Fibromyalgia Syndrome: An Introduction

Note: This paper was writ­ten as an assign­ment for a med­ical com­mu­ni­ca­tions course in 2004. I’ve pub­lished it here after receiv­ing sev­er­al requests that I do so. It needs to be updat­ed, but I haven’t had a chance to do the research in order to do so. 

Fibromyal­gia Syn­drome (FMS) is a debil­i­tat­ing neu­ro­log­i­cal dis­or­der char­ac­ter­ized by chron­ic wide­spread pain and fatigue. It affects approx­i­mate­ly 2% of the pop­u­la­tion and is more com­mon in women than in men. Cen­tral ner­vous sys­tem sen­si­ti­za­tion affects the entire body, lead­ing to many sec­ondary symp­toms. This paper will cov­er the his­to­ry, symp­toms, and caus­es of FMS as well as recent research and known treat­ments for the syndrome. 

Description

Fibromyal­gia has been described as a full-body migraine. Anoth­er com­mon expla­na­tion is to com­pare every­day life with FMS as being sim­i­lar to the aches and pains asso­ci­at­ed with a severe case of influenza. 

FMS patients expe­ri­ence inter­mit­tent flares, which are episodes of increased symp­to­mol­o­gy. Flares usu­al­ly occur in response to phys­i­cal or emo­tion­al stress—a sched­ule change, an ill­ness or injury, a new job, the birth of a child, etc. While fibromyal­gia is not con­sid­ered a degen­er­a­tive dis­or­der, its symp­toms usu­al­ly become more severe if the patient also has a degen­er­a­tive dis­or­der such as arthritis. 

Diagnosis

First, a patient must have expe­ri­enced con­tin­u­ous pain in all four quad­rants of the body for at least three months (Wolfe et al., 1990). Doc­tors will usu­al­ly order many dif­fer­ent tests in order to rule out arthri­tis, Lyme dis­ease, and oth­er con­di­tions that might be con­fused with fibromyalgia. 

The key diag­nos­tic tool for FMS is the ten­der point exam. No more than 4kg/1.54 km² of pres­sure is applied to 18 spe­cif­ic points (see Table 1). If there is sig­nif­i­cant pain in at least 11 of the 18 points, the patient may be diag­nosed with fibromyalgia. 

Front and back views of a nude woman showing FMS tender points

Table 1: Ten­der Point Sites (Wolfe et al., 1990)
Occiput: bilat­er­al, at the sub­oc­cip­i­tal mus­cle insertions.
Low cer­vi­cal: bilat­er­al, at the ante­ri­or aspects of the inter­trans­verse spaces at C5–C7.
Trapez­ius: bilat­er­al, at the mid­point of the upper border.
Supraspina­tus: bilat­er­al, at ori­gins, above the scapu­la spine near the medi­al border.
Sec­ond rib: bilat­er­al, at the sec­ond cos­to­chon­dral junc­tions, just lat­er­al to the junc­tions on the upper surfaces.
Lat­er­al epi­condyle: bilat­er­al, 2 cm dis­tal to the epicondyles.
Gluteal: bilat­er­al, in upper out­er quad­rants of but­tocks in ante­ri­or fold of muscle.
Greater trochanter: bilat­er­al, pos­te­ri­or to the trochanteric prominence.
Knee: bilat­er­al, at the medi­al fat pad prox­i­mal to the joint line.

There are so many com­mon sec­ondary symp­toms that it is not unusu­al for a patient to be treat­ed by mul­ti­ple spe­cial­ists for those symp­toms over a peri­od of years before she is diag­nosed with FMS. Sec­ondary symp­toms need not be present for diag­no­sis and will vary from one patient to the next. 

Table 2: Sec­ondary Symptoms
Migraine or ten­sion-type headaches Tem­per­o­mandibu­lar joint disorder
Irri­ta­ble bow­el disorder Gas­troe­sophageal reflux
Impaired mem­o­ry and concentration Periph­er­al neuropathy
Rest­less leg syn­drome and oth­er sleep disorders Sjo­gren’s syndrome
Ray­naud’s phenomena Peri­od­ic mus­cle spasms and cramps
Myofas­cial pain syndrome Impaired coor­di­na­tion
Inter­mit­tent hear­ing loss or ring­ing noises Skin sen­si­tiv­i­ty, itch­ing, burning
Insom­nia Inter­sti­tial cystitis
Dizzi­ness Chem­i­cal sensitivity
Sen­si­tiv­i­ty to light, smells and sounds Fatigue
Cos­to­chon­dri­tis Dif­fuse pelvic pain
Nau­sea Dyspareunia
Rash­es Dermatographia
Chron­ic sinusi­tis/­post-nasal drip Eye irri­ta­tion, burn­ing or dryness

History

“The night racks my bones, and the pain that gnaws me knows no rest,” laments Job (The Holy Bible: New Revised Stan­dard Ver­sion, Job 30:17). It’s easy to imag­ine that Job suf­fered from FMS. 

Uni­ver­si­ty of Edin­burgh sur­geon William Bal­four described fibromyal­gia, which he called rheuma­tism, in 1815 (Bal­four, 1815, as cit­ed in Star­lanyl, 1999). Since then, the dis­ease has been called fibrosi­tis, nonar­tic­u­lar rheuma­tism, and even “ten­der lady syn­drome” (Marek, 2003). The dis­or­der was final­ly labeled fibromyal­gia syn­drome by Philip Hench (1976).

The Amer­i­can Col­lege of Rheuma­tol­ogy pub­lished its cri­te­ria for the diag­no­sis of fibromyal­gia in 1990 (Wolfe et al.). The Amer­i­can Med­ical Asso­ci­a­tion accept­ed the cri­te­ria in 1987, fol­lowed by the World Health Orga­ni­za­tion in 1992 (WHO, 2004). 

Cause

After almost two cen­turies of study, the eti­ol­o­gy of fibromyal­gia is still a mat­ter of much debate. There are no lab tests for FMS. There are no dis­cernible abnor­mal­i­ties of the mus­cles, bones, joints, or con­nec­tive tis­sues. It is known to involve cen­tral ner­vous sys­tem changes (Star­lanyl and Copeland, 2001), but those changes may be caused by or be the cause of the dis­or­der. Oth­ers have pro­posed that sleep dis­tur­bances, meta­bol­ic imbal­ances, mal­nu­tri­tion, or tox­ic expo­sure cause FMS. 

For the last 25 years, most prac­ti­tion­ers have treat­ed FMS as an autoim­mune dis­or­der, sim­i­lar to arthri­tis. Lev­els of anti­nu­clear anti­bod­ies are used to diag­nose autoim­mune dis­or­ders, but the pres­ence of those anti­bod­ies is sim­i­lar in most FMS patients and healthy con­trols (Star­lanyl & Copeland, 2001). 

Trav­ell and Simons believed that untreat­ed myofas­cial trig­ger points caused fibromyal­gia (1999, as cit­ed in Davies, 2001). Trig­ger points, though, refer pain to dif­fer­ent parts of the body. Ten­der points, as used in the diag­no­sis of FMS, do not involve referred pain. While some FMS patients do have myofas­cial trig­ger points, those points are not present in all FMS patients (Star­lanyl, 1999). 

Some doc­tors per­sist in believ­ing that FMS is a psy­chi­atric dis­or­der, but researchers have been unable to dis­tin­guish between FMS, rheuma­toid arthri­tis, and oth­er patients who expe­ri­ence chron­ic pain using psy­chi­atric tech­niques (Star­lanyl & Copeland, 2001). Some physi­cians have reclas­si­fied fibromyal­gia as a “func­tion­al somat­ic syn­drome,” claim­ing that it is char­ac­ter­ized more by dis­abil­i­ty than med­ical expla­na­tion, sug­gest­ing behav­ioral and psy­chi­atric treat­ment rather than any oth­er ther­a­pies (Barsky & Borus, 1999). While the inci­dence of psy­chi­atric dis­or­ders such as depres­sion is no high­er in patients with FMS than in those with oth­er chron­ic pain dis­or­ders, the num­ber of fibromyal­gia patients who have expe­ri­enced acute or long term trau­ma or abuse is far high­er than that of the gen­er­al pop­u­la­tion (Romans et al., 2002 and Van Houden­hove et al, 2004). 

Research

In the last ten years, sev­er­al new tech­nolo­gies have been used to prove that FMS is a phys­i­cal dis­or­der. Func­tion­al mag­net­ic res­o­nance imag­ing (fMRI) and sin­gle positron emis­sion com­put­ed tomog­ra­phy (SPECT) scans of FMS patients’ brains show sig­nif­i­cant abnor­mal­i­ties in region­al cere­bral blood flow (Grace­ley et al., 2002 and Mountz et al., 1998). FMRIs also demon­strate sig­nif­i­cant­ly increased activ­i­ty in pain-rel­e­vant areas of the brain in response to stim­uli when com­pared to a con­trol group (Cook et al., 2004). Ital­ian researchers have found ele­vat­ed lev­els of the neu­ropep­tide sub­stance P, which is involved in the per­cep­tion of pain, in the spinal flu­id of FMS patients (De Ste­fano et al, 2000). Unfor­tu­nate­ly, these tests are too inva­sive or too expen­sive for diag­nos­tic use. 

Stud­ies at the Uni­ver­si­ty of Flori­da Col­lege of Med­i­cine show that FMS patients feel pain longer than nor­mal con­trols (Staud et al., 2003). One of the researchers, Roland Staud, also found that once a sub­ject with fibromyal­gia is exposed to painful stim­uli, that patient stays more sen­si­tive to fur­ther stim­uli. Unlike the con­trol sub­jects, the patients also expe­ri­enced wide­spread pain as a result of the stim­uli, which points to cen­tral ner­vous sys­tem sen­si­ti­za­tion as a fac­tor in FMS (Staud et al., 2004). 

Van Houden­hove et al. cite mul­ti­ple stud­ies regard­ing the effect of long-term stres­sors on the cen­tral ner­vous sys­tem in var­i­ous mam­mals, includ­ing humans. 

Human stud­ies also sug­gest that the cumu­la­tive effects of phys­i­cal or psy­choso­cial bur­den may increase sus­cep­ti­bil­i­ty to stress in lat­er life, either through sen­si­ti­za­tion or failed inhi­bi­tion of the HPA-axis, pos­si­bly due to glu­co­cor­ti­coid-relat­ed hip­pocam­pal dam­age. For exam­ple, ret­ro­spec­tive stud­ies have shown that emo­tion­al, phys­i­cal or sex­u­al abuse dur­ing child­hood may not only increase future risks for anx­i­ety, depres­sion and soma­ti­sa­tion, but even organ­ic dis­eases such as coro­nary dis­or­ders, CVS, dia­betes, CPOD and viral infections—which may be relat­ed to life­long hyper­re­ac­tiv­i­ty of the LC-NE and HPA axes. (2004, p. 268). 

Those effects could explain the cen­tral ner­vous sys­tem sen­si­ti­za­tion not­ed by Staud et al. Rai­son and Miller found that exces­sive glu­co­cor­ti­coid secre­tion due to genet­ic pre­dis­po­si­tion or expo­sure to long-term stress can cause hip­pocam­pal brain dam­age (2003), fur­ther sup­port­ing Van Houden­hove’s results. 

Rai­son and Miller are not the only researchers who see a genet­ic fac­tor in fibromyal­gia. Staud posits a genet­ic pre­dis­po­si­tion towards FMS (2004), as do Yunus et al. (1999) and Pel­le­gri­no et al., 1989. Van Houden­hove, how­ev­er, points out that gen­er­a­tional behav­ioral cycles, such as those often seen in abu­sive fam­i­lies, could explain some of the appar­ent hered­i­ty (2004).

Treatment

Most treat­ment of FMS is lim­it­ed to the man­age­ment of symp­toms. Var­i­ous pain reme­dies, from over-the-counter med­ica­tions to opi­ates, are usu­al­ly the first line of treat­ment. Mus­cle relax­ants, phys­i­cal ther­a­py, and mas­sage help some patients. Trig­ger point ther­a­py and injec­tions are oth­er pos­si­bil­i­ties. Many FMS patients expe­ri­ence dif­fi­cul­ties in achiev­ing rest­ful sleep, so physi­cians com­mon­ly pre­scribe seda­tives and tran­quil­iz­ers. Low dos­es of anti-seizure med­ica­tions and atyp­i­cal antipsy­chotics, such as Requip and Sero­quel, have been found to be effec­tive in help­ing some fibromyal­gia patients to achieve restora­tive sleep. 

Selec­tive sero­tonin reup­take inhibitors (SSRIs), tri­cyclic anti­de­pres­sants, and oth­er med­ica­tions that affect neu­ro­trans­mit­ters help some fibromyal­gia patients (Marek, 2003). Cym­bal­ta, a new med­ica­tion that inhibits both sero­tonin and nor­ep­i­neph­rine reup­take, seems to improve pain and reduce the num­ber of ten­der points in FMS patients (Arnold et al., 2004). 

Acupunc­ture and biofeed­back have been found effec­tive in the treat­ment of fibromyal­gia (Ebell and Beck, 2001). Gen­tle, non-aer­o­bic exer­cise such as Tai Chi and some forms of yoga may help patients, as well. 

Stress reduc­tion is one of the most impor­tant fac­tors in improv­ing the qual­i­ty of life for fibromyal­gia patients (Williamson, 1998). Regard­less of whether the dis­or­der is caused by stress or not, it is aggra­vat­ed by stress. While it is impos­si­ble for any per­son to com­plete­ly avoid stress, it is pos­si­ble to reduce expo­sure to known stres­sors and learn to bet­ter cope with those that must be endured. 

Mind­ful­ness-based stress reduc­tion (MBSR) pro­grams are rel­a­tive­ly new in the treat­ment of fibromyal­gia in the US. In Full Cat­a­stro­phe Liv­ing, Jon Kabat-Zinn defines mind­ful­ness as, “the com­plete ‘own­ing’ of each moment of your expe­ri­ence, good, bad, or ugly” (1990, p. 11). The the­o­ry is that mind­ful­ness can allow patients to reduce their reac­tions to stress, improv­ing their abil­i­ty to cope with stres­sors. “In devel­op­ing the capac­i­ty to step back and observe the flow of con­scious­ness, mind­ful­ness can short­cir­cuit the fight or flight reac­tion char­ac­ter­is­tic of the sym­pa­thet­ic ner­vous sys­tem, allow­ing indi­vid­u­als to respond to the sit­u­a­tion at hand, instead of auto­mat­i­cal­ly react­ing to it on the basis of past expe­ri­ences.” (Proulx, 3002, p. 201) MBSR pro­grams typ­i­cal­ly last from 8 to 12 weeks and include instruc­tion in med­i­ta­tion, breath­ing tech­niques, phys­i­cal aware­ness, and yoga. They often uti­lize jour­nal­ing and group dis­cus­sions regard­ing atti­tudes and pos­i­tive think­ing. While MBSR par­tic­i­pa­tion does not nec­es­sar­i­ly lead to improve­ment of the phys­i­cal symp­toms of fibromyal­gia, it can lead to improved qual­i­ty of life for the fibromyal­gia patient. 

Conclusion

It is unlike­ly that a cure will be found for fibromyal­gia as long as its eti­ol­o­gy is not ful­ly under­stood. Even as the con­tribut­ing fac­tors are iden­ti­fied, though, the com­plex­i­ty of the syn­drome leads one to believe that it is unlike­ly that any one treat­ment will pro­vide a panacea. The progress made in the last fif­teen years, though, has led to the reclas­si­fi­ca­tion of the dis­ease and improved treat­ments, lead­ing to an improved prog­no­sis for all fibromyal­gia patients. 

References

Arnold, L. M., Crof­ford, L. J., Wohlre­ich, M., Detke, M. j., Iyen­gar, S., & Gold­stein, D. J. (2004, Sep). A Dou­ble-Blind, Mul­ti­cen­ter Tri­al Com­par­ing Dulox­e­tine With Place­bo in the Treat­ment of Fibromyal­gia Patients With or With­out Major Depres­sive Dis­or­der. Arthri­tis and Rheuma­tism, 50(9), 2974–2984.

Bal­four, W. (1815). Obser­va­tions on the Pathol­o­gy and Cure of Rheuma­tism. Edin­burgh Med­ical Sur­gi­cal Jour­nal (Edin­burgh), 15, 168–187.

Barsky, A., & Borus, J. (1999, 1 Jun). Func­tion­al Somat­ic Syn­dromes. Annals of Inter­nal Med­i­cine, 130. 

Camp­bell, B. (2004). The CFIDS & Fibromyal­gia Self-Help Book(2nd ed.). Palo Alto, CA: The CFIDS/Fibromyalgia Self-Help Program. 

Clauw, D. J. (1995, 01/09). Fibromyal­gia: More than just a mus­cu­loskele­tal dis­ease. Amer­i­can Fam­i­ly Physi­cian, 52(3), 843–852.

Cohen-Katz, J. (2004, Sum­mer). Mind­ful­ness-Based Stress Reduc­tion and Fam­i­ly Sys­tems Med­i­cine: A Nat­ur­al Fit. Fam­i­lies, Sys­tems & Health, 22(2), 204–207.

Cook, D., Lange, G., Cic­cone, D., Liu, W., Stef­fen­er, J., & Natel­son, B. (2004, Feb). Func­tion­al imag­ing of pain in patients with pri­ma­ry fibromyal­gia. The Jour­nal of Rheuma­tol­ogy, 31(2), 364–378.

Davies, C. (2001). The Trig­ger Point Ther­a­py Work­book: Your Self-Treat­ment Guide for Pain Relief.Oakland, CA: New Har­bin­ger Pub­li­ca­tions, Inc. 

De Ste­fano, R., Selvi, E., Vil­lano­va, M., Frati, E., Man­ganel­li, S., Frances­chi­ni, E. et al. (2000, Dec). Image analy­sis quan­tifi­ca­tion of sub­stance P immunore­ac­tiv­i­ty in the trapez­ius mus­cle of patients with fibromyal­gia and myofas­cial pain syn­drome. Jour­nal of Rheuma­tol­ogy, 27(12), 2906–2910.

Ebell, M., & Beck, E. (2001, May). How effec­tive are complementary/alternative med­i­cine (CAM) ther­a­pies for fibromyal­gia? Jour­nal of Fam­i­ly Prac­tice, 50(5), 400–402.

World Health Orga­ni­za­tion. (2004). FAQ on ICD. Retrieved 10 August 2004, from http://www.who.int/classifications/help/icdfaq/en/. Forbes, D., & Chalmers, A. (2004, Jun). Fibromyal­gia: Revis­it­ing the Lit­er­a­ture. Jour­nal of the Cana­di­an Chi­ro­prac­tic Asso­ci­a­tion, 48(2), 119–132. Gow­ers, W. (1904). Lum­ba­go: Its lessons and ana­logues. British Med­ical Jour­nal, 1, 117–121.

Grace­ly, R., Pet­zke, F., Wolf, J., & Clauw, D. (2002, May). Func­tion­al mag­net­ic res­o­nance imag­ing evi­dence of aug­ment­ed pain pro­cess­ing in fibromyal­gia. Arthri­tis and Rheuma­tism, 46(5), 1333–1343.

Hench, P. (1976). Nonar­tic­u­lar Rheuma­tism, Twen­ty-Sec­ond Rheuma­tism Review: Review of the Amer­i­can and Eng­lish Lit­er­a­ture for the Years 1973 and 1974. Arthri­tis and Rheuma­tism, 19 (suppl),1081–1089.

Hen­riks­son, C., & Bur­ck­hardt, C. (1996). Impact of fibromyal­gia on every­day life: A study of women in the USA and Swe­den. Dis­abil­i­ty and Reha­bil­i­ta­tion Jour­nal, 18, 241–248.

The Holy Bible: New Revised Stan­dard Version.(1991). Oxford Uni­ver­si­ty Press. 

Jons­dot­tir, I. H. (2000, Oct). Neu­ropep­tides and their inter­ac­tion with exer­cise and immune func­tion. Immunol­o­gy & Cell Biol­o­gy, 78(5), 562–571.

Kabat-Zinn, J. (1990). Full Cat­a­stro­phe Living.New York: Dell Publishing. 

Kabat-Zinn, J., Lip­worth, L., & Bur­ney, R. (1985, Jun). The clin­i­cal use of mind­ful­ness med­i­ta­tion for the self-reg­u­la­tion of chron­ic pain. Jour­nal of Behav­ioral Med­i­cine, 8(2), 163–190.

Kel­ly, J., & Devon­shire, R. (2001/1991). Tak­ing Charge of Fibromyalgia(4th ed.). 

Wayza­ta, MN: Fibromyal­gia Edu­ca­tion­al Sys­tems, Inc. Marek, C. C. (2003). The First Year–Fibromyalgia: An Essen­tial Guide for the New­ly Diagnosed.New York, NY: Mar­lowe & Company. 

McComb, R., Tacon, A., Ran­dolph, P., & Caldera, Y. (2004, Oct). A pilot study to exam­ine the effects of a mind­ful­ness-based stress-reduc­tion and relax­ation pro­gram on lev­els of stress hor­mones, phys­i­cal func­tion­ing, and sub­max­i­mal exer­cise respons­es. The Jour­nal of Alter­na­tive and Com­ple­men­tary Med­i­cine: Research on Par­a­digm, Prac­tice, and Pol­i­cy, 10(5), 819–827.

Mountz, J., Bradley, L., & Alar­cón, G. (1998, Jun). Abnor­mal func­tion­al activ­i­ty of the cen­tral ner­vous sys­tem in fibromyal­gia syn­drome. The Amer­i­can Jour­nal of the Med­ical Sci­ences, 315(6), 385–396.

Pel­le­gri­no, M., Way­lo­nis, G., & Som­mer, A. (1989). Famil­iar occur­rence of pri­ma­ry fibromyal­gia. Archives of Phys­i­cal Med­i­cine and Reha­bil­i­ta­tion, 70(1), 61–63.

Proulx, K. (2003, Jul/Aug). Inte­grat­ing mind­ful­ness-based stress reduc­tion. Holis­tic Nurs­ing Prac­tice, 17(4), 201–209.

Rai­son, C. L., & Miller, A. H. (2003, Sep). When not enough is too much: The role of insuf­fi­cient glu­co­cor­ti­coid sig­nal­ing in the patho­phys­i­ol­o­gy of stress-relat­ed dis­or­ders. The Amer­i­can Jour­nal of Psy­chi­a­try, 160(9), 1554–1565.

Romans, S., Belaise, C., Mar­tin, J., Mor­ris, E., & Raf­fi, A. (2002). Child­hood abuse and lat­er med­ical dis­or­ders in women: An epi­demi­o­log­i­cal study. Psy­chother­a­py and Psy­cho­so­mat­ics, 71,141–150.

Sack, K. (2004). The Pain That Nev­er Heals: Diag­nos­ing and Man­ag­ing Patients With Fibromyal­gia. Advanced Stud­ies in Med­i­cine, 4(8), 401–408.

Schae­fer, K. M. (2003, May/Jun). Sleep Dis­tur­bances Linked to Fibromyal­gia. Holis­tic Nurs­ing Prac­tice, 17(3), 120–128.

Schlenk, E. A., Erlen, J. A., Dun­bar-Jacob, J., McDow­ell, J., Eng­berg, S., Serei­ka, S. M. et al. (1998, Feb). Health-relat­ed qual­i­ty of life in chron­ic dis­or­ders: A com­par­i­son across stud­ies using the MOS SF-36. Qual­i­ty of Life Research, 7(1), 57–65.

Smythe, H. (1972). The fibrosi­tis syn­drome (nonar­tic­u­lar rheuma­tism). In J. Hol­lan­der (Ed.), Arthri­tis and Allied Con­di­tions (pp. 767–777). Philadel­phia: Lea & Febiger. 

Smythe, H. (1978). Two con­tri­bu­tions to under­stand­ing the “fibrosi­tis syn­drome.” Bul­letin of Rheumat­ic Dis­ease, 28, 928–931.

Star­lanyl, D. (1999). The Fibromyal­gia Advo­cate: Get­ting the Sup­port You Need to Cope with Fibromyal­gia and Myofas­cial Pain Syndrome.Oakland, CA: New Har­bin­ger Pub­li­ca­tions, Inc. 

Star­lanyl, D., & Copeland, M. E. (2001/1996). Fibromyal­gia & Chron­ic Myofas­cial Pain: A Sur­vival Man­u­al (2nd ed.). Oak­land, CA: New Har­bin­ger Pub­li­ca­tions, Inc. 

Staud R, Price, D., & Robin­son, M. (2004). Main­te­nance of windup of sec­ond pain requires less fre­quent stim­u­la­tion in fibromyal­gia patients com­pared to nor­mal con­trols. Pain, 110(3), 689–696.

Staud, R. (2004, Mar). Fibromyal­gia pain: Do we know the source? Cur­rent Opin­ion in Rheuma­tol­ogy, 16(2), 157–163.

Staud, R., Can­non, R., Maud­er­li, A., Robin­son, M., Price, D., & Vier­ck, C. J. (2003, Mar). Tem­po­ral sum­ma­tion of pain from mechan­i­cal stim­u­la­tion of mus­cle tis­sue in nor­mal con­trols and sub­jects with fibromyal­gia syn­drome. Pain, 102(1–2), 87–95.

Staud, R., & Smither­man, M. (2002, Aug). Periph­er­al and cen­tral sen­si­ti­za­tion in fibromyal­gia: Patho­genet­ic role. Cur­rent Pain and Headache Reports, 6(4), 259266. 

Staud, R., & Domin­go, M. (2001). Evi­dence for Abnor­mal Pain Pro­cess­ing in Fibromyal­gia Syn­drome. Pain Med­i­cine, 2(3), 208–215.

Trav­ell, J., Simons, D., & Simons, L. (1999). Myofas­cial Pain and Dys­func­tion: The Trig­ger Point Man­u­al Vol. 1 (2nd ed.). Bal­ti­more: Lip­pin­cott Williams and Wilkins. 

Van Houden­hove, B., & Egle, U. T. (2004). Fibromyal­gia: A Stress Dis­or­der? Psy­chother­a­py and Psy­cho­so­mat­ics, 73, 267–275.

Williamson, M. E. (1996). Fibromyal­gia: A Com­pre­hen­sive Approach.US: Wal­ter Pub­lish­ing Com­pa­ny, Inc. 

Williamson, M. E. (1998). The Fibromyal­gia Relief Book.US: Wal­ter Pub­lish­ing Com­pa­ny, Inc. 

Wolfe, F., Ross, K., Ander­son, J., Rus­sell, I., & Hebert L. (1995, Jan). The preva­lence and char­ac­ter­is­tics of fibromyal­gia in the gen­er­al pop­u­la­tion. Arthri­tis and Rheuma­tism, 38(1), 18–28.

Wolfe, F., Smythe, H. A., Yunus, M. o. B., Ben­nett, R. M., Bom­bardier, C., Gold­en­berg, D. L. et al. (1990). Cri­te­ria for the clas­si­fi­ca­tion of fibromyal­gia: Report of the mul­ti­cen­ter cri­te­ria com­mit­tee. Arthri­tis and Rheuma­tism, 33(2), 160–72.

Wood, P. B. (2004). Fibromyal­gia syn­drome: A cen­tral role for the hippocampus–A the­o­ret­i­cal con­struct. Jour­nal of Mus­cu­loskele­tal Pain, 12(1), 19. 

Yunus, M., Kahn, M., Rawl­ings, K., Green, J., Olson, J., & Shah, S. (1999). Genet­ic link­age analy­sis of mul­ti­case fam­i­lies with fibromyal­gia syn­drome. Jour­nal of Rheuma­tol­ogy, 26(2), 408–412.

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