Phys · rheumatological
Fibromyalgia and Chronic Widespread Pain
Also known as fibromyalgia · fibromyalgia syndrome · chronic widespread pain · central sensitisation syndrome · central pain amplification · fibrositis (obsolete)
Consultant-physician-depth guide to fibromyalgia and chronic widespread pain — central sensitisation pathophysiology (amplified CNS pain processing, deficient descending inhibition, the neurotransmitter profile), chronic widespread musculoskeletal pain with fatigue, sleep disturbance and cognitive dysfunction, the cluster of central sensitivity syndromes, the 2016 ACR diagnostic criteria (WPI and SSS, abolition of tender points), the distinction from inflammatory and endocrine mimics, the non-pharmacological-first management (exercise, CBT, sleep hygiene, pacing) with symptom-targeted pharmacotherapy (amitriptyline, duloxetine, pregabalin), the explicit avoidance of opioids and glucocorticoids, and the multidisciplinary approach — structured for FRACP DWE and DCE preparation.
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Red flags
- New focal neurological deficit, weight loss, night sweats or fever in a patient labelled with fibromyalgia — the diagnosis does not confer immunity to malignancy, infection or inflammatory disease; investigate the red flag
- A hot, swollen, single, disproportionately painful joint — always aspirate to exclude septic arthritis; fibromyalgia is widespread, not focal
- A markedly rising ESR or CRP in a patient with fibromyalgia — fibromyalgia has normal inflammatory markers; a rising marker means a new inflammatory, infective or malignant process
- Severe suicidal ideation driven by chronic pain and sleep deprivation — a psychiatric emergency requiring urgent mental health assessment, not a routine rheumatology referral
- Escalating opioid use with worsening pain — opioid-induced hyperalgesia; structured opioid deprescribing is urgent
Fibromyalgia and Chronic Widespread Pain
[1]The one-minute consultant answer
Fibromyalgia is a chronic central pain syndrome defined by widespread musculoskeletal pain lasting at least three months, accompanied by fatigue, non-restorative sleep disturbance, cognitive dysfunction (fibro fog) and somatic symptoms. The mechanism is central sensitisation — amplified processing of nociceptive input in the central nervous system, with deficient descending inhibition. It is NOT inflammatory, NOT autoimmune and NOT a disease of peripheral tissue damage [2]. The 2016 ACR revised criteria abolish the obsolete tender point examination and instead use the Widespread Pain Index (WPI) and the Symptom Severity Scale (SSS): WPI 7 or more with SSS 5 or more, OR WPI 4 to 6 with SSS 9 or more, with generalised pain (at least 4 of 5 body regions) for at least 3 months [1]. Normal inflammatory markers (CRP, ESR) with widespread pain is the single most important diagnostic clue. Management is non-pharmacological first — patient education and validation, graded aerobic exercise (the only EULAR strong-for recommendation), cognitive behavioural therapy, sleep hygiene and pacing [3][7] — with symptom-targeted pharmacotherapy (amitriptyline at night, duloxetine, pregabalin or gabapentin) as adjunct. Opioids, glucocorticoids and repeated invasive investigations are explicitly to be avoided.
References9ShowHide
- [1]Wolfe F, Clauw DJ, Fitzcharles MA, et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria Semin Arthritis Rheum, 2016.PMID 27916278
- [2]Clauw DJ Fibromyalgia: a clinical review JAMA, 2014.PMID 24737367
- [3]Macfarlane GJ, Kronisch C, Atzeni F, et al. EULAR revised recommendations for the management of fibromyalgia Ann Rheum Dis, 2017.PMID 27377815
- [4]Fitzcharles MA, Ste-Marie PA, Pereira JX, et al. 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary Pain Res Manag, 2013.PMID 23748251
- [5]Crofford LJ, Rowbotham MC, Mease PJ, et al. Pregabalin for the treatment of fibromyalgia syndrome: results of a randomized, double-blind, placebo-controlled trial Arthritis Rheum, 2005.PMID 15818684
- [6]Arnold LM, Rosen A, Pritchett YL, et al. A randomized, double-blind, placebo-controlled trial of duloxetine in the treatment of women with fibromyalgia with or without major depressive disorder Pain, 2005.PMID 16298061
- [7]Häuser W, Klose P, Langhorst J, et al. Efficacy of different types of aerobic exercise in fibromyalgia syndrome: a systematic review and meta-analysis of randomised controlled trials Arthritis Res Ther, 2010.PMID 20459730
- [8]Busch AJ, Barber KAR, Overend TJ, Peloso PMJ, Schachter CL Exercise for treating fibromyalgia syndrome Cochrane Database Syst Rev, 2007.PMID 17943797
- [9]Bennett RM, Friend R, Jones KD, Ward R, Han BK, Ross RL The Revised Fibromyalgia Impact Questionnaire (FIQR): validation and psychometric properties Arthritis Res Ther, 2009.PMID 19664287