Oman Medical Journal (2012) Vol. 27, No.

3: 192-195
DOI 10. 5001/omj.2012.44

Review Article

Fibromyalgia Syndrome: An Overview of Pathophysiology, Diagnosis and

Management
Firdous Jahan, Kashmira Nanji, Waris Qidwai, Rizwan Qasim

Received: 15 Feb 2012 / Accepted: 28 Apr 2012

© OMSB, 2012

Abstract

Fibromyalgia Syndrome (FMS) is a chronic condition causing FMS typically presents in young or middle-aged females
pain, stiffness, and tenderness of the muscles, tendons, and as persistent widespread pain, stiffness, fatigue, disrupted
joints. It is also characterized by restless sleep, tiredness, fatigue, unrefreshing sleep, and cognitive difficulties, often accompanied by
anxiety, depression, and disturbances in bowel functions. The multiple other unexplained symptoms, anxiety and/or depression,
etiology of fibromyalgia remains unknown, but recent advances and functional impairment of daily living activities.8-9 There is an
and discoveries have helped to unravel some of the mysteries overall 6% to 15% prevalence rate in the United States with a five
of this disease. Research highlights some of the biochemical, times greater incidence among women than men. In rheumatology
metabolic, and immunoregulatory abnormalities associated with clinics, the rate of new diagnosis is approximately 10% to 20%,
fibromyalgia. Management of FMS at the present time is very whereas in non-specialized settings, the rate is 2.1% to 5.7%.10-11
difficult as it has multiple etiological factors and psychological Clinicians should be familiar with the signs and symptoms
predispositions; however, a patient centered approach is essential of fibromyalgia and diagnose the condition with minimum
to handle this problem. investigation.12 Since the symptoms of fibromyalgia wax and
wane related to stresses,13 treatment (as with that of other chronic
diseases) is an ongoing process rather than management of a single
Keywords: Fibromyalgia; Clinical features; Quality of life;
episode.
Pathophysiology and management of fibromyalgia.
In terms of conditions associated with fibromyalgia; there are
certain conditions associated with fibromyalgia.

Introduction Pathophysiology

Although the etiology remains unclear, characteristic alterations

P ain with its devastating and demoralizing effects remains

in the pattern of sleep and changes in neuroendocrine transmitters
such as serotonin, substance P, growth hormone and cortisol
a challenging problem for both patients and care givers.1
suggest that regulation of the autonomic and neuro-endocrine
Fibromyalgia is one of the most common diseases affecting the
system appears to be the basis of the syndrome. Fibromyalgia is
muscles manifested with pain, stiffness, and tenderness of the
not a life-threatening, deforming, or progressive disease. Anxiety
muscles, tendons, and joints. The painful tissues involved are and depression are the most common association.14 Aberrant pain
not accompanied by tissue inflammation.2-3 Therefore, despite processing, which can result in chronic pain, may be the result of
potentially disabling body pain; patients with fibromyalgia do not several interplaying mechanisms. Central sensitization, blunting
develop tissue damage or deformity.4-5 The pain of fibromyalgia is of inhibitory pain pathways and alterations in neurotransmitters
generally widespread, involving both sides of the body. Pain usually lead to aberrant neuro-chemical processing of sensory signals in
affects the neck, buttocks, shoulders, arms, the upper back, and the the CNS, thus lowering the threshold of pain and amplification of
chest. "Tender points" are localized tender areas of the body that normal sensory signals causing constant pain.15-16
can bring on widespread pain and muscle spasm when touched. 6-7 The frequent co-morbidity of fibromyalgia with mood
disorders suggests a major role for the stress response and for
neuroendocrine abnormalities. The hypothalamic pituitary axis
Firdous Jahn , Rizwan Qasim
Family Medicine Department, Oman Medical College, Sohar, Oman. (HPA) is a critical component of the stress-adaptation response.17
E-mail: [email protected] In FMS, stress adaptation response is disturbed leading to stress
Waris Qidwai, Kashmira Nanji induce symptoms. Psychiatric co-morbidity has been associated
Family vMedicine Dept. Stadium Road Aga Khan University Hospital, Karachi, with FMS and needs to be identified during the consultation
Pakistan.
process, as this requires special consideration during treatment.18

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 Oman Medical Journal (2012) Vol. 27, No. 3: 192-195

Table 1: Conditions associated with fibromyalgia.17-19

Musculoskeletal Genitourinary Gastro intestinal Miscellaneous
• Nondermatomal paresthesia • Dysmenorrhea • Irritable bowel syndrome • Tension/migraine headaches
• Temporo mandibular joint syndrome • Interstitial cystitis • Esophageal dysmotility • Mitral valve prolapsed
• Hyper mobility syndrome • Vulvodynia • Allergy
• Restless legs syndrome • Female urethral syndrome • Vestibular disorders
• Rheumatoid arthritis • Vulvar vestibulitis • Ocular disturbances
• Systemic lupus erythematosus • Premenstrual syndrome • Anxiety disorders
• Sjögren syndrome • Reynaud phenomenon
• Osteoarthritis • Thyroid dysfunction
• Chronic fatigue syndrome • Lyme disease
• Carpal tunnel syndrome • Hyperventilation
• Myofascialpain syndrome • Cognitive dysfunction

Assessment of Fibromyalgia
Although fibromyalgia is the most common chronic widespread 0-19. This number is referred to as the Widespread Pain Index
pain condition, it is often under diagnosed. The diagnosis of (WPI) and it is one of the two required scores needed for a doctor
fibromyalgia has been shown to increase patient satisfaction and to make a diagnosis of fibromyalgia.
reduce healthcare utilization. The second part of the score required to assess the diagnosis of
The assessment of Fibromyalgia is based on the criteria for fibromyalgia involves the evaluation of a person's symptoms. The
the Classification of Fibromyalgia by the American College of patient ranks specific symptoms on a scale of 0-3. These symptoms
Rheumatology, (ACR) 1990.19-21 The criterion involves: include: Fatigue, Waking unrefreshed, Cognitive symptoms,
• History of widespread pain has been present for at least three Somatic (physical) symptoms in general (such as headache,
months. weakness, bowel problems, nausea, dizziness, numbness/tingling,
• Pain in both sides of the body pain above and below the hair loss). The numbers assigned to each are added up, for a total
waist. Pain is considered widespread when all of the following are of 0-12.
present: The diagnosis is based on both the WPI score and the SS score
• Pain in 11 of 18 tender point sites on digital palpation (both either:
side of the body): Occiput (2),Low cervical (2),Trapezius (2), • WPI of at least 7 and SS scale score of at least 5, OR
Supraspinatus (2), Second rib (2), Lateral epicondyle (2), Gluteal • WPI of 3-6 and SS scale score of at least 9.
(2), Greater trochanter (2), Knee (2).
Table 2: New ACR Diagnostic Criteria.
A tender point hurts only at the area where pressure (enough
to cause the examiner's nail bed to blanch, or about 4 kg) is Waking Cognitive
Fatigue
unrefreshed symptoms
applied, and there is no referred pain. An instrument known as a
dolorimeter can be used to apply exactly 4 kg of pressure over the 0 = No problem 0 = No problem 0 = No problem
tender points during the examination.22 1 = Slight or mild 1 = Slight or mild 1 = Slight or mild
problems; problems; problems;
New Diagnostic Criteria Generally mild or Generally mild or Generally mild or
Recently, ACR is proposing a new set of diagnostic criteria for intermittent intermittent intermittent
fibromyalgia that includes common symptoms such as fatigue, 2 = Moderate; 2 = Moderate; 2 = Moderate;
sleep disturbances, and cognitive problems, as well as pain (Table considerable considerable considerable
2). The tender point test is being replaced with a widespread pain Problems; often Problems; often Problems; often
index and a symptom severity (SS) score. The new criteria appear present present and/or at a present and/or at a
in a one-page symptom checklist format that will hopefully be and/or at a moderate level moderate level
moderate level
more suitable for use in the primary-care setting.23 A tender point
evaluation is no longer required although a full physical exam is 3 = severe: 3 = severe: 3 = severe:
still recommended along with other diagnostic tests to identify pervasive, pervasive, pervasive,
continuous, continuous, continuous,
causes for the patients' symptoms besides fibromyalgia. In place of
Life disturbing Life disturbing Life disturbing
the tender point count, patients (or their physician) may endorse problems problems problems
19 body regions in which pain has been experienced during the
past week. One point is given for each area, so the score is between

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Laboratory Investigations reuptake inhibitor is used successfully. Dopamine agonists (e.g.,

Laboratory testing, such as complete blood count, erythrocyte pramipexole), Sodium Oxybate and growth hormone therapy have
sedimentation rate, rheumatoid factor, antinuclear antibody, recently been introduced for FMS.30-31
thyroid-stimulating hormone, T3, T4, creatinine phosphokinase,
Life Style Modifications
a serum muscle enzyme, vitamin D, ESR, CRP, renal function,
and liver function tests are necessary to rule out other disorders. Stress Management: Many patients with fibromyalgia have
X-rays, blood tests, specialized scans such as nuclear medicine and increased levels of stress and feelings of depression, anxiety,
CT scan muscle biopsy are normal in cases of fibromyalgia. and frustration. Several treatment options are available such as
cognitive behavioral therapy; including relaxation training, group
Management of Fibromyalgia therapy, and biofeedback, which are some of the useful options.32
By the time many fibromyalgia patients reach the primary care Exercise: Physical activity can be taken in many ways, including
setting or practice, they may have been seen by multiple healthcare activities such as walking, jogging or sports.33 Exercise is a way of
providers. Patients are often frustrated or discouraged after responding to stress which allows the discharge of the energy the
receiving inadequate answers or diagnosis of their chronic ailments. body is anticipating. 34
Many are relieved to learn that there is an actual diagnosis and Alternative Therapies: Chinese herbal medications, Chinese
possible treatment options for their symptoms.24-25 herbal tea, acupuncture, Tai-chi are the different modalities
available but more research is required in these fields.35-38 It has also
Patients should participate in developing and initiating a care
been suggested that acupuncture triggers the release of endorphins
plan. Being a participant in their care will help the patient to
into the blood stream and are body's natural pain relievers.39
assume control of their lives and focus on positive lifestyle changes
rather than on chronic dysfunction. Patients must try to avoid Conclusion
exacerbating factors and limit anxiety and stress.26-27
A great majority of FMS patients can be managed well Fibromyalgia is a common rheumatologic syndrome characterized
by Family Physicians in ambulatory care by managing stress, by heightened pain sensitivity, fatigue, sleep disturbance, and
depression, pain and life style modification.28 CNS agents, other symptoms as a result of dysregulation of neurophysiologic
antidepressants, muscle relaxants, or anticonvulsants are the most function. Many theories of etiology are under investigation. With
successful pharmacotherapies. the proper treatment coupled with a caring and well informed
physician; patients with fibromyalgia should be able to improve
Therapeutic Measures in FMS function and reduce pain. A variety of neuro-modulatory agents are
Medications have a limited role in FMS treatment to limit showing capability of beneficially affecting the symptom domains
symptoms, so patients can participate in non-pharmacologic of patients with fibromyalgia. Treatment options currently exist
modalities that provide long-term disease management such as to assist patients in relieving symptoms and preventing flare-ups.
exercise, behavioral and education. Non pharmacologic therapies Prompt diagnosis and treatment of fibromyalgia patients may
should be used when possible. 29 produce substantial improvement in quality of life.

Drugs Acknowledgements
There are different pain medications which are useful in the The authors declare no conflict of interest and no funding was received
management of FMS. Paracetamol, NSAIDs have been used but for this work. All authors have contributed in conceptualization,
pain usually do not respond to them. Acetaminophen may ease the and were involved in drafting the manuscript, critically revising it
pain and stiffness caused by fibromyalgia. Besides analgesics, there for important intellectual content and have given final approval of
are drugs used like antidepressant, anti convulsant, Dopamine the version to be published.
agonist and Growth hormone.
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