Fibromyalgia: A problem of over diagnosis of psychiatric disorders? Under diagnosis of cervical spine instability?

Ross Hauser MD,

Fibromyalgia syndrome (FMS) is a chronic disorder affecting mostly women. The condition is characterized by widespread musculoskeletal pain, fatigue, poor sleeping patterns, and multiple tender points that occur in precise, localized areas, particularly in the neck, spine, shoulders, and hips. There is also controversy surrounding a fibromyalgia diagnosis. Let’s explore that controversy first.

The long and winding road of Fibromyalgia

In December 2022, Professor Anne Marit Mengshoel of the University of Oslo wrote in the International Journal of Qualitative Studies on Health and Well-being (1): “Fibromyalgia is a contested (controversial) illness with unknown (origins) and poorly understood development. (The aim of this study) is to explore the pre-diagnostic illness trajectory narrated by individuals recently diagnosed with fibromyalgia.” In other words, what medical journey did these patients go on and what challenges did they face until they were eventually diagnosed with fibromyalgia? In this paper “Individual interviews about the course of the illness were conducted with seven women and three men (age from early 20s to 50s) who had recently been diagnosed with fibromyalgia.”

Results: The findings are expressed in three storylines.

  1. The patient considered themselves as having a “strenuous life.” One they described as difficult and without support.  They suffered from a disease or condition that may fall within fibromyalgia symptomology diagnosed before the fibromyalgia diagnosis. They have bodily sensitivity to stimuli, beyond pain, perhaps light or sound sensitivity.
  2. They suffered from chronic and recurrent pains that hampered their lifestyle. Patients were pushing themselves to meet social obligations until they were unable physically to meet these obligations.
  3. They were somewhat relieved to be diagnosed with fibromyalgia and felt the diagnosis helped in being supported by others, but they were concerned that there are still no solutions regarding what to do about it.

In summary: “The three storylines portray a long, winding trajectory of suffering starting before the onset of illness and unfolding illness gradually becoming persistent and overwhelming. Finally, a diagnosis of fibromyalgia is arrived at, but how the situation will evolve is uncertain.”

Most doctors don’t believe that there is a single cause of fibromyalgia

Fibromyalgia; one terrible condition among many:

This is an email we received, it has been edited:

“I have been diagnosed with hEDS, POTS, Dysautonomia, Mast cell activation syndrome, fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, migraines, allergies/food intolerances, exercise intolerance, light/noise/smell/chemical sensitivity, balance/gait problems, neuropathy, neck and left shoulder injuries, multiple motor vehicle accidents . . . I want to get rid of constant neck pain and headaches. I have been referred to the neurologist, saying surgery will not help. Here I am more than a year later still looking for treatments that help.”

Most doctors don’t believe that there is a single cause of fibromyalgia. Rather, medicine points to a number of different factors and this is what makes isolating a single diagnosis that can be treated with a single protocol impossible and creates the difficulty in offering a treatment program.

  • Some doctors attribute the condition to a reduced amount of serotonin and the substance P (an amino acid) in the brain, which also has been linked to depression, migraines, pain, and gastrointestinal disorders.
  • Some researchers theorize that disturbed sleep patterns may be a cause rather than just a symptom of fibromyalgia.
  • An injury to the upper spinal region has been shown to trigger the development of fibromyalgia in some people.
  • And still, other researchers believe that a viral or bacterial infection may trigger fibromyalgia.

Although these are all possible contributors to the condition, we find that many of the people suffering from fibromyalgia experience this pain as a result of ligament weakness from degenerative diseases like osteoarthritis, injury, or repetitive use damage.

In compensating for the ligament weakness, other areas of the body, including tendons and muscles, can be afflicted with referred pain. In this case, the fatigue, poor sleeping patterns, and tender points associated with this condition are results of ligament damage rather than causes of the condition.

Many doctors do not follow fibromyalgia guidelines

In December 2023, an international team of doctors writing in the Pain practice : the official journal of World Institute of Pain (26) conducted a worldwide survey in which they investigated whether medical doctors are familiar with the American College of Rheumatology (ACR) criteria for fibromyalgia and, if so, whether these medical doctors adhere to the clinical guidelines following evidence-based treatments.

  • In total, 286 medical doctors from 43 countries spread over 6 continents filled out the survey. In most of the countries, the diagnosis fibromyalgia was used.
  • Only 10% adhere to the ACR criteria, widespread pain (44%), unrefreshed sleep (24%), fatigue (20%) and cognitive problems (8%) were most used diagnostic criteria.
  • Of the respondents, 94 (32%) mentioned that the cause is unknown or idiopathic, but also a wide variety of other causes was mentioned.
  • More than 70 different treatment options were provided, of which 24% of the responses were classified as according to the clinical guidelines.

From this study, the doctors concluded that many medical doctors do not follow the ACR criteria; the majority has an inappropriate knowledge of causes for fibromyalgia and that a minority of treatment advice adhere to the guidelines.

Doctors may make Fibromyalgia worse

In December 2023, specialists in France writing in the journal Frontiers in medicine (27) reported on 19 adult patients with fibromyalgia, primarily middle-aged women (84% women, mean age 49.8 years), recruited from two university centers in Paris. The patients revealed these thoughts in regards to their health care:

  • Substantial suffering and considerable functional impairment
  • An ongoing sense of loss of control, exacerbated by an imbalanced patient-doctor relationship.
  • Patients constantly feared not being heard or believed, and they frequently sought attention from their caregivers.
  • Most participants displayed significant ambivalence (a conflicting feeling) toward the nature of their condition and actively sought causal links (all their problems are connected in some way).
  • Patients’ adaptive strategies sometimes worsened their symptoms, as in the case of muscular deconditioning. (They stop doing activities that are painful. This causes loss of muscle. Loss of muscle makes activities painful).
  • The healthcare system appeared deficient in managing these patients, characterized by a lack of health professional training, frequent inappropriate responses from healthcare providers, and stigmatization of psychological conditions.
  • Doctors perceive fibromyalgia as a benign condition. The authors suggest it should be treated as a  severe condition due to its substantial long-term consequences.

Overdiagnosis of psychiatric disorders

The controversy surrounding fibromyalgia is that few treatments seem to help. After more unsuccessful treatments are noted, the pain sufferer will be sent to a pain center where the diagnosis of depression will be made. (See our article When Depression and Anxiety Prevent Healing). After several thousands of dollars of treatment, diagnostic tests, and a lot of frustration and misery, the person will be given that all-inclusive, “so everyone will know I’m not crazy” diagnosis: fibromyalgia. Nearly anyone who has had pain long enough and seeks enough medical opinions will eventually be labeled with this diagnosis.

The 18 trigger points of Fibromyalgia

Fibromyalgia and myofascial pain syndrome are often diagnosed in the same patient. Myofascial pain syndrome (MPS) is a common painful muscle disorder caused by taut bands or trigger points in the muscles. Myofascial trigger points are tender areas in muscles causing local and referred muscle pain. Trigger points may cause tight muscles and tight muscles may cause trigger points.

To make the diagnosis of fibromyalgia, one of the cardinal features is tenderness over specific points on the body. The diagnosis is made when at least 11 of the 18 points are tender. The unilateral sites are the occiput (insertion of the suboccipital muscles), inter-transverse ligaments C5 through C7, trapezius muscle, the origin of the supraspinatus muscle, the second costochondral junction (ligament), lateral epicondyle (wrist extensor muscle insertions), gluteal area (gluteus maximus muscle), greater trochanter (gluteus medius muscle insertion), and the medial fat pad of the knee (medial collateral ligament).

In essence, 14 of the 18 points are located where either a ligament, tendon, or muscle inserts, and the remaining four are in the middle of a particular muscle. As we discuss below, Prolotherapy injections help to promote ligament, tendon, and muscle tissue growth where they attach to the bone, alleviating and possibly eliminating trigger points and the pain of fibromyalgia.

“Our findings also suggest avoiding repeated or unnecessary rule-out tests and the over-diagnosis of psychiatric disorders is necessary.”

overdiagnosis of psychiatric disorders

Let’s look at doctors in Finland, writing about their experiences with fibromyalgia patients in the medical journal The European Journal of General Practice, December 2022. (2)

“Fibromyalgia is a functional syndrome. Despite recent findings, there is still considerable uncertainty about its diagnostic process. . .  The main unifying entities (characteristics among patients) were the uncertainty and contradictions fibromyalgia patients faced on several occasions (Confusing diagnosis). Physicians sometimes offered other diagnoses – like depression – as an explanation for the symptoms, or used repetitive tests to eliminate other possible diagnoses. Furthermore, patients expressed their wishes for a holistic, empathetic, and up-to-date approach to their symptoms. . . . In our interviews, a good doctor-patient relationship and continuity of care were necessary, as were the physician’s attitude and knowledge of fibromyalgia. Our findings also suggest avoiding repeated or unnecessary rule-out tests and the overdiagnosis of psychiatric disorders is necessary.”

The diagnosis of fibromyalgia remains controversial “that still lack either a gold standard or at least supportive laboratory findings.”

As we see, in recent research, the medical community acknowledges that the diagnosis of fibromyalgia remains controversial. Further, offering a diagnosis of fibromyalgia may lead to patients’ “over-medicalization,” whereas others have raised concerns about under-diagnosing Fibromyalgia and under-treatment for patients.

In a November 2020 paper in the International Journal of Molecular Sciences (3) Dr. Massimo E. Maffei of the Department of Life Sciences and Systems Biology, University of Turin wrote: “Diagnosis of fibromyalgia is based on clinical features and criteria that still lack either a gold standard or at least supportive laboratory findings. Fibromyalgia diagnostic criteria may include heterogeneous (a mixed group without an obvious connection to the cause of their symptoms) patients also in clinical trials and this may impair evaluation of clinically meaningful treatment effect.”

The review of the literature suggests that a multidisciplinary therapeutic approach, based on the combination of pharmacologic and alternative therapy (including thermal, light, electrostimulation, and body exercise treatments) could improve the quality of life and reduce pain and other symptoms related to fibromyalgia. However, sometimes the ability of patients to participate in alternative therapies is impeded by the level of pain fatigue, poor sleep, and cognitive dysfunction. These patients may need to be managed with medications before initiating nonpharmacologic therapies.”

In other words, fibromyalgia is hard to diagnose and it is better to talk to the patient and be proactive in treatment while neither overmedicating nor undertreating, however, medications may be necessary.

In the image below, the common symptoms of fibromyalgia are shown. The symptoms are listed below and linked to other articles on our site that address these problems.

 

the common symptoms of fibromyalgia

Many of these symptoms are also seen in patients with cervical spine instability, the links will take you to articles that may explain these connections. I will also discuss this subject further below.

Symptoms:

Loss of memory and cognitive performance in women with fibromyalgia. By the time of diagnosis, how much cognitive decline is there?

During COVID-19, many patients, and in the case of this study, women, could not get a diagnostic evaluation for their symptoms. A September 2022 paper in the journal Applied Neuropsychology. Adult (4) aimed to obtain evidence of the role of pain and the effect of time since fibromyalgia diagnosis and cognitive performance using a novel online protocol of neuropsychological evaluation. This novel or online approach was developed during the COVID-19 pandemic. A sample of 70 adult women was evaluated (50 with fibromyalgia and 19 controls) using online questionnaires that evaluated pain and executive functioning (impulsivity, inhibition control, monitoring, and planning). Afterward, participants were evaluated by trained neuropsychologists in a 30 min online session using virtually adapted cognitive tests.

The delayed diagnosis did matter

In their results, the researchers found: “the role of pain as a mediator on cognitive performance, specifically in executive functions which are directly affected by the cumulative effect of the time of diagnosis. Furthermore, the importance of considering a broader perspective for assessment and treatment including novel procedures via tele-neuropsychology.”

Long-Term Effects of Fibromyalgia Pain – Changes in the brain

Long-Term Effects of Fibromyalgia Pain - Changes in the brain

Recent research is showing that living with fibromyalgia pain is not a viable option. In fact, it is now known that living with fibromyalgia causes significant changes in the brain. Let’s start with a 2007 study and work our way forward. In this study researchers at McGill University’s McGill Centre for Research on Pain wrote in The Journal of Neuroscience (5) compared brain images of 10 women with fibromyalgia to 10 women without fibromyalgia. Results showed that there was a significantly lower amount of gray matter in the brain in women with fibromyalgia. The researchers wrote: “The longer the individuals had had fibromyalgia, the greater the gray matter loss, with each year of fibromyalgia being equivalent to 9.5 times the loss in normal aging.” Gray matter plays an integral role in the central nervous system. Although gray matter loss naturally occurs with age, it appears to occur three times faster in people with fibromyalgia. The researchers stated: “In particular, fibromyalgia appears to be associated with an acceleration of age-related changes in the very substance of the brain. . . These findings reveal for the first time that patients with fibromyalgia have brain gray matter atrophy. Interestingly, the normal age-related decrease in gray matter was accelerated in fibromyalgia patients and related to disease duration.”

Chronic pain, as demonstrated in Fibromyalgia, can cause cognitively impaired

This research was used as reference material in the following studies, in February 2022 a paper in the Journal of the American Geriatrics Society (6). In this study the association between the persistence of pain and its relationship to cognitive problems in older adults such as cognitive performance, cognitive impairment, and subjective memory decline. What the researchers found was “Persistence of pain presence was associated with an increased risk of cognitive impairment. Only the persistence of pain interference (chronic, stubborn pain), not pain intensity (severity), was significantly associated with poorer cognitive performance or being classified as cognitively impaired. (In other words, no matter the intensity of pain, chronic long-term pain was significantly associated with cognitive impairment.)

Further:

  • “For every 2 years, the persistence of pain interference was associated with 21% increased odds of cognitive impairment. . . “Persistence of pain is associated with poorer cognitive performance in community-dwelling older adults, especially when involving ongoing interference in chores and work. Facilitating pain management might be important for helping to maintain later-life cognition and reduce dementia risk.”

Self-stretching for fibromyalgia and myofascial pain syndrome

The illustration shows the upper trapezius muscles.

In an October 2022 study (7) researchers assessed a clinical trial of self-stretching with and without mindful breathing (an eyes-closed period before and after the self-stretching while concentrating on deep breathing) and the intervention’s immediate effect on pressure pain and range of motion in myofascial pain syndrome. Stretching poses were performed at least four times repeatedly and held for 150 seconds per pose.

  • The participants were 30 females per group, aged 30-59 years with myofascial pain syndrome (MPS).
  • The participants were evaluated via the pressure pain threshold (PPT) at the upper trapezius muscles and the cervical neck range of motion.

Results: Both groups (stretching alone and stretching with breathing) showed that the pressure pain threshold (PPT) at the upper trapezius muscles significantly increased after performing the stretching. The cervical neck range of motion in the stretching/breathing group significantly increased in extension, left and right lateral flexion, and left rotation. The researchers concluded: “Since this treatment is a non-pharmacological intervention and was considered as part of active self-care, we suggest that this therapy could be used as an alternative therapy for patients with myofascial pain syndrome.”

The role of anxiety and depression – “the behavior of avoiding activity due to pain-induced fear exacerbates the pain and even contributes to its chronicity”

A September 2022 paper in the journal Medicine (8) aimed to determine whether there is a relationship between fibromyalgia and depression, anxiety, anxiety sensitivity, fear-avoidance beliefs, and quality of life in female patients with a diagnosis of fibromyalgia. The researchers wrote: “In fibromyalgia patients, it has been determined that anxiety, depression and perceived pain severity reduce social functionality and quality of life in areas such as mental health, physical function, and emotional role difficulties. It was determined that the functionality and quality of life of patients diagnosed with fibromyalgia decreased in daily life. An important contribution of the study to the literature is that it shows that the behavior of avoiding activity due to pain-induced fear exacerbates the pain and even contributes to its chronicity. These results, which show the effects of anxiety, depression, anxiety sensitivity, and fear-avoidance behavior on the prognosis of the disease in the behavior of avoiding activity due to pain-induced fear exacerbates the pain and even contributes to its chronicity patients, indicate that psychiatric evaluation and treatment in FM patients is an important factor that determines the functionality and quality of life.”

Amitriptyline and Duloxetine

A May 2022 study in the JAMA network open (9), a companion journal to the Journal of the American Medical Association (JAMA) compared Amitriptyline (a depression and nerve pain medication which is also an off-label treatment for fibromyalgia and current US Food and Drug Administration-Approved Treatments for Fibromyalgia:  pregabalin, duloxetine, and milnacipran. A total of 36 studies (11,930 patients) were included.

In this study following doses were compared:

  • 60-mg and 120-mg duloxetine;
  • 150-mg, 300-mg, 450-mg, and 600-mg pregabalin;
  • 100-mg and 200-mg milnacipran;
  • and amitriptyline.

Average patient profile:

  • The average age of the patients was 48.4 (10.4) year
  • 11,261 patients (94.4%) were women.

Compared with placebo:

  • Amitriptyline was associated with reduced sleep disturbances, fatigue, and improved quality of life.
  • Duloxetine 120 mg was associated with the highest improvement in pain and depression vs placebo.
  • All treatments were associated with inferior acceptability (higher dropout rate) than placebo, except amitriptyline.
  • Duloxetine 120 mg was associated with higher efficacy for treating pain and depression, while amitriptyline was associated with higher efficacy for improving sleep, fatigue, and overall quality of life.

The role of chronic opioid therapy in the treatment of Fibromyalgia

A person writes us an email: It has been edited for clarity:

“My goals are to come off of my current medications, eventually, I know this may be a long-term goal. I would like to feel mentally sharper, more like my old self.”

In October 2016, (10) Doctors from the University of Washington published findings on chronic pain-killer medications and fibromyalgia:

  • Many consider chronic opioid therapy to be ineffective for fibromyalgia
  • Among patients who discontinued opioids by 12 months, those with fibromyalgia were more likely to report bothersome side effects and less likely to report pain improvement as important reasons for discontinuation
  • Among patients continuing chronic opioid therapy, pain and activity interference outcomes were worse.

Medications often given to treat fibromyalgia such as NSAIDs and narcotics inhibit the normal inflammatory healing cascade. They prevent healing.

Why fibromyalgia patients stopped taking opioids: side-effects and the opioids were not helping their pain.

A July 2022 paper in the International Association for the Study of Pain’s journal Pain Reports (11), wrote: “Many consider chronic opioid therapy to be ineffective for fibromyalgia, but empirical (the observable benefit seen in patients) evidence is limited. Among patients identified as initiating chronic opioid therapy, (the researchers) examined whether fibromyalgia was associated with different relationships of opioid use to pain and activity interference outcomes 12 months later. (In other words, what was the opioid usage compared to perceived pain in the fibromyalgia patients? Did fibromyalgia patients need more? Fewer opioids?)

The researchers examined the medical records of 429 patients diagnosed with fibromyalgia. They looked at the patient’s pain symptoms and opioid response at baseline, four, and 12 months.

  • Patients with and without fibromyalgia who had intermittent/lower-dose or regular/higher-dose opioid use at 12 months had similar 12-month pain intensity scores. However, among patients with minimal/no opioid use at 12 months, 12-month pain intensity was greater for those with fibromyalgia than for those without. (What is being said is that patients with pain, using opioids, whether they had fibromyalgia or not, had similar pain responses.)
  • “Among patients who discontinued opioids by 12 months, those with fibromyalgia were more likely to report bothersome side effects and less likely to report pain improvement as important reasons for discontinuation.”
  • “In sum, at 12 months, among patients who had discontinued opioids or used them minimally, those with fibromyalgia had worse outcomes and were less likely to have discontinued because of pain improvement.”

Low-dose naltrexone (LDN)

A June 2023 study (12) from Emory University researchers examined the use of Low-Dose Naltrexone (LDN) for chronic pain. They write: Low-dose naltrexone (LDN) has increased in popularity as a non-opioid medication that may decrease chronic pain symptoms. Low-Dose Naltrexone is most commonly used to treat fibromyalgia, complex regional pain syndrome (CRPS), and painful diabetic neuropathy. Other studies suggest that Low-Dose Naltrexone provides general symptom reduction in inflammatory conditions such as Crohn’s disease and multiple sclerosis.”

Here the researchers gave outcomes of their own patients.

  • Low-Dose Naltrexone (LDN) was prescribed to 137 patients. 44% of these patients had no evidence of ever filling the prescription, and 4.4% of the responses were not charted. Of the remaining 70 who took LDN, 64% had some relief and were designated as ‘Responders’.
  • The most common pain diagnosis was neuropathic pain which, when added to the diagnosis of complex regional pain syndrome, accounted for 51% of responders to LDN.
  • Patients who experienced greater than 50% pain relief from LDN were more likely to have the diagnosis of neuropathic pain or complex regional pain syndrome
  • Patients with spondylosis were much less likely to respond to LDN when compared with other diagnoses.

An April 2023 study from the Mayo Clinic (13) identified that a majority of patients (65%) who took LDN for any pain indication reported a benefit in their pain symptoms. A significant portion of this study group comprised patients with fibromyalgia, which is an often challenging condition to diagnose and treat.

Most prescribing physicians were from integrative medicine/fibromyalgia clinics (29%), primary care (19%), and neurology (19%). Pain medicine physicians comprised only a small portion of prescribing physicians (13%). One suggestion for the low rate of prescribing among the pain physician group was many specialties may be unfamiliar with LDN as an analgesic due to its limited evidence base in chronic pain treatment and concerns for its side effect profile and its potential interaction with opioid medications. The authors noted a high rate of discontinuation (36%) of LDN in the current study.

It is difficult to tell if exercise is working for fibromyalgia patients.

Woman doing tai chi exercise.

It is difficult to tell if exercise is working for fibromyalgia patients

Intuitively some patients know if exercise is helping because they feel better. Doctors however have a hard time making these feel better results show up in data. This is expressed by Greek doctors and researchers writing in November 2022 in the medical journal Rheumatology International (14)

“For many years, pharmaceutical management of pain was the mainstay of treatment. In the latest decade, conventional low-impact aerobic exercise and complementary and alternative medical (CAM) exercise have become important when structuring a personalized therapeutic plan, since side effects are practically inexistent. Heterogenous (mixed group) studies with different methodological approaches have failed to display a clear clinical effect.”

In this study, the researchers conducted a systematic review with a meta-analysis of clinical trials putting emphasis on standardized measurable outcomes (Fibromyalgia Impact Questionnaire, FIQ). They wanted to put numbers with symptom improvement to show complementary and alternative medical (CAM) exercise’s effect.

After analyzing 14 studies, including 886 patients, the researchers demonstrated that complementary and alternative medical (CAM) exercise had a beneficial effect on patients’ Fibromyalgia Impact Questionnaire and FIQ score reports. Dance and Tai chi had a more profound effect. “However, the risk of bias was overall medium to high and statistical heterogeneity (too mixed to make definitive conclusions) was very high. . . Even though more experimental studies should be done on this subject, CAM exercise seems beneficial for patients with Fibromyalgia.

A November 2022 paper in the journal Rheumatology International (15) tested the effects of different programs of physical exercise on fibromyalgia symptoms.

In reviewing 16 previously published studies on the subject of exercise and fibromyalgia, the researchers noted that exercise showed good evidence for providing a reduction in the Fibromyalgia Impact Questionnaire, FIQ score. They suggested that exercise programs lasting 13-24 weeks should be used to reduce pain, and each session should last between 30 and 60 minutes. In addition, the intensity should always be carried out gradually and progressively.

Pain, fear of pain, fibromyalgia, and obesity

A September 2022 study published in the Journal of pain research (16) evaluated the role of pain catastrophizing, kinesiophobia (fear of movement), and pain acceptance as mediators of the association between perceived pain severity and physical functioning in individuals with fibromyalgia and obesity.

  • 165 women with fibromyalgia and obesity completed self-report questionnaires of perceived pain severity, pain catastrophizing, kinesiophobia, pain acceptance, and perceived physical functioning In addition, a performance-based test (ie, a 6-minute walking test) was conducted to assess objective physical functioning.
  • Results: Pain acceptance and kinesiophobia mediated the relationship between pain severity and self-reported physical functioning. Pain catastrophizing and kinesiophobia mediated the relationship between pain severity and performance-based functioning. What does this mean? People who accepted their pain and those with a fear of movement had different outcomes, according to the researchers.

Conclusion: Pain acceptance, kinesiophobia, and pain catastrophizing should be addressed in rehabilitative intervention to improve physical functioning. Interestingly, the subjective and objective aspects of physical functioning are influenced by different factors. Therefore, interventions for women with fibromyalgia and obesity should focus on factors related to both subjective and performance-based physical functioning.

Hyperbaric oxygen treatment

A March 2021 study in the journal Diving and hyperbaric medicine (17) wrote: “A broad spectrum of conditions including neuropathic pain, complex regional pain syndrome (CRPS) and fibromyalgia, have been implicated as causes of chronic pain. There is a need for new and effective treatments that patients can tolerate without significant adverse effects. One potential intervention is hyperbaric oxygen treatment (HBOT).” In a case report of a patient with complex regional pain syndrome (CRPS), it was shown successful as a treatment.

Fibromyalgia and cervical spine instability

In this section, we will present the evidence that a large number of fibromyalgia patients have neck instability and that this neck instability may be the cause of the patient’s fibromyalgia.

“A straight neck without other radiographic abnormalities may be a major anatomical abnormality in fibromyalgia that has gone unnoticed.”

Researchers from Rush Medical University and Northwestern University Medical Center published a March 2023 paper in the Journal of clinical rheumatology (18) suggesting “a straight cervical spine is an underappreciated and often overlooked finding in fibromyalgia.” What is the significance of this? Let’s explore the research findings:

The researchers looked at 270 cervical spine radiographs of consecutive patients with neck pain, Of these patients, one hundred fifty-five patients met full American College of Rheumatology criteria for fibromyalgia.

What the researchers found was “Most patients with fibromyalgia share an abnormality in common that is verifiable by a simple radiograph (Abnormal cervical spine curves). In 83.2% of the patients, the cervical spine was essentially straight (Cobb angle ≤10 degrees).” Let’s explain the Cobb angle and the significance of these findings.

The Cobb Angle measures the curvature of the cervical spine. The caption of this image reads: “As the cervical curve breaks down because of ligamentous cervical instability, the Cobb angle not only decreases (the spine is straightening and losing its natural curve) but as the lordotic curve becomes kyphotic, the atlas and dens of the axis protrude forward increasing the C6-atlas interval (and demonstrating Atlantoaxial instability and Atlas displacement.)

In the conclusion to their research, the Rush Medical University and Northwestern University Medical Center investigators found: “In fibromyalgia patients, the loss of cervical curvature was approximately 6.5 times greater than in control subjects (50.3% vs. 7.8%). A straight neck without other radiographic abnormalities may be a major anatomical abnormality in fibromyalgia that has gone unnoticed. It may assist in the diagnosis, as well as suggest increased muscle tension/pressure as a possible etiology.”

In other words, muscle spasms in the neck, caused by cervical spine instability, maybe a component or cause of Fibromyalgia symptoms.

Text neck and Fibromyalgia

We are going to start with a May 2023 case history presented by doctors at Kochi Medical School, Kochi University in Japan, and published in the journal Rheumatology (19). In this case history the doctors reported on a 50-year-old man with pain around the head, neck, and shoulder blades and paraesthesia in both upper limbs. He had been treated with painkillers for 7 years for suspected fibromyalgia, but the symptoms did not improve. He had normal inflammatory markers (C-reactive protein and matrix metalloproteinase-3 levels). Serological (looking for viruses or antibodies) test results were negative. However, radiography and magnetic resonance imaging revealed a straightening of the cervical spine.

At this point, the doctors corrected the diagnosis from fibromyalgia to a cervical spine disorder or more specifically a diagnosis of “text neck syndrome.” The patient was educated to take frequent rests and raise his smartphone to eye level while texting. His neck pain was reduced, and neurological symptoms resolved. The doctors here warned clinicians that they should be aware of the risk of ineffective treatment for fibromyalgia due to misdiagnosis. They also warned that “if untreated, text neck can cause problems such as cervical curvature alteration, neck and shoulder strain, impaired neck muscle perception, posterior ligamentous injury, and entrapment neuropathies.” Problems that would mimic fibromyalgia.

Not all doctors were in agreement that text neck syndrome creates a problem that could be attributed to a misdiagnosis of fibromyalgia. University-based doctors in Brazil responded to this article by suggesting “text neck syndrome is not a valid diagnosis since there is no evidence that the habit of using smartphones in a neck flexed posture is associated with neck pain.” (20)

The Kochi Medical School researchers responded: (21) “In Japan, with the spread of smartphones and personal computers, the number of patients who experience pain in the head, neck, shoulders and back, and paresthesia in the upper extremities is increasing. Furthermore, it is widely known that in such patients, lateral images of the cervical spine taken by X-ray or MRI show that the cervical spine is deformed into a straight line, in contrast to the cervical spine in healthy subjects, which has a forward convex arch. . . . Additionally, this cervical spine deformity is often accompanied by cervical disc herniation and cervical spinal canal stenosis; thus, patients often complain of chronic pain in the shoulders, shoulder blades, and back, and discomfort and stiffness in the hands.”

The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability
Cervical instability is a progressive disorder causing a normal lordotic curve to end up as an “S” or “Snake” curve with crippling degeneration.

In response to the validity of the term “Text neck syndrome,” the researchers wrote: “. . . the main problem related to cervical spine deformity is that it is not widely recognized. As cervical spine deformity does not appear to have any major abnormalities initially, it is not of interest in the field of orthopaedic surgery because it is not indicated for surgery. Our search (of the medical literature) yielded no results when we searched for the term ‘straight neck’, which is commonly used to denote this cervical spine deformity in Japan. Moreover, there are very few papers on text neck, which signifies the same disease concept and symptoms. . . . In addition to not being widely recognized, patients with muscle pain and stiffness may be misdiagnosed with fibromyalgia…”

They concluded: “We wished to raise awareness of the possibility that such patients may receive the wrong medical care and treatment for long periods of time.”

In November 2022, doctors published a case history in the International medical case reports journal (22) which described the long-term remission of fibromyalgia symptoms in a 44-year-old female patient following the application of different spinal manipulation techniques.

The woman came to the doctors suffering from chronic headaches, severe neck pain, shoulder pain, and back pain lasting for more than years after experiencing domestic violence. She had sleep disorders, fatigue, and depressive mood. Her primary care physician diagnosed her with fibromyalgia and depression. Despite treatment with non-steroidal anti-inflammatory drugs, muscle relaxants, anti-depressants, anti-epileptics, acupuncture, and aqua-therapy, she did gain meaningful symptom relief.

She then sought a chiropractic evaluation and potential treatment for her symptoms. At the first examination, the clinicians noticed tenderness in the neck, shoulder, back, anterior chest, abdominal wall, and buttock. Radiographs showed loss of cervical lordosis, widespread degenerative spondylosis, and osteitis pubis (groin pain).

The doctors diagnosed fibromyalgia after surface electromyography (sEMG) revealed neck and thoracic paraspinal muscle spasms and the other symptomology she suffered from including cervical spondylosis. Treatment was initiated and described: “Multimodal chiropractic approaches, which consisted of spinal manipulation, massage, and intermittent motorized cervical traction, were used twice weekly to relieve soft tissues and intervertebral joints and stretch core musculatures. The patient’s physical and mental complaints were mostly resolved near the end of 9 months of treatment. Her symptom alleviation was associated with the corresponding change in normalized sEMG signal and cervical spine realignment at the 16th- and 26th-month follow-ups.”

The sense of balance of fibromyalgia patients

In February 2022, Turkish researchers writing in the journal Rheumatology International (23) examined the sense of balance of fibromyalgia patients. They wrote: “Proprioceptive (the sense of movement) abnormalities, balance, and postural disorders have been previously reported in fibromyalgia syndrome, but unlike previous research, the aim of this study according to the researchers “was to compare the proprioception of the cervical region of patients with FMS with a healthy control group.  The relationship between cervical proprioception impairment and loss of balance was also examined.”

In this study, 96 female fibromyalgia patients and 96 female healthy control subjects were enrolled in this case-control study.

A cervical joint position error test (CJPET) was administered as s cervical proprioception evaluation. In this test, a blindfolded patient faces straight ahead and then they turn their head to the side. The test measures the patient’s ability to return their head to the neutral starting point. The fibromyalgia patients had significantly impaired cervical joint position error test results in all directions. The researchers also found as activity and fatigue levels increased, the deterioration in cervical proprioception became more evident (the patient’s balance became worse). The researchers then recommended that “proprioception and balance assessments should be integrated into the physical examination processes of fibromyalgia patients.”

Prolotherapy for Fibromyalgia Pain

What is Prolotherapy?

Prolotherapy is the injection of simple sugars or dextrose into areas of pain and injury. A Prolotherapist’s approach to fibromyalgia involves a multi-layered approach depending on the individual patient. Prolotherapy is almost always part of the treatment as it addresses the underlying ligament laxity behind chronic joint pain. Some Prolotherapy offices have the capability to address hormone levels, diet for fibromyalgia, and sleep problems. Resigning to live with your pain clearly has undesirable long-term effects. Chronic use of pain medications also has undesirable long-term effects. A better option is to consider an experienced Prolotherapist who can address the whole patient and the underlying causes of fibromyalgia.

Fibromyalgia and myofascial pain syndrome may be diagnosed in the same patient due to their overlapping and vague descriptions, both involving pain throughout specific tender areas or trigger points that cause both local and referred pain. Digging a little deeper into a patient’s health can help the clinician and the patient understand if the pain is due to issues that can be helped with Natural Medicine, such as food sensitivities, low hormones, poor sleep, and/or infections, among others. On the other hand, the physical exam may demonstrate undiagnosed joint instability in the areas exhibiting tender muscles and trigger points. The latter cases have good success with Prolotherapy as a standalone treatment. Oftentimes, a combined approach is necessary to help the patient fully recover. As the joints repair, the muscles can relax and the pain is alleviated. With the pain relief, sleep is improved and the vicious cycle is stopped.

In March 2020, doctors writing in the QJM: An International Journal of Medicine (24) assessed the potential role of prolotherapy in treating the most tender points of fibromyalgia patients as a trial to improve symptoms. In this study, 20 primary fibromyalgia received prolotherapy treatments that addressed at least six trigger points. The patients then received treatments every other week for up to six weeks.

The doctors noted that prolotherapy reduced the number of painful trigger points. On average patients with 6 – 16 tender points saw a significant reduction to 5 – 9 trigger points after treatments. In regard to the patient’s whole body average pain, there was a highly statistically significant difference between the Numeric rate scale for pain (0 no pain to 10 worse imaginable pain) before injection (ratings were 5 (beginnings of severe pain -10 worst imaginable pain), which decreased to a range of (2 (mild pain) -6 (severe pain)) after injection, with a positive change of 39.57%. Depression was noted to have improved by 25.37% in the patient group.

The doctors of this study concluded: “Prolotherapy may offer great therapeutic advantages for fibromyalgia patients, as it is well tolerated with minimal or no side effects. Moreover, prolotherapy injection reduces pain intensity and functional disability in daily life activities. ”

A 2019 study in the Journal of Back and Musculoskeletal Rehabilitation (25) compared the effectiveness of regenerative injection therapy (RIT), i.e. prolotherapy, and repetitive transcranial magnetic stimulation (rTMS) in the treatment of fibromyalgia syndrome. Repetitive transcranial magnetic stimulation (rTMS) is electrical non-invasive brain stimulation.

  • This study included 120 female, age-matched fibromyalgia patients.
    • Group 1 received prolotherapy three times, two weeks apart, and
    • Group 2 received rTMS sessions every other day for one month. The assessment was performed before treatment, immediately after treatment, and one month later.

A significant improvement in pain was noted in the prolotherapy group compared to the repetitive transcranial magnetic stimulation (rTMS) group immediately after and one month after treatment. There was a statistically significant difference in mean scores for the number of tender points in the prolotherapy group compared to the repetitive transcranial magnetic stimulation (rTMS) group after treatment and one month later. The patients improved functionally, with a statistically significant difference in the quality of life in the prolotherapy group compared to the repetitive transcranial magnetic stimulation (rTMS)  one month after treatment. However, there was a significant difference in improvement in depression during the repetitive transcranial magnetic stimulation (rTMS) compared to the prolotherapy group after treatment and one month later.

The researchers concluded: “Prolotherapy had the advantage in clinical and functional improvement in fibromyalgia patients, while repetitive transcranial magnetic stimulation (rTMS) had better results regarding depression. . . ”

If you have questions about PRP for your hip pain, Get help and information from our Caring Medical staff

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This article was updated June 22, 2023

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