Medicine – Essential Features of Fibromyalgia

Fibromyalgia is a chronic pain syndrome characterised by widespread musculoskeletal pain, increased sensitivity to pressure, fatigue, sleep disturbance, and a variety of associated somatic symptoms. Despite the severity of the patient’s symptoms, routine physical examination and investigations usually do not demonstrate inflammatory, neurological, or structural abnormalities. The condition may therefore produce a noticeable difference between the degree of symptoms and disability reported by the patient and the objective clinical findings.

1. Pain

Pain is the most prominent feature of fibromyalgia. It commonly affects the neck and back, although many patients describe widespread or generalized pain involving several areas of the body. The discomfort may be persistent, aching, or burning in character and can fluctuate considerably in severity. Symptoms are often aggravated by psychological stress, exposure to cold weather, and physical activity, although the pattern varies between individuals.

2. Generalised Morning Stiffness

Patients frequently experience generalised stiffness on waking in the morning. Rather than being confined to a single joint, the stiffness may involve several regions of the body and can contribute to difficulty beginning normal daily activities. Unlike inflammatory arthropathies, however, the stiffness of fibromyalgia is not accompanied by objective evidence of joint inflammation or synovitis.

3. Paraesthesiae

Paraesthesiae of the hands and feet are commonly reported. Patients may describe tingling, numbness, prickling, or abnormal sensations in the extremities. These symptoms can resemble those produced by peripheral neurological disorders, but neurological examination is usually normal and there is typically no objective sensory or motor deficit.

4. Fatigue

Persistent fatigability is another major feature of fibromyalgia. Patients may feel tired even after relatively minor physical or mental activity and may experience a persistent lack of energy throughout the day. Fatigue can significantly interfere with work, exercise, concentration, and other normal activities and is often closely related to disturbed sleep.

5. Non-restorative Sleep

Sleep disturbance is particularly characteristic of fibromyalgia. Although patients may sleep for an apparently adequate number of hours, the sleep is often non-restorative, meaning that they wake feeling tired and unrefreshed. Poor-quality sleep can worsen pain sensitivity, daytime fatigue, cognitive difficulties, and overall functioning.

6. Headache

Recurrent headaches are frequently associated with fibromyalgia. These may occur as tension-type headaches or sometimes have migraine-like features. Headache symptoms often coexist with neck and shoulder discomfort and may become more prominent during periods of stress, fatigue, or poor sleep.

7. Gastrointestinal Symptoms

Some patients experience diffuse abdominal pain accompanied by changes in bowel habit. Bowel symptoms may include episodes of constipation, diarrhoea, or alternating patterns of both. These gastrointestinal manifestations often overlap with symptoms commonly associated with functional bowel disorders such as irritable bowel syndrome.

8. Urinary Frequency

Increased urinary frequency may occur despite the absence of a urinary tract infection or other obvious structural abnormality. Patients may feel the need to pass urine more frequently than usual, and these urinary symptoms may accompany the other functional or somatic complaints associated with fibromyalgia.

9. Dysmenorrhoea

Women with fibromyalgia may experience dysmenorrhoea, or painful menstruation. Menstrual discomfort may be more pronounced in some patients because of the increased sensitivity to pain that characterises the disorder.

Clinical Signs

1. Discordance Between Symptoms and Objective Findings

A characteristic clinical feature is the disproportion between the severity of reported symptoms and the limited objective abnormalities found on examination. Patients may experience substantial pain and functional limitation even though joints, muscles, neurological examination, and routine investigations show no corresponding structural or inflammatory abnormality.

2. Absence of Objective Weakness, Synovitis, or Neurological Abnormality

Despite complaints of pain, fatigue, numbness, or weakness, examination typically demonstrates no true muscle weakness, synovitis, or focal neurological abnormality. Muscle power and neurological function are generally preserved. This absence of objective inflammatory or neurological findings can help distinguish fibromyalgia from inflammatory arthritis, myopathy, and neurological disease.

3. Multiple Hyperalgesic Sites

Patients may have multiple areas of hyperalgesia, meaning that stimuli that would normally cause only mild discomfort are perceived as unusually painful. This increased pain sensitivity reflects altered processing of painful stimuli and is an important clinical characteristic of fibromyalgia.

4. Tenderness on Rolling the Mid-Trapezius Skin Fold

Marked tenderness may be produced by rolling or pinching the skin fold over the mid-trapezius region. The degree of discomfort can be substantially greater than would normally be expected from such light mechanical stimulation, reflecting the increased sensitivity to pressure and touch seen in fibromyalgia.

5. Cutaneous Hyperaemia After Palpation

Palpation of tender areas may sometimes produce local cutaneous hyperaemia, with visible redness of the skin occurring after pressure has been applied. This response can accompany the pronounced tenderness and increased sensitivity found at symptomatic sites.

6. Negative Control Sites

When examining a patient for tenderness, control sites may remain relatively non-tender compared with symptomatic areas. This finding helps demonstrate that the pain response is not necessarily uniform throughout the body and can assist in assessing the distribution of tenderness during clinical examination.