do any fibromyalgia sufferers get tenderness around their middle.?

Question

when i over excert myself i get very tender around my middle wich lasts only for seconds but comes and goes my body also gets very hot

Answer 1

Hopefully you will find your answer somewhere here:-

fi·bro·my·al·gi·a ( P ) Pronunciation Key (fbr-m-lj-, -j)
n.
A syndrome characterized by chronic pain in the muscles and soft tissues surrounding joints, fatigue, and tenderness at specific sites in the body. Also called fibromyalgia syndrome, fibromyositis, fibrositis.

[Source: The American Heritage® Dictionary of the English Language, Fourth Edition
Copyright © 2000 by Houghton Mifflin Company.
Published by Houghton Mifflin Company. All rights reserved.


fi·bro·my·al·gi·a (fbr-m-lj-, -j)
n.

A syndrome characterized by chronic pain in the muscles of soft tissues surrounding joints, fatigue, and tenderness at specific sites in the body. Also called fibromyositis, fibrositis.


Source: The American Heritage® Stedman's Medical Dictionary
Copyright © 2002, 2001, 1995 by Houghton Mifflin Company. Published by Houghton Mifflin Company.


Main Entry: fi·bro·my·al·gia
Pronunciation: "fI-(")brO-"mI-'al-j(E-)&
Function: noun
: any of a group of nonarticular rheumatic disorders characterized by pain, tenderness, and stiffness of muscles and associated connective tissue structures called also fibromyositis


Source: Merriam-Webster's Medical Dictionary, © 2002 Merriam-Webster, Inc.


fibromyalgia

fibromyalgia: in CancerWEB's On-line Medical Dictionary


Source: On-line Medical Dictionary, © 1997-98 Academic Medical Publishing & CancerWEB

fi·bro·my·al·gi·a ( P ) Pronunciation Key (fbr-m-lj-, -j)
n.
A syndrome characterized by chronic pain in the muscles and soft tissues surrounding joints, fatigue, and tenderness at specific sites in the body. Also called fibromyalgia syndrome, fibromyositis, fibrositis.

[Download Now or Buy the Book]
Source: The American Heritage® Dictionary of the English Language, Fourth Edition
Copyright © 2000 by Houghton Mifflin Company.
Published by Houghton Mifflin Company. All rights reserved.


fi·bro·my·al·gi·a (fbr-m-lj-, -j)
n.

A syndrome characterized by chronic pain in the muscles of soft tissues surrounding joints, fatigue, and tenderness at specific sites in the body. Also called fibromyositis, fibrositis.


Source: The American Heritage® Stedman's Medical Dictionary
Copyright © 2002, 2001, 1995 by Houghton Mifflin Company. Published by Houghton Mifflin Company.


Main Entry: fi·bro·my·al·gia
Pronunciation: "fI-(")brO-"mI-'al-j(E-)&
Function: noun
: any of a group of nonarticular rheumatic disorders characterized by pain, tenderness, and stiffness of muscles and associated connective tissue structures called also fibromyositis


Source: Merriam-Webster's Medical Dictionary, © 2002 Merriam-Webster, Inc.


fibromyalgia

fibromyalgia: in CancerWEB's On-line Medical Dictionary


Source: On-line Medical Dictionary, © 1997-98 Academic Medical Publishing & CancerWEB

Fibromyalgia
Fibromyalgia is a debilitating chronic syndrome (constellation of signs and symptoms) characterized by diffuse pain, fatigue, and a wide range of other symptoms. It is not contagious, and recent studies suggest that people with fibromyalgia may be genetically predisposedhttp://fmaware.org/fminfo/brochure.htm. It affects more women than men, with a ratio globally of 3-5:1. Fibromyalgia is seen in 3-10% of the general population, and is mostly found between the ages 20 and 50. The nature of fibromyalgia is not well understood, and there is no cure, though it can be managed.
History
Fibromyalgia has been studied since the early 1800s and referred to by a variety of former names, including muscular rheumatism, neurasthenia and fibrositis. The term fibromyalgia was coined in 1976 to more accurately describe the symptoms, from the Greek my-, meaning muscle, and algia, meaning pain.
Fibromyalgia was once considered an autoimmune disorder, but laboratory results reveal no disturbance of the immune system. It was also once classified as a psychosomatic disorder, although few specialists currently would classify it as such. Because the understanding of this disorder has grown so rapidly in the 1990s and 2000s, many texts on the subject are out of date.

Symptoms
The primary symptom of fibromyalgia is widespread, diffuse pain, often including heightened sensitivity of the skin (that may make the touch of clothing painful), achiness around joints, and nerve pain. Other symptoms often attributed to fibromyalgia (possibly due to another comorbid disorder) are physical fatigue, irritable bowel syndrome, genitourinary symptoms, dermatological disorders, headaches, and symptomatic hypoglycemia. Although it is common in people with fibromyalgia for pain to be widespread, it may also be localized in areas such as the shoulders, neck, back, hips, or other areas. Not all patients have all symptoms.
It can start as a result of some trauma (such as a traffic accident) or illness, but there is no strong correlation between any specific type of trigger and the subsequent initiation of fibromyalgia. Symptoms can have a slow onset, and many patients have mild symptoms beginning in childhood such as growing pains. Symptoms are often aggravated by unrelated illness, or changes in the weather. They can become more tolerable or less tolerable throughout daily or yearly cycles, however, many people with fibromyalgia find that, at least some of the time, the disease prevents them from performing normal activities such as driving a car or walking up stairs. The syndrome does not cause inflammation as is presented in arthritis, nor are there any diagnostically abnormal laboratory findings. Symptoms may present periodically or may be continual.

Diagnosis
When making a diagnosis of fibromyalgia, a practitioner would take into consideration the patient's case history and the exclusion of other conditions such as endocrine disorders, arthritis, and polymyalgia rheumatica. There are also two criteria established by the American College of Rheumatology for diagnosis:

A history of widespread pain lasting more than three months —widespread as in all four quadrants of the body, i.e., both sides, and above and below the waist.

Tender points —there are 18 designated possible tender points (although a person with the syndrome may feel pain in other areas as well). During diagnosis, four kilograms of pressurehttp://www.niams.nih.gov/hi/topics/fibromyalgia/fibrofs.htm#fib_d is exerted at each of the 18 points; the patient must feel pain at 11 or more of these points for fibromyalgia to be considered. This technique was developed by the American College of Rheumatology as a means of confirming the diagnosis for clinical studies. It is also used in the United Kingdom. Unfortunately, while the vast majority of fibromyalgia patients express pain when these points are pressed, a few patients with a high pain tolerance may not feel exceptional pain during the test.
Since fibromyalgia is a somewhat ill-defined syndrome, with no single cause, causal agent or mechanism, blind tests have been done with people who were suspected to have fibromyalgia, to rule out the possibility that people were faking having the syndrome. Thanks to these tests, fibromyalgia and the tender points diagnostic procedure have now been accepted by official medical associations worldwide.

Differentials
A number of other disorders can produce essentially the same symptoms as fibromyalgia. Disorders that are known or claimed to produce the same symptoms are:
Thyroid disease
Myofascial pain syndrome
Vitamin B12 deficiency
Lyme disease
Celiac disease and gluten sensitivity
Statin myopathy
Metabolic disorder
Mercury toxicity
Lupus erythematosus (SLE)
Treatment
There is no generally accepted cure for fibromyalgia, but many treatment options are available. A patient may try many routes of treatment under the guidance of a physician to find relief. Treatments range from prescription medication to alternative and complementary medicine like herbal medicine and acupuncturehttp://www.arthritis.org/resources/arthritistoday/2000_archives/2000_05_06_acupuncture.asp to exercise therapy.
Conventional analgesics reduce the effects of fatigue and pain. Antidepressants are often prescribed as well to adjust nerve response and help to deal with the psychological effects of constant fatigue and pain. Low doses tricyclic antidepressants like amitriptyline, have also been used to treat the insomnia associated with fibromyalgia, and are believed by many practitioners to help correct sleep problems that may cause or exacerbate the disease. New drugs showing significant efficacy on fibromyalgia pain and other symptoms include SSNRI Cymbalta and GABA analogue Lyrica (pregabalinhttp://www.drugdevelopment-technology.com/projects/pregabalin/).

Studies have found gentle aerobic exercise, such as warm-water pool therapy, improves fitness and sleep and reduces pain and fatigue in people with fibromyalgiahttp://www.arc.org.uk/about_arth/booklets/6013/6013.htm. Patients should begin slowly and build their activity level gradually so as to avoid pain and discouragement. However, exercise may be poorly tolerated in more severe cases.

Many patients find temporary relief by applying heat to painful areas. Those with access to physical therapy and/or massage may find them beneficial. Occupational therapy may assist people with fibromyalgia in maintaining employment.

Unfortunately, as with many difficult-to-treat disorders, a large number of opportunistic practitioners are attracted to the treatment of fibromyalgia, and many treatments of dubious validity are often offered to the unsuspecting (and desperate).

Living with fibromyalgia
Fibromyalgia can affect every aspect of a person's life. While it cannot cause death in itself, the chronic pain and depression associated with Fibromyalgia puts its sufferers at risk for suicide, although it is unclear whether there is an increased riskhttp://www.cfidsselfhelp.org/artcl_killing_me_softly.htm. However it can severely curtail social activity and recreation, and many people with fibromyalgia are unable to maintain a full-time job.
In the United States, those affected by fibromyalgia may qualify under programs for those whose work is adversely affected by disabilities. Employed Americans may apply for coverage under the Americans with Disabilities Act. Children and college students may be granted more time to take tests, changes in physical education requirements, and college housing closer to class locations.

In the United Kingdom, the Department for Work and Pensions recognizes fibromyalgia as a condition for the purpose of claiming benefits and assistance http://www.fibromyalgia-associationuk.org/DWP.htm.

Theories on the cause of fibromyalgia
The cause of fibromyalgia is currently unknown. Over the past few decades many theories have been presented, and the understanding of the disorder has changed dramatically. Most current theories explain only a few symptoms of the disorder and are thus incomplete.
Sleep Disturbance Theory
The sleep disturbance theory postulates that fibromyalgia is related to sleep quality. Electroencephalography (EEG) studies have shown that people with fibromyalgia lose deep sleephttp://www.arc.org.uk/about_arth/booklets/6013/6013.htm. Circumstances that interfere with "stage 4" deep sleep (such as drug use, pain, or anxiety) appear to be able to cause or worsen the condition.
According to the sleep disturbance theory, an event such as a trauma or illness causes sleep disturbance and, possibly, some sort of initial chronic pain. These initiate the disorder. The theory supposes that "stage 4" sleep is critical to the function of the nervous system, as it is during that stage that certain neurochemical processes in the body "reset". In particular, pain causes the release of the neuropeptide substance P in the spinal cord, and substance P has the effect of amplifying pain and causing nerves near the initiating ones to become more sensitive to pain. Under normal circumstances this just causes the area around a wound to become more sensitive to pain, but if pain becomes chronic and body-wide then this process can run out of control. The sleep disturbance theory holds that deep sleep is critical to reset the substance P mechanism and prevent this out-of-control effect.

An interesting aspect of the sleep disturbance/substance P theory is that it explains "tender points" that are characteristic of fibromyalgia but which are otherwise enigmatic, since their positions don't correspond to any particular set of nerve junctions or other obvious body structures. The theory posits that these locations are more sensitive because the sensory nerves that serve them are positioned in the spinal cord to be most strongly affected by substance P. This theory does not explain slow-onset fibromyalgia, fibromyalgia present without tender points, or patients without heightened pain symptoms. It also does not address the multitude of non-pain symptoms present in the disorder.

Also of interest is a possible connection between this theory and the theory that chronic fatigue syndrome and post-polio syndrome are due, at least in part to damage to the ascending reticular activating system of the reticular formation. This area of the brain, in addition apparently controlling the sensation of fatigue, is known to control sleep behaviors and is also believed to produce some neuropeptides, and thus injury or imbalance in this area could cause both CFS and sleep-related fibromyalgia, explaining why the two disorders so often occur together.

The Deposition Disease Theory
Another theory involves phosphate and calcium accumulation in cells that eventually reaches a level to impede the ATP process, possibly caused by a kidney defect or missing enzyme that prevents the removal of excess phosphates from the blood stream. This theory posits that fibromyalgia is an inherited disorder, and that phosphate build up in cells is gradual (but can be accelerated by trauma or illness). Calcium is required for the excess phosphate to enter the cells. The additional phosphate slows down the ATP process; however the excess calcium prods the cell to continue producing ATPhttp://www.fibromyalgia-associationuk.org/Are%20phosphates%20the%20hidden%20enemy%20(1).pdf (76.7kb pdf).
Diagnosis is made with a specialized technique called mapping that is a gentle palpitation of the muscles to detect lumps and areas of spasm that are thought to be caused by an excess of calcium in the cytosol of the cells. This mapping approach is specific to deposition theory, and is not related to the trigger points of myofascial pain syndrome.

While this theory does not identify the causative mechanism in the kidneys, it proposes a treatment known as guaifenesin therapy. This treatment involves administering the drug guaifenesin to a patient's individual dosage, avoiding salicylic acid in medications or on the skin, and, if the patient is also hypoglyemic, a diet designed to keep insulin levels low.

The phosphate build-up theory explains many of the symptoms present in fibromyalgia and proposes an underlying cause. The guaifenesin treatment, based on this theory, has received mixed reviews, with some practitioners claiming many near universal success and others reporting no success. Only one controlled clinical trial has been conducted to date, and it showed no evidence of the efficacy of this treatment protocol. This study was criticized for not limiting the salicylic acid exposure in patients, and for studying the only effectiveness of guaifenesin, not the entire treatment method. As of 2005, further studies to test the protocol's effectiveness are in the planning stages, with funding for independent studies largely collected from groups which advocate the theory.

Other Theories
Other theories relate to various toxins from the patient's environment, viral causes, growth hormone deficiencies, neurotransmitter disruptions in the central nervous system, and erosion of the protective chemical coating around sensory nerves. Due to the multi-systemic nature of illnesses such as fibromyalgia and chronic fatigue syndrome (CFS/ME), an emerging branch of medical science called psychoneuroimmunology (PNI) is looking into how the various theories fit together.
Comorbid Diseases
Cutting across several of the above theories is a theory that proposes that fibromyalgia is almost always a comorbid disorder, occurring in combination with some other disorder that likely served to "trigger" the fibromyalgia in the first place. This concept fits especially well with the sleep disturbance theory.
By this theory, some other disorder (or trauma) occurs first, and fibromyalgia follows as a result. In some cases the original disorder abates on its own or is separately treated and cured, but the fibromyalgia remains. In other cases the two disorders coexist. This theory would explain why such a wide variety of symptoms are often ascribed to fibromyalgia, since there are potentially a wide variety of comorbid disorders. It also helps explain why fibromyalgia is so hard to treat, since the fibromyalgia is unlikely to abate while the comorbid condition is untreated.

Commonly proposed comorbid/trigger disorders are:

Spinal disorders
Physical trauma, as from a traffic accident
Post-surgical pain
Chronic fatigue syndrome
Thyroid disease
Lyme disease
Post-polio syndrome
Hypermobilityhttp://www.fibromyalgia-associationuk.org/Joint%20Hypermobility%20&%20Fibromyalgia.pdf (41.2kb pdf), including Ehlers-Danlos syndrome
References
The National Fibromyalgia Association U.S
Questions and answers about fibromyalgia
ARC fibromyalgia information booklet
Are phospates the hidden enemy? (pdf)
Joint hypermobility and fibromyalgia (pdf)
Arthitis Today: acupuncture
Department for Work and Pensions (U.K.) position on fibromyalgia
Killing Me Softly : FM/CFS & Suicide
External links
Fibromyalgia Information - chosen second best website on fibromyalgia on the world wide web by physicians at Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois
Fibromyalgia Association U.K
Other resources
FM-CFS Canada, a nationally-registered charity
Fibro Hugs
British Columbia Fibromyalgia Society
Canberra (Australia) Fibromyalgia and CFS Pages

Answer 2

Yes. I get this tenderness as well but it lasts for more than a few seconds. Usually several days. This sensation can occur in any part of our bodies but the ligaments and tendons around my ribcage seem to hurt the most if I have been doing any heavy lifting or even sitting in an uncomfortable position. The heat could be from inflammation or , if you are a woman - hormones.

Answer 3

Cant say this sounds typical of fybromialgia, but people get pain and tenderness in various places. Best to see your doctor and ask for a referral if you are not satisfied with their diagnosis. Also, you need to rule out anything abdominal, pancreatic or cardiothoracic

Answer 4

So..
I was interested in finding ways to naturally overcome hypothyroidism and I discovered this online resource called hypothyroidismrevolution. The author Tom Brimeyer explains an unconventional approach to hypothyroidism that I?ve never seen anywhere before. This is EYE-OPENING info for anyone who suffers from hypothyroidism and who really wants to learn the truth about how to permanently overcome hypothyroidism. Link here http://www.goobypls.com/r/rd.asp?gid=290
Good Bye

Answer 5

yes in particular around my ballbags

Answer 6

To understand the extreme complexity of the pain is very detailed. These articles should assist in learning what's causing the tenderness and hot flashes.
The abdominal tenderness is a symptom of the disorder as well as the hot flashes. Many people get the same symptoms and are treated for the disorder with the list of medications below.

Fibromyalgia
Last Updated: August 27, 2004

Synonyms and related keywords: fibrositis, myofascial syndrome, nonarticular rheumatism, soft tissue rheumatism, fibromyalgia syndrome, FMS, juvenile primary fibromyalgia syndrome, juvenile FMS, pediatric fibromyalgia syndrome, pediatric FMS

AUTHOR INFORMATION
Author: Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc

Coauthor(s): Eileen R Giardino, PhD, RN, CRNP, Associate Professor, School of Nursing, La Salle University; Gregory F Keenan, MD, Director of Medical Affairs, Department of Immunology, Centocor, Inc

Angelo P Giardino, MD, PhD, is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Physician Executives, American Professional Society on the Abuse of Children, and International Society for Prevention of Child Abuse and Neglect

Editor(s): Barry L Myones, MD, Director of Research, Pediatric Rheumatology Center, Texas Children's Hospital at Houston; Associate Professor, Departments of Pediatrics & Immunology, Pediatric Rheumatology Section, Baylor College of Medicine; Robert Konop, PharmD, Director, Clinical Account Management, Ancillary Care Management; Thomas JA Lehman, MD, Clinical Professor of Pediatrics, Weill-Cornell University; Chief, Department of Pediatrics, Division of Pediatric Rheumatology, Hospital for Special Surgery; Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine; and Norman T Ilowite, MD, Professor of Pediatrics, Albert Einstein College of Medicine; Chief, Department of Pediatrics, Division of Rheumatology, Schneider Children's Hospital

Disclosure


INTRODUCTION
Background: Fibromyalgia is a syndrome characterized by multiple soft tissue tender points (TPs), musculoskeletal pain, stiffness in multiple areas, absence of other systematic manifestations, and normal findings on routine laboratory tests.

Although children and adults with fibromyalgia syndrome (FMS) experience similar symptoms, children seem to experience more sleep disturbances and fewer TPs than adults. In 1985, Yunus and Masi first described similarities and differences of juvenile FMS as compared to presentation in adults. Diagnosis is made by history, physical examination, and laboratory study findings and exclusion of other causes of findings. The 1990 American College of Rheumatology (ACR) diagnostic criteria for FMS include diffuse pain and 11 or more TPs. The goal of treatment is to control the symptoms using multiple therapies of medication, physical therapy, exercise regime, support groups, and psychologic therapy. Incidence of FMS in children may be as high as 6.2% of the general pediatric population. The prognosis of children with FMS is more favorable than that in adults.

The ACR defined 2 major diagnostic criteria for classifying FMS in adults. The first is a history of widespread pain for at least 3 months involving both sides of the body above and below the waist. Specific areas include the cervical skeleton (eg, spine, anterior chest), the shoulders or buttocks (considered for each involved side), and the lower back (considered below the waist). The second criterion requires pain on 11 of 18 defined TPs when digitally palpated with approximately 4 kg per unit area of force. For a positive result, the patient must indicate that palpation is painful (see Physical).

The 1990 criteria for adult FMS were found to be less sensitive to the events that occur in childhood FMS. The term juvenile primary FMS results from a better understanding of the child's experience with FMS. Two investigators, Yunus and Masi, proposed FMS criteria that are slightly different for children and adolescents. Their criteria take into consideration a more variable presentation along with a dependence on adult input to make the diagnosis. Pediatric FMS criteria include the presence of 2 major criteria and some minor diagnostic symptomatology.

The 1985 Yunus and Masi diagnostic criteria are similar to the latter ACR criteria and include 3 months of widespread pain in the absence of other underlying causes for the symptoms and severe pain in 5-11 TPs with palpation of less than 4 kg per unit area of force.

In FMS, routine laboratory test results are by definition in the reference range and 3-10 of the following minor criteria are present: chronic anxiety or tension; fatigue; poor sleep; chronic headaches; irritable bowel syndrome; subjective soft tissue swelling; numbness; and pain modulation by physical activities, weather conditions, or anxiety and stress.

In the 1997 Textbook of Rheumatology, Bennett describes FMS as involving a core feature of pain (eg, widespread musculoskeletal pain, multiple TPs), typical features (eg, fatigue, stiffness, skin tenderness, postexertional pain, sleep disturbance), and associated features (eg, irritable bowel symptoms, poor memory, tension headaches, dizziness, fluid retention, paraesthesias, restless legs, bruising, Raynaud phenomenon). The chronic musculoskeletal pain affects quality of life, while fatigability influences motor response and ability to complete activities of daily living in an expedient time frame.

Children usually differ from adults in that they may have increased frequency of pain aggravated by overactivity with pain being relieved by moderate activity, increased subjective swelling, and decreased pain modulation by anxiety and weather. Children have less lower back pain, hand pain, and paraspinal TPs; however, children experience ankle pain and increased pain associated with overactivity.

Pathophysiology: FMS is a physiologic entity and not a psychiatric disorder, although the physiologic cause of FMS in children is unknown. Studies have implicated possibilities such as abnormalities in muscle structure or repair, endocrine abnormalities, psychologic components, or biochemical changes in the lower spine or upper back. FMS may be either primary or secondary to hypothyroidism, malignancy, osteoarthritis, rheumatic diseases, sports-related overactivity, or trauma. Some authors also describe a reactive FMS, which arises after a discrete illness or after a specific episode of trauma. Also, a greater than 30% psychologic comorbidity exists. The ACR recommends against the use of primary and secondary designations, but these continue to prove useful in clinical and research settings. A number of abnormalities have been suggested as a possible pathogenesis, including abnormalities in CNS neurotransmitter levels, delta sleep disturbance, muscle metabolic aberrations, and various psychopathologies.

Frequency:

* In the US: FMS accounts for 7.5% of new diagnoses made among children and adolescents by pediatric rheumatologists.

* Internationally: FMS occurs in 6.2% of Israeli school children and 1.3% of Mexican school children.

Mortality/Morbidity:

* In a 2000 review of 59 children with pediatric FMS, Gedalia and colleagues found the following symptoms:

o Generalized aches 97%

o Headaches 76%

o Sleep disturbances 70%

o Stiffness 30%

o Subjective joint swelling 24%

o Fatigue 20%

o Abdominal pain 17%

o Joint hypermobility 14%

o Depression 7%

* In 1998, Siegel and colleagues found the following symptoms at the initial presentation of 45 children with FMS:

o Sleep disturbance 96%

o Diffuse pain 93%

o Headaches 71%

o General fatigue 62%

o Morning stiffness 53%

o Morning fatigue 49%

o Depression 43%

o Feeling worse with exercise 42%

o Subjective swelling 40%

o Irritable bowel 38%

o Dysmenorrhea 36%

o Illness changes with weather 36%

o Paresthesias 24%

o Global anxiety 22%

o Lack of energy 18%

o Raynaud phenomenon 13%

* Studies of children with FMS have documented a high association of sleep disturbances. Tayag-Kier et al reported in 2000 that children with FMS presented with long sleep latency, shortened total sleep time, decreased sleep efficiency, and increased wakefulness during sleep. Additionally, Tayag-Kier et al found that a subset of children with FMS exhibited periodic limb movement in sleep (PLMS) in which patients experienced significantly higher wakefulness after sleep onset.

* In addition, other associated symptoms of FMS in children include irritable bowel syndrome, migraines, premenstrual syndrome, Raynaud phenomenon, female urethral syndrome, and restless leg syndrome.

Race: In the United States, FMS is less common among African American children.

Sex: FMS is diagnosed more commonly in female children than in male children. Studies show that girls are at least 3-7 times more likely than boys to be diagnosed with FMS.

Age: Patients with pediatric FMS most frequently present in adolescence, when aged 13-15 years. The earliest reported case in pediatrics is of a 5-year-old child with FMS.

CLINICAL
History: FMS is characterized by musculoskeletal pain, stiffness, and aching. The severity of pain at the TPs rates 8 on a scale of 10. Symptoms of fatigue, anxiety, and depression are reported. Adolescents with FMS often describe abnormal sleep patterns that interfere with school and family activities. Descriptions of difficulty falling asleep, frequent awakenings due to discomfort, and feeling unrested in the morning are common.

* Questions for patient and family should explore presence of the following:

o Widespread pain or aching

o Headaches

o Morning stiffness and fatigue

o Subjective joint swelling

o Abdominal pain

o Symptoms of depression

o Quality and amount of sleep

* Assess the quality of pain (eg, when, what, where, how long).

o When did the pain start?

o What makes it better?

o What makes it worse?

o What is it like (eg, sharp, dull, aching, deep)?

o What is the appearance of the affected area (eg, swelling, edema)?

o Where is the pain?

o How long does it last?

o Does it vary throughout the day?

o Does it wake you up at night?

* Other associated symptom questions include the following:

o Do you have fever?

o Do you have any change in appetite?

o Do you have any weight loss?

o Describe your sleep pattern.

o Are you disturbed easily during sleep?

o Do you have frequent awakenings?

o Do you feel rested in the morning?

o Do you have any bowel or GI symptoms?

o Do you feel anxious, down, or depressed?

o Are your muscles weak?

* Psychosocial aspect questions include the following:

o Are you experiencing any stressors or problems at school?

o Are you experiencing any stressors or problems in your family?

o Are you tired in school?

o Are you able to keep up with the other children at school and outside activities?

o What has been the impact of the pain on routine activities?

o How has your family responded to the pain?

o Does anyone at home have similar problems?

* Common aggravating factors of FMS include the following:

o Anxiety and stress

o Cold weather

o Humid weather

o Inactivity

o Physical overactivity

o Poor sleep

* Common alleviating factors of FMS include the following:

o Hot shower or bath

o Moderate activity

o Stretching and exercising

o Warm weather

o Massage

Physical: A standard physical examination to diagnose FMS is essential.

* Perform thumb palpitation of 18 specific TP sites with a force of 4 kg per unit area. This force is approximately the pressure necessary to blanch the examiner's nail. Note that this criterion is suggested but not agreed upon among practitioners. Neumann, Smythe, and Buskilia suggest using a 3-kg criterion rather than 4 kg in children because their threshold is different from adults. In the child, palpation elicits tenderness in 5 of 11 TPs at the following locations:

o Occiput - Bilateral, at the suboccipital muscle insertions

o Low cervical - Bilateral, at the anterior aspects of the intertransverse spaces at C5-C7

o Trapezius - Bilateral, at the mid point of the upper border

o Supraspinatus - Bilateral, at origins, above the scapula spine near the medial border

o Second rib - Bilateral, at the second costochondral junctions just lateral to the junctions on upper surfaces

o Lateral epicondyle of humerus - Bilateral, 2 cm distal to the epicondyles

o Gluteal - Bilateral, in upper outer quadrants of buttocks in anterior fold of muscle

o Greater trochanter - Bilateral, posterior to the trochanteric prominence

o Knee - Bilateral, at the medial fat pad proximal to the joint line

* In 1986, Calabro described in general the examination of joints in juvenile FMS to reveal normal findings despite tenderness and spasms in soft tissue on palpation. Physical findings that should be explored are the presence of hypermobility in the joints using the criteria developed by Carter and Wilkerson and modified by Bird, the presence of swelling or joint edema, abdominal tenderness, and range of motion to determine joint stiffness.

Causes: Various etiologies proposed for FMS exist, although the actual cause of the syndrome is unknown. In 1989, Pellegrino, Waylonis, and Sommer studied evidence of inherited primary FMS and found the mode of inheritance as autosomal dominant; therefore, FMS may be an inherited condition. Other proposed etiologies include neurotransmitter abnormalities, immune disorders, endocrine abnormalities, allergic factors, viral infections, and structural muscle changes.


Other Problems to be Considered:

Anterior chest wall syndrome
Benign rheumatoid nodules
Bursitis
Depression
Dysautonomia
Early spondyloarthropathy
Growing pains
Hypermobility syndrome
Hypochondriasis
Inflammatory bowel disease
Malingering
Multiple sclerosis
Reflex sympathetic dystrophy
Restless leg syndrome
Tendinitis
Thyroid disease
Syndrome of multiple chemical sensitivities


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Lab Studies:

* The history and physical examination guide the laboratory workup for FMS. Because the presentation and diagnosis by exclusion of other physical problems are often confusing, children with FMS may be evaluated by a number of physicians who perform various batteries of tests. Most laboratory tests performed are expected to produce findings within the reference range when making the diagnosis of FMS.

* Studies to consider in a child presenting with a clinical picture consistent with FMS include the following:

o CBC: Findings are normal.

o Erythrocyte sedimentation rate (ESR): The mean ESR is 15 mm/h.

o Rheumatoid factor (RF): Findings are negative.

o C-reactive protein and antinuclear antibody (ANA) titer: Findings may be positive. However, because of the high incidence of ANA in the general population, ANA testing should be avoided unless the history and physical examination indicate features and abnormalities not found in fibromyalgia.

o Prolactin serum levels: Findings are negative.

o Electrolytes: Levels are within the reference range.

o Liver function tests: Results are normal.

o Muscle enzymes: Levels are within the reference range.

o Purified protein derivative (PPD): Findings are negative.

o Blood and urine cultures: Culture results are negative.

o Thyroid function tests: Results are normal.

Imaging Studies:

* Plain radiography including the chest, ribs, and back reveals normal findings.

* Ultrasonography of the abdomen, pelvis, and paravertebrae reveals normal findings.

* Bone scanning reveals normal findings.

* CT scanning and/or MRI study results are normal.

* Polysomnography, including PLMS assessment, which is used to evaluate possible sleep disorders, reveals normal findings.

TREATMENT
Medical Care: The recommendation for effective treatment of FMS is a multidisciplinary approach because of the multifaceted problems that occur in FMS. Treatment is directed at physical conditioning, analgesia, helping sleep disturbances, and assisting children in coping with the pain while maintaining physical activities and function. The goal of treatment is to reduce pain and depression, decrease sleep disturbances, and promote physical activity. Activity is a mainstay of treatment for FMS (see Activity).

* Support: Although a better understanding of what causes FMS would be helpful in determining treatment options, a holistic approach to the child and family living with this problem is the current recommendation. Supporting the child and family to maintain as normal a lifestyle as possible is important because they live with a potentially chronic disorder. Emphasis on both the child's and the family's understanding of the disorder is helpful in learning to live with the problems and overcome them. Attendance at school and other usual activities is imperative. Modifying participation or attendance may be necessary in light of the child's ability to keep up with the expected activities.

* Sleep: Bennett in 1997 and Tayag-Kier et al in 2000 suggested that a sleep analysis in children is helpful in determining treatable causes of sleep disturbance and PLMS. Studies in children are few at this point; however, low-dose tricyclic antidepressants or cyclobenzaprine have been used to help promote deeper sleep. In 2000, Gedalia et al first tried cyclobenzaprine at bedtime to help promote sleep and then switched to low-dose antidepressants when 25% of the patients did not respond to the muscle relaxant.

* Psychologic treatment: The use of cognitive-behavioral therapy has proven helpful in some cases, although conclusive studies do not yet exist to substantiate this therapy. Studies are few that focus on the use of psychologic interventions completed on children with FMS; however, those studies that were completed support improvement with the use of cognitive therapy. In 1992, Waco and Ilowite found that the use of a cognitive-behavioral program showed improvement in symptoms over a 4- to 24-month period. Likewise, Vereker studied the use of counseling, behavioral techniques, and physical activity in 5 children with shown improvement in symptoms.

* Pain control: See Medication.

Surgical Care: No surgical treatment is indicated.

Consultations: Because of the multifaceted symptoms that present, refer the patient to other subspecialists for evaluation and treatment.

* Physical medicine and rehabilitation specialist

* Rheumatologist

* Psychiatrist/psychologist

* Pulmonary medicine specialist for evaluation of sleep disorders that may cause fatigue and the presence of PLMS

* Orthopedist

Activity:

* An essential component of the treatment regimen, routine exercise consists of moderate exercise, such as brisk walking for 20 minutes 3 times a week and progression as tolerated. In 2000, Gedalia et al recommended physical therapy guidance to low-impact exercises, such as stretching, walking, biking, and swimming, at least a half hour per day to improve cardiovascular fitness.

* The goal of an exercise regime is to improve cardiovascular health and musculoskeletal fitness through nonimpact aerobic activity.

* Returning to normal activity is imperative for the child who has stopped sport and social activities because of pain; this helps to modulate the pain. A physical therapist may be extremely helpful in establishing a reasonable exercise and activity regime.

* Other modalities found to be helpful in modulating pain include hypnotherapy, cognitive-behavioral intervention, physical therapy, and transcutaneous electrical nerve stimulation (TENS). Using palliative measures to treat symptoms and minimizing physical disability is an important treatment mainstay.

* Maintaining the child's physical conditioning is imperative in the long-term outcome of FMS.

Typical medication regimens for pediatric FMS primarily include skeletal muscle relaxants and low-dose tricyclic antidepressants. Some evidence reports that pain and symptom management with nonsteroidal anti-inflammatory drugs (NSAIDs) in combination with antidepressants and nonaddictive analgesics is effective. The most well-described medications used in the treatment of pediatric FMS are low-dose antidepressants, skeletal muscle relaxants, and NSAIDs. Low-dose antidepressants, such as amitriptyline (Elavil), and skeletal muscle relaxants, such as cyclobenzaprine (Flexeril), help decrease the hyperarousal mechanisms in FMS and, in turn, help the child and adolescent sleep better. Both medications are administered at bedtime or 1-2 hours before bedtime. Some debate exists in the literature as to which medication is used initially. Some authorities, such as Gedalia et al, suggest use of cyclobenzaprine first in treatment, while others begin medication therapy with low-dose tricyclic antidepressants.

Depending on which medication is started first, either skeletal muscle relaxants or low-dose tricyclic antidepressants have been used when the child or adolescent does not respond to the initial medication. An NSAID or acetaminophen is used in conjunction with the muscle relaxants or antidepressants in some cases that are unresponsive to the mainstay therapies alone. Active investigation is underway looking at the potential role for S-adenosylmethionine (SAMe) and the selective serotonin reuptake inhibitors (SSRIs) in the adult population.

Drug Category: Tricyclic antidepressants -- Help decrease pain intensity and improve sleep quality. They counteract the hyperarousal mechanism in FMS and promote deeper sleep in children and adolescents. Both medications are administered at bedtime or 1-2 hours before bedtime. SSRIs have been found useful for treating chronic pain states.
Drug Name
Amitriptyline (Elavil) -- Used for analgesia for certain chronic and neuropathic pain.
Adult Dose30-100 mg PO hs
Pediatric Dose<2 years: Not recommended
Children: 0.1 mg/kg PO qhs, may increase as tolerated over 2-3 wk to 0.5-2 mg/kg hs
Adolescents: 5-40 mg qhs or 2 h before bedtime
ContraindicationsDocumented hypersensitivity; MAOI use in past 14 d; seizures; cardiac arrhythmias; glaucoma; urinary retention
InteractionsPhenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
PregnancyD - Unsafe in pregnancy
PrecautionsCaution in cardiac conduction disturbances and history of hyperthyroidism and renal or hepatic impairment; avoid using in elderly patients
Drug Category: Skeletal muscle relaxants -- May act centrally by a selective action on the CNS and are principally used for relieving painful muscle spasms or spasticity occurring in musculoskeletal and neuromuscular disorders. Their mechanism of action may be due, in part, to their CNS-depressant activity.
Drug Name
Cyclobenzaprine (Flexeril) -- Helps decrease the hyperarousal mechanisms in FMS and, in turn, helps the child sleep better. Is structurally related to tricyclic antidepressants and exhibits similar pharmacologic effects. Acts primarily on the CNS at the brain stem level.
Adult Dose20-40 mg/d PO divided bid/qid; not to exceed 60 mg/d
Pediatric Dose<15 years: Not established
>15 years: 5-30 mg PO qhs
ContraindicationsDocumented hypersensitivity; concomitant use of MAOIs; MAOI use in last 14 d; depression; hyperthyroidism; urinary retention; cerebral palsy; QT prolongation
InteractionsCoadministration with MAOIs and tricyclic antidepressants may increase toxicity; cyclobenzaprine may have additive effect when used concurrently with anticholinergics; effects of alcohol, CNS depressants, and barbiturates may be enhanced with cyclobenzaprine
PregnancyB - Usually safe but benefits must outweigh the risks.
PrecautionsUrinary retention, angle-closure glaucoma, increased intraocular pressure
Drug Category: Nonsteroidal anti-inflammatory drugs -- Used for their anti-inflammatory, analgesic, and antipyretic effects. They are useful for the relief of mild to moderate pain.
Drug Name
Ibuprofen (Motrin, Ibuprin) -- May help achieve analgesia when used in combination with skeletal muscle relaxants or tricyclic antidepressants. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult Dose200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric Dose4-10 mg/kg/dose PO q6-8h
ContraindicationsDocumented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
InteractionsCoadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
PregnancyB - Usually safe but benefits must outweigh the risks.
PrecautionsCategory D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Drug Name
Acetaminophen (Tylenol, Feverall, Tempra) -- DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, patients with upper GI disease, or those who are taking PO anticoagulants.
Adult Dose325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric Dose<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h
ContraindicationsDocumented hypersensitivity; known G-6-P deficiency
InteractionsRifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
PregnancyB - Usually safe but benefits must outweigh the risks.
PrecautionsHepatotoxicity possible with overdose or long-term high doses; severe or recurrent pain or high or continued fever may indicate a serious illness; contained in many OTC products and combined use with these products may result in cumulative doses exceeding recommended maximum dose
FOLLOW-UP Prognosis:

* Improvement in signs and symptoms of FMS is likely in children and adolescents. In 2000, Gedalia and colleagues observed children in a rheumatology clinic, collecting data on 50 children with an average follow-up period of 18 months. They found that 60% of the children had improved, 36% stayed the same, and 4% worsened compared to their initial presentation. Nearly all of the children needed to continue medications for up to 4 years after initial presentation.

* In 1995, Buskila and colleagues studied FMS among children aged 9-15 years. Data on 15 of the children showed that 73% (ie, 11 of the 15) no longer met criteria for FMS at 30 months follow-up. The mean number of TPs and the amount of force necessary to elicit pain at each point showed significant improvement. Symptoms among the 4 children who still met criteria for FMS included abdominal pain, headache, paresthesias, morning stiffness, and sleep disturbance. Additionally, 7 children were observed who did not progress to the point of meeting the full criteria over the 30 months, and all 7 children had improved.

* In 1998, Siegel and colleagues observed 33 patients with a mean follow-up of 2.6 years. Improvement was observed in most patients during that follow-up time, with all patients showing some positive response to treatment. Given prognostic findings, children with FMS as a whole are more likely to have a favorable outcome than adults diagnosed with FMS.

Patient Education:

* Health care providers are responsible to educate children and families about every facet of FMS in an effort to improve basic knowledge and coping mechanisms to deal with the long-term aspects of the disease. All individuals involved must have full understanding of the goals of treatment, including exercise regimes, expectations of medication therapy, and overriding aspects of living with chronic pain. Successful treatment and improved outcomes are enhanced when the patient has a multifaceted approach to treatment, including medical care, psychologic interventions, and physical therapy. Education concerning every aspect of care and intervention is a key to successful treatment of FMS.

* In summary, the understanding of FMS in children still is in its infancy stage; however, strides in both diagnosis and treatment modalities have progressed in the past 10 years. Because prevalence of FMS in children is increasing, diagnosing the disorder early in its course and then recommending a multidisciplinary approach to treating the child's disorder is important. An approach that involves support for the family and specific recommendations for treatment may help decrease the symptomatology and increase the child's functioning.

* For excellent patient education resources, visit eMedicine's Muscle Disorders Center, Mental Health and Behavior Center, and Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education articles Fibromyalgia, Chronic Fatigue Syndrome, Chronic Pain, and Fatigue.

Overview

Fibromyalgia is a chronic musculoskeletal syndrome characterized by pain, achiness, tenderness, and stiffness in the muscle tissue, ligaments, and tendons. It most frequently affects the neck, shoulders, chest, legs, and lower back. Pain is generally accompanied by sleep disorders, fatigue, gastrointestinal disorders, and depression. Many of its symptoms are similar to those of chronic fatigue syndrome, myofascial pain syndrome, and temporomandibular joint syndrome (TMJ).

Incidence and Prevalence
It is estimated that 6 to 8 million people in the United States suffer from fibromyalgia. About 80% of patients are women. While fibromyalgia can occur at any age, the highest incidence occurs among women 20 to 40 years of age.

There have been reports of fibromyalgia in children. What may be considered "growing pains" might in fact be fibromyalgia, especially if the child complains of having difficulty sleeping.

Risk Factors

Risk factors for fibromyalgia include the following:

* Age (more common in young adults)
* Gender (more common in women than men)
* Genetic (familial patterns suggest the disorder may be inherited)
* Sleep disorders (whether sleep difficulties are a cause or a result of fibromyalgia is unknown)

Causes

Causes of fibromyalgia are not known. The condition produces vague symptoms that may be associated with diminished blood flow to certain parts of the brain and increased amounts of substance P, which is thought to be a sensory neurotransmitter involved in the communication of pain, touch, and temperature from the body to the brain. Researchers have identified several other possible causes, including the following:

* Autonomic nervous system dysfunction
* Chronic sleep disorders
* Emotional stress or trauma
* Immune or endocrine system dysfunction
* Upper spinal cord injury
* Viral or bacterial infection

Signs and Symptoms

While the symptoms of fibromyalgia can be debilitating, they are not life threatening. Symptoms vary, depending on stress level, physical activity, time of day, and the weather. Pain is the primary symptom, found in virtually 100% of cases—specifically, pain and tenderness in certain areas of the body when pressure is applied to them. These areas include:

* Back of the head
* Elbows
* Hips
* Knees
* Neck
* Upper back
* Upper chest

Pain may be aching, burning, throbbing, or move around the body (migratory). Many patients also experience muscle tightness, soreness, and spasms. The patient may be unable to carry out normal daily activities, even though muscle strength is not affected. The pain is often worse in the morning, improves throughout the day, and worsens at night.

Fibromyalgia is a chronic condition and symptoms may be constant or intermittent for years or even a lifetime. Other common symptoms of fibromyalgia include:

* Sleep disorders (e.g., restless leg syndrome, sleep apnea)

* Gastrointestinal (e.g., abdominal pain, bloating, gas, cramps, alternating diarrhea and constipation)

* Numbness or tingling sensations

* Chronic headaches (may include facial and jaw pain)

* Heightened sensitivity to odors, loud noises, bright lights, various foods, medicines, and changes in weather

* Painful menstrual periods (dysmenorrhea) and painful sexual intercourse (dyspareunia)

* Frequent urination, strong urge to urinate, and painful urination (dysuria)

* Rapid or irregular heart rate, and shortness of breath

* Sensation of swelling (edema) in the hands and feet, even though swelling is not present