Medical Review of Fibromyalgia

Dr. Declan O’Keeffe, Pain Management Consultant, Dublin
Fibromyalgia syndrome (FMS) is a debilitating disorder characterised by chronic (>3
months) widespread muscle pain, persistent fatigue, sleep disturbance, depression and
skin sensitivity. Fibromyalgia is believed to affect up to 5% of the general population,
predominantly women. Fibromyalgia pain is consistently felt in deep tissues including
ligaments, joints and muscles. Patients report that their muscles feel overworked or

The severity of symptoms varies from patient to patient and may resemble a post viral
state.Fibromyalgia (FM) is thought to arise from influencing factors such as stress, medical illness,
and a variety of pain conditions in some, but not all patients, in conjunction with a
variety of nerve chemical and hormonal disturbances. Increased release of chemicals
from nerve cells in specific muscle sites trigger immune cells to release sensitising


There are no genetic or biochemical markers and patients often present with other
diseases, such as migraines, interstitial cystitis and irritable bowel syndrome. A unifying
hypothesis is that FMS results from sensitization of the central nervous system.
Persistent or intense pain can lead to changes in the spinal cord and brain resulting in
central sensitisation and pain. After central sensitisation has been established, only
minimal pain input is required for the maintenance of the chronic pain state. Poor sleep
and a hypervigilance state results in chronically increased muscle tone. Poor blood flow
aggravates and maintains pain in muscles and soft tissue.

Diagnosis includes the presence of 11 out of 18 trigger points (painful points that
precipitate muscle pain), but many patients with early symptoms might not fit this
definition. Diagnosis and treatment have been especially challenging due to limited
knowledge of the cause and poor response to conventional treatment of pain.

Current evidence advocates a multifaceted programme emphasising patient
education, medications for improving symptoms, and aggressive use of exercise and
cognitive-behavioural approaches to retain or restore function.

Cognitive behavioural therapy (CBT) techniques offer short-term, goal-orientated
psychotherapy. It emphasises changes in thought patterns and behaviours and
beneficial effects can be achieved in 10-20 sessions. The results from 13 programmes over
18 years using CBT showed improvements in pain-relation behaviour, self-efficacy,
coping strategies and overall physical function. Sustained improvements in pain were
most evident when individualised CBT was used to treat patients with juvenile
Fibromyalgia. In particular, specific sub-groups of patients characterised by relatively
high levels of psychological distress seem to benefit most from non-pharmacological
interventions. Preliminary evidence of retrospective treatment analysis suggest
that the efficacy may be enhanced by offering tailored treatment approaches in an
early stage to patients who are at risk of developing chronic physical and psychological

To date, no drugs have been officially approved for the indication of fibromyalgia, and
randomised, controlled clinical trials with Fibromyalgia patients are taking place to
identify potential therapeutic approaches.

A range of medical treatments, including anti-depressants, opioids, nonsteroidal
anti-inflammatory drugs, sedatives, muscle relaxants, and antiepileptics, have been
used to treat FM. Non drug treatment modalities, including exercise, physical therapy,
massage, acupuncture, and cognitive behavioural therapy, can be helpful. There is
no curative treatment. Recent nutraceutical formulations containing the natural
anti-inflammatory and mast cell inhibitory flavonoid quercetin hold promise, since
they can be used together with other treatment modalities.