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  • Fibromyalgia syndrome (FM, FMS)
  • Chronic fatigue syndrome

  • 729.1 Myalgia and myositis unspecified

  • M79.7 Fibromyalgia


  • Widespread musculoskeletal pain and fatigue for at least three months
  • Commonly involves mood disturbances
  • Preliminary new criteria from American College of Rheumatology in 2010 include Widespread Pain Index and Symptom Severity Score instead of tender points
  • Current criteria: tender points in at least 11 of 18 areas
    • Arms, chest, buttocks, knees, low back, neck, rib cage, thighs, shoulders

Essentials of Diagnosis

  • Diagnosis based primarily on symptoms of widespread pain
  • Fatigue, typically begins on rising from sleep
  • Morning stiffness, typically lasting all day, does not diminish with activity
  • Controversy over diagnosing as psychosomatic disorder
  • Tenderness with palpation in at least 11 of 18 areas throughout the body

General Considerations


  • 75 to 90% of cases in females
  • Female-to-male ratio 9:1
  • Affects 2 to 4% of general population
  • Most people develop symptoms between ages 20 to 55 years

Signs and Symptoms

  • Widespread pain and fatigue
  • Headaches
  • Tenderness in multiple specific anatomic locations
  • Mood disturbances, depression, anxiety
  • Muscle pain
  • Cognitive dysfunction
  • Irritable bowel
  • Morning stiffness
  • Sleep disturbances with constant interruptions of sleep
  • Muscle spasm
  • Nerve pain
  • Sympathetic hyperactivity
  • Associated symptoms may include paresthesias, burning, tingling

Functional Implications

  • Pain and stiffness may limit daily activities
  • Difficulty concentrating and performing tasks

Possible Contributing Causes

  • Cold or humid weather
  • Non-restorative sleep
  • Stress
  • Anxiety
  • Physical or mental fatigue/trauma
  • Myofascial pain
  • Rheumatoid arthritis

Differential Diagnosis

  • Chronic fatigue syndrome
  • Hypothyroidism
  • Lyme disease
  • Systemic lupus erythematosus
  • Rheumatoid arthritis
  • Polymyalgia rheumatica
  • Sleep disorders
  • Depression
  • Chronic neck and back pain

Laboratory Tests

  • CBC, ESR, C-reactive protein, rheumatoid factor, thyroid profile to look for negative results


Diagnostic Procedures

  • Widespread Pain Index (WPI)
  • Symptom Severity Score

  • X-ray negative
  • MRI negative
  • Negative laboratory tests, such as CBC, ESR, C-reactive protein, rheumatoid factor, thyroid profile


  • Analgesics (Tylenol, Ultram)
  • Low-dose anti-depressants (tricyclics, SSRI’s, SNRI’s)
  • Pregabalin, duloxetine, milnacipran

  • To other therapist for gentle osteopathic manipulative treatment
  • To dietician for nutritional counseling
  • To pain clinic for pain management
  • To psychologist for cognitive-behavioral therapy, psychological support
    • Counseling
    • Support groups
    • Biofeedback
    • Relaxation techniques

  • Limited walking and ...

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