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Fibromyalgia

Fibromyalgia as a perioperative risk modifier (corpus-synthesised).

Overview

Fibromyalgia represents a condition characterized by severe symptoms in individuals meeting criteria-based definitions, arising from a general dysregulation of the central nervous system [1]. At least some symptoms are associated with brain dysfunctions or alterations [4], while the apparent paradox of fewer myoelectrical manifestations of fatigue serves as the electrophysiological expression of muscle remodelling [10]. This remodelling involves a prevalence of slow conducting fatigue-resistant type I fibres [10].

Epidemiological data indicate a prevalence of 1.6% in the French population [3] and 4.4% in low socioeconomic status populations assisted by the public primary health care system [8]. Despite the severity of symptoms, most (73%) persons identified with criteria-based fibromyalgia have not received a clinical diagnosis [2]. Persons with the condition are more likely to report hearing loss [1], and the prevalence of post-COVID-19 in these patients is similar to that in patients with other rheumatic diseases [5].

Diagnostic evaluation relies on multidimensional assessments that demonstrate comprehensiveness and validity [19], with various tools showing significant correlations with the Fibromyalgia Impact Questionnaire [19]. Emerging research suggests the gut microbiota may play a role within the gut-musculoskeletal axis, though a paucity of quality research currently exists regarding this association [7].

Background & Causes

Fibromyalgia is a syndrome characterized by chronic widespread pain, hyperalgesia, and allodynia [15], alongside symptoms such as fatigue, sleep disturbance, and impaired cognition [15]. Persons identified with criteria-based fibromyalgia present with severe symptoms [2], yet 73% of these individuals have not received a clinical diagnosis [2]. The condition affects 1.6% of the French population [3] and may represent a sympathetically maintained pain syndrome [6].

The pathophysiology involves a general dysregulation of the central nervous system [1], with at least some symptoms associated with brain dysfunctions or alterations [4]. Some patients with severe fibromyalgia may exhibit a dorsal root ganglia sodium channelopathy [14]. Electrophysiologically, the apparent paradox of fewer myoelectrical manifestations of fatigue reflects muscle remodelling characterized by a prevalence of slow conducting, fatigue-resistant type I fibres [10]. Additionally, both cardiac output and arteriovenous oxygen difference contribute to lower peak oxygen uptake in these patients [22].

Psychological and environmental factors significantly modulate the clinical presentation. Repeated cognitive stress increases pain intensity [17], while patients show elevated muscle activity, particularly in the trapezius, during imposed stress, sympathetic activation, and putative anticipatory stress [21]. The stage of chronicity acts as an important moderator of psychological vulnerability for fibromyalgia impact [30], and studies have assessed the importance of pain-related psychological constructs on function and pain over a one-year follow-up [9]. Higher physical fitness is consistently associated with lower fibromyalgia severity in women [29].

Emerging research explores other systemic axes. The prevalence of post-COVID-19 in fibromyalgia patients is similar to that in patients with other rheumatic diseases [5]. Indications exist that the gut microbiota may play a role in fibromyalgia within the emerging field of the gut-musculoskeletal axis [7], though there is a paucity of quality research regarding the gut microbiome and its biomarkers in this condition [7].

Symptoms & Presentation

Fibromyalgia is a common syndrome characterized by chronic widespread pain, hyperalgesia, and allodynia [15], with a prevalence of 1.6% in the French population [3] and 4.4% in low socioeconomic status populations assisted by public primary health care systems [8]. Despite severe symptoms, most patients (73%) have not received a clinical diagnosis [2]. The condition presents with fatigue, sleep disturbance, and impaired cognition [15], where the majority of individuals describe fatigue as more severe than normal tiredness [18]. Persons with fibromyalgia or other musculoskeletal pain are also more likely to report hearing loss [1].

Current evidence supports the view that at least some symptoms are associated with brain dysfunctions or alterations [4], and the condition may be a sympathetically maintained pain syndrome [6]. The apparent paradox of fewer myoelectrical manifestations of fatigue is the electrophysiological expression of muscle remodelling in terms of the prevalence of slow conducting fatigue-resistant type I fibres [10]. Some patients with severe fibromyalgia may have a dorsal root ganglia sodium channelopathy [14]. Pain-related psychological constructs correlate with and predict function and pain in patients with fibromyalgia over a one-year follow-up [9].

The prevalence of post-COVID-19 in fibromyalgia patients is similar to that in patients with other rheumatic diseases [5]. A multidimensional assessment for patients with fibromyalgia demonstrates significant correlations between various assessment tools and the Fibromyalgia Impact Questionnaire [19]. Trazodone significantly improved fibromyalgia severity and associated symptomatology [13]. Issues identified for further research include the prescribing habits of fibromyalgia health care providers, the role of emotional precipitants, the impact of obesity, the significance of low back pain, and the nature of fibromyalgia-related stiffness [28].

Management

Fibromyalgia is a common condition with a prevalence of 1.6% in the French population [3] and 4.4% in low socioeconomic status populations assisted by the public primary health care system [8]. Despite severe symptoms, 73% of persons identified with criteria-based fibromyalgia have not received a clinical diagnosis [2]. The prevalence of post-COVID-19 in fibromyalgia patients is similar to that in patients with other rheumatic diseases [5]. Current evidence supports the view that at least some fibromyalgia symptoms are associated with brain dysfunctions or alterations [4], consistent with the hypothesis that fibromyalgia is related to a general dysregulation of the central nervous system [1]. This finding supports the hypothesis that fibromyalgia may be a sympathetically maintained pain syndrome [6].

Pathophysiology and Triggers: Repeated cognitive stress increases pain intensity in fibromyalgia patients [17], while daytime napping is associated with increased symptom severity [11]. Emerging research indicates a paucity of quality studies, though the gut microbiota may play a role in fibromyalgia within the gut-musculoskeletal axis [7].

Pharmacologic and Non-Pharmacologic Interventions: Trazodone significantly improved fibromyalgia severity and associated symptomatology [13], with utility surpassing its hypnotic activity in doses higher than those usually prescribed as hypnotic [20]. Traditional Chinese Exercise exhibits significant efficacy in ameliorating pain, enhancing sleep quality, and alleviating symptoms of anxiety and depression [24]. For exercise prescription in sedentary women with fibromyalgia syndrome, 52% to 60% HRR or 75% to 80% HRMax must be used at threshold intensity [23]. An intervention based on pain neuroscience education and exercise is feasible and seems effective in primary care [26].

Self-Management and Coaching: Such improvements do not typically occur spontaneously, suggesting that health and wellness coaching deserves further consideration as an intervention [25]. It is feasible to recruit people with fibromyalgia from Primary Care to participate in a randomised controlled trial testing the Fibromyalgia Self-management Programme in a community setting [12]. However, the self-management programme had no effect on psychological distress, functional and symptomatic consequences and self-efficacy, except for a small short-term effect on skills and behaviour that are important for managing and participating in health care [16]. High-quality scientific works are required to highlight physiotherapy as one of the most recommended treatment options for fibromyalgia [27].

Key Considerations

Fibromyalgia represents a central nervous system dysregulation characterized by severe symptoms in criteria-based cases, with at least some manifestations linked to identifiable brain dysfunctions or alterations [1][4]. Despite this severity, the majority of affected individuals (73%) remain undiagnosed clinically [2]. The condition is more prevalent in women, being uncommon in men, yet men with the syndrome experience worse health outcomes than women [31]. Prevalence rates vary by population, estimated at 1.6% in the general French population and rising to 4.4% within low socioeconomic status groups assisted by public primary care [3][8].

Comorbidities and Associations: Patients frequently report hearing loss and severe fatigue described as exceeding normal tiredness [1][18]. The syndrome may function as a sympathetically maintained pain syndrome, and post-COVID-19 prevalence mirrors that of other rheumatic diseases [5][6]. Emerging research suggests a potential role for gut microbiota within the gut-musculoskeletal axis, though quality evidence regarding this association remains scarce [7].

Management and Prognosis: Daytime napping correlates with increased symptom severity [11]. While recruiting from primary care for community-based self-management trials is feasible [12], a one-week multidisciplinary inpatient programme demonstrated no effect on psychological distress, functional consequences, or self-efficacy, though it yielded small short-term improvements in skills and healthcare participation behaviors [16]. Long-term assessments of pain-related psychological constructs on function and pain over one year have also been conducted [9].

Key Evidence

  • [L3] Our findings are consistent with the hypothesis that fibromyalgia is related to a general dysregulation of the central nervous system. (10.1186/s12891-016-1331-1)
  • [L3] Persons identified with criteria-based fibromyalgia have severe symptoms, but most (73%) have not received a clinical diagnosis of fibromyalgia. (10.1371/journal.pone.0138024)
  • [L4] Fibromyalgia is a common condition with a prevalence of 1.6% in the French population, corroborating figures published in the European literature. (10.1186/1471-2474-12-224)
  • [L5] Current evidence supports the view that at least some fibromyalgia symptoms are associated with brain dysfunctions or alterations, giving the long-held 'it is all in your head' view of the disorder a new meaning. (10.1155/2012/585419)
  • [L3] The prevalence of post-COVID-19 in fibromyalgia patients is similar to that in patients with other rheumatic diseases. (10.1186/s12891-022-05436-0)
  • [L2] This finding supports the hypothesis that fibromyalgia may be a sympathetically maintained pain syndrome. (10.1186/1471-2474-3-2)
  • [L1] The results suggest there is a paucity of quality research in this area, with indications that the gut microbiota may play a role in fibromyalgia within the emerging field of the gut-musculoskeletal axis. (10.1186/s12891-020-03201-9)
  • [L4] Fibromyalgia is prevalent in the low socioeconomic status population assisted by the public primary health care system with a prevalence of 4.4%. (10.1186/1471-2474-10-64)
  • [L3] The study aims to assess the importance of pain-related psychological constructs on function and pain in patients with fibromyalgia, specifically evaluating correlations and predictive validity over a one-year follow-up. (10.1186/1471-2474-12-4)
  • [L3] The apparent paradox of fewer myoelectrical manifestations of fatigue in fibromyalgia is the electrophysiological expression of muscle remodelling in terms of the prevalence of slow conducting fatigue-resistant type I fibres. (10.1186/1471-2474-10-78)
  • [L4] Given the common use of daytime napping in people with fibromyalgia evidence based guidelines on the use of daytime napping in people with chronic pain are urgently needed. (10.1186/s12891-015-0464-y)
  • [L2] It is feasible to recruit people with fibromyalgia from Primary Care to participate in a randomised controlled trial testing the FSMP in a community setting. (10.1186/s12891-022-05529-w)
  • [L4] Trazodone significantly improved fibromyalgia severity and associated symptomatology. (10.1186/1471-2474-12-95)
  • [L3] These preliminary results raise the possibility that some patients with severe fibromyalgia may have a dorsal root ganglia sodium channelopathy. (10.1186/1471-2474-13-23)
  • [L5] Fibromyalgia is a syndrome characterized by chronic widespread pain, hyperalgesia, and allodynia, along with symptoms such as fatigue, sleep disturbance, and impaired cognition. (10.1016/b978-0-7020-4086-3.00033-3)
  • [L1] The study shows that in patients with fibromyalgia the self-management programme had no effect on psychological distress, functional and symptomatic consequences and self-efficacy, except for a small short-term effect on skills and behaviour that are important for managing and participating in health care. (10.1186/1471-2474-13-189)
  • [L3] Repeated cognitive stress increases pain intensity in fibromyalgia patients. (10.1186/s12891-021-04013-1)
  • [L4] The majority of individuals with FM who participated in this study experience fatigue and describe it as more severe than normal tiredness. (10.1186/1471-2474-11-216)
  • [L3] The study demonstrates the comprehensiveness and validity of a multidimensional assessment for patients with fibromyalgia, showing significant correlations between various assessment tools and the Fibromyalgia Impact Questionnaire. (10.1186/s12891-025-09270-y)
  • [L4] In doses higher than those usually prescribed as hypnotic, the utility of trazodone in fibromyalgia management surpasses its hypnotic activity. (10.1186/1471-2474-11-204)
  • [L3] FM patients show elevated muscle activity (in particular trapezius activity) in situations with imposed stress, including sympathetic activation, and putative anticipatory stress. (10.1186/1471-2474-14-97)
  • [L3] Both cardiac output and arteriovenous oxygen difference contribute to lower peak oxygen uptake in fibromyalgia patients. (10.1186/s12891-023-06589-2)
  • [L2] For the prescription of exercises in the threshold intensity, 52% to 60% HRR or 75% to 80% HRMax must be used in sedentary women with fibromyalgia syndrome. (10.1186/1471-2474-11-54)
  • [L1] Traditional Chinese Exercise (TCE) exhibits significant efficacy in ameliorating pain, enhancing sleep quality, and alleviating symptoms of anxiety and depression in fibromyalgia patients. (10.1186/s12891-024-07194-7)
  • [L4] Such improvements do not typically occur spontaneously in FM patients, suggesting that HWC deserves further consideration as an intervention for FM. (10.1186/s12891-016-1316-0)
  • [L3] An intervention based on PNE and exercise in patients with FM is feasible and seems effective in PC. (10.1186/s12891-022-05284-y)
  • [L2] High-quality scientific works are required to highlight physiotherapy as one of the most recommended treatment options for this syndrome. (10.1186/s12891-016-1364-5)
  • [L4] This descriptive data has a heuristic function, in that it identifies several issues for further research, such as the prescribing habits of FM health care providers, the role of emotional precipitants, the impact of obesity, the significance of low back pain and the nature of FM related stiffness. (10.1186/1471-2474-8-27)
  • [L4] Our results suggest that higher physical fitness is consistently associated with lower FM severity in women with FM. (10.1016/j.apmr.2015.03.015)
  • [L4] These findings provide preliminary evidence that stage of chronicity is an important moderator of psychological vulnerability for FM impact and should be taken into account by tailoring psychological interventions. (10.1186/1471-2474-11-251)
  • [L3] Although FMS was uncommon in men, health outcomes were worse than in women in our study population. (10.1053/sarh.2000.8363)

References

[1] Are persons with fibromyalgia or other musculoskeletal pain more likely to report hearing loss? A HUNT study. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1331-1

[2] The Prevalence and Characteristics of Fibromyalgia in the 2012 National Health Interview Survey. PLOS ONE. 2015. DOI: 10.1371/journal.pone.0138024

[3] Prevalence of fibromyalgia in France: a multi-step study research combining national screening and clinical confirmation: The DEFI study (Determination of Epidemiology of FIbromyalgia). BMC Musculoskeletal Disorders. 2011. DOI: 10.1186/1471-2474-12-224

[4] Neurobiology Underlying Fibromyalgia Symptoms. Pain Research and Treatment. 2012. DOI: 10.1155/2012/585419

[5] Prevalence of post-COVID-19 in patients with fibromyalgia: a comparative study with other inflammatory and autoimmune rheumatic diseases. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05436-0

[6] Norepinephrine-evoked pain in fibromyalgia. A randomized pilot study ISCRTN70707830. BMC Musculoskeletal Disorders. 2002. DOI: 10.1186/1471-2474-3-2

[7] Determining the association between fibromyalgia, the gut microbiome and its biomarkers: A systematic review. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03201-9

[8] Prevalence of fibromyalgia in a low socioeconomic status population. BMC Musculoskeletal Disorders. 2009. DOI: 10.1186/1471-2474-10-64

[9] Correlational analysis and predictive validity of psychological constructs related with pain in fibromyalgia. BMC Musculoskeletal Disorders. 2011. DOI: 10.1186/1471-2474-12-4

[10] Central motor control failure in fibromyalgia: a surface electromyography study. BMC Musculoskeletal Disorders. 2009. DOI: 10.1186/1471-2474-10-78

[11] Daytime napping associated with increased symptom severity in fibromyalgia syndrome. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0464-y

[12] A feasibility randomised controlled trial of a Fibromyalgia Self-management Programme for adults in a community setting with a nested qualitative study (FALCON). BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05529-w

[13] Trazodone plus pregabalin combination in the treatment of fibromyalgia: a two-phase, 24-week, open-label uncontrolled study. BMC Musculoskeletal Disorders. 2011. DOI: 10.1186/1471-2474-12-95

[14] A SCN9A gene-encoded dorsal root ganglia sodium channel polymorphism associated with severe fibromyalgia. BMC Musculoskeletal Disorders. 2012. DOI: 10.1186/1471-2474-13-23

[15] Fibromyalgia. Handbook of Clinical Neurology. 2014. DOI: 10.1016/b978-0-7020-4086-3.00033-3

[16] Effects of a one week multidisciplinary inpatient self-management programme for patients with fibromyalgia: a randomised controlled trial. BMC Musculoskeletal Disorders. 2012. DOI: 10.1186/1471-2474-13-189

[17] Muscle activity and acute stress in fibromyalgia. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04013-1

[18] Fatigue in fibromyalgia: a conceptual model informed by patient interviews. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-216

[19] Comprehensiveness and validity of a multidimensional assessment of patients with fibromyalgia: a prospective cohort study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09270-y

[20] Trazodone for the treatment of fibromyalgia: an open-label, 12-week study. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-204

[21] Trapezius activity of fibromyalgia patients is enhanced in stressful situations, but is similar to healthy controls in a quiet naturalistic setting: a case-control study. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-97

[22] Cardiac output and arteriovenous oxygen difference contribute to lower peak oxygen uptake in patients with fibromyalgia. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06589-2

[23] Intensity level for exercise training in fibromyalgia by using mathematical models. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-54

[24] Effects of traditional Chinese exercise therapy on pain scores, sleep quality, and anxiety-depression symptoms in fibromyalgia patients: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07194-7

[25] A pilot study of health and wellness coaching for fibromyalgia. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1316-0

[26] Effectiveness of a group intervention using pain neuroscience education and exercise in women with fibromyalgia: a pragmatic controlled study in primary care. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05284-y

[27] Effectiveness of Aquatic Therapy vs Land-based Therapy for Balance and Pain in Women with Fibromyalgia: a study protocol for a randomised controlled trial. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-016-1364-5

[28] An internet survey of 2,596 people with fibromyalgia. BMC Musculoskeletal Disorders. 2007. DOI: 10.1186/1471-2474-8-27

[29] Association of Physical Fitness With Fibromyalgia Severity in Women: The al-Ándalus Project. Archives of Physical Medicine and Rehabilitation. 2015. DOI: 10.1016/j.apmr.2015.03.015

[30] Stages of chronicity in fibromyalgia and pain catastrophising: a cross-sectional study. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-251

[31] Fibromyalgia syndrome in men. Seminars in Arthritis and Rheumatism. 2000. DOI: 10.1053/sarh.2000.8363

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a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

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