefits where due to placebo suggestion.<ref>{{cite web |author=Robert Bennett |title=Speculation as to the mechanism whereby some of Dr. St. Amand's fibromyalgia patients experienced improvement while taking guaifenesin |url=http://www.myalgia.com/Treatment/guaifspe.htm |date= |publisher=Fibromyalgia Information
Foundation |accessdate=2008-01-06}}</ref> The results of the study have since been contested by Dr St. Amand, who was a co-author or the original research report.<ref>{{cite journal | url = http://www.fibromyalgiatreatment.com/Research_Oregon.htm | title = A Response To The Oregon Study's Implication | accessdate = 2007-06-23 | first = R. Paul | last = St. Amand | journal = Clinical Bulletin of Myofascial Therapy | volume = 2 | issue = 4 | year = 1997 }}</ref>
 
[[Dextromethorphan]] is an over-the-counter cough medicine with activity as an [[NMDA receptor antagonist]].  It has been used in the research setting to investigate the nature of fibromyalgia pain<ref name="pmid15890634">{{cite journal |author=Staud R, Vierck CJ, Robinson ME, Price DD |title=Effects of the N-methyl-D-aspartate receptor antagonist dextromethorphan on temporal summation of pain are similar in fibromyalgia patients and normal control subjects |journal=The journal of pain : official journal of the American Pain Society |volume=6 |issue=5 |pages=323-32 |year=2005 |pmid=15890634 |doi=10.1016/j.jpain.2005.01.357}}</ref><ref> {{cite web |title=''Cough Drug May Help Fibromyalgia Pain: Findings Could Affect Other Chronic Pain Conditions'' |author=Salynn Boyles |url=http://www.webmd.com/content/article/106/108142 |publisher= WebMD |date=May 23, 2005}}</ref>; however, there are no controlled trials of safety or efficacy in clinical use.
 
==Living with fibromyalgia==
Fibromyalgia can affect every aspect of a person's life. While neither degenerative nor fatal, the chronic pain associated with fibromyalgia is pervasive and persistent. FMS can severely curtail social activity and recreation, and as many as 30% of those diagnosed with fibromyalgia are unable to maintain full-time employment. Like others with disabilities, individuals with FMS often need accommodations to fully participate in their education or remain active in their careers.
 
In the United States, those who are unable to maintain a full-time job due to the condition may apply for Social Security Disability benefits. Although fibromyalgia has been recognized as a genuine, severe medical condition by the government, applicants are often denied benefits, since there are no formal diagnostic criteria or medically provable symptoms. Because of this, if an applicant does have a medically verifiable condition that would justify disability benefits in addition to fibromyalgia, it is recommended that they not list fibromyalgia in their claim. However, most are awarded benefits at the judicial level; the entire process often takes two to four years.
 
In the United Kingdom, the [[Department for Work and Pensions]] recognizes fibromyalgia as a condition for the purpose of claiming benefits and assistance.<ref>[http://www.fibromyalgia-associationuk.org/content/view/57/2/ The Fibromyalgia Association of the UK]</ref>


Fibromyalgia is often referred to as an "invisible" illness or disability due to the fact that generally there are no outward indications of the illness or its resulting disabilities. The invisible nature of the illness, as well as its relative rarity and the lack of understanding about its pathology, often <!--subject is singular-->has psychosocial complications for those that have the disorder. Individuals suffering from invisible illnesses in general often face disbelief or accusations of malingering or laziness from others that<!--not "who," for a distinction between the two groups of people is being made--> are unfamiliar with the disorder.
A trial found that "12-week multicomponent treatment based on pain neuroscience education, therapeutic exercise, cognitive behavioral therapy, and mindfulness" was beneficial<ref name="pmid34499174">{{cite journal| author=Serrat M, Sanabria-Mazo JP, Almirall M, Musté M, Feliu-Soler A, Méndez-Ulrich JL | display-authors=etal| title=Effectiveness of a Multicomponent Treatment Based on Pain Neuroscience Education, Therapeutic Exercise, Cognitive Behavioral Therapy, and Mindfulness in Patients With Fibromyalgia (FIBROWALK Study): A Randomized Controlled Trial. | journal=Phys Ther | year= 2021 | volume= 101 | issue= 12 | pages=  | pmid=34499174 | doi=10.1093/ptj/pzab200 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34499174  }} </ref>.


There are a variety of support groups on the Web that cater to fibromyalgia sufferers.
==Case Studies==
:[[Fibromyalgia case study one|Case #1]]


==Controversies==
The validity of fibromyalgia as a unique clinical entity is a matter of some contention among researchers in the field.  For example, it has been proposed that the pathophysiology responsible for the symptoms that are collectively classified as representing "fibromyalgia" is poorly understood, thereby suggesting that the fibromyalgia [[phenotype]] which is the difference between an individual’s heredity and what that heredity produces, may result from several different disease processes that have global hyperalgesia - an increased sensitivity to pain - and allodynia in common, <ref>http://www.springerlink.com/content/1271314042w8405g/  Mueller W, et al.  The classification of fibromyalgia syndrome.  Rheumatol Int. 2007 Jul 25</ref><ref>The association or otherwise of the functional somatic syndromes.Psychosom Med. 2007 Dec;69(9):855-9. Review. PMID: 180400</ref><ref>Comorbidity of fibromyalgia and psychiatric disorders.Curr Pain Headache Rep. 2007 Oct;11(5):333-8. Review. PMID: 17894922</ref>  an observation that has led to the proposition that current diagnostic criteria are insufficient to differentiate patient groups from each other.<ref>An integrated model of group psychotherapy for patients with fibromyalgia.Int J Group Psychother. 2007 Oct;57(4):451-74</ref>  Alternatively, there is evidence for the existence of differing pathophysiological - which is the study of the disturbance of normal mechanical, physical, and biochemical functions of the body - within the greater fibromyalgia construct<ref>[http://www.ncbi.nlm.nih.gov/pubmed/17084146?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Psychophysiological responses in patients with fib...[J Psychosom Res. 2006&#93; - PubMed Result<!-- Bot generated title -->]</ref><ref>[http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16356200 Heterogeneity of psychophysiological stress responses in fibromyalgia syndrome patients<!-- Bot generated title -->]</ref>, which may be interpreted to represent evidence for the existence of biologically distinct "sub-types" of the disorder akin to conditions such as [[epilepsy]], [[schizophrenia]] and [[major depressive disorder]].  In a January 14, 2008 article in the New York Times, the controversy of the reality of the disease and its proposed cures are discussed, while citing that the [[American College of Rheumatology]], the [[Food and Drug Administration]] and insurers recognize fibromyalgia as a diagnosable disease. Drug companies are aggressively pursuing fibromyalgia treatments, seeing the potential for a major new market.<ref name="NYTimes">Alex Berenson, ''[http://www.nytimes.com/2008/01/14/health/14pain.html?_r=1&ref=health&oref=slogin Drug Approved. Is Disease Real?]'' [[New York Times]], January 14, 2008</ref>


==References==
==References==
<div style="height: 90px; overflow: auto; padding: 3px;text-align: left; border:solid 1px;" title="braglist:-/"; >{{reflist|1}}</div>
{{reflist|2}}


==Further reading==
==Related Chapters==
* [http://fm-cfs.ca/pharmacists.pdf Fibromyalgia for Pharmacists, a medication guide]
* [http://piedmontpmr.com/store.html Resloving Complex Pain]
==See also==
* [[Somatosensory Amplification]]
* [[Somatosensory Amplification]]


{{Diseases of the musculoskeletal system and connective tissue}}
{{Diseases of the musculoskeletal system and connective tissue}}
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[[Category:Rheumatology]]
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Latest revision as of 14:50, 20 January 2022

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Robert G. Schwartz, M.D. [2], Aditya Ganti M.B.B.S. [3]

Synonyms and keywords: Fibromyositis; fibrositis; fibromyalgia primary; fibromyalgia secondary; fibromyalgia-fibromyositis syndrome; fibrositis.

Overview

Historical Perspective

Pathophysiology

Causes

Differentiating Fibromyalgia from other Diseases

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A trial found that "12-week multicomponent treatment based on pain neuroscience education, therapeutic exercise, cognitive behavioral therapy, and mindfulness" was beneficial[1].

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Case #1


References

  1. Serrat M, Sanabria-Mazo JP, Almirall M, Musté M, Feliu-Soler A, Méndez-Ulrich JL; et al. (2021). "Effectiveness of a Multicomponent Treatment Based on Pain Neuroscience Education, Therapeutic Exercise, Cognitive Behavioral Therapy, and Mindfulness in Patients With Fibromyalgia (FIBROWALK Study): A Randomized Controlled Trial". Phys Ther. 101 (12). doi:10.1093/ptj/pzab200. PMID 34499174 Check |pmid= value (help).

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