What is fibromyalgia and why is it (still) controversial?


In 1987, DL Goldenberg published a paper in JAMA, “Fibromyalgia syndrome. An emerging but controversial condition.” [JAMA. 1987 May 22-29;257(20):2782-7.] Nearly three dozen years later, fibromyalgia has fully emerged, but is no less controversial.  


In general, a diagnosis may be controversial because there is disagreement about what causes it, how to diagnose it, or how to treat it. In the case of fibromyalgia, all three apply, but there is the added controversy: Is it real?


Regarding fibromyalgia, here are the basics:

  • The American College of Rheumatology (as of 2020) says fibromyalgia is “a common neurologic health problem” featuring widespread pain and tenderness that appears in different places and at different times.
  • Fatigue and disorders of sleep are common.
  • Fibromyalgia is thought to be found in about 2% of adults, females more than males.
  • There is no objective examination, such as a radiograph or a laboratory test, to diagnose fibromyalgia.
  • There is no cure. Treatment is supportive. The U.S. Food and Drug Administration has approved three drugs for the treatment of fibromyalgia: duloxetine (Cymbalta), milnacipran (Savella), and pregabalin (Lyrica).


Elements of controversy:

  1. Fibromyalgia cannot be established objectively: musculoskeletal fields rely heavily on objective evidence such as radiographs and laboratory tests. Accordingly, the lack of such evidence casts doubt on the validity of the diagnosis (especially to many musculoskeletal practitioners).
  2. Treating patients with fibromyalgia is challenging: physicians may become easily frustrated by the difficulty of treatment (as can patients too, of course!). As a defense mechanism, the physician may question the validity of the complaints.
  3. The underlying pathophysiology of fibromyalgia remains largely unclear: The most widely supported mechanism is a concept known as “central sensitization,” when central nervous system (CNS) pain processing becomes dysfunctional and leads to increased sensitivity to pain. This is supported by some, but not all, studies of cerebrospinal fluid (CSF) and functional magnetic resonance imaging (fMRI).
  4. In the recent past, the American College of Rheumatology diagnostic criteria included “trigger points” and tenderness in specific locations. The locations of these points were easily found on the internet, and thus thought to aid malingering.
  5. Many of the presenting symptoms are suggestive of psychological overlay, including:
  • Ubiquitous pain, “It hurts all over” with a lack of signs such as swelling, warmth, or erythema,
  • Hyperalgesia: abnormally low pain threshold, 
  • Allodynia: patients may experience pain with tactile stimuli that would normally not be painful, such as brushing the skin,
  • Sensory hypersensitivity: may describe excess sensitivity to bright light, loud noise, and odors,
  • Sleep disorders: subjective poor sleep quality and fatigue, 
  • Overt psychiatric disease: Depression is a common comorbid diagnosis and may increase suspicion for fibromyalgia.

 

(See Fibromyalgia is Real Clin Orthop Relat Res. 2016 Feb; 474(2): 304–309. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4709307/