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The Fibromyalgia Spectrum – Part of the Big Picture in Understanding Fibromyalgia

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Dr. Pellegrino has seen more than 25,000 FM patients in his practice at the Ohio Rehab Center, and has been a fibromyalgia patient himself since childhood.


As a senior resident at The Ohio State University in 1988, I gave a lecture on Fibromyalgia at the Physical Medicine Grand Rounds. One of my lecture slides was entitled “Fibromyalgia, A Spectrum of Conditions?”

I discussed how Fibromyalgia appears to be a “broader” condition with specific subsets. Fibromyalgia was in that area between normal and disease – the “gray” area.

Some of the subsets were closer to normal, involving regional pain only, or milder symptoms without numerous associated conditions. Some subsets were closer to abnormal, with some features of connective tissue or rheumatic diseases, but were not quite “there.”

Today I’m convinced Fibromyalgia is indeed a “broader” condition with various subsets. I believe this information is helpful in explaining why everyone’s symptoms are different even though they all have Fibromyalgia. This chapter addresses how the Fibromyalgia spectrum is part of the big picture in understanding Fibromyalgia.

Fibromyalgia Is a Distinct Medical
Entity, and Appropriately So

We have long recognized, however, that many conditions overlap it, and various conditions exist that can lead to secondary Fibromyalgia. Dr. Muhammad Yunus, MD, [a professor and FM specialist at the University of Illinois College of Medicine] has developed the concept of Dysregulation Spectrum Syndrome (DSS) to describe how conditions overlap.(1)

Dr. Yunus describes DSS as representing various associated conditions that share similar clinical characteristics and pathologic mechanisms with Fibromyalgia. Ten conditions are in the DSS umbrella: Fibromyalgia, Chronic Fatigue Syndrome, Irritable Bowel Syndrome, tension headaches, migraine headaches, primary dysmenorrhea, periodic limb movement disorder, restless leg syndrome, temporomandibular pain syndrome, and myofascial pain syndrome. He predicts other entities will be added to this list in the future.

[Note: Dr. Yunus is also a co-author of the American College of Rheumatology’s proposed new, broader, diagnostic criteria for Fibromyalgia, published May 13, 2010.]

According to Dr. Yunus, Conditions in DSS
Share a Number of Characteristics:

1. Patients with different conditions sharing similar profiles.

2. Common shared symptoms, such as pain, poor sleep, fatigue, and female predominance.

3. Hypersensitivity to pain.

4. No “diagnostic” pathology that can be measured.

5. Shared psychological complaints such as depression and anxiety.

6. Shared common genetic factor likely.

7. Common neurohormonal dysfunctions.

8. Treatments directed at the central nervous system leading to improvement.

9. TMJ [temporomandibular joint] dysfunction.

I have discussed the Fibromyalgia spectrum with my patients to help them understand the various subsets possible. I do not see Fibromyalgia as a member of a bigger family, but as the main condition. It is the “founding father” and keeps its name. If Fibromyalgia is the founding father, then the various overlapping conditions and subsets become the children. The name Fibromyalgia remains, but different subsets have unique characteristics and together they become the Fibromyalgia spectrum.

This diagram shows the concept of the Fibromyalgia spectrum. The Fibromyalgia entity partially overlaps with the normal entity on one side and the disease entity on the other side. Within the Fibromyalgia entity are 8 subsets. The first subset is in the most “normal” portion of Fibromyalgia, and the 8th subset is in the most “diseased” portion of Fibromyalgia. Each number represents a distinct subset with distinct characteristics.

The Eight Subsets of the
Fibromyalgia Spectrum Are:

1. Predisposed state
2. Prodromal [preceding] state
3. Undiagnosed Fibromyalgia
4. Regional Fibromyalgia
5. Generalized Fibromyalgia
6. Fibromyalgia with particular associated conditions
7. Fibromyalgia with coexisting mild disease
8. Secondary Fibromyalgia reactive to disease.

An individual can move up this spectrum – from a lower numbered subset to a higher numbered subset, but once in a particular subset, she/he does not return to a lower numbered subset. One can achieve a remission, but stays in that subset.

In other words, there is no going back. Let’s review the features of each subset.

Subset 1: Predisposed State

The individual is asymptomatic. Clinical Fibromyalgia is not present in this state.

The individual is at risk for developing Fibromyalgia due to hereditary factors, which may include one or both parents with Fibromyalgia or a rheumatic/connective tissue disease, or a sibling or first-degree relative with Fibromyalgia.

Subset 2: Prodromal State

Prodromal means preceding, or the state leading to the condition. Clinical Fibromyalgia is still not present. There is no widespread pain or painful tender points.

The individual is not asymptomatic, however. Associated conditions common with Fibromyalgia may be present in this stage, such as headaches, restless leg syndrome, fatigue, or irritable bowel syndrome. Pain may be present at times, but intermittently (not chronic, persistent pains). Even though the individual may have one or more associated condition(s), widespread persistent pain is not present, so therefore Fibromyalgia is not yet present.

Typical Fibromyalgia pain must be present before we can diagnose clinical Fibromyalgia, no matter how many associated conditions may be present, but those who have numerous associated conditions are at risk.

Subset 3: Undiagnosed Fibromyalgia

Chronic pain is now present, either regional or generalized in nature. This is the point of no return. The person has painful tender points which may or may not meet the American College of Rheumatology-defined 11 of 18 criteria.

The person in this stage usually has milder symptoms and has not yet seen a doctor or been officially diagnosed with Fibromyalgia. If this individual were to see a knowledgeable physician, that diagnosis would be made.

Subset 4: Regional Fibromyalgia

Individuals in this stage have been diagnosed with Fibromyalgia, but not generalized. Chronic pain is limited to one or a few areas such as the upper body or the low back. The symptoms may wax and wane.

Usually, this subset is triggered by a trauma. I believe myofascial pain syndrome is part of this regional Fibromyalgia, and both terms are essentially synonymous. Myofascial pain syndrome has become familiar through the work of the late Dr. Janet Travell, MD, and Dr. David Simons, MD.(2)

Myofascial pain syndrome is defined by painful muscles and the presence of triggerpoints and taut bands of muscle fibers which are ropey and painful when palpated. An involuntary shortening of the fibrous muscle band can create a local twitch response.

Some of those who work with myofascial pain syndrome will argue that it is a separate distinct entity from Fibromyalgia. I disagree. The similarities between myofascial pain syndrome and Fibromyalgia are far greater than their differences. They both have trigger points, tender points, ropey muscles, sympathetic nerve dysfunction, ATP abnormalities, peripheral and central mechanisms, regional and generalized versions, and associated conditions. Sound familiar? The treatments are essentially the same.

As our clinical experience has evolved and our knowledge and research have become more refined, I think it is clear that myofascial pain syndrome is a part of the overall Fibromyalgia spectrum.

Individuals with regional Fibromyalgia, over time, often develop generalized Fibromyalgia. Or they can remain in this stage indefinitely. Identifying the regional stage early and treating it can definitely help to prevent progression.

Subset 5: Generalized Fibromyalgia

Individuals in this stage have widespread pain and tender points. They will usually meet the American College of Rheumatology-defined 11 of 18 criteria, but as previously explained, one can still have generalized Fibromyalgia with fewer tender points.

Various associated conditions seen with Fibromyalgia can be present – sleep disorder, irritable bowel syndrome, depression, fatigue, and so on. These associated conditions are not taking on a life of their own, so to speak, but are part of the whole and managed with the overall Fibromyalgia treatment.

Regional Fibromyalgia can progress to this subset. Various causes of generalized Fibromyalgia include genetic factors, trauma, infections, and more, but secondary Fibromyalgia from a primary disease is not included in this subset.

Subset 6: Fibromyalgia with Particular Associated Conditions

People in this group have developed associated conditions that are giving them particular problems which appear as “separate” entities requiring separate attention. Some of these particular associated conditions include irritable bowel syndrome, chronic fatigue syndrome [ME/CFS], fatigue, tension/migraine headaches, and depression. None of these conditions in themselves have “classic” disease laboratory markers or cause tissue destruction, yet they may require treatments in addition to the overall Fibromyalgia treatment.

Another associated condition is dysautonomia (dysfunction of the small nerves), which can cause abnormalities such as hypoglycemia [low blood sugar], hypotension [low blood pressure], cardiac arrhythmia, irritable bowel syndrome, and vascular headaches.

Subset 7: Fibromyalgia with Coexisting Disease

Individuals in this category have a specific disease, and also have Fibromyalgia. The disease doesn’t necessarily cause Fibromyalgia, but can aggravate it if it’s already present. Examples of diseases that can be present and worsen the Fibromyalgia symptoms include:

• Hormonal problems (hypothyroidism, low estrogen, low growth hormone, and low cortisol)

Infectious problems (yeast, parasite or viral infections).

Low grade rheumatic or connective tissue disease (lupus, autoimmune disorders, dry eyes syndrome described by Dr. Don Goldenberg, MD, [Chief of Rheumatology at Newton-Wellesley Hospital and Professor of Medicine at Tufts University School of Medicine] may be part of a low grade Sjogren’s syndrome).

Arthritic conditions (cervical spinal stenosis, osteoarthritis, osteoporosis, scoliosis).

Neurological conditions (multiple sclerosis, polio sequelae, neuropathy, head injury residuals). For example, people who have both diabetes and Fibromyalgia will often have more painful Fibromyalgia because the diabetes caused the nerves to be more sensitive. Diabetes is a common cause of neuropathy, or damage to the small nerves, which is painful in itself and even more so with Fibromyalgia. One needs to keep the diabetes under good control to help the pain.

Lung conditions. I see a number of people who have Fibromyalgia along with a lung problem such as emphysema, asthma, chronic bronchitis, or heavy tobacco use. Cigarette smoking can increase Fibromyalgia pain. The nicotine in the smoke causes constriction of the blood vessels, decreasing blood flow, oxygen, and nutrients to the muscles, thereby increasing pain and spasms. Also, carbon monoxide in smoke enters the bloodstream and binds to the hemoglobin molecules in the blood. this blocks oxygen from binding to the hemoglobin, further decreasing oxygen availability to the muscles (and increasing pain). Stop smoking and your muscles will feel better!

These diseases exist concurrently with Fibromyalgia but probably do not cause it. Any of these diseases can progress from a mild to a more severe state, and Fibromyalgia worsens as the disease worsens. The physician determines if the disease is coexisting with and aggravating Fibromyalgia (subset 7), or if a disease caused the Fibromyalgia (subset 8).

Subset 8: Secondary Fibromyalgia Reactive to Disease

Individuals in this category have secondary Fibromyalgia. They have a primary disease (for example lupus, rheumatoid arthritis) – and Fibromyalgia developed as a result of this disease.

People in this subset probably wouldn’t have Fibromyalgia if they never had the primary disease. The primary disease requires treatment, and Fibromyalgia may improve with this treatment. However, the Fibromyalgia often requires its own treatment, and can continue to be a major problem even when the primary disease is treated or is in remission.

Overall – A Useful Explanatory Model

I find that the Fibromyalgia spectrum provides a useful clinical model for me when evaluating and treating my patients. It helps me to “organize” them better! When I diagnose Fibromyalgia, I try to be as specific as possible about what the cause is and what subset it fits. This helps me to better explain Fibromyalgia to the patients and to individualize their treatment programs.

Of course, if I’ve diagnosed Fibromyalgia it would be subset 4 or greater. The patient wouldn’t be seeking a medical consultation for subsets 3, 2, or 1. If possible, I note the cause. Each subset can have flare-ups or remissions within it, and I note that as well, if appropriate.

Subsets 1, 2, and 3 [predisposed state, prodromal state, undiagnosed Fibromyalgia] are useful in appreciating the progression of Fibromyalgia through the spectrum, and can be helpful when advising patients and family members who have specific concerns and questions.

Let’s Review Some Patient Profiles to Determine the
Subset they Fit into in the Fibromyalgia Spectrum

Patient #1
Mary is a 25-year-old receptionist with severe neck and shoulder pain. She had always been very active with aerobics and bicycling and had never had any pain requiring treatment until after a motor vehicle accident… when she was rear-ended and suffered a whiplash injury. The pain never went away, and when I saw her I found numerous painful tender points and trigger points with localized spasms in the neck and shoulder muscles.

Mary has regional Fibromyalgia (subset 4). She was most likely predisposed to Fibromyalgia, and a traumatic event triggered the development of her regional Fibromyalgia. She “leaped” from predisposed state (subset 1) to regional Fibromyalgia (subset 4).

Patient #2
Martha is a 30-year-old housewife. She was diagnosed with Fibromyalgia 5 years ago, and she was at a stable baseline with her home program of stretches, exercises, and using a hot tub.

In the past year, she has been having increasing pain and fatigue, and difficulty managing her Fibromyalgia. She reports that in the past year she has been getting frequent yeast infections. She is on birth control pills and has had a couple of bladder infections requiring antibiotics in the past year. Her more recent history is otherwise unremarkable.

Martha has Fibromyalgia with a coexisting disease – chronic yeast infection (subset 7). Her birth control pills, antibiotic treatment, and perhaps Fibromyalgia have contributed to the chronic yeast infection. In turn, the yeast infection has aggravated her Fibromyalgia. [See also Dr. Pellegrino’s explanation of “Candidiasis – Yeast Infection and Nutritional Repair.” ]

Patient #3
Jamie is a 38-year-old school teacher. She has lupus, diagnosed when she was 13 years old, and has been on various medications since then.

She has been in remission for a number of years, but has developed widespread pain. Her sedimentation rate is not elevated to suggest active inflammation. Her clinical exam does not reveal any joint inflammation or active lupus findings, but she does have 16 of 18 painful tender points.

Jamie has secondary Fibromyalgia from a disease (subset 8). In her case, the lupus is in remission, but her Fibromyalgia is causing her problems and needs to be treated.

Patient #4
Jamie’s 12-year-old son has been complaining of leg pains. The pains occur at nighttime, and Jamie has to rub the legs and use warm compresses. The pediatrician told her his pains were growing pains. Jamie’s son gets occasional headaches, and sometimes he feels exhausted. He plays many sports, and if he works out a lot his muscles are very sore for several days. On exam, there are no areas of pain or painful tender points.

Jamie’s son is probably in a prodromal state (subset 2). He is at risk because his mother has Fibromyalgia and a connective tissue disease, and he has some associated conditions with intermittent pains, but has not developed the persistent widespread pain or painful tender points yet.

Patient #5
Bob is 42 years old and has an awful lot of pain for his age. His pains are more severe than everyday pain, and sometimes he has had to miss work. He is an assembly line worker. He mentions this to his primary care doctor when he is there for his yearly physical. He is examined and found to have 12 of 18 positive painful tender points.

Bob had undiagnosed Fibromyalgia (subset 3) until he became official, “entering the books” with generalized Fibromyalgia (subset 5) after he saw his primary care doctor.

In Conclusion

There is much disagreement and controversy among medical professionals and patients about categories and subsets of Fibromyalgia or similar conditions. I’m not attempting to stir the waters with my version of the Fibromyalgia spectrum – rather I’m trying to help you understand the fairly complicated nature of the condition and the different types I see. I find this model useful and practical in my everyday clinical practice. Remember one of my mottos: Keep things as simple as possible and make sure they make sense!

[This chapter of Fibromyalgia: Up Close and Personal also offers a “Fibromyalgia Spectrum Test” that outlines several cases, posing questions about them, and provides the answers.]

* This article is excerpted with kind permission from Dr. Pellegrino’s very popular book, Fibromyalgia: Up Close and Personal.Published in 2005 by Anadem Publishing. © Anadem Publishing, Inc. and Mark Pellegrino, MD, 2005, all rights reserved. The book may now be purchased in the ProHealth.com store.

1. Mohammad B. Yunus, a professor at the University of Illinois College of Medicine, was the first to publish a study describing FM’s clinical characteristics 25 years ago. In 2000 he published the article, “Central Sensitivity Syndromes: A unified concept for Fibromyalgia and other similar maladies,” JIRA 2000;8:27-33. And recently in June 2007, Yunus, et al. published a report in the journal Seminars in Arthritis and Rheumatism suggesting that Fibromyalgia and overlapping disorders be categorized as “Central Sensitivity Syndromes” (CSS), based on “mutual associations” and evidence for central sensitization (hypersensitization of the central nervous system) among several of the disorders. See also “Fibromyalgia and Overlapping Disorders: The Unifying Concept of Central Sensitivity Syndromes.” And “Central Sensitivity Syndromes: A New Paradigm and Group Nosology for Fibromyalgia and Overlapping Conditions, and the Related Issue of Disease Versus Illness,” Jan 11, 2008.

2. Drs. Travell and Simons are authors of the two-volume set, Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual.

Note: This information has not been evaluated by the FDA. It is generic information only and is not meant to diagnose, treat, cure, or prevent any illness, disease, or condition. It is very important that you never make any change in your health support plan or regimen without first reviewing and discussing it collaboratively with your professional healthcare team.

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12 thoughts on “The Fibromyalgia Spectrum – Part of the Big Picture in Understanding Fibromyalgia”

  1. DeborahLynn says:

    I enjoyed this article, but wondered why Chronic Fatigue Syndrome wasn’t mentioned. I believe it should be included in the description of subsets 7 and 8. CFS often co-exists with Fibromyalgia. I was diagnosed with CFS two weeks after I was diagnosed with FM; both diagosises made after over four years of searching, with my symptoms increasing.

    Thank you so very much for the good information in this article! It puts FM in easier to understand stages.


  2. painfree73 says:

    I agree with you DeborahLynn. I was actually diagnosed with my CFS/ME in 1996 and diagnosed with Fibro in 2000. So I was to wondering why that didn’t get mentioned in any of the subsets. My fatigue is terrible, but come lately my pain is almost unbearable.


  3. waterrates says:

    Dear Doctor

    If what you say is true, we all MUST find a way to work with those in these early stages to save the from this horrible disease, fibromyalgia. The severe pain and aldenia came on me like a storm when I was only 8. I am now 52 and in stage 7. Without morphine and Lyrica I am a non-functional invalid.

    I think fibromyalglia is a malfunction in the pain pathways in the gut and brain. Like the way memories are developed in the brain in layers that become deeper and clearer over time,

    For example, you drive to a new friend’s house for the first time and get lost; the second time you study the directions at every turn, the third time you are not confident, but you remember the landmarks along the way. The next time you make it without difficulty. Later, you can make the drive there without even thinking about it. You know many details of the landmarks along the way. Decades later, you could drive there in you sleep and clearly remember the details of the things along the way.

    I believe pain and the memory of pain get’s laid down in the gut and brain in layers in a similar manner. You can call the pain back up at will through your memories. You can experience the pain again and again.

    How and why the system malfunctions so that pains start firing off all over the body for no good reason is the mystery. In my case, the years that I was 7 and 8 I lived in constant fear of my family breaking up and that if it did, no one wanted me. I was very anxious and depressed and worried about it daily. I continually thought about “what ifs” running bad event over and over in my mind. After I was exposed to hazardous chemicals, the fibromyalgia came on me like a storm. I had already laid down the perfect route for it by memorizing the details of every painful experience I had ever had. I got no sympathy or treatment until I was 45.

    The boy you mention in this article needs help. Ask him if he is thinking through his heartaches repeatedly. He and others in stage 1&2 need to know the risk and learn to “set your mind on things above” and not dwell on painful events and not call up memories of them.

    I hope to God you are wrong about the impossibility of moving downward on your scale.

    1. oneformikki68 says:

      Thank you for this article it helps people to understand that Fibromyalgia has several stages and you could be a part of any one of them. However, even though there are studies and headway being made in Fibro research there is still no real good treatment. All of the doctors I have seen for my conditions tell me that non of them are disabling, but my pain level is so great most of the time it is hard for me to go up or down my steps, then the other conditions kick in and I can’t leave the house. I haven’t been able to find a doctor that will acutally listen to me about what is going on with my body.

      Please continue the research because even though I haven’t found a doctor to help me, the information you give is very helpful. It helps me feel that I am not losing my mind!!!

    2. Susan17 says:

      I found this article helpful in clarifying the several stages of this disorder, most of which I have personally experienced. It is especially strengthening to realize that depression and anxiety are a part of the disorder, and not a psychosomatic symptom or reaction. To everyone who suffers from this, I want to say: it can be managed. I was diagnosed in 1999 after several years of near disability. Since then, I am much improved. Most of the time I am pain free, except for relapses which occur primarily when I am over stressed, over extended physically, or I eat something I shouldn’t. To achieve this state, I have used alternative health care practitioners almost exclusively, since Western trained doctors are completely unprepared to deal with this disorder. A fact which almost all of you know by now!

      There have been changes, however: now I mostly have to cope with CFS, a chronic exhaustion. I can do no exercise without tremendous pain the next day, and a 2-3 day recovery. I need a LOT of sleep; and wake up unrefreshed in any case. I have eliminated dairy, wheat, gluten, soy, and acid from my diet. It’s hard but it helps. EVen with all the dietary changes, I still struggle with weight gain, and find it hard to slim down.

      The primary health care system I use is Homeopathy. I strongly recommend you find a Homeopathic physician and consult him or her regularly. This is one system that really works and has no side effects, though it may take some time.

    3. grannycfs says:

      I too feel that Dr. Pelligrino should have discussed the subject of ME/CFS in relation to Fibromyalgia. I know there is much controvery with the primary issue being that CFS was given an erroneous name for a potentially very serious disorder. Myalgic Encephalomyelitis was defined decades ago. CFS research and awareness has suffered because of that mistake.

      Regardless, there’s much misdiagnosis because doctors are not aware of either disorder although perhaps more so ME/CFS. But the truth is that many, many have ME/CFS as the primary disorder just as he listed many other disorders that Fibromyalgia accompanies other disorders. I have primary ME/CFS with associated Fibromyalgia. I’ve had this nearly 25 years and was diagnosed by Dr. Lapp, one of the worlds leading experts.

      I find Dr. Pelligrino’s books to be very good but leaving out ME/CFS is a serious mistake for those patients who are going to end up being misdiagnosed.

    4. tebeling-siravo says:

      Great article and graphic. I plan on sharing this with my support group as well as my new doctor. It explains why all of us can have FMS, but have different and varying symptoms. I do agree that CFS should have been included since most of us have both. On a personal note, I KNEW smoking was not helping the FMS or RA….I needed to see it in print…hopefully this will help me quit for good.

    5. RNinpain says:

      I used to live about 25 miles from Dr. Pellegrino’s office in Ohio and he confirmed that I had fibromyalgia as my internist and I thought. I can’t say enough good things about him! I’ve never had a doctor talk to me for so long and take such an exhaustive history. Reading this article I am definitely a 7. Other than the fibro I’ve been “healthy” (if that word really even applies) but 2 months ago I suddenly had a seizue. I’ve never had a seizure in my life, and I am 44! None of the doctors can tell me why it happened, but I am certain that it’s the fibro. Considering that fibro is now pretty much regarded as a neurological problem, it only makes sense that it’s the reason for the seizure. So now I have yet another pill to swallow — WooHoo!!

    6. Daisys says:

      My condition started as ME (in 78 before anyone knew anything about it), progressed to diagnosed FM in the early 90’s, and stayed somewhat steady: relasping, sort of remitting, for years until I entered menopause._____

      Then my condition got much worse, and I happened to find a doctor who recognised Lyme disease, and has treated me for over 2 years. I’m now on maintenance herbs, diet, etc. to manage the Lyme infections, which has gradually gone away, but I seem to be left with CFS/ME and FM._____

      It’s very frustrating to work so hard, and end back in a state of almost total inactivity, especially now that the brain fog is gone: my mind is raring to go, but the body just won’t move._____

      An important point I’d like to make: When I went to the Lyme forums, I found most had been diagnosed with ME and FM before finding out they had lyme disease all along. That “flu that never goes away” could well be the initial bite and infection infiltration. Most don’t see the bull’s eye that is the bugs moving away from the site of entry._______

      I think everyone who has these conditions should try to find a lyme literate medical professional to rule out (or in) the possibility of Lyme disease.

    7. Rosamelle says:

      This article by Dr Pellegrino has opened my eyes to some of the why’s of what is going on with my body. I live with nearly all of the conditons that are secondary to Fibro. In addition to that I have scoliosis with soft tissue damage at L3 to L5 of the spine (pain daily0, chronic depression, CMP, carpel tunnel, heel spur, thyroid disease, and the list goes on. I choose what I will do on a daily basis based on what hurts the most. I find that the weather changes also contribute greatly to making some of the conditions worse. Luckily I do not have to work anymore, but the low pension is a challenge. I have also found that a lot of organizations do not recognize Fibromyalgia as a real condition. Whether it be good or bad it sure would be appropriate to have Fibromyalgia classified appropriately as a REAL condition or dare I say a disease.

    8. IanH says:

      I have always used Professor Yunus’ idea to help me understand my familial illness. I like Doctor Pellegrino’s very practical book too. However I think very differently about fibromyalgia. To me it is always a symptom of an underlying illness with an unidentified cause. I think the same about chronic fatigue and irritable bowel and other symptoms associated with these conditions.

      Recently good studies are pointing us strongly in the direction of infection being a major cause of unrelenting fibromyalgia. If not the infection itself then an immune system dysfunction which doesn’t easily correct itself. Most people with CFS/ME have fibromyalgia. Most people with FMS have post exertional fatigue.
      Studies by Prof Alan Light have demonstrated the underlying immunological dysfunction occurring after exertion in people with CFS and FMS. It is outstanding work. The cytokine upregulation of substanceP, IL-1b, IL-6 and IL-13 and many other neuropeptides explain the pain amplification and possibly the ibs and some of the fatigue. More work is needed to relate the many other symptoms but no doubt there is research around which can relate the syptoms to immunological factors.

      I don’t think you get fibromyalgia because you have CFS or vice versa. I think they are both consequences of an underlying illness/infection state. Some people will get more pain, some people will get more fatigue, still others will be bugged mainly by IBS. These differences are probably as a result of genetics and historical behaviour.


      Someone like me who developed bad postural habits, then suffered a car accident with consequent cervical, lumber and thoracic (minor) injury is a sitting duck for fibromyalgia, if I get the infection, because I have pain sources. Without the infection they are just minor niggles now and then – at least that is what an MRI would predict.

      The first Rheumatologist I saw diagnosed reactive arthropathy. He focused on the severe bouts of diarrhea, fibromyalgia and muscle cramps. He was wrong. The treatment failed to help after one year.

      The second Rheumatologist diagnosed FMS and Rx amitriptyline (a tricyclic antidepressant). This reduced the pain to a more tolerable half but did little for the fatigue, cramps and diarrhea.

      Then I read Prof Yunus’ paper and I realised that FMS was just a label to describe one lot of prominent symptoms which the Rheumatologist was oriented to diagnose as an illness.

      Then my wife and daughter became ill. With the same set of symptoms – just in a different degree:
      Symptoms in order of disabling effect:
      ME: fibromyalgia, post exertional fatigue, muscle cramps, diarrhea, orthostatic intolerance, new vascular headaches, memory problems, insomnia, vertigo, trembling, jerks and cognitive fuzz.
      WIFE: severe p.e. fatigue, trembling, diarrhea, jerks, cognitive fuzz, fibromyalgia, diplopia, memory problems, orthostatic intolerance, general dystonia.
      DAUGHTER: cognitive fuzz, diarrhea, candidiasis, multiple chemical sensitivity, fibromyalgia, orthostatic intolerance, p.e. fatigue, excessive unrestful sleep.

      My wife was diagnosed CFS and my daughter was diagnosed MCS by different Physicians of course. Now it seems highly unlikely that we have three people in such close relationship with totally different illnesses.

      I believe we do not have different illnesses but we differ in our symptoms. My daughter was a world champion athlete and doesn’t have pain sources to be magnified but she has had allergic sensitivities for many years. My wife has been a very energetic boom or bust driving sort of person who has suffered a few crashes of energy in the past.

      The point I am driving at is that it is possibly the genetic and lifestyle differences which account for much of the differences in symptoms, not the different symptomatic labels given to the illness.

      So I do adhere to Prof Yunus theory but maybe go one step further and say this is a hypersensitivity neuro-immune dysfunction.

    9. IanH says:

      Like you, after many years of fms/cfs I had several collapses rendering me unconscious for several seconds which appeared to be a seizure but was actually probably caused by taking DHC (dihydrocodeine) in conjunction with neurontin (gabapentin) for pain. I could feel the collapse coming on for a few seconds with a strange disorientation and vertigo. Having been off the DHC/gabapentin for 11 months now I have had no further problems. You may have another underlying illness but I would check on the drugs if you are taking any. Iatrogenic (medically induced) complications are common in these illness.

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