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Fibromyalgia: an update on clinical characteristics, aetiopathogenesis and treatment

Abstract

Fibromyalgia is characterized by chronic widespread pain, fatigue, sleep disturbances and functional symptoms. The etiopathogenesis, diagnostic criteria and classification criteria of fibromyalgia are still debated and, consequently, so are the strategies for treating this condition. Fibromyalgia is the third most frequent musculoskeletal condition, and its prevalence increases with age. However, although diagnosis has improved with the evolution of more accurate diagnostic criteria, a considerable proportion of physicians still fail to recognize the syndrome. Many factors contribute to the development of fibromyalgia in a unique manner: genetic predisposition, personal experiences, emotional–cognitive factors, the mind–body relationship and a biopsychological ability to cope with stress. The multiple components of the pathogenesis and maintenance of the condition necessitate a multi-modal treatment approach. Individually tailored treatment is an important consideration, with the increasing recognition that different fibromyalgia subgroups exist with different clinical characteristics. Consequently, although an evidence-based approach to fibromyalgia management is always desirable, the approach of physicians is inevitably empirical, and must have the aim of creating a strong alliance with the patient and formulating shared, realistic treatment goals.

Key points

  • Fibromyalgia is a fairly common syndrome in the general population, reaching a prevalence of 2–3% worldwide.

  • The complex polysymptomatology of fibromyalgia comprises not only chronic widespread pain, fatigue and sleep alterations but also autonomic disturbances, cognitive dysfunction, hypersensitivity to external stimuli, somatic symptoms and psychiatric disorders.

  • Owing to the subjectivity of the symptoms and the lack of biomarkers, diagnosis is exquisitely clinical, and diagnostic criteria are constantly evolving; early diagnosis and prevention are still elusive goals.

  • Fibromyalgia severity and progression or improvement can be evaluated by means of a plethora of composite tests.

  • Fibromyalgia pathogenesis is not fully understood; hypotheses state that genetic predisposition, stressful life events, peripheral (inflammatory) and central (cognitive–emotional) mechanisms interplay to create pain dysperception owing to neuromorphological modifications (‘nociplastic pain’).

  • Treatment should be multimodal and built on four pillars (patient education; fitness; pharmacotherapy; and psychotherapy); the approach should be individualized, symptom-based and stepwise, establishing shared goals with the patient.

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Fig. 1: Estimated prevalence of fibromyalgia in different regions using different diagnostic criteria or questionnaires.
Fig. 2: Principal fibromyalgia symptoms.
Fig. 3: Hypothesized interplay between potential pathogenic mechanisms and nociplastic alterations in fibromyalgia.
Fig. 4: Proposed treatment strategy for fibromyalgia.

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P.S.-P., V.G. and D.M. wrote the article. P.S.-P. and F.A. substantially contributed to discussion of content. P.S.-P., V.G., D.M. and F.A. researched data for the article and reviewed and edited the manuscript before submission.

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Correspondence to Piercarlo Sarzi-Puttini.

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Nature Reviews Rheumatology thanks M.-A. Fitzcharles, G. Littlejohn and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Glossary

Biopsychosocial model of medicine

An interdisciplinary model commonly used in the field of chronic pain that incorporates the interactions among biological factors (such as physio-pathological factors), psychosocial factors (that is, emotional factors, such as distress or fear) and behavioural factors.

Paraesthesia

A qualitative alteration of the sensitivity of the skin (which can be an abnormal sensation of pricking, tingling and numbness).

Fibro-fog

A symptom of fibromyalgia involving an inability to think clearly or difficulties in concentrating.

Raynaud phenomenon

A condition that causes decreased blood flow to the extremities (such as the fingers, toes, ears and nose) due to vasospasm; such spasms occur in response to cold, stress or emotional upset.

Nociplastic pain

A clinical definition of pain arising from altered nociception, despite no evidence of tissue damage causing the activation of nociceptors or evidence of disease or lesions of the somatosensory system causing the pain.

Central sensitization

A neurophysiological process of pain amplification in the central nervous system; this process occurs physiologically after injuries to elicit a protective behaviour and maximize the healing process.

Hyperalgesia

A condition in which a painful stimulus is perceived as being even more painful.

Allodynia

A condition in which a normal stimulus is perceived as being painful.

Temporal summation

The perception of repetitive noxious stimulation as being increasingly painful.

Dysaesthesia

An unpleasant abnormal sensation (that can be spontaneous or evoked) that is usually associated with irritation or injury to a sensory nerve or nerve root.

Small fibre neuropathy

Damage to small myelinated (type Aδ) nerve fibres or unmyelinated C peripheral nerve fibres; these small somatic fibres have sensory functions including thermal perception and nociception.

Dysautonomia

An umbrella term used to describe several different medical conditions that cause a malfunction of the autonomic nervous system.

Catastrophizing

An exaggerated amplification of emotional aspects that leads individuals to consider pain terrible and intolerable.

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Sarzi-Puttini, P., Giorgi, V., Marotto, D. et al. Fibromyalgia: an update on clinical characteristics, aetiopathogenesis and treatment. Nat Rev Rheumatol 16, 645–660 (2020). https://doi.org/10.1038/s41584-020-00506-w

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