Fibromyalgia Pain (including CFS/ME)

Fibromyalgia Pain (including CFS/ME)

Fibromyalgia syndrome (FMS) is a diffuse musculoskeletal pain and fatigue disorder for which an exact etiology remains unknown and medical diagnosis can be challenging. Estimates are that more than 9 million American adults have the disorder, predominantly women. Pain, the cardinal symptom of fibromyalgia, seems to emanate from muscles, tendons, ligaments, bursa, and joints. Most patients describe the pain as steady, radiating, burning, and spreading over large areas of the body. Fatigue, lethargy, depression, sleep disturbances, bowel irregularities, cognitive difficulties, and other symptoms also may be present. Therefore, this section also includes Chronic Fatigue Syndrome (CFS), which is also called Myalgic Encephalomyelitis (ME). A variety of pharmacologic and nonpharmacologic therapies offering clinical benefit have been recommended for FMS, along with patient education and exercise programs. Documents in this section focus primarily on those approaches and strategies that have proven most successful for the management of fibromyalgia pain and associated symptoms.

Researchers/Reviewers: Winnie Dawson, MA, RN, BSN; Stewart B. Leavitt, MA, PhD.

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 For additional and more specific fibromyalgia pain documents, see the following sections….

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Exercise Therapy for Fibromyalgia

By: Busch AJ, Webber SC, Brachaniec M, et al. Curr Pain Headache Rep. 2011(Oct);15(5):358–367. Access checked 8/8/12.

PDF available at:

Patients with fibromyalgia syndrome often fail to understand the beneficial effects of exercise in reducing the symptoms of pain, fatigue, sleep disturbances, and overall quality of life. The investigators of this review have examined the results of recent research on exercise for people with fibromyalgia. A variety of studies show evidence for the value of aerobic exercise and strength-training. Additionally, results are reported for trials that used mind-body forms of exercise — such as yoga, tai chi, and Pilates. Advice for clinicians and patients includes guidance regarding the selection of exercise type and intensity, as well as techniques to develop and manage exercise programs that will help patients realize optimal benefits.

Chronic Fatigue Syndrome – Myalgic Encephalomyelitis: A Primer for Clinical Practitioners

From: International Association for CFS/ME; 2012; 42 pages. Access checked 6/28/12.

PDF available for download at:

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This monograph begins with a history of the challenges in the identification and diagnosis of chronic fatigue syndrome, also known as myalgic encephalomyelitis (CFS/ME). In the past 25 years, scientists have identified several physiological abnormalities that tend to be present in patients with CFS/ME, including: neurological defects, impaired energy metabolism, chronic T-cell activation, and evidence of infectious disease triggers. An algorithm provides a potential model for triggers and physiological dysregulation in CFS/ME, with supporting research evidence. Additional tools include a clinician worksheet for patient diagnosis, a list of useful laboratory tests, and a table of co-existing conditions and considerations for differential diagnosis. Recommendations for treatment include drug therapy for sleep issues, pain management, fatigue reduction, and cognitive concerns, plus existing evidence for dietary modifications and complementary therapies.

Fibromyalgia: An Afferent Processing Disorder Leading to a
Complex Pain Generalized Syndrome

By: Smith HS, Harris R, Clauw D. Pain Physician. 2011 Mar-Apr;14(2):E217-245. Access checked 7/15/11.

PDF available for download:,,,/2011/march/…pdf

As an aid to the evolution of our understanding of the pathophysiology of fibromyalgia, the authors review the science behind the 2010 changes in the revised American College of Rheumatology diagnostic criteria. Discussions include the work of other investigators who have proposed fibromyalgia symptom inventories as an aid to identifying whether pain is due to central sensitivity or peripheral causes. In addition to reviewing diagnostic approaches, the article provides a thorough review of the pharmacologic and non-pharmacologic therapy options (and challenges) when treating pain and other common fibromyalgia symptoms. Emphasis is placed on the need for individual treatment plans due to wide variations in type and intensity of patient symptoms as well as the potential for overlapping symptoms from related conditions.

New Developments in the Diagnosis of Fibromyalgia Syndrome: Say Goodbye to Tender Points?

By: Wilke WS. Cleveland Clinic J Med. 2009:76(6):345-352. Access checked 7/3/09.

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This article describes a relatively new diagnostic tool, the Symptom Intensity Scale, which assesses both regional pain and fatigue, and can be used in daily practice to establish a diagnosis of fibromyalgia syndrome and to measure its severity without the need to count tender points. It also can be used to detect fibromyalgia as a comorbidity in other clinical illnesses, and it correlates strongly with measures of depression and general health. The Symptom Intensity Scale questionnaire consists of two parts: a list of 19 anatomic areas in which the patient indicates if he/she feels pain (the total number of “yes” answers being the Regional Pain Scale score), and this is combined with the score on a 10 cm. visual analogue scale for assessing fatigue. This Symptom Intensity Scale is easier to use than traditional ACR criteria, more fully describes the essence of fibromyalgia in which fatigue is usually present and often severe, and has high specificity and sensitivity.

Fibromyalgia: Psychiatric Drugs Target CNS-Linked Symptoms

By: Stanford SB. Current Psychiatry Online. 2009(Mar);8(3). Access checked 3/16/09.

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Current understandings of the origins of fibromyalgia symptoms appear to implicate neurotransmitters and pain pathways. Therefore, the author proposes that antidepressants and anticonvulsants may play important therapeutic roles for appropriate patients. Common medical and cognitive symptoms in patients with suspected fibromyalgia are reviewed and it is suggested that, while musculoskeletal pain is a common symptom, it is frequently not the most problematic symptom. The American College of Rheumatology (ACR) criteria for a fibromyalgia diagnosis is reviewed briefly, but a structured diagnostic interview that follows the DSM-IV-TR (a classification of mental disorders by symptom) format is provided as a more beneficial tool. Tests that can aid in the differential diagnosis of fibromyalgia syndrome are provided in an easy-to-read table. Treatment recommendations include an important role for multi-disciplined therapy as well as the beneficial effects of pharmacotherapy for the treatment of fibromyalgia symptoms.

Fibromyalgia – Special Edition, The Pain Practitioner

From: American Academy of Pain Management. 2008 [Spring];18(1):100 pages. Access checked 1/15/09.


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This special issue of The Pain Practitioner journal focusing on fibromyalgia (FM) is designed to show exactly how real the syndrome is and how far it has come medically. The National Fibromyalgia Association (NFA), led by Lynne Matallana, partnered with the American Academy of Pain Management to assemble this excellent compendium of 9 articles authored by experts in the field. Topics include advances in FM research, new treatment options, treating comorbidities of FM, psychosocial aspects of the disease, and adopting integrative approaches that combine basics strategies with innovative therapies.

Understanding the Fibromyalgia Syndrome

By: Rao GR, Gendreau JF, Kranzler JD. Medscape Ob/Gyn & Women’s Health; 2008; 27 pages. Reprinted in full-text from Psychopharmacology Bulletin. 2007;40(4):24-56. Access checked 1/15/09.

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This recent review, written for psychopharmacology clinicians and researchers, updates a 2005 paper by the authors and includes the most current understanding of pain and treatment options in fibromyalgia. The paper provides a thorough summary of the multisystem physiological effects of fibromyalgia syndrome, including a thorough review of the influence that neurotransmitters can have on troublesome symptoms beyond pain. Using current levels of knowledge of the pain pathways in acute and chronic pain, and the author’s model of fibromyalgia as a bidirectional cycle of symptoms, the efficacy of 3 specific classes of drugs are discussed. The results of the phase II pregabalin trial are summarized and tables are provided that list effective drugs with associated studies showing positive results for fibromyalgia syndrome symptom relief.

The Diagnosis and Treatment of Fibromyalgia

By: Horowitz S. Alternative & Complementary Therapies. 2008(Feb);14(1):13-18. Access checked 1/15/09.

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This article opens with a historical summary of the etiology and diagnostic challenges related to establishing fibromyalgia as a recognized syndrome. Consistent with current thinking that the most successful pain relief in fibromyalgia includes multidisciplinary interventions, this article reviews some of the research that has been done in exercise, cognitive-behavioral therapy, and patient education. More specifically, the results of studies on low-intensity exercise, yoga, T’ai Chi, biofeedback, mindfulness training, cranial electrotherapy stimulation, and various nutritional supplements are noted. The authors encourage health professionals to reassure patients that their pain is real and their condition is treatable.


By: Chakrabarty S, Zoorob R. American Family Physician. 2007(Jul 15);76(2):247-254. Access checked 1/15/09.

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Fibromyalgia is a multi-system syndrome that is characterized by widespread musculoskeletal pain and tenderness, with additional symptoms that can include disturbed sleep, fatigue, headache, morning stiffness, paresthesias, and anxiety. In addition to a discussion of clinical complaints and diagnosis, the Fibromyalgia Impact Questionnaire is presented as a useful tool to assess the functional impact of the disorder on the patient’s daily life. A brief review of the 1990 American College of Rheumatology (ACR) components of the classification criteria for fibromyalgia, common comorbid conditions, and considerations for differential diagnosis are covered. Guidance for management includes the American Pain Society Fibromyalgia Panel recommendations and evidence-based therapy presented by the review by Goldenberg and colleagues (JAMA, 2004;292[19] — article below).

EULAR Guidelines for the Treatment of Fibromyalgia Syndrome

By: Barclay L. Medscape Medical News; 2007; 4 pages. Adapted from: Carville SF, Arendt-Nielsen S, Bliddal H, et al. EULAR evidence based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis. 2007(Oct); Early online publication prior to print. Access checked 1/15/09.

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The treatment of fibromyalgia syndrome—commonly characterized by musculoskeletal pain and tenderness with additional widespread symptoms—has been controversial and recommendations for multimodality management have been few. A multidisciplinary task force of experts from 11 European countries examined published literature for treatment outcomes in patients who were evaluated according to the American College of Rheumatology fibromyalgia classification criteria. The results showed evidence for effective therapy in several disciplines and the European League Against Rheumatism (EULAR) issued the first European guidelines for the treatment of fibromyalgia syndrome. The guidelines include 9 evidence-based pharmacological and nonpharmacological recommendations made by the expert panel as reported in the September 2007 issue of the Annals of the Rheumatic Diseases.

A Review of Fibromyalgia and Its Treatment

By: St. Onge EL, Rose RL, Alighanbari V. Drug Topics. 2005(Nov 21):38-47. Access checked 1/15/09.

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This continuing education program faculty from the University of Florida College of Pharmacy examines the physiological benefits behind available pharmacotherapy for fibromyalgia. The focus of this article is a review of the evidence of efficacy for several antidepressant drugs; additionally, non-opioid analgesics and S-adenosyl-L-methionine (SAMe), a dietary supplement, are briefly explored. Pregabalin (Lyrica®)—a drug approved by the FDA in June 2007 for the treatment of fibromyalgia—is not included in the review. This course is no longer available for CME credit but the full-text article is available through the link provided above.

The Lyrica package insert can be downloaded at: (access checked 3/05/08).

The Fibromyalgia Impact Questionnaire (FIQ): a Review of its Development, Current Version, Operating Characteristics and Uses

By: Bennett R. Clin Exp Rheumatol. (2005);23(Suppl. 39):S154-S162. Access checked 1/15/09.

PDF full-text article available for download: FIQ review.pdf

PDF 10-item questionnaire available for download:

PDF FIQ scoring information available for download:

The Fibromyalgia Impact Questionnaire (FIQ) was originally developed in the late 1980s as a tool to aid practitioners in gathering symptom-related information from patients diagnosed with fibromyalgia according to the American College of Rheumatology criteria developed in 1990 (Wolfe et al.; see below). The full-text article contains the most recent version of the questionnaire and the scoring methodology, as well as a summary of the developmental and validation history of the tool. The additional web links offer PDF versions of the 2-page FIQ and the 2-page instruction document for scoring the FIQ.

Management of Fibromyalgia Syndrome

By: Goldenberg DL, Burckhardt C, Crofford L. JAMA. 2004(Nov 17);292(19):2388-2395. Access checked 1/15/09.

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While recent research on the fibromyalgia syndrome (FMS) has shown evidence of abnormal pain processing similar to other chronic pain syndromes, the fact that the disorder lacks unique pathophysiological characteristics can present challenges in diagnosis and management. This article presents the results of a comprehensive literature review and reports on the levels of efficacy for a variety of treatment modalities. Recommendations are based on the strongest evidence for efficacy and include a stepwise treatment program that emphasizes patient education, low-dose tricyclic antidepressants, cardiovascular exercise, and cognitive behavioral therapy.

A Review of Fibromyalgia

By: Nampiaparampil DE, Schmerling RH. American Journal of Managed Care. 2004(Nov);10(11 Pt 1):794-800. Access checked 1/15/09.

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The authors of this review focus on issues related to the importance of the initial workup and the complexities of the diagnosis. The American College of Rheumatology (ACR) criteria for fibromyalgia diagnosis are reviewed and issues related to laboratory testing are explored. A detailed discussion of pathogenesis includes an examination of the research supporting abnormalities in the musculoskeletal system, the neuroendocrine system, the peripheral nervous system, and the CNS limbic system. The importance of self-efficacy for the self-management of fibromyalgia is discussed and, overall, multi-disciplinary management is strongly recommended. Finally, research on prognosis, disability, and long-term quality-of-life issues is reviewed.

The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia

By: Wolfe F, Smythe HA, Yunus MB, et al. Arthritis and Rheumatism. 1990(Feb);33(2):160-172. Access checked 1/15/09.

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This American College of Rheumatology (ACR) document presents the research methods, examination process, and results that formed the basis for the ACR criteria for the classification/diagnosis of fibromyalgia syndrome. While the report was published in 1990, it continues to be the standard for the diagnosis of fibromyalgia in research and clinical practice. The criteria includes widespread pain in combination with tenderness at 11 or more of 18 specific tender point sites identified in the document. The report also includes a table that compares the sensitivity and specificity data for all criteria items. An added original goal of the committee included a distinction between primary and secondary-concomitant fibromyalgia, but this aspect of classification was abandoned because the differences between the 2 conditions were indistinguishable.

The Science of Fibromyalgia: Understanding Chronic Pain and Fibromyalgia: A Review of Recent Discoveries

By: Bennett RM. From National Fibromyalgia Association; undated. Access checked 1/15/09.

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The complexities of pain in fibromyalgia syndrome are examined in relationship to our current understanding of the pathophysiology of chronic pain. The mechanisms involved in the dysregulation of sensory processing, often called central sensitization, are explored in terms of the theoretical association in fibromyalgia pain. The article concludes with a discussion of the psychological aspects of chronic pain, including the role of the limbic system and the potential for the re-activation of the memory of pain.

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