Misplaced Pages

Fibromyalgia

Article snapshot taken from Wikipedia with creative commons attribution-sharealike license. Give it a read and then ask your questions in the chat. We can research this topic together.

This is an old revision of this page, as edited by 76.202.6.243 (talk) at 17:25, 10 July 2009. The present address (URL) is a permanent link to this revision, which may differ significantly from the current revision.

Revision as of 17:25, 10 July 2009 by 76.202.6.243 (talk)(diff) ← Previous revision | Latest revision (diff) | Newer revision → (diff) Medical condition
Fibromyalgia

Fibromyalgia (new lat., fibro-, fibrous tissue, Gk. myo-, muscle, Gk. algos-, pain), meaning muscle and connective tissue pain (also referred to as FM or FMS), is a [[medically Some health care providers continue to dispute the validity or efficacy of the diagnosis. See the "Controversies" section.

Signs and symptoms

The defining symptoms of fibromyalgia are chronic, widespread pain, fatigue, and heightened pain in response to pressure (allodynia). Other symptoms may include tingling of the skin, prolonged muscle spasms, weakness in the limbs, nerve pain, functional bowel disturbances, and chronic sleep disturbances.

Many patients experience cognitive dysfunction (known as "brain fog" or "fibrofog"), which may be characterized by impaired concentration, problems with shortCite error: A <ref> tag is missing the closing </ref> (see the help page). reported that the most frequently cited factors perceived to worsen fibromyalgia symptoms were emotional distress (83%), weather changes (80%), sleeping problems (79%), strenuous activity (70%), =21 |issue=4 |pages=207 |year=1992 |pmid=1529291 |doi=10.3109/03009749209099225}}</ref> The mode of inheritance is currently unknown, but it is most probably polygenic. Research has demonstrated that fibromyalgia is associated with polymorphisms of genes in the serotoninergic, dopaminergic) and with depression.

Stress

Stress may be an important precipitating factor in the development of fibromyalgia. Two studies that employed single-voxel magnetic resonance spectroscopy (1H-MRS) reported metabolic abnormalities within the hippocampal complex in patients with fibromyalgia, with significant correlations between hippocampal metabolic abnormalities and severity of clinical symptoms. This proposition is supported in part by a prospective epidemiology study which found that variations in HPA function characterized by high levels of circulating cortisol following dexamethasone suppression testing, low levels of morning salivary cortisol and high levels of evening salivary cortisol are all associated with the development of chronic widespread pain.Cite error: A <ref> tag is missing the closing </ref> (see the help page). which is a condition found |journal=Arthritis Rheum. |volume=52 |issue=8 |pages=2495–505 |year=2005 |month=August |pmid=16052595 |doi=10.1002/art.21191 |accessdate=2008-05-21}}</ref>

Abnormal serotonin metabolism

In 1975, researchers hypothesized that serotonin, a neurotransmitter that regulates sleep patterns, mood, concentration and pain, could be involved in the pathophysiology of fibromyalgia-associated symptoms. In 1992, decreased serotonin metabolites in patient blood samples and cerebrospinal fluid were reported. Duloxetine (Cymbalta), a SNRI originally used to treat depression and painful diabetic neuropathy, has been demonstrated by controlled trials to relieve symptoms of some patients. However, the relevance of dysregulated serotonin metabolism to pathophysiology is a matter of debate. Complicating the analysis, one of the more effective types of medication for the treatment of the disorder (i.e. serotonin 5-HT3 antagonists) actually blocks some of the effects of serotonin.Cite error: A <ref> tag is missing the closing </ref> (see the help page). There is disagreement about the role of HGH in fibromyalgia. Indeed, the sensation of pain has at least two dimensions: a sensory dimension which processes the magnitude of the brain that participate in affective pain processing, but not in areas involved in sensory processing which indicate that the amplification of the sensory dimension of pain in fibromyalgia occurs independently of mood or emotional processes.

An alternative hypothesis regarding the development of fibromyalgia in relationship to psychological conflict proposes that the disorder may be a psychosomatic illness as described by John E. Sarno's writing related to "tension myositis syndrome," in which chronic pain is proposed to be a psychic diathesis of the mind's subconscious strategy of distracting painful or dangerous emotions. Education, attitude change, and in some cases, psychotherapy are proposed as treatments.

Malingering

Because there is not currently an objective clinical test for Fibromyalgia, it continues to be a significant target for malingering, which is a type of fraud wherein a patient feigns having an illness or exaggerates symptoms for non-medical personal gain (often financial), including obtaining access to prescription drugs for recreational use or for illegal resale.

A 2007 review observes that 25-30% of supposed fibromyalgia cases are due to malingering

See also the section on " The first objective findings associated with the disorder were reported in 1975 by Moldofsky and colleagues, who reported the presence of anomalous alpha wave activity (typically associated with arousal states) on sleep electroencephalogram (EEG) during non-rapid-eye-movement sleep. By disrupting stage IV sleep consistently in young, healthy subjects, the researchers reproduced a significant increase in muscle tenderness similar to that experienced in fibromyalgia but which resolved when the subjects were able to resume their normal sleep patterns.Cite error: A <ref> tag is missing the closing </ref> (see the help page). Together these results point to dysregulation of the nociceptive system at the central level.

Neuroendocrine disruption

Patients with fibromyalgia have been demonstrated to have a disruption of normal neuroendocrine function, characterized by mild hypocortisolemia, hyperreactivity of pituitary adrenocorticotropin hormone release in response to challenge, and glucocorticoid feedback resistance. A progressive reduction of serum growth hormone levels has also been documented—at baseline in a minority of patients, while most demonstrate reduced secretion in response to exercise or pharmacological challenge. Other abnormalities hormones.

Sympathetic hyperactivity

Functional analysis of the autonomic system in patients with fibromyalgia has demonstrated disturbed activity characterized by hyperactivity of the sympathetic nervous system at baseline with reduced sympathoadrenal reactivity in response to a variety of stressors including physical exertion and mental stress.Cite error: A <ref> tag is missing the closing </ref> (see the help page). In addition, plasma levels of neuropeptide Y, which is co-localized with norepinephrine in the sympathetic nervous system, have been reported as low in patients with fibromyalgia, while circulating levels of epinephrine and norepinephrine have been variously reported as low, normal and high.Cite error: A <ref> tag is missing the closing </ref> (see the help page). The mean concentration of nerve growth factor, a substance known to participate in structural and functional plasticity of nociceptive pathways within the dorsal root ganglia and spinal cord, is elevated. There is also evidence for increased excitatory amino acid release within cerebrospinal fluid, with a correlation demonstrated between levels for metabolites of glutamate and nitric oxide and clinical indices of pain.

Brain imaging studies

Evidence of abnormal brain involvement in fibromyalgia has been provided via functional neuroimaging. The first findings reported were decreased blood flow within the thalamus and elements of the basal ganglia and mid-brain (i.e., pontine nucleus). Differential activation in response to painful stimulation has also been demonstrated. A significant negative correlation was demonstrated between abnormal metabolite ratios and a validated index of the clinical severity (i.e. the Fibromyalgia Impact Questionnaire). Correlations between clinical pain severity and concentrations of the excitatory amino acid neurotransmitter glutamate within the insular cortex have also been demonstrated using 1H-MRS. An acceleration of normal age-related brain atrophy has been demonstrated using voxel-based morphometry (VBM) with areas of reduced gray matter located in the cingulate cortex, insula and parahippocampal gyrus. Studies utilizing positron emission tomography have demonstrated reduced dopamine synthesis in the brainstem and elements of the limbic cortex. A significant negative correlation between pain severity and dopamine synthesis was demonstrated within the insular cortex. A subsequent study demonstrated gross disruption of dopaminergic reactivity in response to a tonic pain stimulus within the basal ganglia with a significant positive correlation between the defining feature of the waist.

  • Tender points—there are 18 designated possible tender or trigger points (although a person with the disorder may feel pain in other areas as well). During diagnosis, four kilograms-force (39 newtons) of force is exerted at each of the 18 points; the patient must feel pain at 11 or more of these points for fibromyalgia to be considered. Four kilograms of force is about the amount of pressure required to blanch the thumbnail when applying pressure.

This set of criteria was developed by the American College of Rheumatology as a means of classifying an individual as having fibromyalgia for both clinical and research purposes. While these criteria for classification of patients were originally established as inclusion criteria for research purposes and were not intended for clinical diagnosis, they have become the de facto diagnostic criteria in the clinical setting. It should be noted that the number of tender points that may be active at any one time may vary with time and circumstance.

Treatment

As with many other medically unexplained syndromes, there is no known cure or universally accepted treatment for fibromyalgia, and treatment is typically aimed at symptom management. Developments in the understanding of the pathophysiology of the disorder have led to improvements in treatment, which include prescription medication, behavioral intervention, exercise, and alternative and complementary medicine. Indeed, integrated treatment plans that incorporate medication, patient education, aerobic exercise and cognitive-behavioral therapy have been shown to be effective in alleviating pain and other fibromyalgia-related symptoms. In 2005, the American Pain Society produced the first comprehensive guidelines for patient evaluation and management.Cite error: A <ref> tag is missing the closing </ref> (see the help page).

Antidepressants

A 2009 meta analysis in the Journal of the American Medical Association reported that some antidepressants were effective, for the treatment of fibromyalgia syndrome: results of a randomized, double-blind, placebo-controlled trial |journal=Arthritis Rheum. |volume=52 |issue=4 |pages=1264–73 |year=2005 |pmid=15818684 |doi=10.1002/art.20983}}</ref> A Cochrane Database analysis of pregabalin use in chronic pain concluded that “A minority of patients will have substantial benefit with pregabalin, and more will have moderate benefit. Many will have no or trivial benefit, or will discontinue because of adverse events.”

Dopamine agonists

Dopamine agonists (e.g. pramipexole (Mirapex) and ropinirole (ReQuip) resulted in some improvement in a minority of patients, but numerous side effects, including the onset of impulse control disorders like compulsive gambling and shopping, have led to concern about this approach. A trial of transdermal rotigotine is currently ongoing.Cite error: A <ref> tag is missing the closing </ref> (see the help page).

Physical treatments

Studies have found exercise improves fitness and sleep and may reduce pain and fatigue in some people with fibromyalgia. Many patients find temporary relief by applying heat to painful areas. Those with access to physical therapy, massage, or acupuncture may find them beneficial. Most patients find exercise, even low intensity exercise to be extremely helpful.Cite error: The <ref> tag has too many names (see the help page). Accordingly, some doctors have claimed to have successfully treated fibromyalgia when a psychological cause is accepted.

Prognosis

Although neither degenerative nor fatal, the chronic pain of fibromyalgia is pervasive and persistent. Most fibromyalgia patients report that their symptoms do not change over time. An evaluation of 332 consecutive new fibromyalgia patients found that, out of 15 factors, pain levels, self-assessed inability to work, psychological distress, pending litigation, helplessness, level of education, and coping ability had a significant and independent association with symptom severity and function.

Epidemiology

Fibromyalgia is seen in about 2% of the general population and affects more females than males, with a ratio of 9:1 by ACR criteria. It is most commonly diagnosed in individuals between the ages of 20 and 50, though onset can occur in childhood.

History

Many names, including “muscular rheumatism,” “fibrositis,” “psychogenic rheumatism,” and “neurasthenia” were applied historically to symptoms resembling those of fibromyalgia. The term fibromyalgia was coined in 1976 from the Latin fibra (fiber) and the Greek words myo (muscle) and algos (pain). -6|url= |accessdate=2008-05-21}}</ref> and in 1986, trials of the first proposed medications for fibromyalgia were published.

A 1987 article in the Journal of the American Medical Association used the term "fibromyalgia syndrome" while saying it was a "controversial condition." The American College of Rheumatology (ACR) published its first classification criteria for fibromyalgia in 1990, although these are not strictly diagnostic criteria.

Controversies

Fibromyalgia continues to be a disputed diagnosis. Many members of the medical community consider fibromyalgia a ‘non-disease’ because of a lack of abnormalities on physical examination, the absence of objective diagnostic tests, and extensive overlap with other proposed conditions like chronic fatigue syndrome.

Several controversial issues exist with regard to fibromyalgia that range from questions regarding the validity of the disorder as a clinical entity, to issues regarding primary pathophysiology and the potential existence of fibromyalgia subtypes.

According to the article "Fibromyalgia wars", “the large majority of physicians, sociologists, and medical historians” are skeptical about the validity of fibromyalgia as a clinical entity. Some call fibromyalgia a “non-disease” and “an over-inclusive and ultimately meaningless label.” Frederick Wolfe, the most-cited fibromyalgia researcher and lead author of the 1990 paper that first defined the fibromyalgia classification criteria, questions the validity of fibromyalgia as a disease. He considers fibromyalgia a physical response to stress, depression, and economic and social anxiety, and believes the associated symptoms are a normal part say that labeling fibromyalgia as a "disease" simply legitimizes patients’ sickness behavior, slowing their recovery and harming them.

In a study of 100 individuals identified as having fibromyalgia, physical functioning decreased significantly over time, and individuals who had been diagnosed earlier had larger numbers of reported symptoms and greater severity. However, there was also a statistically significant improvement in satisfaction with health following classification. The authors of the study concluded that the ‘fibromyalgia label’ does not have a meaningful adverse affect on clinical outcome over the long term. It is however possible that these results can be accounted for by Regression toward the mean.

The validity of fibromyalgia as a unique clinical entity is also a matter of contention. There is considerable overlap between fibromyalgia and other medically unexplained syndromes, which are frequently referred to collectively as "functional somatic syndromes" (e.g. irritable bowel syndrome, chronic fatigue syndrome).

Some researchers believe that differences in psychological and autonomic nervous system profiles among affected individuals may indicate the existence of fibromyalgia subtypes. A 2007 review divides individuals with fibromyalgia into four groups as well as “mixed types”:

  1. “extreme sensitivity to pain but no associated psychiatric conditions” (may respond to medications that block the 5-HT3 receptor)
  2. “fibromyalgia and comorbid, pain-related depression” (may respond to antidepressants)
  3. “depression with concomitant fibromyalgia syndrome” (may respond to antidepressants)
  4. “fibromyalgia due to somatization” (may respond to psychotherapy).

See also

References

  1. Cite error: The named reference p15361320 was invoked but never defined (see the help page).
  2. Moldofsky H, Scarisbrick P, England R, Smythe H (1975). "Musculosketal symptoms and non-REM sleep disturbance in patients with "fibrositis syndrome" and healthy subjects". Psychosom Med. 37 (4): 341–51. PMID 169541. Retrieved 2008-05-21.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  3. Cite error: The named reference p17092441 was invoked but never defined (see the help page).
  4. ^ Leavitt F, Katz RS, Mills M, Heard AR (2002). "Cognitive and Dissociative Manifestations in Fibromyalgia". J Clin Rheumatol. 8 (2): 77–84. doi:10.1097/00124743-200204000-00003. PMID 17041327.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  5. Arnold LM, Hudson JI, Hess EV; et al. (2004). "Family study of fibromyalgia". Arthritis Rheum. 50 (3): 944–52. doi:10.1002/art.20042. PMID 15022338. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  6. Buskila D, Sarzi-Puttini P (2006). "Biology and therapy of fibromyalgia. Genetic aspects of fibromyalgia syndrome". Arthritis Res Ther. 8 (5): 218. doi:10.1186/ar2005. PMC 1779444. PMID 16887010.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  7. Cohen H, Buskila D, Neumann L, Ebstein RP (2002). "Confirmation of an association between fibromyalgia and serotonin transporter promoter region (5- HTTLPR) polymorphism, and relationship to anxiety-related personality traits". Arthritis Rheum. 46 (3): 845–7. doi:10.1002/art.10103. PMID 11920428. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  8. Buskila D, Dan B, Cohen H; et al. "An association between /pii/S0016508502001208". {{cite journal}}: Cite journal requires |journal= (help); Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  9. Hudson JI, Mangweth B, Pope HG JR, De COL C, Hausmann A, Gutweniger S, Laird NM, Biebl W, Tsuang MT. Family study of affective spectrum disorder. Arch Gene Psychiatry. 2003;60:170–177. doi: 10.1001/archpsyc.60.2.170.
  10. Anderberg UM, Marteinsdottir I, Theorell T, von Knorring L (2000). "The impact of life events in female patients with fibromyalgia and in female healthy controls". Eur Psychiatry. 15 (5): 33–41. doi:10.1016/S0924-9338(00)00397-7. PMID 10954873. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  11. Emad Y, Ragab Y, Zeinhom F, El-Khouly G, Abou-Zeid A, Rasker JJ. (2005). "Hippocampus dysfunction may explain symptoms of fibromyalgia syndrome. A study with single-voxel magnetic -adrenal stress axis function and the relationship with chronic widespread pain and its antecedents". Arthritis Res Ther. 7 (5): R992 – R1000. PMID 16207340.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  12. ^ Moldofsky H, Scarisbrick P, England R, Smythe H (1975). "Musculosketal symptoms and non-REM sleep disturbance in patients with "fibrositis syndrome" and healthy subjects". Psychosom Med. 37 (4): 341–51. PMID 169541. {{cite journal}}: Unknown parameter |day= ignored (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  13. Russell IJ, Michalek JE, Vipraio GA, Fletcher EM, Javors MA, Bowden CA (1992). "Platelet 3H-imipramine uptake receptor density and serum serotonin levels in patients with fibromyalgia/fibrositis syndrome". J Rheumatol. 19 (1): 104–9. PMID 1313504. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  14. Russell IJ, Vaeroy H, Javors M, Nyberg F (2006). "Cerebrospinal fluid biogenic amine metabolites in fibromyalgia/fibrositis syndrome and rheumatoid arthritis". Arthritis Res Ther. 8 (4): 212. doi:10.1186/ar1971. PMC 1779399. PMID 16762044.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
  15. Jaschko G, Hepp U, Berkhoff M; et al. (2007). "Serum serotonin levels are not useful in diagnosing fibromyalgia". Ann Rheum Dis. 66 (9): 1267–8. doi:10.1136/ard.2006.058842. PMID 17693607. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  16. Shuer, ML (2003). "Fibromyalgia: symptom constellation and potential therapeutic options". Endocrine. 22 (1): 67–76. doi:10.1385/ENDO:22:1:67. PMID 14610300.
  17. Yuen, KC (2007). "Is further evaluation for growth hormone (GH) deficiency necessary in fibromyalgia patients with low serum insulin-like growth factor (IGF)-I levels?". Growth hormone & IGF research. 17 (1): 82–8. doi:10.1016/j.ghir.2006.12.006. PMID 17289417. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  18. Bennett, RM. "Hypothalamic-pituitary-insulin-like growth factor-I axis dysfunction in patients with fibromyalgia". J Rheumatology. 24 (7): 1384–9. PMID 9228141. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  19. McCall-a comprehensive review. (2008). Curr Med Res Opin. 24 (8): 2359–71. doi:10.1185/03007990802288338. PMID 18606054. {{cite journal}}: Missing or empty |title= (help); More than one of |author= and |last= specified (help); Unknown parameter |month= ignored (help)
  20. Giesecke T, Gracely RH, Williams DA, Geisser ME, Petzke FW, Clauw DJ (2005). "The relationship between depression, clinical pain, and experimental pain in a chronic pain cohort". Arthritis Rheum. 52 (5): 1577–84. doi:10.1002/art.21008. PMID 15880832. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  21. Sarno, Dr. John E.; et al. (2006). The Divided Mind: The Epidemic of Mindbody Disorders. New York: HC. pp. 21–2, 235–7, 294–8. ISBN 0-06-085178-3. {{cite book}}: Explicit use of et al. in: |first= (help)
  22. McDermott BE, Feldman MD (2007). "Malingering in the medical setting". Psychiatr Clin North Am. 30 (4): 645–62. {{cite journal}}: Text "17938038" ignored (help)
  23. Gur A, Cevik R, Sarac AJ, Colpan L, Em S (2004). "Hypothalamic-pituitary-gonadal axis and cortisol in young women with primary fibromyalgia: the potential roles of depression, fatigue, and sleep disturbance in the occurrence of hypocortisolism". Ann. Rheum. Dis. 63 (11): 1504–6. doi:10.1136/ard.2003.014969. PMC 1754816. PMID 15479904. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  24. Griep EN, Boersma JW, Lentjes EG, Prins AP, van der Korst JK, de Kloet ER (1998). "Function of the hypothalamic-pituitary-adrenal axis in patients with fibromyalgia and low back pain". J. Rheumatol. 25 (7): 1374–81. PMID 9676772. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  25. Bennett RM (2002). "Adult growth hormone deficiency in patients with fibromyalgia". Curr Rheumatol Rep. 4 (4): 306–12. doi:10.1007/s11926-002-0039-4. PMID 12126582. {{cite journal}}: Unknown parameter |month= ignored (help)
  26. Neeck G, Crofford LJ (2000). "Neuroendocrine perturbations in fibromyalgia and chronic fatigue syndrome". Rheum. Dis. Clin. North Am. 26 (4): 989–1002. doi:10.1016/S0889-857X(05)70180-0. PMID 11084955. {{cite journal}}: Unknown parameter |month= ignored (help)
  27. Martinez-Lavin M. Biology and therapy of fibromyalgia. Stress, the stress response system, and fibromyalgia. Arthritis Res Ther. 2007;9(4):216.
  28. Anderberg UM, Liu Z, Berglund L, Nyberg F (1999). "Elevated plasma levels of neuropeptide Y in female fibromyalgia patients". Eur J Pain. 3 (1): 19–30. doi:10.1016/S1090-3801(99)90185-4. PMID 10700334. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  29. Vaerøy H, Helle R, Førre O, Kåss E, Terenius L (1988). "Elevated CSF levels of substance P and high incidence of Raynaud phenomenon in patients with fibromyalgia: new features for diagnosis". Pain. 32 (1): 21–6. doi:10.1016/0304-3959(91)90068-9. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  30. Giovengo SL, Russell IJ, Larson AA (1999). "Increased concentrations of nerve growth factor in cerebrospinal fluid of patients with fibromyalgia". J Rheumatol. 26 (7): 1564–9. PMID 10405946. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  31. Larson AA, Giovengo SL, Russell IJ, Michalek JE (2000). "Changes in the concentrations of amino acids in the cerebrospinal fluid that correlate with pain in patients with fibromyalgia: implications for nitric oxide pathways". Pain. 87 (2): 201–11. doi:10.1016/S0304-3959(00)00284-0. PMID 10924813. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  32. Mountz JM, Bradley LA, Modell JG; et al. (1995). "Fibromyalgia in women. Abnormalities of regional cerebral blood flow in the thalamus and the caudate nucleus are associated with low pain threshold levels". Arthritis Rheum. 38 (7): 926–38. doi:10.1002/art.1780380708. PMID 7612042. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  33. Kwiatek R, Barnden L, Tedman R; et al. (2000). "Regional cerebral blood flow in fibromyalgia: single-photon-emission computed tomography evidence of reduction in the pontine tegmentum and thalami". Arthritis Rheum. 43 (12): 2823–33. doi:10.1002/1529-0131(200012)43:12<2823::AID-ANR24>3.0.CO;2-E. PMID 11145042. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  34. Emad Y, Ragab Y, Zeinhom F, El-Khouly G, Abou-Zeid A, Rasker JJ (2008). "Hippocampus dysfunction may explain symptoms of fibromyalgia syndrome. A study with single-voxel magnetic resonance spectroscopy". J Rheumatol. 35 (7): 1371–7. PMID 18484688. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  35. Cite error: The named reference p18771960 was invoked but never defined (see the help page).
  36. Burckhardt CS, Clark SR, Bennett RM. (1991). "The fibromyalgia impact questionnaire: development and validation". J Rheumatol. 18 (5): 728–33. PMID 1865419. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  37. Harris RE, Sundgren PC, Pang Y, Hsu M, Petrou M, Kim SH, McLean SA, Gracely RH, Clauw DJ. (2008). "Dynamic levels of glutamate within the insula are associated with improvements in multiple pain domains in fibromyalgia". Arthritis Rheum. 58 (3): 903–7. PMID 18311814. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  38. Kuchinad A, Schweinhardt P, Seminowicz DA, Wood PB, Chizh BA, Bushnell MC (2007). "Accelerated brain gray matter loss in fibromyalgia patients: premature aging of the brain?". J Neurosci. 27 (15): 4004–7. doi:10.1523/JNEUROSCI.0098-07.2007. PMID 17428976. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  39. Wood PB, Patterson JC, Sunderland JJ, Tainter KH, Glabus MF, Lilien DL (2007). "Reduced presynaptic dopamine activity in fibromyalgia syndrome demonstrated with positron emission tomography: a pilot study". J Pain. 8 (1): 51–8. doi:10.1016/j.jpain.2006.05.014. PMID 17023218. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  40. National Institute of Arthritis and Musculoskeletal and Skin Diseases (2004). "Questions and Answers About Fibromyalgia – How Is Fibromyalgia Diagnosed?". National Institutes for Health. {{cite web}}: Unknown parameter |month= ignored (help)
  41. Goldenberg DL (2008). "Multidisciplinary modalities in the treatment of fibromyalgia". J Clin Psychiatry. 69: 30–4. PMID 18537461. {{cite journal}}: Unknown parameter |suppl= ignored (help)
  42. Moore RA, Straube S, Wiffen PJ, Derry S, McQuay HJ. Pregabalin for acute and chronic pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD007076. DOI: 10.1002/14651858.CD007076.pub2
  43. Cite error: The named reference pmid16052595 was invoked but never defined (see the help page).
  44. J Gambl Stud. 2009 Feb 25. Impulse Control Disorder Behaviors Associated with Pramipexole Used to Treat Fibromyalgia. Holman AJ
  45. Busch A, Schachter CL, Peloso PM, Bombardier C (2002). "Exercise for treating fibromyalgia syndrome". Cochrane database of systematic reviews (Online) (3): CD003786. doi:10.1002/14651858.CD003786. PMID 12137713.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  46. Berman BM, Ezzo J, Hadhazy V, Swyers JP (1999). "Is acupuncture effective in the treatment of fibromyalgia?". The Journal of family practice. 48 (3): 213–8. PMID 10086765.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  47. Leonard-Segal, Dr. Andrea (2006). "A Rheumatologist's Experience With Psychosomatic Disorders". The Divided Mind: The Epidemic of Mindbody Disorders. ReganBooks. pp. 264–5. ISBN 0-06-085178-3.
  48. Goldenberg DL, Mossey CJ, Schmid CH. (1995). "A model to assess severity and impact of fibromyalgia". J Rheumatol. 22 (12): 2313–8. PMID 8835568. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  49. Chakrabarty, S (2007). "Fibromyalgia". American Family Physician. 76 (2): 247–254. PMID 17695569. Retrieved 2008-01-06. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  50. Fibromyalgia at eMedicine
  51. Health Information Team (2004). "Fibromyalgia". BUPA insurance. {{cite web}}: Unknown parameter |month= ignored (help)
  52. "Fibro-". Dictionary.com. Retrieved 2008-05-21.
  53. Meaning of myo
  54. Meaning of algos
  55. Cite error: The named reference Inanici was invoked but never defined (see the help page).
  56. Goldenberg DL (1987). "Fibromyalgia syndrome. An emerging but controversial condition". JAMA. 257 (20): 2782–7. doi:10.1001/jama.257.20.2782. PMID 3553636. {{cite journal}}: Unknown parameter |month= ignored (help)
  57. Cite error: The named reference Wolfe was invoked but never defined (see the help page).
  58. ^ Müller W, Schneider EM, Stratz T (2007). "The classification of fibromyalgia syndrome". Rheumatol Int. 27 (11): 1005–10. doi:10.1007/s00296-007-0403-9. PMID 17653720. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  59. ^ Wolfe F (2009). "Fibromyalgia wars". J Rheumatol. 36 (4): 679–83. PMID 19342721. {{cite journal}}: Unknown parameter |month= ignored (help)
  60. ^ Goldenberg DL (1995). "Fibromyalgia: why such controversy?". Ann. Rheum. Dis. 54 (1): 3–5. PMC 1005499. PMID 7880118. {{cite journal}}: Unknown parameter |month= ignored (help)
  61. Cite error: The named reference Deary was invoked but never defined (see the help page).
  62. Buchwald D, Garrity D (1995). "Comparison of patients with chronic fatigue syndrome, fibromyalgia, and multiple chemical sensitivities". Arch Intern Med. 154 (18): 2049–53. PMID 8092909. {{cite journal}}: Unknown parameter |month= ignored (help)
  63. Wolfe F, Rasker JJ “Fibromyalgia.” In: Firestein GS, Budd RC, Harris ED, Jr, McInnes IB, Ruddy S, Sergent JS, editors. Kelley’s textbook of rheumatology. 8th ed. Amsterdam: Elsevier; 2008
  64. Baillieres Best Pract Res Clin Rheumatol. 1999 Sep;13(3):421-5. “Is fibromyalgia a distinct clinical entity? The disapproving rheumatologist's evidence.” Cohen ML
  65. http://www.nytimes.com/2008/01/14/health/14pain.html
  66. White KP; et al. (2002). "Does the label "fibromyalgia" alter health status, function, and health service utilization? A prospective, within-group comparison in a community cohort of adults with chronic widespread pain". Arthritis Rheum. 47 (3): 260–5. PMID 12115155. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)
  67. Kanaan RA, Lepine JP, Wessely SC (2007). "The association or otherwise of the functional somatic syndromes". Psychosom Med. 69 (9): 855–9. doi:10.1097/PSY.0b013e31815b001a. PMC 2575798. PMID 18040094. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

External links