PainScience.com Sensible advice for aches, pains & injuries
 
 

Fibromyalgia

The mysterious disease of pain, exhaustion, and mental fog

updated
by Paul Ingraham, Vancouver, Canadabio
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of ScienceBasedMedicine.org for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about PainScience.com

Fibromyalgia is a label for an illness of chronic pain, fatigue, and mental fog that has no other explanation, a diagnosis of exclusion. It often goes with conditions like irritable bowel syndrome, migraines, and mood disorders. About 1–2% of the population suffer from this.1 Some people get better, but many don’t. There are no proven treatments, just a few promising approaches help some people.

The biology of fibromyalgia remains a mystery. There are intriguing theories only. Many professionals still assume it’s a psychogenic problem (much like migraines were until surprisingly recently). Many others now believe that fibromyalgia is a disease of neurological sensitization — an overactive alarm system — but this is unproven and awkwardly at odds with some of what we do know about the condition. We just don’t know what’s going on, even though fibromyalgia research is booming (because most of it is worthless).

Controversy, stigma, and quackery swirl around fibromyalgia like a bad smell. It is often not diagnosed when it should be, and even more often these days it is diagnosed when it shouldn’t.2 No medical speciality specializes in it. Rheumatologists and neurologists often get “stuck” with fibromyalgia patients, but have no idea what to do with them unless they’ve taken a special interest in the topic. Alternative medicine has rushed into the medical gap with a dizzying array of crackpot cures.

Here’s a good 1-minute primer on fibromyalgia from One-Minute Medical School:

Fibromyalgia Syndrome 1:00

Classic fibromyalgia symptoms

Many fibromyalgia symptoms are maddeningly non-specific: that is, they could be the symptoms of practically anything, or nothing. Headaches are the single most common pain complaint, but most have no specific cause. Almost all diseases cause fatigue. And pain is the most basic response to biological adversity that there is. And every other person you pass on the street is depressed, anxious, insomniac, or all of the above. It’s almost like fibromyalgia’s symptoms are just a list of the most common sufferings of humanity. It’s only when they occur together — a strong, relentless pattern — that a fibromyalgia diagnosis can be taken seriously.

“Fibromyalgia” is like a “UFO”

If you have unexplained chronic fatigue and pain aggravated by exercise, you have fibromyalgia by definition, because fibromyalgia is a description of those symptoms, not a diagnosis (explanation) of them per se. It’s like “unidentified flying object.” If an object is flying, and you don’t know what it is… it’s a UFO. That doesn’t mean it’s piloted by aliens, and a diagnosis of fibromyalgia doesn’t imply any specific cause either: fibromyalgia is the word we use to describe feeling a certain way, badly enough, for long enough. But the UFO could be piloted by aliens, and the fibromyalgia could be caused by a specific pathology.

MUS are the UFOs of medicine: medically unexplained symptoms. Just like a UFO technically refers to an unexplained phenomenon but there’s a popular suspicion about what’s really going on (aliens!), MUS are also unexplained by definition and yet there’s a popular belief about what’s really going on: psychosomatic! Others understand that there’s probably a better explanation:

Clearly there are many patients who have chronic diffuse pain, fatigue, poor sleep, and other comorbidities. These symptoms often take a great toll on quality of life. Nothing in the scientific discussion about fibromyalgia as a diagnosis calls into question these symptoms. The question is entirely about how we understand the possible cause or causes of these symptoms in order to guide our treatment and research.

Neurologist Dr. Steven Novella, “Is Fibromyalgia Real?

Fibromyalgia is nearly synonymous with MUS. You could define fibromyalgia for a doctor by saying “it’s a case of MUS dominated by pain.” Calling it fibromyalgia might make it seem like something more specific, but it’s not: it’s still just a bunch of unexplained symptoms. It’s important to bear in mind that fibromyalgia is actually just a common pattern of unexplained symptoms, probably the most common one.

Types of pain and where fibromyalgia fits in (or doesn’t)

There are two main categories of pain: nociceptive and neuropathic. Fibromyalgia doesn’t seem to fit well into either. The most familiar kind of pain is nociceptive, caused by damage to tissues and reported to the brain for assessment. When the reporting system itself is damaged — a pinched nerve, say — you get neuropathic pain.

Two kinds of damage, two kinds of pain.

Maybe someday we’ll know that fibromyalgia is caused by some kind of subtle damage to the nervous system & that would make it just another neuropathy after all, ho hum.

Fibromyalgia is something else, a third category, a dysfunction. It involves no confirmed damage to the nervous system, but its misbehaviour, and so it’s not welcome at the neuropathy club. It was before 2011! But the definition of neuropathy changed to officially exclude anything that didn’t involve a known lesion.3

Maybe there are unknown lesions? Maybe someday we’ll know that fibromyalgia is caused by some kind of subtle damage to the nervous system.4 There are at least two theories of subtle lesions of this type.5 That would make it just another neuropathy after all, ho hum.

But for now it’s still more plausible that it’s a dysfunction, arising from widespread problems in a complex system, and no clear point of failure will ever be discovered.67 But who knows. Science is not finished with fibromyalgia.

Meanwhile, what do we call it? And other miserable pain problems (complex regional pain syndrome, irritable bowel syndrome) that arise from neurological dysfunction? No one has decided. File under “other.” FWIW, I favour “algopathic” pain: pathological perception/sensation.8 It’s the Greek way to say “pain disease.” For more naming possibilities, see The Basic Types of Pain.

What about “central sensitization”?

Fibromyalgia involves a lot of sensory over-reaction to stimuli: more pain with less provocation, known as sensitization. This sensitivity is probably caused by the central nervous system. So, Central Sensitization in Chronic Pain.

Some patients even feel pain when touched softly (allodynia [Wikipedia]), a terrible thing. Fibromyalgia is hell.

It has become trendy lately to “explain” fibromyalgia with central sensitization, or to claim that central sensitization is the primary mechanism. CS clearly occurs in fibromyalgia, but it doesn’t explain it, and there’s plenty going on in fibromyalgia that is not explained by central sensitization (like fatigue and mental fog, for starters). It’s more like a more precise description than an explanation. Even if fibromyalgia is 90% CS, you still need to explain that, which is just as hard puzzle as why someone would get fibromyalgia. Why would someone get terrible central sensitization? It’s practically the same question.

Maybe it’s the constant irritation of systemic inflammation, though. I think that might get me feeling mighty sensitive!

Inflammation as a driver of sensitization

Fibromyalgia patients seem to be on fire a little bit: in 2017, Bäckryd et al studied inflammatory markers in fibromyalgia patients in much greater detail than ever before, and identified an “extensive inflammatory profile.”9 It’s conceviable that this is caused by sensitization, but it’s more likely that being constantly inflamed all over for a long time turns people in wrecks of sensitization.

If fibromyalgia patients are more inflamed than sensitized, that doesn’t really help us all that much, because we still don’t know why people get so inflamed — it’s almost as much a puzzle as the sensitization! But it does feel a little less bizarre than a malfunction consisting of “pure” sensitization. Bäckryd et al write:

Fibromyalgia seems to be characterized by objective biochemical alterations, and the lingering characterization of its mechanisms as essentially idiopathic or even psychogenic should be seen as definitively outdated.

But they don’t attempt an explanation of the inflammation they found!

Conditions that may be confused with fibromyalgia

Practically everything that can go wrong with human biology seems to be able to cause any of the classic non-specific symptoms that define fibromyalgia. Many people troubleshooting health problems have bitterly made the observation that “everything causes everything.” Nearly any symptom can and will occur in at least some people as an atypical variation of nearly any disease.

So this is tricky! But here are some of the conditions that are the most likely to masquerade as fibromyalgia for long periods.

Fibromyalgia can be confused with almost any condition that corrodes your vitality or causes weird aches and pains (which is quite a huge list), but without other obvious symptoms that would expose them for what they really are (which is mercifully shorter).

The particularly tricky relationship between fibromyalgia and myofascial pain syndrome

They may be related but distinct. Or it may be a word game: different words for different aspects of the same thing. But they are almost certainly not exactly the same thing.

Like fibromyalgia, “trigger points” is a label for a poorly understood phenomenon: sore spots in muscles, which sometimes feel like hard lumps. They are probably little micro cramps, small lesions in muscle tissue,11 as common and unpleasant as pimples (and sometimes a lot worse). When people seem to have many and severe trigger points, another arbitrary diagnostic label is often applied: “myofascial pain syndrome.”

Severe MPS and mild fibromyalgia are nearly impossible to tell apart. Trigger points and MPS may just be the tip of the fibromyalgia iceberg, or they may be different things with similar symptoms. No one knows.

Most people with fibromyalgia seem to have more than their fair share of trigger points, but it’s hard to tell because people with fibromyalgia tend to be sore eveywhere. And yet many people with trigger points would never be diagnosed with fibromyalgia. Robust, healthy people can have temporary trouble with a trigger point.

Tender points vs. trigger points

Positional cervical cord compression and fibromyalgia

One of the most interesting ideas to emerge from the fibromyalgia research mess is the possibility that the pain is caused by a subtle pinching of the spinal cord, a form of myelopathy [Wikipedia] — symptoms caused by poor spinal cord function. The cervical spinal cord is a neurological bottleneck through which every nerve impulse from or to the body must pass. Symptoms caused by troule at this level of the spinal cord are notoriously variable and can cause symptoms essentially anywhere, such as shooting pains in the backs of the legs (sciatica).13

As all over the map as they are, there’s a suspicious overlap between the symptoms of myelopathy and fibromyalgia. Many fibromyalgia patients are quite myelopathy-ish, but without enough classic myelopathy symptoms to attract that diagnosis. Could they be related? Could fibromyalgia be sub-category of myelopathy?

That real possibility was exposed by a 2008 paper by Dr. Andrew Holman. His research, sadly still unreplicated, showed that minor spinal cord pinching was present in a shockingly high percentage of patients with fibromyalgia and chronic widespread pain: about seventy percent of them.14 Specifically, he reported positional cervical cord compression (PC3), which is pinching of the spinal cord that occurs only or mainly in specific positions (mostly with the head tilted back).

And treating PC3 seems to show some promise for treating fibromyalgia.

Erratic low-grade irritation of the cervical spinal cord could actually be the direct, specific & mechanical cause of fibromyalgia.

Unfortunately, conventional MRI images, taken with the neck in a neutral position, will miss a lot of PC3 — at least half.15 Neurologists who would otherwise be interested in fibromyalgia patients may dismiss them because their myelopathy-like symptoms can’t be explained by a neutral MRI that does not reveal the PC3.

The implication of all this is that erratic low-grade irritation of the cervical spinal cord could actually be the direct, specific, and mechanical cause of fibromyalgia (possibly not the only cause, but a major one). It’s a dramatic and sensational hypothesis, but it’s not outrageous. We already know that myelopathy is spooky and unpredictable and often involves widespread pain. We also know that intermittent compression of nerves causes different kinds of symptoms in the peripheral nervous system than constant pressure, so it’s not much of a reach to suppose the central nervous system also responds a differently: an atypical, subtle myelopathy, caused by pinching that’s invisible to all but the most thorough MRI examination… a diagnostic technology that is notoriously unreliable!16

It would hardly be a shock if such a thing had been missed until now.

And then there’s the “autonomic arousal” thing!

There’s one final mind-blowing piece of the PC3 puzzle: irritation of the cervical spinal cord may have unusual properties, different from other parts of the spinal cord. Specifically, PC3 may cause strong arousal of the autonomic nervous system… the same effect as severe chronic stress.

If that is the case, the implications would be astonishing: it would simultaneously provide an organic explanation for many cases of fibromyalgia and support the idea that the disease can also be caused by external stresses. That is an awfully potent explanation for a whole lot.

This suggests that stress could be the underlying mechanism of fibromyalgia — but it can be either life stresses, or “artificial” stress caused by a messed up spine. mind blown

All unproven. All needs more research. But there’s a lot of veeery interesting smoke here.

An avalanche of useless fibromyalgia research

Dr. Fred Wolfe is about as expert as a fibromyalgia expert gets: he’s largely responsible for the official diagnostic criteria for fibromyalgia (the original in 199017 and then the important revisions in 2010/2011,1819 which ditched “tender points” and factored in symptom severity, in a nutshell).

Since 2013, Dr. Wolfe has been blogging erratically but superbly, and in this short post he explains (with snark!) how fibromyalgia is being buried by an avalanche of crappy, useless research. (And you could substitute nearly any other difficult or controversial condition, like “trigger points” for instance.)

PubMed reports 659 publications in the last 12 months relating to fibromyalgia. For those who are interested, there are 9,366 articles listed in the all the years that data are available. For 1990, the year the American College of Rheumatology 1990 fibromyalgia criteria were published, PubMed cites 95 articles. If you think that after all these years of research you and your patients are much better off, think again. A kind, conscientious physician treating a fibromyalgia patient in 1980 or 1990 will have done as well as the 2016 health workers with access to all of these new publications and expensive if not very efficacious medications.

Some sketchier theories about fibromyalgia

Can we blame infections and/or vaccinations? It’s particularly popular to point a finger at diseases like hepatitis C, Epstein-Barr virus, parvovirus, and — of course — Lyme disease. These are all probably red herrings, however: “There is no clear-cut evidence of fibromyalgia or chronic widespread pain due to infections or vaccinations, no correlations with persistent infection, and no proven relationship between infection, antimicrobial therapies and pain improvement.”20 I don’t think it’s possible to completely rule out infections — microorganisms keeping turning up where we didn’t expect them — but if fibromyalgia is related to an infection, it’s a completely mysterious one.

How about defective metabolism? Excess phosphate? For many years, a common ingredient in cough syrups — guaifenesin, a chemical derived from a tree — has been prescribed as a natural treatment for fibromyalgia based on the idea that it purges an excess of phosphate, which allegedly accumulates due to [insert unclear metabolic defect]. That is what a skeptic would call an “extraordinary claim”: an overconfident explanation of a notoriously unexplained disease. The “guaifenesin protocol” is popular, but has very little expert support, even from alt-med friendly physicians, and was proven ineffective by its own proponents long ago,21 and fibromyalgia patients do not appear to have excess phosphate in the first place.22

Incidentally, guaifenesin is probably not even an effective cough syrup ingredient. *sad trombone*23 However, it is actually a muscle relaxant as well, and maybe that explains why some fibromyalgia patients are pleased with its effects.

A colorful, glowing hand representing the idea of therapeutic touch or reiki.

Please don’t waste your money on aura massage.

An “energy disturbance” is the culprit according to many alternative medicine practitioners. Although the same practitioners will blame practically anything on disturbed energy (funny that), common medically unexplained conditions like fibromyalgia are singled out for special attention — as long as there’s no better explanation, “energy” remains a contender that many will take seriously, god of the pathological gaps. It’s the basis for treatment with acupuncture above all, follow by aura massage: ritualistic movement of the hands through the space around you, a technique ironically called therapeutic “touch”. It’s all nonsense, debunked ad nauseum for decades now. Acupuncture is ineffective for all pain, never mind complex case of unexplained chronic pain.24 Therapeutic touch practitioners can’t even detect auras in blinded tests.25 All the benefits derived from energy therapies are easily attributed to the good (social) vibes and optimism we get from being cared for and being impressed by healing rituals, a psychological phenomenon.

Fibromyalgia and your rheumatologist or neurologist

Fibromyalgia often resembles the early stages of rheumatological diseases like lupus or ankylosing spondylitis. Indeed, fibromyalgia actually co-exists with them. And so fibromyalgia patients often end up being referred to rheumatologists… and then many patients and rheumatologists end up frustrated and baffled by each other.

Rheumatology is the medical speciality devoted to arthritis, particularly the inflammatory arthritides (autoimmune diseases). Rheumatologists are appropriately preoccupied with those very serious and complicated problems. Many of them sub-specialize in just one! In the big picture, it isn’t fair or reasonable to expect rheumatologists to “get” fibromyalgia. The only rheumatologists who do are the ones who have taken an interest and gone out of their way to study it. But they are the exception. In Canada, rheumatologists have been told by their professional organization that fibromyalgia is out of their scope of practice — they aren’t technically allowed to help fibromyalgia patients!

Of course, there’s no excuse for a rheumatologist being an insensitive jerk about it, either.

Neurology is the other medical speciality that attracts fibromyalgia cases, which is probably a less bad fit — although neurologists are also appropriately preoccupied with many serious conditions that are much better understood. Many of them sub-specialize in a disease (multiple sclerosis), or a class of neurological problems like movement disorders, and really don’t know the first thing about fibromyalgia, any more than pro football coach would know what to do with a volleyball team. But some neurologists generalize and take a professional interest in problems like fibromyalgia.

Other relevant medical specialities

In all cases, there’s the potential for good help if the individual professional is keen on the topic of fibromyalgia. But there simply is no speciality that clearly lends itself to that. There just are no “fibromyalgia doctors.” Here are the closest remaining possibilities, after rheumatology and neurology:

Orthopaedists are the “carpenters” of medicine, generally focussing on surgical repairs of (allegedly) biomechanical problems, and sports medicine. They are mostly not a good choice for fibromyalgia patients.

Physical medicine & rehabilitation (AKA physiatry) is one of the newest medical specialities, and PM&R docs are basically like advanced physical therapists.

Pain specialists are usually board certified anesthesiologists, neurologists, physiatrists, psychiatrists, or oncologists with additional training in pain management. They often work in multidisciplinary pain clinics/programs. This can be a good route for fibromyalgia patients, but — yet again — fibromyalgia may be a second class citizen, overshadowed by more overtly serious and sensational diseases.

Psychiatrists and psychologists are potentially useful not because fibromyalgia is “all in your head,” but to help rule out (or treat) symptoms caused by anxiety and depression.

Massage therapists have little hope altering the progression of fibromyalgia, but they do reliably offer something almost no other professional can: at least some temporary but meaningful symptom relief, and soothing of the nervous system. Nervous system soothing may be more valuable than it sounds, more than just relaxation, insofar as a very pleasant sensory experience may actually reduce sensitization.

Exercise for fibromyalgia

Regular moderate exercise you enjoy is good medicine for fibromyalgia.26272829

Maybe.30

Although exercise is famously “the closest thing there is to a miracle cure” for many medical problems,31 it’s much less of a slam dunk for chronic pain in general,32 and clearly it can backfire and actually cause pain,33 especially in fibromyalgia patients. Indeed, feeling like you can’t exercise — because it’s painful, because it wipes you out — is one of the signature features of fibromyalgia!

Still, fibromyalgia is among the most likely of chronic pain conditions to benefit… if you do it right. But what’s right? No one knows for sure, of course, but here are some evidence-inspired tips:

Other treatment advice for fibromyalgia

Treat sleep like it’s precious. Learn everything you can about insomnia and sleep problems, learn and practice the best possible sleep hygiene, and protect your sleeping conditions like it’s life or death. See The Insomnia Guide.

Treat the treatable. Fibromyalgia patients have other medical problems, like tendinitis,41 but suffer from them more and longer. Focus on taming whatever issues you have as best you can. It’s an uphill battle, but it’s all the more important. The fewer sources of pain, the better. PainScience.com has many self-help guides for common pain problems and injuries, and a guide to unusual sources of pain.

Change everything. Change your life. If fibromyalgia is a complex disease caused by many factors, if it’s a “meltdown” of our ability to adapt to stress, then seek out a different and better life. See Pain Relief from Personal Growth. Less drastically, but in the spirit, launch a campaign to eliminate every possible stress from your life — not easy, of course, but worthwhile regardless. Meditation, yoga, and related practices may be appealing and appropriate for some people.

Experiment with anti-inflammatory dieting. Although there is clear evidence that fibromyalgia is inflammatory,42 there is none that any kind of diet would help. And yet an anti-inflammatory diet is basically just a “heart healthy” diet — so low stakes, worth a shot, worst case scenario you’re eating healthier in general. For some more detailed recommendations, see Chronic, Subtle, Systemic Inflammation.

“Ignore” it. I’m not being cute here, I swear. This isn’t a trite suggestion—it’s absolutely earnest. Pain is like noise pollution: the more you pay attention to it, the worse it gets. It thrives on attention and drama. Try to act normal and get on with your life as best you can. Embrace stoicism. For much more about this and other “mind over pain” strategies, see Pain is Weird.

Try marijuana. There are drug therapies for fibromyalgia, but none of them show much promise. The Opioids for Chronic Aches & Pains are notably not effective. Alternatively, the efficacy of marijuana for chronic pain is modest but well-established.

Take vitamin D. Vitamin D deficiency is extremely common (especially in northern latitudes), strongly correlated with chronic pain in general and fibromyalgia in particular, and safe to supplement. See Vitamin D for Pain.

Hang out in a pressure chamber? Hyperbaric oxygen therapy for fibromyalgia

Hyperbaric oxygen therapy (HBOT) involves sitting in a pressurized chamber with an oxygen-rich atmosphere. The idea is that it squeeeezes extra O₂ into your body! It’s an experimental, expensive treatment with some promising preliminary evidence for some conditions, like autism and migraine. The risks are unknown, but probably minimal.

Predictably, there’s not much evidence on this topic, and what we have is of questionable value (see above, “An avalanche of useless fibromyalgia research”). As of 2017, there are a couple dozen slightly encouraging animal and human trials of HBOT for “chronic pain” in general,43 and just one more intriguing scientific study of HBOT for fibromyalgia in particular,44 with a conclusion that sounds fabulous:

CONCLUSIONS: The study provides evidence that HBOT can improve the symptoms and life quality of FMS patients. Moreover, it shows that HBOT can induce neuroplasticity and significantly rectify abnormal brain activity in pain related areas of FMS patients.

It’s a substantial speculative leap from “HBOT facilitates neuroplasticity maybe possibly” all the way to “and therefore fibromyalgia cure!”

Unfortunately, we have no strong reason think that HBOT is going to be an effective treatment for fibromyalgia specifically. It’s not a crazy idea, but it’s still a substantial speculative leap from “HBOT facilitates neuroplasticity maybe possibly” all the way to “and therefore fibromyalgia cure!” The whole thing smacks of wishful thinking and perhaps even self-promotion (which is a bit of a plague on HBOT research). Although bias is normal, and nothing actually gets studied if people aren’t keen on it, this is a complex study with a high-risk of bias. These researchers are obviously heavily invested in the idea of HBOT, and the more complicated the study, the more ways there are to unconsciously distort the experiment and its results.

The inclusion of SPECT assessment, while fascinating, adds a bunch more complexity to what is already a complicated trial. Although well-written with good, thorough disclosure of some of the obvious limitations (like the problematic absence of a true placebo control), there’s still way too much wiggle room here, and the results are essentially meaningless without good replication... and probably an (impossible?) solution to the placebo problem. Although the authors think the results were “not likely to be a placebo” and cite a couple reasons why — like the fact that patients actually worsened initially — by no means is that doubt fully resolved.

But there is a bright side: the final results did seem to be quite robust, and they shouldn’t be carelessly dismissed. I just can’t take it too seriously without replication. But watch this space. I wouldn’t have bothered including an HBOT section if I didn’t think there was some potential.


About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.

Recommended Reading

I think this is the most credible and useful of the many fibromyalgia books available is Fibromyalgia: The Final Chapter. This article is just a primer: go read Dr. Goldenberg’s book next.

DOCTOR MASSEUSE: Or My Personal Pain Puzzle,” by Jared Updike: a practical and hopeful article by a PainScience.com reader about wrestling with fibromyalgia over the last few years, more or less successfully. But it wasn’t easy:

What do you do when all your effort backfires and makes things worse, where you feel like your body is allergic to effort? (And you tried "resting" or doing nothing for months but that clearly did not work either?) Especially if you are the type of person that thrives on effort (professional life and hobbies and ways to blow off steam?)

For several years, the pain, fatigue, isolation, anxiety and low mood cycles were hell. The harder I tried, the worse it made everything: I was used to trying harder making things better, but this was its own beast. During this time, I had trouble walking without my muscles (eventually my whole system) complaining for days. I had trouble driving. I felt trapped in my apartment.

Jared perfectly demonstrates a thoughtful, systematic approach to learning about fibromyalgia and experimenting with treatments. He’s open-minded, but — crucially — not too open-minded. His writing about that process is a great bonus, clear and interesting. The main article is short, but some of his “Additional Notes” are actually longer and the best part: be sure to click/tap to show those.

What’s new in this article?

Nine updates have been logged for this article since publication (Jan 21st, 2017). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more When’s the last time you read a blog post and found a list of many changes made to that page since publication? Like good footnotes, this sets PainScience.com apart from other health websites and blogs. Although footnotes are more useful, the update logs are important. They are “fine print,” but more meaningful than most of the comments that most Internet pages waste pixels on.

I log any change to articles that might be of interest to a keen reader. Complete update logging of all noteworthy improvements to all articles started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.

See the What’s New? page for updates to all recent site updates.

JuneNew section: Some sketchier theories about fibromyalgia (infection and vaccines, excess phosphate, and energy disturbance).

JuneNew section: Inflammation as a driver of sensitization, based on new evidence of an “extensive inflammatory profile” in fibromyalgia patients (Bäckryd).

MayNew section: Hyperbaric oxygen therapy for fibromyalgia.

MayNew section: Exercise for fibromyalgia, with some evidence-inspired tips.

MarchAdded small-fibre neuropathies and positional cervical cord compression to the differential diagnosis section. Expanded the description of relevant medical specialities. Added a paragraph about medically unexplained symptoms (MUS). Miscellaneous editing.

FebruaryAdded an introduction to the differential diagnosis section (“everything causes everything”!), and items about B12 deficiency and celiac disease.

FebruaryMore detail about positional cervical cord compression; beefed up the list of conditions that can be confused with fibromyalgia; added an expert quote and an important reading recommendation; miscellaneous editing.

JanuaryAdded a whimsical analogy between UFOs and fibromyalgia.

JanuarySubstantive editing.

JanuaryPublication.

Notes

  1. Jones GT, Atzeni F, Beasley M, et al. The prevalence of fibromyalgia in the general population: a comparison of the American College of Rheumatology 1990, 2010, and modified 2010 classification criteria. Arthritis Rheumatol. 2015 Feb;67(2):568–75. PubMed #25323744. BACK TO TEXT
  2. Www.fmperplex.com [Internet]. Wolfe F. 75% of Persons in the General Population Diagnosed with Fibromyalgia Don’t Have It, But It Is Worse Than That… – The Fibromyalgia Perplex; 2017 January 11 [cited 17 Jan 19].

    This is a scholarly commentary on the substantial over and under diagnosis of fibromyalgia, with an estimate 75% of people with diagnosis actually not fitting diagnostic criteria, about 1.5% of the US population:

    By our calculations almost 3 million people who do not meet fibromyalgia criteria have been given a fibromyalgia diagnosis. At the other end of the spectrum, there are almost 3 million persons who satisfy fibromyalgia criteria, but have not been diagnosed with the disorder by a physician.

    The authors argue that misdiagnosis is driven more by “socially-constructed factors” like pharmaceutical companies aggressively teaching doctors to diagnose fibromyalgia and prescribe (unproven) drugs for it; patient advocacy groups trying to legitimize the diagnosis; and doctors seeking prestige by publishing about fibromyalgia.

    They also make some important points about the state of our understanding of fibromyalgia along the way, most notably that central sensitization remains both unproven and problematic as a major cause or mechanism of fibromyalgia.

    BACK TO TEXT
  3. Jensen TS, Baron R, Haanpää M, et al. A new definition of neuropathic pain. Pain. 2011 Oct;152(10):2204–5. PubMed #21764514.

    IASP has recently [2008] published a new definition of neuropathic pain according to which neuropathic pain is defined as ‘pain caused by a lesion or disease of the somatosensory system.’ This definition replaces the 17-year old definition that appeared in the Classification of Chronic Pain published by IASP in 1994, which defined neuropathic pain as ‘pain initiated or caused by a primary lesion, dysfunction, or transitory perturbation of the peripheral or central nervous system’. Even though the definition has not been changed dramatically, there are two important changes in the new version: (1) the word ‘dysfunction’ has been removed and (2) a lesion or disease affecting the nervous system has been specified to be a lesion or disease of the somatosensory system.

    The whole paper is excellent, but skipping to the cogent conclusion:

    A definition of neuropathic pain is only useful if it distinguishes conditions in a clinically meaningful way. If the definition does not provide additional benefit in terms of understanding and treating the condition(s), then there is no reason to keep it. Hopefully, the new definition of neuropathic pain will act as a stimulant to discuss the definition in more detail and provide input for studies that can be used to test the value of the definition.

    BACK TO TEXT
  4. Multiple sclerosis attacks nerves in quite a dramatic way, which we could see in autopsies, but the lesions were invisible in living patients until the invention of MRI. It’s plausible that there are still plenty of biological “lesions” that we haven’t yet learned to detect, because they are just too small and transient. Despite all of our modern technological wizardy, most of the action in biology happens at the nanoscale, cells moving molecules and atoms around at dazzling speeds through the chaos of the molecular storm (brownian motion). There are probably nanoscale lesions. BACK TO TEXT
  5. Both will be discussed below: Both small fibre peripheral neuropathy and positional cervical cord compression are candidate neuropathic etiologies: both hard to detect, both capable of explaining at least some of the symptoms of fibromyalgia, both associated with people who have diagnosed with fibromyalgia. BACK TO TEXT
  6. Lyon P, Cohen M, Quintner J. An evolutionary stress-response hypothesis for chronic widespread pain (fibromyalgia syndrome). Pain Med. 2011 Aug;12(8):1167–78. PubMed #21692974. “Drawing on diverse findings in neurobiology, immunology, physiology, and comparative biology, we suggest that the form of central sensitization that leads to the profound phenomenological features of chronic widespread pain is part of a whole-organism stress response, which is evolutionarily conserved, following a general pattern found in the simplest living systems.” BACK TO TEXT
  7. BetterMovement.org [Internet]. Hargrove T. A Systems Perspective on Chronic Pain; 2014 Oct 23 [cited 16 Sep 12].

    This deep but beautifully readable article explains, with many pictures and apt examples, how “chronic pain is often driven by dysregulation of a ‘supersystem’ that coordinates defensive responses to injury. The supersystem results from dynamic interaction between different subsystems, most notably the nervous system, immune system, and endocrine system.” It’s hard to believe, but the article also manages to make this information seem quite practical.

    BACK TO TEXT
  8. Kosek E, Cohen M, Baron R, et al. Do we need a third mechanistic descriptor for chronic pain states? Pain. 2016 Jul;157(7):1382–6. PubMed #26835783. PainSci #53276. BACK TO TEXT
  9. Bäckryd E, Tanum L, Lind AL, Larsson A, Gordh T. Evidence of both systemic inflammation and neuroinflammation in fibromyalgia patients, as assessed by a multiplex protein panel applied to the cerebrospinal fluid and to plasma. J Pain Res. 2017;10:515–525. PubMed #28424559. PainSci #53589.

    Although inflammation has been suspected in fibromyalgia, it has been poorly studied to date. This experiment went much further, employing “a new multiplex protein panel enabling simultaneous analysis of 92 inflammation-related proteins.” They looked for these markers in the cerebrospinal spinal fluid and blood of 40 fibromyalgia patients and compared with healthy controls, finding an “extensive inflammatory profile.”

    BACK TO TEXT
  10. Although fibromyalgia may include the burning pain or nerve tingling characteristic of SFPN, most with SFPN don’t have the hallmark FMS symptom of widespread deep tissue pain, or other classic fibromyalgia symptoms like severe fatigue. BACK TO TEXT
  11. PS Ingraham. The Trigger Point Identity Crisis: The biological evidence that a trigger point is a lesion in muscle tissue. PainScience.com. 3314 words. BACK TO TEXT
  12. Www.practicalpainmanagement.com [Internet]. Holman A. Using Dynamic MRI to Diagnose Neck Pain: The Importance of Positional Cervical Cord Compression (PC3); 2017 January 12 [cited 17 Feb 28].

    A remarkable article for a medical audience, technical and scholarly but cogent, exploring fascinating potential connections between PC3 and/or Chiari malformation and fibromyalgia and chronic widespread pain.

    BACK TO TEXT
  13. Chan CK, Lee HY, Choi WC, Cho JY, Lee SH. Cervical cord compression presenting with sciatica-like leg pain. Eur Spine J. 2011 Jul;20 Suppl 2:S217–21. PubMed #20938789. PainSci #53701.

    A report on two cases of cervical spinal cord impingement causing leg pain — both examples of pain at a location unusually remote from a subtle lesion (referred pain) — both successfully treated surgically. Notably, both cases involved previous lumbar spine problems.

    Interestingly, such distant referred pain is tangentially relevant to the hypothetical phenomenon of cervical spinal cord irritation causing fibromyalgia (see Using Dynamic MRI to Diagnose Neck Pain).

    BACK TO TEXT
  14. Holman AJ. Positional cervical spinal cord compression and fibromyalgia: a novel comorbidity with important diagnostic and treatment implications. J Pain. 2008 Jul;9(7):613–22. PubMed #18499527. BACK TO TEXT
  15. Zhang L, Zeitoun D, Rangel A, et al. Preoperative evaluation of the cervical spondylotic myelopathy with flexion-extension magnetic resonance imaging: about a prospective study of fifty patients. Spine (Phila Pa 1976). 2011 Aug;36(17):E1134–9. PubMed #21785299.

    This study demonstrates that much more information can be obtained by imaging the neck in a range of positions (dynamic MRI), as opposed to just a neutral position. 50 patients on their way to neck surgery to help with spinal cord trouble were much more thoroughly scanned than they normally would have been. Cord impingement was spotted in just 17 patients in the neutral position, but thirty-seven in extension (and several in flexion as well). Cord inflammation was visible in just 13 patients in neutral position but twenty in a flexed position. The authors concluded that “Dynamic MRI is useful to determine more accurately the number of levels where the spinal cord is compromised.”

    BACK TO TEXT
  16. Herzog R, Elgort DR, Flanders AE, Moley PJ. Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. Spine J. 2016 Nov. PubMed #27867079.

    In this study, one patient with sciatica was sent for ten MRIs, which produced 49 distinct “findings,” 16 of them unique, none of which occurred in all ten reports. On average, each radiologist made about a dozen errors, seeing one or two things that weren’t there about missing about ten things that were. Yikes. Read a more detailed and informal description of this study.

    BACK TO TEXT
  17. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990 Feb;33(2):160–72. PubMed #2306288. BACK TO TEXT
  18. Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010 May;62(5):600–10. PubMed #20461783. BACK TO TEXT
  19. Wolfe F, Clauw DJ, Fitzcharles MA, et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol. 2011 Jun;38(6):1113–22. PubMed #21285161.

    The original ACR diagnostic criteria for fibromyalgia were published in 1990 (Wolfe) and the first major revision was published in 2010 (Wolfe), and this paper added the FMS symptom scale, “which measures what the authors call the overall ‘fibromyalgianess’ of a patient.”

    This paper is not directly useful to patients, but Neha Garg does a good job of explaining it: New and Modified Fibromyalgia Diagnostic Criteria. See also Wolfe’s 2015 paper, “Editorial: the status of fibromyalgia criteria”.

    BACK TO TEXT
  20. Cassisi G, Sarzi-Puttini P, Cazzola M. Chronic widespread pain and fibromyalgia: could there be some relationships with infections and vaccinations? Clin Exp Rheumatol. 2011;29(6 Suppl 69):S118–26. PubMed #22243559. BACK TO TEXT
  21. Bennett RM, De Garmo P, Clark SR. A Randomized, Prospective, 12 Month Study To Compare The Efficacy Of Guaifenesin Versus Placebo In The Management Of Fibromyalgia. Arthritis Rheum. 1996;39 (Supplement 9)(S212). PainSci #52913.

    Despite a high risk of bias in favour of this treatment, the authors concluded that “this study provides persuasive evidence that the improvement was not due to a disease specific effect of guaifenesin on the underlying pathophysiology of fibromyalgia.”

    BACK TO TEXT
  22. Simms RW, Roy SH, Hrovat M, et al. Lack of association between fibromyalgia syndrome and abnormalities in muscle energy metabolism. Arthritis Rheum. 1994 Jun;37(6):794–800. PubMed #8003050. “This study demonstrates that under the conditions studied, muscle energy metabolism in FMS is no different than that in sedentary controls. These findings do not support the hypothesis that detectable defects in muscle energy metabolism occur in FMS.” BACK TO TEXT
  23. Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC) medications for acute cough in children and adults in community settings. Cochrane Database Syst Rev. 2014 Nov;(11):CD001831. PubMed #25420096. “Three trials compared the expectorant guaifenesin with placebo; one indicated significant benefit, whereas the other two did not.” BACK TO TEXT
  24. Acupuncture has a good reputation it does not deserve. Although heavily researched, its support comes only from heavily biased junk science, while it fails all the good quality scientific tests. It does not work for pain or anything else and we shouldn’t be surprised: it’s based on mysticism and myths. It’s surprisingly modern rather than ancient and wise, for instance, and cannot actually be used for anesthesia. More study is not needed. For more information, see Does Acupuncture Work for Pain? A review of modern acupuncture evidence and myths, particularly with regards to treating low back pain and other common pain problems. BACK TO TEXT
  25. Rosa L, Rosa E, Sarner L, Barrett S. A close look at therapeutic touch. JAMA. 1998 Apr 1;279(13):1005–10. PubMed #9533499. PainSci #56856.

    This paper is an entertaining chapter in the history of the science of alternative medicine: a child’s science fair project published in the Journal of the American Medical Association, showing that “twenty-one experienced therapeutic touch practitioners were unable to detect the investigator's ‘energy field.’ Their failure to substantiate TT's most fundamental claim is unrefuted evidence that the claims of TT are groundless and that further professional use is unjustified.”

    Therapeutic touch practitioners could not demonstrate any ability to detect a person by feeling their aura, let alone manipulating it therapeutically. The test made them look ridiculous.

    BACK TO TEXT
  26. Rain C, Seguel W, Vergara L. Does exercise improve symptoms in fibromyalgia? Medwave. 2015 Dec;15 Suppl 3:e6335. PubMed #26730713. “We conclude that regular physical exercise probably reduces pain in patients with fibromyalgia.” BACK TO TEXT
  27. Fernandes G, Jennings F, Nery Cabral MV, Pirozzi Buosi AL, Natour J. Swimming Improves Pain and Functional Capacity of Patients With Fibromyalgia: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2016 Aug;97(8):1269–75. PubMed #26903145. “Swimming, like walking, is an effective method for reducing pain and improving both functional capacity and quality of life in patients with fibromyalgia.” BACK TO TEXT
  28. Bidonde J, Busch AJ, Webber SC, et al. Aquatic exercise training for fibromyalgia. Cochrane Database Syst Rev. 2014 Oct;(10):CD011336. PubMed #25350761. “Low to moderate quality evidence relative to control suggests that aquatic training is beneficial for improving wellness, symptoms, and fitness in adults with fibromyalgia.” BACK TO TEXT
  29. Busch AJ, Webber SC, Richards RS, et al. Resistance exercise training for fibromyalgia. Cochrane Database Syst Rev. 2013 Dec;(12):CD010884. PubMed #24362925. “The evidence (rated as low quality) suggested that moderate- and moderate- to high-intensity resistance training improves multidimensional function, pain, tenderness, and muscle strength in women with fibromyalgia.” BACK TO TEXT
  30. None of that evidence is actually strong. All of those papers have positive results based on low quality evidence, because most trials have major problems. Overall the evidence looks encouraging, but it’s far from proven. BACK TO TEXT
  31. Academy of Medical Royal Colleges. Exercise: The miracle cure and the role of the doctor in promoting it. AOMRC.org.uk. 2015 Feb. PainSci #53672.

    This is the primary authoritative source of the quote “exercise is the closest thing there is to a miracle cure.”

    BACK TO TEXT
  32. Geneen LJ, Moore RA, Clarke C, et al. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017 Jan;1:CD011279. PubMed #28087891.

    Chronic pain, exercise, and physical activity are all heavily studied, but the result of this massive review of reviews — pooling data from more than 37,000 participants — somehow amounts only to “it’s promising, but more study needed.” IT was based on hundreds of studies, but nearly all them underpowered and flawed. Garbage in, garbage out…on a huge scale! But where there’s smoke there’s probably at least a small fire: “The available evidence suggests physical activity and exercise is an intervention with few adverse events that may improve pain severity and physical function, and consequent quality of life.” But it’s far from the conclusion we’d like to see, even from underpowered studies. Obviously some kinds of pain probably respond better to exercise than others.

    Such as fibromyalgia? Hopefully!

    BACK TO TEXT
  33. Lima LV, Abner TS, Sluka KA. Does exercise increase or decrease pain? Central mechanisms underlying these two phenomena. J Physiol. 2017 Mar. PubMed #28369946. “Regular physical activity is recommended for treatment of chronic pain and its effectiveness has been established in clinical trials for people with a variety of pain conditions. However, exercise can also increase pain making participation in rehabilitation challenging for the person with pain.” BACK TO TEXT
  34. Staud R, Robinson ME, Weyl EE, Price DD. Pain variability in fibromyalgia is related to activity and rest: role of peripheral tissue impulse input. J Pain. 2010 Dec;11(12):1376–83. PubMed #20451465.

    Does activity help fibromyalgia or make it worse? Is rest necessary? Maybe a combination of both is the best answer? This is a study of the effects of alternating exercise with rest on 34 FM patients and 36 age-related healthy controls. Strenuous activity was reported as painful for most FM patients, but overall “clinical pain consistently decreased during the rest periods.” Their conclusions:

    Alternating strenuous exercise with brief rest periods not only decreased overall clinical pain of FM subjects but also their mechanical hyperalgesia. No prolonged worsening of overall FM pain and hyperalgesia occurred despite vigorous muscle activity. Our findings contribute further evidence that FM pain and hyperalgesia are at least partially maintained by muscle impulse input, and that some types of exercises may be beneficial for FM.

    BACK TO TEXT
  35. Nijs J, Kosek E, Van Oosterwijck J, Meeus M. Dysfunctional endogenous analgesia during exercise in patients with chronic pain: to exercise or not to exercise? Pain Physician. 2012 Jul;15(3 Suppl):ES205–13. PubMed #22786458.

    Exercise is great medicine for many chronic pain conditions, but there is an an important “but”: it’s unclear if it’s a bandaid or if it actually “has positive effects on the processes involved in chronic pain (e.g. central pain modulation).” This narrative review concludes that it’s complicated and it depends, and some patients definitely have a “dysfunctional response” to exercise, and thus “exercise therapy should be individually tailored with emphasis on prevention of symptom flares.”

    BACK TO TEXT
  36. Hooten WM, Qu W, Townsend CO, Judd JW. Effects of strength vs aerobic exercise on pain severity in adults with fibromyalgia: A randomized equivalence trial. Pain. 2012 Apr;153(4):915–23. PubMed #22341565.

    People with fibromyalgia, and many other forms of chronic pain, often benefit from exercise. But what works better: strength training or aerobics? In these fibromyalgia patients, both types of exercise were effective: “This study found that strength and aerobic exercise had equivalent effects on reducing pain severity among patients with fibromyalgia.”

    BACK TO TEXT
  37. Ellingson LD, Stegner AJ, Schwabacher IJ, Koltyn KF, Cook DB. Exercise Strengthens Central Nervous System Modulation of Pain in Fibromyalgia. Brain Sci. 2016 Feb;6(1). PubMed #26927193. PainSci #53576. “…exercise appeared to stimulate brain regions involved in descending pain inhibition in FM patients, decreasing their sensitivity to pain. Thus, exercise may benefit patients with FM via improving the functional capacity of the pain modulatory system.” BACK TO TEXT
  38. Hyland ME, Hinton C, Hill C, et al. Explaining unexplained pain to fibromyalgia patients: finding a narrative that is acceptable to patients and provides a rationale for evidence based interventions. Br J Pain. 2016 Aug;10(3):156–61. PubMed #27583142. PainSci #53579.

    In the case of FM, the aim of the ‘body reprogramming’ psychoeducational group programme is to empower patients to teach their bodies messages that can be learned only through experience. The two principal messages are as follows:

    1. The world they live in is a safe place – where actions never lead to stop signals and in particular the stop signal of danger (e.g. movement does not equate to danger). Interventions include relaxation (e.g. mindfulness) and slow graded exercise, but with an emphasis on combining physical movement with a positive mental state.
    2. The world they live in is a good place – where actions are rewarding as well as being health promoting. Interventions include strategies for reducing negative cognitions and promoting positive cognitions, with an emphasis on behaviour change so as to produce a more rewarding and health promoting lifestyle.

    The body ‘learns’ these therapeutic messages through a combination of physical exercise and psychological techniques that are individualised and consistent with evidence based techniques

    BACK TO TEXT
  39. Wang C, Schmid CH, Rones R, et al. A randomized trial of tai chi for fibromyalgia. N Engl J Med. 2010 Aug;363(8):743–54. PubMed #20818876.

    The study, funded by The National Center for Complementary and Alternative Medicine, shows that taiji has some beneficial effects for fibromyalgia patients. However, there’s nothing the least bit mystical about that, and it has no business being presented like a victory for “alternative” medicine. This is interesting in itself, but it is also the second embarrassing example of this in the New England Journal of Medicine (see Berman). See Dr. David Gorski’s detailed analysis: Tai chi and fibromyalgia in the New England Journal of Medicine.

    BACK TO TEXT
  40. For many people, the mysticism and ritual of exercise like taiji, yoga, and meditation is big a turn off, not a selling point. Read more about the tyranny of yoga & meditation. BACK TO TEXT
  41. About “tendinitis” versus “tendonitis”: Both spellings are considered acceptable these days, but the first is technically correct and more formal, while the second is an old misspelling that has only achieved respectability through popular use. The word is based on the the Latin “tendo” which has a genitive singular form of tendinis, and a combining form that is therefore tendin. (Source: Stedmans Electronic Medical Dictionary.) BACK TO TEXT
  42. Bäckryd 2017, op. cit. BACK TO TEXT
  43. Sutherland AM, Clarke HA, Katz J, Katznelson R. Hyperbaric Oxygen Therapy: A New Treatment for Chronic Pain? Pain Pract. 2016 06;16(5):620–8. PubMed #25988526. BACK TO TEXT
  44. Efrati S, Golan H, Bechor Y, et al. Hyperbaric oxygen therapy can diminish fibromyalgia syndrome--prospective clinical trial. PLoS One. 2015;10(5):e0127012. PubMed #26010952. PainSci #53581. BACK TO TEXT