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Fibromyalgia Syndrome (FMS)

Fibromyalgia is a chronic condition of widespread pain and profound fatigue. The pain tends to be felt as a diffuse aching or burning often described as head to toe. The fatigue ranges from feeling tired to the exhaustion of flu-like illness. The name fibromyalgia is a combination of three terms. Fibro comes from Latin for fibrous tissue such as tendons and ligament. The Greek prefix myo indicates muscles and algia is from a Greek word indicative of pain. It is known as a syndrome because it is a collection of symptoms rather than a specific disease process that is well understood.
The definition of Fibromyalgia Syndrome (FMS) as stated by the American College of Rheumatology (ACR 1990) is as follows:
A history of widespread pain for at least three months
Pain is considered widespread when all of the following are present: pain in the left side of the body, the right side of the body, below the waist and above the waist. In addition there should be axial pain (cervical spine or anterior chest or thoracic spine or low back).
ANRC Physiotherapy Clinic East Grinstead 2. Pain (with the patient reporting ‘pain’ and not just ‘tenderness’) in 11 of 18 tender point sites

  • At the suboccipital muscle insertions (close to where rectus capitis posterior minor inserts)
  • At the anterior aspects of the inter-transverse spaces between C5 and C7
  • At the midpoint of the upper border of upper trapezius muscle
  • At the origins of supraspinatus muscle above the scapula spines
  • At the second costochondral junctions, on the upper surface, just lateral to the junctions
  • 2cm distal to the lateral epicondyles of the elbows
  • In the upper outer quadrants of the buttocks in the anterior fold of gluteus medius
  • Posterior to the prominence of the greater trochanter (piriformis insertion)
  • On the medial aspect of the knees, on the fatty pad, proximal to the joint line


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Fibromyalgiahave been reported for hundreds of years, under many names, including the most unsatisfactory term ‘fibrositis’. It was also coined the term muscular rheumatism which became popular. In 1987, the American Medical Association recognized fibromyalgia as a distinct syndrome (Starlanyl& Copeland 1996), although at that time detailed knowledge of what the syndrome comprised was not as clear.

In early 1904, a study carried out by William Gowers coined the word fibrositisbelieving erroneously that inflammation was a key feature of ‘muscular rheumatism’. Ralph Stockman (1904) offered support for Gowers’s suggestion by reporting finding evidence of inflammation in connective tissue in such cases and suggested that pain sensations emanating from nodules could be due to nerve pressure.This term was not changed to fibromyalgia until 1976.

In 1912 a German physician A. Muller made a break-through in the field of Fibromyalgia. He noted that there are nodules and taut bands and in order to identify them required refined palpation skills which he suggested, by lubricating the skin.

By 1929 F. Albee andMurray had coined the term ‘Myofascitis and ‘myofibrositis’. In 1933C. Hunterdescribed referred pain (myalgia) resulting from tender points situated in the musculature. J. Edeiken, C. Wolferthin the year 1936 showed that pressure applied to tender points in scapula region muscles could reproduce shoulder pain already being experienced. This work influenced Janet Travell.

Smythe laid the foundation of modern FMS in 1972 by describing widespread pain and tender points. M. Yunus, A. Masi, et al 1981first popularized the word fibromyalgia. Janet Travell, David Simons (1983) diddefinitive work on the subject of myofascial pain syndrome (MPS). 1990 R. Bennett reported that many ‘tender points’ in fibromyalgia are in reality latent trigger points. He believes that MPS and FMS are distinctive syndromes but are ‘closely related’states that many people with MPS progress to develop fibromyalgia.

Finally American College of Rheumatology( ACR) in the year 1990 formed criteria for the classification of Fibromyalgia. ACR gave the official definition for FMS syndrome which was subsequently expanded in 1992 by the Copenhagen Declaration: Consensus Document on Fibromyalgia (Copenhagen Declaration 1992.


ANRC Physiotherapy Clinic East Grinstead

The etiology of fibromyalgia is multifactorial and includes both environmental and genetic factors.

Biologic variables

Certain biologic variables contribute to the development and persistence of fibromyalgia (eg, physical trauma, exposure to toxins).


FMS has a genetic predisposition. First degree relatives of individuals with FMS display an eightfold greater risk of developing fibromyalgia than those in the general population.


Sex-related effects are important in fibromyalgia and with pain in general. Aversive stimuli and stressful tasks are more likely to evoke SNS, HPA axis, and psychological responses in females than in males.


Almost all patients with fibromyalgia sleep poorly, and a night of poor sleep is followed by a more painful day. This contributes to negative mood and cognitive difficulties.

Other variables

Age is a variable; most cases occur between the ages of 20 and 50 years. Physical de-conditioning is also a variable.

Psychological variables

ANRC Physiotherapy Clinic East Grinstead Behavioral and Psychological Factors

Pain and other symptoms of fibromyalgia might cause individuals to function less well in the various aspects of their lives. There is cessation of pleasurable activities and reduction of exercise.

Self-efficacy and coping

Perceived self-efficacy is the level of confidence that the patient requires to control pain effectively. People with high self-efficacy beliefs engage in coping behaviours until success is achieved. People with low self-efficacy beliefs anticipate failure and stop using effective coping strategies. Higher coping self-efficacy is associated with less negative mood and less pain. Pain processing system

Once a susceptible individual has symptoms of fibromyalgia, the most consistently detected objective anomalies involve the pain and sensory processing systems. Studies have demonstrated that FMS patients cannot detect electrical, pressure or thermal stimuli at lower levels than normal through-ut the entire body.

Environmental and socio-cultural variables ANRC Physiotherapy Clinic East Grinstead

Environmental and socio-cultural variables include the following:

  • Psychosocial experiences during childhood
  • Spousal and family support
  • Ethnologic factor
  • Focus on definable causes
  • Media hype
  • Primary and secondary gain

Time rule
According to American College of Rheumatology criteria, there should be chronic widespread pain for at least three months on a more or less continue basis.

Signs and symptoms

Besides pain and fatigue, fibromyalgia symptoms often include:

  • Unrefreshing sleep – waking up tired and stiff
  • Headaches – ranging from ordinary to migraine
  • Irritable bowel, frequent diarrhoea or constipation sometimes accompanied by gas in the abdomen or nausea
  • Cognitive disturbance including lack of concentration and word mix up
  • Clumsiness and dizziness
  • Sensitivity to changes in the weather and to noise, bright light, smoke and other environment factors
  • Allergies

Numerous instruments have been used in clinical trials of fibromyalgia syndrome. Pain - Vastly used and validated methods are

  • Visual Analog Scale (VAS)
  • Numeric rating scale
  • McGill pain Questionnaire
Pressure Pain Threshold Measurement

Pressure pain threshold is assessed by a semiobjectivequantitive method called dolorimeter. It is used to measure pressure algometry
Pressure algometry
ANRC Physiotherapy Clinic East Grinstead A useful device for rough quantitation of pain perception and pain tolerance is a pressure algometer, or dolorimeter. Pressure algometry (dolorimetry) provides a simple determination of pressure pain thresholds at 4 tender points associated with fibromyalgia (ie, both lateral epicondyles, midpoints of the trapezii). Normal values are 4 kg/cm2 or greater.
Pressure algometry can also serve as a useful tool for educating the patient regarding the nature of altered central nociceptive processing, allodynia (pain with stimuli that should not cause pain, such as gentle touching) and hyperalgesia (amplification of pain experienced from peripheral stimuli that are expected to be painful). On follow-up visits, it can provide a semiquantitative guide to therapy


Fatigue is a common feature of FMS. The commonest unidimentional instruments used are Functional Assessment of Chronic Illness Therapy- Fatigue Scale and Fatigue Severity Scale.
Sleep : Non refreshed sleep is common and the thought to be an important pathological feature.


Patients with fibromyalgia do not have characteristic or consistent abnormalities on laboratory testing. However, routine laboratory and imaging studies are important to help rule out diseases with similar manifestations and to assist in diagnosis of certain inflammatory diseases that frequently coexist with fibromyalgia. In addition to complete blood cell (CBC) count and differential count, basic metabolic panel, and urinalysis, the following limited evaluation is reasonable. 5-6

  • Thyroid-stimulating hormone: Hypothyroidism shares many clinical features with fibromyalgia, especially diffuse muscle pain and fatigue
  • Creatinine phosphokinase (CPK): This study is used to exclude inflammatory myopathies
  • Erythrocyte sedimentation rate (ESR)
  • Antinuclear antibodies (ANA)
  • Rheumatoid factor
  • Serum transferrin saturation and serum ferritin screening
  • Antipolymer antibodies

Differentials Diagnosis
The list of differential diagnoses includes diseases which may cause widespread pain and weakness7

  • Physical Medicine and Rehabilitation for Complex Regional Pain Syndromes
  • Hepatitis C
  • Rheumatoid arthritis
  • Hyperparathyroidism
  • Hypochondriasis
  • Hypothyroid Myopathy
  • Malingering
  • Personality Disorders
  • Polymyalgia Rheumatica
  • Posttraumatic Stress Disorder
  • Addison Disease

Physiotherapy management for fibromyalgia – Contact ANRC Physiotherapy Clinic- East Grinstead


Many rheumatologist recognize 2 types of fibromyalgia6

  • Primary
  • Secondary

Primary fibromyalgia is the most universally accepted form of fibromyalgia and is normal diagnosed when no underlying causes are present (such as arthritis, lupus etc) and at least 11 of 18 designated points are confirmed. The cause of primary fibromyalgia syndrome is unknown but it can be induced by trauma, infection, stress, inflammation or their factors.

Secondary fibromyalgia maybe triggered by conditions such as RA, Lupus, hypothyroidism, HIV. It may also triggered by physical trauma. Secondary fibromyalgia is sometimes referred to as post traumatic fibromyalgia. It is also known as regional fibromyalgia and is present in patient who experience pain at fewer than 11 of the 18 positive tender points.

ANRC Physiotherapy Clinic East Grinstead CLINICAL FEATURES

1. Pain
The chief complaint in patients with fibromyalgia is often pain. The quality of this constant pain is described as burning, aching, and soreness. They report feeling of bruised all over, even though there are no physical signs of this. The pain radiates diffusely from the axial skeleton over large areas of the body, predominantly involving muscles and musculoskeletal junctions, but also in joints. Regional pains in fibromyalgia may include

  • Noncardiac chest pain
  • Dyspepsia
  • Headache
  • Scalp tenderness
  • Abdominal cramping (irritable bowel syndrome)
  • Temporomandibular pain
  • Chronic pelvic pain
  • Dysmenorrhea
  • Flare-ups

Patients may experience flare-ups, with an acute, intense increase in symptoms that last more than a day. The pain may reach such intense levels that the patient becomes bedridden. Flares-ups usually are triggered by a stressor, such as infection, trauma, or changes in medication, sleep, or exercise. Onset of allergies, changes in diet, and a change in usual activity may bring on a flare-up.

2.Tender point and tenderness
Patients with FMS have reduced pressure pain threshold, experiencing pain with normal innocuous pressure:

3. Sleep
Patients generally do not volunteer a history of a sleeping disorder, but a carefully taken history reveals unrefreshing sleep in about 65% of patients and morning fatigue in about 80%. Patients awaken as tired as they were before sleeping. Most patients awaken frequently throughout the night, and some have difficulty falling asleep. They finally fall asleep in the early morning hours, describing this as their best sleep.

4. Fatigue
Many patients with fibromyalgia report that fatigue is second only to pain as a source of distress. The fatigue is worse in the morning and early evening. By 10 or 11 o'clock in the morning, the fatigue subsides somewhat.

5. Cognitive problems
Cognitive problems (known as "fibrofog") may be a primary symptom of fibromyalgia. Cognitive symptoms include confusion and forgetfulness, an inability to concentrate and recall simple words and numbers, and the transposition of words and numbers. Cognitive functions are often so impaired that patients cannot perform the activities of daily living; they may become lost in familiar places or lose the ability to communicate effectively. Patients who work may fear losing their job, and many paediatric patients drop out of school because of their inability to complete their schoolwork.

6. Other features

  • Weight fluctuations
  • Allergic symptoms (eg, nasal congestion) and hypersensitivity to environmental stimuli (eg, odours, bright lights, loud noises) and medications
  • Dizziness
  • Shortness of breath
  • Urinary frequency and urgency (female urethral syndrome, interstitial cystitis)
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