Spectrum - Part of the Big Picture in Understanding Fibromyalgia
by Mark J. Pellegrino, MD 08-04-2007
Today Im convinced Fibromyalgia is indeed
a broader condition with various subsets - and a Fibromyalgia Spectrum
model is helpful in organizing and educating patients, writes Dr. Mark J. Pellegrino, MD,
a Fibromyalgia expert specialized in Physical Medicine and Rehabilitation. Access a
copy of Dr. Pellegrinos highly praised book, Fibromyalgia: Up Close and
Personal for an explaination of the spectrum of conditions the doctor has observed in
caring for his patients. Dr. Pellegrino himself is a Fibromyalgia patient.
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
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 Im convinced Fibromyalgia is indeed a
broader condition with various subsets. I believe this information is helpful
in explaining why everyones 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
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.
According to Dr. Yunus, Conditions in DSS
Share a Number of Characteristics:
1. Patients with different conditions sharing similar
2. Common shared symptoms, such as pain, poor sleep,
fatigue, and female predominance.
3. Hypersensitivity to pain.
4. No diagnostic pathology that can be
5. Shared psychological complaints such as depression
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
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
In other words, there is no going back. Lets
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
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
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
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 6: Fibromyalgia with Particular Associated
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, 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
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 doesnt necessarily cause Fibromyalgia, but
can aggravate it if its already present. Examples of diseases that can be present
and worsen the Fibromyalgia symptoms include:
n Hormonal problems (hypothyroidism, low estrogen, low
growth hormone, and low cortisol)
n Infectious problems (yeast, parasite or viral
n 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 Sjogrens syndrome).
n Arthritic conditions (cervical spinal stenosis,
osteoarthritis, osteoporosis, scoliosis).
n 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.
n 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 wouldnt 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 Ive diagnosed Fibromyalgia it
would be subset 4 or greater. The patient wouldnt 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.
Lets Review Some Patient Profiles to Determine
Subset they Fit into in the Fibromyalgia Spectrum
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).
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
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.
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.
Jamies 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. Jamies 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
Jamies 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.
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.
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.]
* Fibromyalgia: Up Close & Personal by Mark Pellegrino, MD, was published in 2005 by
Anadem Publishing. © Anadem Publishing, Inc. (www.anadem.com) and Mark Pellegrino, MD,
2005, all rights reserved. This book may be purchased for $24.50 plus S&H from Dr.
Mark J. Pellegrino at the Ohio Rehab Center (phone 330/498-9865 or fax 330/498-9869).
1. Mohammad B. Yunus, a professor at the University of
Illinois College of Medicine, was the first to publish a study describing FMs
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.
2. Drs. Travell and Simons are authors of the
two-volume set, Travell & Simons Myofascial Pain and Dysfunction: The Trigger
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.