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Can fibromyalgia cause fever: Fibromyalgia Flares: A Qualitative Analysis | Pain Medicine

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Fibromyalgia Flares: A Qualitative Analysis | Pain Medicine

Abstract

Objective. Patients with fibromyalgia report periods of symptom exacerbation, colloquially referred to as “flares” and despite clinical observation of flares, no research has purposefully evaluated the presence and characteristics of flares in fibromyalgia. The purpose of this qualitative study was to describe fibromyalgia flares in a sample of patients with fibromyalgia.

Methods. Using seven open-ended questions, patients were asked to describe how they perceived fibromyalgia flares and triggers and alleviating factors associated with flares. Patients were also asked to describe how a flare differs from their typical fibromyalgia symptoms and how they cope with fibromyalgia flares. Content analysis was used to analyze the text.

Results. A total of 44 participants completed the survey. Responses to the seven open-ended questions revealed three main content areas: causes of flares, flare symptoms, and dealing with a flare. Participants identified stress, overdoing it, poor sleep, and weather changes as primary causes of flares. Symptoms characteristic of flares included flu-like body aches/exhaustion, pain, fatigue, and variety of other symptoms. Participants reported using medical treatments, rest, activity and stress avoidance, and waiting it out to cope with flares.

Conclusions. Our results demonstrate that periods of symptom exacerbation (i.e., flares) are commonly experienced by patients with fibromyalgia and symptoms of flares can be differentiated from every day or typical symptoms of fibromyalgia. Our study is the first of its kind to qualitatively explore characteristics, causes, and management strategies of fibromyalgia flares. Future studies are needed to quantitatively characterize fibromyalgia flares and evaluate mechanisms of flares.

Introduction

Fibromyalgia is a complex disorder characterized by chronic, widespread pain, fatigue, cognitive complaints, poor sleep, and mood difficulties. While these symptoms are characteristic of fibromyalgia, patients frequently report a host of other, less well-defined symptoms that occur with varying degrees of severity, including headache, gastrointestinal symptoms, dizziness, heat/cold intolerance, numbness or tingling, and low-grade fevers [1–3]. These symptoms, along with others of fibromyalgia, appear to undergo periods of exacerbation or worsening, often colloquially referred to as “flares” by patients and their health care providers.

Despite clinical observation supporting the presence of flares, no research has purposefully evaluated the presence and characteristics of flares in fibromyalgia and only a couple of publications provide even brief description of flares [4–6]. In one qualitative study, participants stated that over-doing it on a “good day” could lead to fibromyalgia symptom worsening. No further description of how a flare differed from typical or “normal” fibromyalgia symptoms was provided [4]. In a second qualitative study, participants describe flares as a “sudden increase in symptoms, usually to the point where everyday tasks become impossible” [5]. For some patients, flares were characterized by a worsening of existing symptoms (increased or altered pain), whereas others reported new symptoms (flu-like symptoms). In a third study, patients reported that fibromyalgia flares were associated with activity and weather changes [6]. These studies indicate that periods of symptom worsening or flares may be present in fibromyalgia, however, none of the above studies describe whether there are symptoms that are unique to flares or how flares differ from typical fibromyalgia symptoms.

The purpose of this qualitative descriptive study was to describe fibromyalgia flares in a well-characterized sample of patients with fibromyalgia. Using open-ended questions, we sought to understand how patients perceived fibromyalgia flares and what triggers and alleviating factors patients identified for their own symptoms (if any).

Methods

To obtain patient descriptions of fibromyalgia flares, patients were asked to respond to seven open-ended questions assessing quality, severity, and duration. The questions asked about symptoms that may appear during a flare that are not present at other times, how a flare differs from a patient’s typical fibromyalgia experience, flare triggers, and how patient’s cope with fibromyalgia flares (Table 1). Patients were each paid $20.00 for their time and participation. This study was reviewed and approved by the Mayo Clinic Institutional Review Board and all participants provided written informed consent.

Table 1

Open-ended items included on the qualitative questionnaire

Questionnaire Items
If you were describing a fibromyalgia flare to someone who had never experienced one, how would you describe it? 
Do you experience any new symptoms during a fibromyalgia flare that are not typical of your everyday fibromyalgia symptoms? Please describe 
How is a fibromyalgia flare different from your everyday experience of fibromyalgia symptoms? 
Do you find that there are things or events that trigger a fibromyalgia flare for you? If so, please explain 
How do you cope with a fibromyalgia flare? 
What, if anything, reduces the symptoms of a fibromyalgia flare? 
Is there any additional information you would like us to know about your fibromyalgia flares? 
Questionnaire Items
.  
If you were describing a fibromyalgia flare to someone who had never experienced one, how would you describe it? 
Do you experience any new symptoms during a fibromyalgia flare that are not typical of your everyday fibromyalgia symptoms? Please describe 
How is a fibromyalgia flare different from your everyday experience of fibromyalgia symptoms? 
Do you find that there are things or events that trigger a fibromyalgia flare for you? If so, please explain 
How do you cope with a fibromyalgia flare? 
What, if anything, reduces the symptoms of a fibromyalgia flare? 
Is there any additional information you would like us to know about your fibromyalgia flares? 

Table 1

Open-ended items included on the qualitative questionnaire

Questionnaire Items
If you were describing a fibromyalgia flare to someone who had never experienced one, how would you describe it? 
Do you experience any new symptoms during a fibromyalgia flare that are not typical of your everyday fibromyalgia symptoms? Please describe 
How is a fibromyalgia flare different from your everyday experience of fibromyalgia symptoms? 
Do you find that there are things or events that trigger a fibromyalgia flare for you? If so, please explain 
How do you cope with a fibromyalgia flare? 
What, if anything, reduces the symptoms of a fibromyalgia flare? 
Is there any additional information you would like us to know about your fibromyalgia flares? 
Questionnaire Items
.  
If you were describing a fibromyalgia flare to someone who had never experienced one, how would you describe it? 
Do you experience any new symptoms during a fibromyalgia flare that are not typical of your everyday fibromyalgia symptoms? Please describe 
How is a fibromyalgia flare different from your everyday experience of fibromyalgia symptoms? 
Do you find that there are things or events that trigger a fibromyalgia flare for you? If so, please explain 
How do you cope with a fibromyalgia flare? 
What, if anything, reduces the symptoms of a fibromyalgia flare? 
Is there any additional information you would like us to know about your fibromyalgia flares? 

Participants

Participants for this study were recruited from an existing, national registry of patients with fibromyalgia who have been seen at Mayo Clinic in Rochester, MN [7]. Patients in the fibromyalgia registry were seen at Mayo Clinic between January 1, 2000 and December 31, 2012 and had a diagnosis of fibromyalgia that was confirmed via medical record review. At the time of enrollment in the registry, all participants completed the Fibromyalgia Research Survey Criteria [8]. To be eligible for this qualitative study, registry participants were between the ages of 18 and 69 years, met Fibromyalgia Research Survey Criteria at the time of enrollment, able to read and write English, and provided an email address by which we could contact them with the electronic survey.

Procedure

The survey was administered electronically using the Research Electronic Data Capture (REDCap) Survey tool [9]. Patients were selected so that the female to male ratio was 4:1. Patients were divided into the following three age groups: 18–35, 36–53, and 54–69. A random number generator was used to select 24 women and 6 men from each of the age groups (total 90 invited). Of those, 44 agreed to participate and completed the study questionnaire.

Analysis

Content analysis [10] was used to analyze the text. Participant responses to each question were read for overall understanding of the content. Responses to the survey questions were analyzed and sorted into categories that described the meaning of the text. After all text was coded, the investigators independently reviewed the coding scheme to ensure the themes and subthemes were accurate. The few discrepancies and the final scheme was determined by consensus.

Results

A total of 44 participants completed the survey. The majority of participants were female (77%) and non-Hispanic white (93%). Fifty-seven percent of participants were married, 9% were divorced, and 34% were single. The average age of participants was 45.5 (standard deviation 14.6). Responses to the seven questions were found to demonstrate three main content areas: causes of flares, flare symptoms, and dealing with a flare. Content analysis of participant responses identified several key themes within each of these content areas. Each of these are detailed below and summarized in Table 2.

Table 2

Content areas and themes identified using content analysis

Content Areas
Themes
Frequency (%)
Causes of flares  “Stress, Stress, Stress!”  28 (63.6) 
“Overdoing It”  19 (43.2) 
“Poor Sleep”  11 (25.0) 
“Weather Changes”  11 (25.0) 
Flare symptoms  “Flu-like Symptoms”  14 (31.8) 
“Pain”  38 (86.4) 
“Fatigue”  15 (34.1) 
“Other Symptoms”*  49 (>100) 
Dealing with a flare  “Treatments”  25 (56.8) 
“Avoid Everything”  10 (22.7) 
“Wait It Out”  8 (18.2) 
Content Areas
Themes
Frequency (%)
Causes of flares  “Stress, Stress, Stress!”  28 (63.6) 
“Overdoing It”  19 (43.2) 
“Poor Sleep”  11 (25.0) 
“Weather Changes”  11 (25.0) 
Flare symptoms  “Flu-like Symptoms”  14 (31.8) 
“Pain”  38 (86.4) 
“Fatigue”  15 (34.1) 
“Other Symptoms”*  49 (>100) 
Dealing with a flare  “Treatments”  25 (56.8) 
“Avoid Everything”  10 (22.7) 
“Wait It Out”  8 (18.2) 

Table 2

Content areas and themes identified using content analysis

Content Areas
Themes
Frequency (%)
Causes of flares  “Stress, Stress, Stress!”  28 (63.6) 
“Overdoing It”  19 (43.2) 
“Poor Sleep”  11 (25.0) 
“Weather Changes”  11 (25.0) 
Flare symptoms  “Flu-like Symptoms”  14 (31.8) 
“Pain”  38 (86.4) 
“Fatigue”  15 (34.1) 
“Other Symptoms”*  49 (>100) 
Dealing with a flare  “Treatments”  25 (56.8) 
“Avoid Everything”  10 (22.7) 
“Wait It Out”  8 (18.2) 
Content Areas
Themes
Frequency (%)
Causes of flares  “Stress, Stress, Stress!”  28 (63.6) 
“Overdoing It”  19 (43.2) 
“Poor Sleep”  11 (25.0) 
“Weather Changes”  11 (25.0) 
Flare symptoms  “Flu-like Symptoms”  14 (31.8) 
“Pain”  38 (86.4) 
“Fatigue”  15 (34.1) 
“Other Symptoms”*  49 (>100) 
Dealing with a flare  “Treatments”  25 (56.8) 
“Avoid Everything”  10 (22.7) 
“Wait It Out”  8 (18.2) 

Causes of Flares

Participants hypothesized the causes of flares. Most stated a cause with only a few saying they were unable to identify a particular cause. Subthemes describing the causes of flares include stress, overdoing it, poor sleep, and weather changes.

 “Stress, Stress, Stress!”

When asked to identify causes of flares, stress was a common theme. This relationship is captured well by one participant’s comment, “Stress I would say is my BIGGEST trigger. There are days that stress makes my life awful.” Most participants used the term stress, but some also used anxiety to describe emotional turmoil related to a flare. Stress of any sort, including work and life stresses were reported. Specific examples included deadlines, emotional extremes, or upsets such as grief, family concerns, preparing to travel, and holiday stress. This is highlighted by one participant, “I find that for me I have flare ups in times of high stress with work or life.” Reactions to stress were also reported to influence flares; one participant stated that for her, flares were influenced by “extreme emotions such as grief. For instance when my best friend’s dad passed away I had a flare from the sadness I felt.”

 “Overdoing it”

Another key theme identified from participant responses was “overdoing it.” Overdoing it included physical exertion as well as variations in normal activity patterns (e.g., trips, social events). Work activity was cited as one source of overexertion, in addition to work at home that included things like yard work, cleaning, and vacuuming. Increased social activity was also described as a source of overextension. For example, one participant stated “If I am over-exerting at work, physically, or socially, I can flare.” Participants also highlighted the influence that overdoing their activities 1 day could have on the following day, for example, one participant stated “I’m an all or nothing gal. I do too much one day and can’t do anything the next.” In addition to overdoing activities, overdoing it in combination with inadequate rest was also cited as a cause by several participants. For example, one participant stated “I can induce a flare pretty easily if I work too much and don’t rest enough. If I push myself too hard … I can expect a flare in the coming days.”

 “Poor Sleep”

Difficulty sleeping or poor quality sleep was another theme identified from participant responses. One participant stated, “low sleep over a course of a couple of days or more can do it.” The relationship between poor sleep and fibromyalgia flares is obfuscated by the fact that when a patient is experiencing a flare, quality sleep often becomes more difficult to obtain. This circuitous relationship was described well by one participant, “If I don’t get enough sleep that will cause a flare-up, but it also causes me to not be able to sleep at the same time.”

 “Weather Changes”

Another common theme identified in participant responses was weather changes. Drops in barometric pressure, heat, and storms were implicated in development of a flare. Sudden changes in weather, in particular, seemed to be more problematic. One participant stated, “the changing of seasons when the weather swings really hard.” Another participant described how rapid weather fluctuations could induce rapid symptom changes, “It seems like whenever the barometric pressure changes drastically, the symptoms come on quickly and leave just as quickly.”

Flare Symptoms

When asked how flares differ from everyday symptoms of fibromyalgia, participants reported that although they may experience symptoms that are unique to a flare (e.g., flu-like body aches and exhaustion), their flare experience was largely an increased intensity of usual symptoms to the point “where it feels disabling.” “My flares are different because the pain is more intense and is continual. It carries on even after I have rested or taken medication. That’s how I distinguish between the daily fibromyalgia and a flare.” As the symptoms were more intense, they were also more difficult to manage, “I can normally work a regular 40 hour week, complete chores and errands and have somewhat of a social life with ‘normal’ fibromyalgia. With a bad flare, that’s not possible.” Common subthemes that emerged from patient-reported flare symptoms are detailed below.

 “Flu-like symptoms”

Participant responses often included description of the severe “full body aching and exhaustion” experienced during flares as akin to a severe flu and different from usual fibromyalgia symptoms. As described by one participant, “If you’ve ever had a flu sneak up on you after you went to sleep one night and you wake up with your entire body aching, you’ve got an inkling of what a flare is. It’s not gradual.” Similarly, other participants described flares as “the worst flu you’ve ever had,” “it feels like I have the flu in my bones really bad.”

 “Pain”

The pain experienced during a flare was also described as different and more severe than typical pain. According to one participant, flare pain is “intense pain that makes me not want to move or be touched.” The intensity of this pain is almost palpable in another participant’s description, “it feels like someone is taking a carrot peeler to my bones … like a giant wearing a mountain-boot is standing on that part of my body.”

 “Fatigue”

Similar to extreme pain experienced during a flare, the fatigue characteristic of a fibromyalgia flare is severe and debilitating. Participants described the fatigue as “complete exhaustion” that resulted in being “too tired to move,” which in turn severely impacted function. This was so extreme that, according to one participant, even “lifting a finger was exhausting.”

 “Other Symptoms”

In addition to flu-like symptoms, pain, and fatigue, participants reported experiencing a wide variety of other symptoms. One such symptom was decreased concentration. Participants noted, “I find my concentration is less than normal” and “[have] fogginess in my head. ” Muscle tightness was another symptom reported by several participants. They stated “my legs feel like they are extremely tight” such that “nearly every major muscle is tight and locked up.” Additionally, participants reported “severe headaches/migraines,” “sensitivity to touch,” and feeling as although their “hands and feet are swollen,” which necessitated “significantly scaling back on activities during flares.” In addition to worsening of physical symptoms, patients reported an increased intensity of emotional responses and significant difficulty with mood. The “emotional and psychological repercussions are more intense,” “[flares] make me feel depressed and not want to be around other people.”

Dealing with a Flare

The third theme included strategies used by participants to prevent or manage flares (Table 3). Participants listed a wide variety of strategies, and from these four subthemes were identified: treatments, rest, avoiding everything, and waiting it out.

Table 3

Strategies adopted by patients to deal with flares

Strategies
Frequency (%)
Physical therapy  2 (4.5) 
Hydrotherapy  1 (2.3) 
Meditation  7 (15.9) 
Breathing exercises  8 (18.2) 
Massage  10 (22.7) 
Hot or cold therapy  6 (13.6) 
Medications  34 (77.3) 
Strategies
Frequency (%)
Physical therapy  2 (4.5) 
Hydrotherapy  1 (2.3) 
Meditation  7 (15.9) 
Breathing exercises  8 (18.2) 
Massage  6 (13.6) 
Medications  34 (77.3) 

Table 3

Strategies adopted by patients to deal with flares

Strategies
Frequency (%)
Physical therapy  2 (4.5) 
Hydrotherapy  1 (2.3) 
Meditation  7 (15.9) 
Breathing exercises  8 (18.2) 
Massage  10 (22.7) 
Hot or cold therapy  6 (13.6) 
Medications  34 (77.3) 
Strategies
Frequency (%)
Physical therapy  2 (4.5) 
Hydrotherapy  1 (2.3) 
Meditation  7 (15.9) 
Breathing exercises  8 (18.2) 
Massage  10 (22.7) 
Hot or cold therapy  6 (13.6) 
Medications  34 (77.3) 

 “Treatments”

Despite the questions’ focus on coping strategies, participants identified a number of treatments used to cope with or manage symptoms, which included pharmacological and nonpharmacological modalities. Acetaminophen and ibuprofen were the most commonly used medications. In addition to medications, participants reported using physical modalities such as massage, heat/cold, hydrotherapy, and gentle exercise. Meditation, deep breathing, prayer, and humor were also used.

 “Rest”

The majority of participants described getting more rest or staying home, particularly in bed, as the major coping strategy for a flare. This is well captured in the response of one participant, “I recognize my body isn’t able to handle/cope with things as usual, so I try to slow my pace, rest if needed, take shorter walks, and just be good to myself.” Another participant described how she limited her activities during a flare to rest, “[I] collapsed on the couch in my old living room and cut out extra social engagements, errands that could wait, cooking (just ate out or made simple meals like sandwiches etc.), because I had no energy for those things.” This rest often required limiting work and social engagements, including doctor’s appointments. Another participant stated, “[I] stay at home, sleep (if I can), rest in my big recliner. I usually just phone and cancel appointments for doctors and meetings with friends.”

 “Avoid Everything”

Beyond simple rest, avoidance of all activities and social interactions was described as a protective coping strategy to prevent untoward outcomes. As one participant stated, a severe flare was “similar to a migraine, when you don’t want to see or hear from anyone.” Another participant stated, “all I want to do is crawl in bed and sleep until it’s over.” During a flare, “social contact and other activity is limited or nonexistent.” For some participants, social interactions were emotionally and physically challenging, “[I] just try to avoid dealing with people as I feel grumpy and get mad more easily.”

 “Wait it out”

Flares were described as a part of the fibromyalgia experience to be waited out and tolerated as best possible. Participants described how reminding themselves that a flare will pass served as a coping strategy. Ignoring the symptoms and “pushing through it” were the associated strategies. One participant stated, “I try to remind myself that it will pass, it’s temporary, and just keep moving forward and do what needs to be done.” Other participants “cope by giving [themselves] time and permission to take it slow” and acknowledging that “it will subside and there is nothing you can do about it.” Instead of avoiding everything, some participants agreed that you “just have to go with it.”

Discussion

This qualitative study is the first of its kind to describe a patient’s experience of a fibromyalgia flare. Despite the term “flare” being used frequently by health care providers and patients, little research has purposefully evaluated the presence and characteristics of fibromyalgia flares. Using content analysis, we identified themes in three content areas related to the causes, symptoms, and methods for dealing with a flare. This study provides the first step toward better defining flares so that they may be systematically studied.

Our results are consistent with the few previous papers that mention fibromyalgia flares, such as the one that describes activity and weather changes as potential causes of flares [6], but significantly add to the knowledge of what a flare looks and feels like for a patient with fibromyalgia. This study suggests that fibromyalgia symptoms do flare or fluctuate over time and that patients report that flares are often triggered by stress, overdoing it, and lack of sleep. As in previous studies, stress was identified as a trigger of flare-ups and the symptoms were interrelated; flare-ups of one symptom often exacerbated another (vicious cycle) [3].

In addition to exacerbation of common fibromyalgia symptoms, there seem to be symptoms that are unique to a flare, in particular, flu-like achiness. In one previous study of the patient experience of fibromyalgia, a woman reported feeling “feverish … almost like I have the flu.” [6], which is consistent with the description several study participants provided. The flu-like like achiness during a flare often makes the flare debilitating, severely impacting home and work life and social activity, which was also consistent with what participants reported in this study.

Although most of the study findings were consistent with what we observe clinically, we were somewhat surprised to find that in addition to rest and medical treatment, one of the most common methods of dealing with a flare was avoidance of physical, social, and psychological stimulation. Avoiding everything may indicate a lack of knowledge of or ability to use healthy coping strategies, and therefore, future research could evaluate the potential effects of teaching patients healthy coping strategies as one method to deal with symptom flares.

While the findings of this exploratory study shed light on the experience of a fibromyalgia flare as experienced by patients, there are inherent limitations. First, the data are collected by text response to survey questions. The use of interview or focus group might allow for deeper understanding of the experience. Second, while the sample of patients was randomly selected from a large, national fibromyalgia registry, it includes patients from only one academic medical center, and therefore, the results may not be generalizable to other patients with fibromyalgia. Third, in this study, we did not specifically conceptualize flares in terms of pain or fatigue, key symptoms of fibromyalgia, but allowed patients to report their experience regarding all symptoms that they have during a flare. Therefore, it is possible that comorbid depression or untreated sleep disorders could have contributed to a patient’s flare experience. Future research is needed to evaluate flare characteristics in a larger, more diverse sample of patients with fibromyalgia.

Conclusions

This study is the first of its kind to qualitatively explore patient perspectives regarding characteristics, causes, and management strategies of fibromyalgia flares. The presence of exacerbation or “flare” is a phenomenon readily described by these 44 patients diagnosed with fibromyalgia. Based on patient descriptions, a flare can be differentiated from typical or every day symptoms of fibromyalgia. The causes of flares are attributed to a wide variety of stressors. Strategies aimed at managing flare symptoms largely focus on rest and not “overdoing”. Future research assessing symptoms over time would be valuable in quantitatively characterizing the frequency of fibromyalgia flares and the changes in fibromyalgia symptoms that occur before, during, and after a flare.

Acknowledgments

Study data were collected and managed using REDCap electronic data capture tools hosted at Mayo Clinic REDCap (Research Electronic Data Capture) is a secure, web-based application designed to support data capture for research studies, providing 1) an intuitive interface for validated data entry; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for importing data from external sources.

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Author notes

© 2015 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: [email protected]

Fibromyalgia Flares: A Qualitative Analysis | Pain Medicine

Abstract

Objective. Patients with fibromyalgia report periods of symptom exacerbation, colloquially referred to as “flares” and despite clinical observation of flares, no research has purposefully evaluated the presence and characteristics of flares in fibromyalgia. The purpose of this qualitative study was to describe fibromyalgia flares in a sample of patients with fibromyalgia.

Methods. Using seven open-ended questions, patients were asked to describe how they perceived fibromyalgia flares and triggers and alleviating factors associated with flares. Patients were also asked to describe how a flare differs from their typical fibromyalgia symptoms and how they cope with fibromyalgia flares. Content analysis was used to analyze the text.

Results. A total of 44 participants completed the survey. Responses to the seven open-ended questions revealed three main content areas: causes of flares, flare symptoms, and dealing with a flare. Participants identified stress, overdoing it, poor sleep, and weather changes as primary causes of flares. Symptoms characteristic of flares included flu-like body aches/exhaustion, pain, fatigue, and variety of other symptoms. Participants reported using medical treatments, rest, activity and stress avoidance, and waiting it out to cope with flares.

Conclusions. Our results demonstrate that periods of symptom exacerbation (i.e., flares) are commonly experienced by patients with fibromyalgia and symptoms of flares can be differentiated from every day or typical symptoms of fibromyalgia. Our study is the first of its kind to qualitatively explore characteristics, causes, and management strategies of fibromyalgia flares. Future studies are needed to quantitatively characterize fibromyalgia flares and evaluate mechanisms of flares.

Introduction

Fibromyalgia is a complex disorder characterized by chronic, widespread pain, fatigue, cognitive complaints, poor sleep, and mood difficulties. While these symptoms are characteristic of fibromyalgia, patients frequently report a host of other, less well-defined symptoms that occur with varying degrees of severity, including headache, gastrointestinal symptoms, dizziness, heat/cold intolerance, numbness or tingling, and low-grade fevers [1–3]. These symptoms, along with others of fibromyalgia, appear to undergo periods of exacerbation or worsening, often colloquially referred to as “flares” by patients and their health care providers.

Despite clinical observation supporting the presence of flares, no research has purposefully evaluated the presence and characteristics of flares in fibromyalgia and only a couple of publications provide even brief description of flares [4–6]. In one qualitative study, participants stated that over-doing it on a “good day” could lead to fibromyalgia symptom worsening. No further description of how a flare differed from typical or “normal” fibromyalgia symptoms was provided [4]. In a second qualitative study, participants describe flares as a “sudden increase in symptoms, usually to the point where everyday tasks become impossible” [5]. For some patients, flares were characterized by a worsening of existing symptoms (increased or altered pain), whereas others reported new symptoms (flu-like symptoms). In a third study, patients reported that fibromyalgia flares were associated with activity and weather changes [6]. These studies indicate that periods of symptom worsening or flares may be present in fibromyalgia, however, none of the above studies describe whether there are symptoms that are unique to flares or how flares differ from typical fibromyalgia symptoms.

The purpose of this qualitative descriptive study was to describe fibromyalgia flares in a well-characterized sample of patients with fibromyalgia. Using open-ended questions, we sought to understand how patients perceived fibromyalgia flares and what triggers and alleviating factors patients identified for their own symptoms (if any).

Methods

To obtain patient descriptions of fibromyalgia flares, patients were asked to respond to seven open-ended questions assessing quality, severity, and duration. The questions asked about symptoms that may appear during a flare that are not present at other times, how a flare differs from a patient’s typical fibromyalgia experience, flare triggers, and how patient’s cope with fibromyalgia flares (Table 1). Patients were each paid $20.00 for their time and participation. This study was reviewed and approved by the Mayo Clinic Institutional Review Board and all participants provided written informed consent.

Table 1

Open-ended items included on the qualitative questionnaire

Questionnaire Items
If you were describing a fibromyalgia flare to someone who had never experienced one, how would you describe it? 
Do you experience any new symptoms during a fibromyalgia flare that are not typical of your everyday fibromyalgia symptoms? Please describe 
How is a fibromyalgia flare different from your everyday experience of fibromyalgia symptoms? 
Do you find that there are things or events that trigger a fibromyalgia flare for you? If so, please explain 
How do you cope with a fibromyalgia flare? 
What, if anything, reduces the symptoms of a fibromyalgia flare? 
Is there any additional information you would like us to know about your fibromyalgia flares? 
Questionnaire Items
If you were describing a fibromyalgia flare to someone who had never experienced one, how would you describe it? 
Do you experience any new symptoms during a fibromyalgia flare that are not typical of your everyday fibromyalgia symptoms? Please describe 
How is a fibromyalgia flare different from your everyday experience of fibromyalgia symptoms? 
Do you find that there are things or events that trigger a fibromyalgia flare for you? If so, please explain 
How do you cope with a fibromyalgia flare? 
What, if anything, reduces the symptoms of a fibromyalgia flare? 
Is there any additional information you would like us to know about your fibromyalgia flares? 

Table 1

Open-ended items included on the qualitative questionnaire

Questionnaire Items
If you were describing a fibromyalgia flare to someone who had never experienced one, how would you describe it? 
Do you experience any new symptoms during a fibromyalgia flare that are not typical of your everyday fibromyalgia symptoms? Please describe 
How is a fibromyalgia flare different from your everyday experience of fibromyalgia symptoms? 
Do you find that there are things or events that trigger a fibromyalgia flare for you? If so, please explain 
How do you cope with a fibromyalgia flare? 
What, if anything, reduces the symptoms of a fibromyalgia flare? 
Is there any additional information you would like us to know about your fibromyalgia flares? 
Questionnaire Items
If you were describing a fibromyalgia flare to someone who had never experienced one, how would you describe it? 
Do you experience any new symptoms during a fibromyalgia flare that are not typical of your everyday fibromyalgia symptoms? Please describe 
How is a fibromyalgia flare different from your everyday experience of fibromyalgia symptoms? 
Do you find that there are things or events that trigger a fibromyalgia flare for you? If so, please explain 
How do you cope with a fibromyalgia flare? 
What, if anything, reduces the symptoms of a fibromyalgia flare? 
Is there any additional information you would like us to know about your fibromyalgia flares? 

Participants

Participants for this study were recruited from an existing, national registry of patients with fibromyalgia who have been seen at Mayo Clinic in Rochester, MN [7]. Patients in the fibromyalgia registry were seen at Mayo Clinic between January 1, 2000 and December 31, 2012 and had a diagnosis of fibromyalgia that was confirmed via medical record review. At the time of enrollment in the registry, all participants completed the Fibromyalgia Research Survey Criteria [8]. To be eligible for this qualitative study, registry participants were between the ages of 18 and 69 years, met Fibromyalgia Research Survey Criteria at the time of enrollment, able to read and write English, and provided an email address by which we could contact them with the electronic survey.

Procedure

The survey was administered electronically using the Research Electronic Data Capture (REDCap) Survey tool [9]. Patients were selected so that the female to male ratio was 4:1. Patients were divided into the following three age groups: 18–35, 36–53, and 54–69. A random number generator was used to select 24 women and 6 men from each of the age groups (total 90 invited). Of those, 44 agreed to participate and completed the study questionnaire.

Analysis

Content analysis [10] was used to analyze the text. Participant responses to each question were read for overall understanding of the content. Responses to the survey questions were analyzed and sorted into categories that described the meaning of the text. After all text was coded, the investigators independently reviewed the coding scheme to ensure the themes and subthemes were accurate. The few discrepancies and the final scheme was determined by consensus.

Results

A total of 44 participants completed the survey. The majority of participants were female (77%) and non-Hispanic white (93%). Fifty-seven percent of participants were married, 9% were divorced, and 34% were single. The average age of participants was 45.5 (standard deviation 14.6). Responses to the seven questions were found to demonstrate three main content areas: causes of flares, flare symptoms, and dealing with a flare. Content analysis of participant responses identified several key themes within each of these content areas. Each of these are detailed below and summarized in Table 2.

Table 2

Content areas and themes identified using content analysis

Content Areas
Themes
Frequency (%)
Causes of flares  “Stress, Stress, Stress!”  28 (63.6) 
“Overdoing It”  19 (43.2) 
“Poor Sleep”  11 (25.0) 
“Weather Changes”  11 (25.0) 
Flare symptoms  “Flu-like Symptoms”  14 (31.8) 
“Pain”  38 (86.4) 
“Fatigue”  15 (34.1) 
“Other Symptoms”*  49 (>100) 
Dealing with a flare  “Treatments”  33 (75.0) 
“Rest”  25 (56.8) 
“Avoid Everything”  10 (22.7) 
“Wait It Out”  8 (18.2) 
Content Areas
Themes
Frequency (%)
Causes of flares  “Stress, Stress, Stress!”  28 (63.6) 
“Overdoing It”  19 (43.2) 
“Poor Sleep”  11 (25.0) 
“Weather Changes”  11 (25.0) 
Flare symptoms  “Flu-like Symptoms”  14 (31.8) 
“Pain”  38 (86.4) 
“Fatigue”  15 (34.1) 
“Other Symptoms”*  49 (>100) 
Dealing with a flare  “Treatments”  33 (75.0) 
“Rest”  25 (56.8) 
“Avoid Everything”  10 (22.7) 
“Wait It Out”  8 (18.2) 

Table 2

Content areas and themes identified using content analysis

Content Areas
Themes
Frequency (%)
Causes of flares  “Stress, Stress, Stress!”  28 (63.6) 
“Overdoing It”  19 (43.2) 
“Poor Sleep”  11 (25.0) 
“Weather Changes”  11 (25.0) 
Flare symptoms  “Flu-like Symptoms”  14 (31.8) 
“Pain”  38 (86.4) 
“Fatigue”  15 (34.1) 
“Other Symptoms”*  49 (>100) 
Dealing with a flare  “Treatments”  33 (75.0) 
“Rest”  25 (56.8) 
“Avoid Everything”  10 (22.7) 
“Wait It Out”  8 (18.2) 
Content Areas
Themes
Frequency (%)
Causes of flares  “Stress, Stress, Stress!”  28 (63.6) 
“Overdoing It”  19 (43.2) 
“Poor Sleep”  11 (25.0) 
“Weather Changes”  11 (25.0) 
Flare symptoms  “Flu-like Symptoms”  14 (31.8) 
“Pain”  38 (86.4) 
“Fatigue”  15 (34.1) 
“Other Symptoms”*  49 (>100) 
Dealing with a flare  “Treatments”  33 (75.0) 
“Rest”  25 (56.8) 
“Avoid Everything”  10 (22.7) 
“Wait It Out”  8 (18.2) 

Causes of Flares

Participants hypothesized the causes of flares. Most stated a cause with only a few saying they were unable to identify a particular cause. Subthemes describing the causes of flares include stress, overdoing it, poor sleep, and weather changes.

 “Stress, Stress, Stress!”

When asked to identify causes of flares, stress was a common theme. This relationship is captured well by one participant’s comment, “Stress I would say is my BIGGEST trigger. There are days that stress makes my life awful.” Most participants used the term stress, but some also used anxiety to describe emotional turmoil related to a flare. Stress of any sort, including work and life stresses were reported. Specific examples included deadlines, emotional extremes, or upsets such as grief, family concerns, preparing to travel, and holiday stress. This is highlighted by one participant, “I find that for me I have flare ups in times of high stress with work or life.” Reactions to stress were also reported to influence flares; one participant stated that for her, flares were influenced by “extreme emotions such as grief. For instance when my best friend’s dad passed away I had a flare from the sadness I felt.”

 “Overdoing it”

Another key theme identified from participant responses was “overdoing it.” Overdoing it included physical exertion as well as variations in normal activity patterns (e.g., trips, social events). Work activity was cited as one source of overexertion, in addition to work at home that included things like yard work, cleaning, and vacuuming. Increased social activity was also described as a source of overextension. For example, one participant stated “If I am over-exerting at work, physically, or socially, I can flare.” Participants also highlighted the influence that overdoing their activities 1 day could have on the following day, for example, one participant stated “I’m an all or nothing gal. I do too much one day and can’t do anything the next.” In addition to overdoing activities, overdoing it in combination with inadequate rest was also cited as a cause by several participants. For example, one participant stated “I can induce a flare pretty easily if I work too much and don’t rest enough. If I push myself too hard … I can expect a flare in the coming days.”

 “Poor Sleep”

Difficulty sleeping or poor quality sleep was another theme identified from participant responses. One participant stated, “low sleep over a course of a couple of days or more can do it.” The relationship between poor sleep and fibromyalgia flares is obfuscated by the fact that when a patient is experiencing a flare, quality sleep often becomes more difficult to obtain. This circuitous relationship was described well by one participant, “If I don’t get enough sleep that will cause a flare-up, but it also causes me to not be able to sleep at the same time.”

 “Weather Changes”

Another common theme identified in participant responses was weather changes. Drops in barometric pressure, heat, and storms were implicated in development of a flare. Sudden changes in weather, in particular, seemed to be more problematic. One participant stated, “the changing of seasons when the weather swings really hard.” Another participant described how rapid weather fluctuations could induce rapid symptom changes, “It seems like whenever the barometric pressure changes drastically, the symptoms come on quickly and leave just as quickly.”

Flare Symptoms

When asked how flares differ from everyday symptoms of fibromyalgia, participants reported that although they may experience symptoms that are unique to a flare (e.g., flu-like body aches and exhaustion), their flare experience was largely an increased intensity of usual symptoms to the point “where it feels disabling.” “My flares are different because the pain is more intense and is continual. It carries on even after I have rested or taken medication. That’s how I distinguish between the daily fibromyalgia and a flare.” As the symptoms were more intense, they were also more difficult to manage, “I can normally work a regular 40 hour week, complete chores and errands and have somewhat of a social life with ‘normal’ fibromyalgia. With a bad flare, that’s not possible.” Common subthemes that emerged from patient-reported flare symptoms are detailed below.

 “Flu-like symptoms”

Participant responses often included description of the severe “full body aching and exhaustion” experienced during flares as akin to a severe flu and different from usual fibromyalgia symptoms. As described by one participant, “If you’ve ever had a flu sneak up on you after you went to sleep one night and you wake up with your entire body aching, you’ve got an inkling of what a flare is. It’s not gradual.” Similarly, other participants described flares as “the worst flu you’ve ever had,” “it feels like I have the flu in my bones really bad.”

 “Pain”

The pain experienced during a flare was also described as different and more severe than typical pain. According to one participant, flare pain is “intense pain that makes me not want to move or be touched.” The intensity of this pain is almost palpable in another participant’s description, “it feels like someone is taking a carrot peeler to my bones … like a giant wearing a mountain-boot is standing on that part of my body.”

 “Fatigue”

Similar to extreme pain experienced during a flare, the fatigue characteristic of a fibromyalgia flare is severe and debilitating. Participants described the fatigue as “complete exhaustion” that resulted in being “too tired to move,” which in turn severely impacted function. This was so extreme that, according to one participant, even “lifting a finger was exhausting.”

 “Other Symptoms”

In addition to flu-like symptoms, pain, and fatigue, participants reported experiencing a wide variety of other symptoms. One such symptom was decreased concentration. Participants noted, “I find my concentration is less than normal” and “[have] fogginess in my head.” Muscle tightness was another symptom reported by several participants. They stated “my legs feel like they are extremely tight” such that “nearly every major muscle is tight and locked up.” Additionally, participants reported “severe headaches/migraines,” “sensitivity to touch,” and feeling as although their “hands and feet are swollen,” which necessitated “significantly scaling back on activities during flares.” In addition to worsening of physical symptoms, patients reported an increased intensity of emotional responses and significant difficulty with mood. The “emotional and psychological repercussions are more intense,” “[flares] make me feel depressed and not want to be around other people.”

Dealing with a Flare

The third theme included strategies used by participants to prevent or manage flares (Table 3). Participants listed a wide variety of strategies, and from these four subthemes were identified: treatments, rest, avoiding everything, and waiting it out.

Table 3

Strategies adopted by patients to deal with flares

Strategies
Frequency (%)
Physical therapy  2 (4.5) 
Hydrotherapy  1 (2.3) 
Meditation  7 (15.9) 
Breathing exercises  8 (18.2) 
Massage  10 (22.7) 
Hot or cold therapy  6 (13.6) 
Medications  34 (77.3) 
Strategies
Frequency (%)
Physical therapy  2 (4.5) 
Hydrotherapy  1 (2.3) 
Meditation  7 (15.9) 
Breathing exercises  8 (18.2) 
Massage  10 (22.7) 
Hot or cold therapy  6 (13.6) 
Medications  34 (77.3) 

Table 3

Strategies adopted by patients to deal with flares

Strategies
Frequency (%)
Physical therapy  2 (4.5) 
Hydrotherapy  1 (2.3) 
Meditation  7 (15.9) 
Breathing exercises  8 (18.2) 
Massage  10 (22.7) 
Hot or cold therapy  6 (13.6) 
Medications  34 (77.3) 
Strategies
Frequency (%)
Physical therapy  2 (4.5) 
Hydrotherapy  1 (2.3) 
Meditation  7 (15.9) 
Breathing exercises  8 (18.2) 
Massage  10 (22.7) 
Hot or cold therapy  6 (13.6) 
Medications  34 (77.3) 

 “Treatments”

Despite the questions’ focus on coping strategies, participants identified a number of treatments used to cope with or manage symptoms, which included pharmacological and nonpharmacological modalities. Acetaminophen and ibuprofen were the most commonly used medications. In addition to medications, participants reported using physical modalities such as massage, heat/cold, hydrotherapy, and gentle exercise. Meditation, deep breathing, prayer, and humor were also used.

 “Rest”

The majority of participants described getting more rest or staying home, particularly in bed, as the major coping strategy for a flare. This is well captured in the response of one participant, “I recognize my body isn’t able to handle/cope with things as usual, so I try to slow my pace, rest if needed, take shorter walks, and just be good to myself.” Another participant described how she limited her activities during a flare to rest, “[I] collapsed on the couch in my old living room and cut out extra social engagements, errands that could wait, cooking (just ate out or made simple meals like sandwiches etc.), because I had no energy for those things.” This rest often required limiting work and social engagements, including doctor’s appointments. Another participant stated, “[I] stay at home, sleep (if I can), rest in my big recliner. I usually just phone and cancel appointments for doctors and meetings with friends.”

 “Avoid Everything”

Beyond simple rest, avoidance of all activities and social interactions was described as a protective coping strategy to prevent untoward outcomes. As one participant stated, a severe flare was “similar to a migraine, when you don’t want to see or hear from anyone.” Another participant stated, “all I want to do is crawl in bed and sleep until it’s over.” During a flare, “social contact and other activity is limited or nonexistent.” For some participants, social interactions were emotionally and physically challenging, “[I] just try to avoid dealing with people as I feel grumpy and get mad more easily.”

 “Wait it out”

Flares were described as a part of the fibromyalgia experience to be waited out and tolerated as best possible. Participants described how reminding themselves that a flare will pass served as a coping strategy. Ignoring the symptoms and “pushing through it” were the associated strategies. One participant stated, “I try to remind myself that it will pass, it’s temporary, and just keep moving forward and do what needs to be done.” Other participants “cope by giving [themselves] time and permission to take it slow” and acknowledging that “it will subside and there is nothing you can do about it.” Instead of avoiding everything, some participants agreed that you “just have to go with it.”

Discussion

This qualitative study is the first of its kind to describe a patient’s experience of a fibromyalgia flare. Despite the term “flare” being used frequently by health care providers and patients, little research has purposefully evaluated the presence and characteristics of fibromyalgia flares. Using content analysis, we identified themes in three content areas related to the causes, symptoms, and methods for dealing with a flare. This study provides the first step toward better defining flares so that they may be systematically studied.

Our results are consistent with the few previous papers that mention fibromyalgia flares, such as the one that describes activity and weather changes as potential causes of flares [6], but significantly add to the knowledge of what a flare looks and feels like for a patient with fibromyalgia. This study suggests that fibromyalgia symptoms do flare or fluctuate over time and that patients report that flares are often triggered by stress, overdoing it, and lack of sleep. As in previous studies, stress was identified as a trigger of flare-ups and the symptoms were interrelated; flare-ups of one symptom often exacerbated another (vicious cycle) [3].

In addition to exacerbation of common fibromyalgia symptoms, there seem to be symptoms that are unique to a flare, in particular, flu-like achiness. In one previous study of the patient experience of fibromyalgia, a woman reported feeling “feverish … almost like I have the flu.” [6], which is consistent with the description several study participants provided. The flu-like like achiness during a flare often makes the flare debilitating, severely impacting home and work life and social activity, which was also consistent with what participants reported in this study.

Although most of the study findings were consistent with what we observe clinically, we were somewhat surprised to find that in addition to rest and medical treatment, one of the most common methods of dealing with a flare was avoidance of physical, social, and psychological stimulation. Avoiding everything may indicate a lack of knowledge of or ability to use healthy coping strategies, and therefore, future research could evaluate the potential effects of teaching patients healthy coping strategies as one method to deal with symptom flares.

While the findings of this exploratory study shed light on the experience of a fibromyalgia flare as experienced by patients, there are inherent limitations. First, the data are collected by text response to survey questions. The use of interview or focus group might allow for deeper understanding of the experience. Second, while the sample of patients was randomly selected from a large, national fibromyalgia registry, it includes patients from only one academic medical center, and therefore, the results may not be generalizable to other patients with fibromyalgia. Third, in this study, we did not specifically conceptualize flares in terms of pain or fatigue, key symptoms of fibromyalgia, but allowed patients to report their experience regarding all symptoms that they have during a flare. Therefore, it is possible that comorbid depression or untreated sleep disorders could have contributed to a patient’s flare experience. Future research is needed to evaluate flare characteristics in a larger, more diverse sample of patients with fibromyalgia.

Conclusions

This study is the first of its kind to qualitatively explore patient perspectives regarding characteristics, causes, and management strategies of fibromyalgia flares. The presence of exacerbation or “flare” is a phenomenon readily described by these 44 patients diagnosed with fibromyalgia. Based on patient descriptions, a flare can be differentiated from typical or every day symptoms of fibromyalgia. The causes of flares are attributed to a wide variety of stressors. Strategies aimed at managing flare symptoms largely focus on rest and not “overdoing”. Future research assessing symptoms over time would be valuable in quantitatively characterizing the frequency of fibromyalgia flares and the changes in fibromyalgia symptoms that occur before, during, and after a flare.

Acknowledgments

Study data were collected and managed using REDCap electronic data capture tools hosted at Mayo Clinic REDCap (Research Electronic Data Capture) is a secure, web-based application designed to support data capture for research studies, providing 1) an intuitive interface for validated data entry; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for importing data from external sources.

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Author notes

© 2015 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: [email protected]

Fibromyalgia Flares: A Qualitative Analysis | Pain Medicine

Abstract

Objective. Patients with fibromyalgia report periods of symptom exacerbation, colloquially referred to as “flares” and despite clinical observation of flares, no research has purposefully evaluated the presence and characteristics of flares in fibromyalgia. The purpose of this qualitative study was to describe fibromyalgia flares in a sample of patients with fibromyalgia.

Methods. Using seven open-ended questions, patients were asked to describe how they perceived fibromyalgia flares and triggers and alleviating factors associated with flares. Patients were also asked to describe how a flare differs from their typical fibromyalgia symptoms and how they cope with fibromyalgia flares. Content analysis was used to analyze the text.

Results. A total of 44 participants completed the survey. Responses to the seven open-ended questions revealed three main content areas: causes of flares, flare symptoms, and dealing with a flare. Participants identified stress, overdoing it, poor sleep, and weather changes as primary causes of flares. Symptoms characteristic of flares included flu-like body aches/exhaustion, pain, fatigue, and variety of other symptoms. Participants reported using medical treatments, rest, activity and stress avoidance, and waiting it out to cope with flares.

Conclusions. Our results demonstrate that periods of symptom exacerbation (i.e., flares) are commonly experienced by patients with fibromyalgia and symptoms of flares can be differentiated from every day or typical symptoms of fibromyalgia. Our study is the first of its kind to qualitatively explore characteristics, causes, and management strategies of fibromyalgia flares. Future studies are needed to quantitatively characterize fibromyalgia flares and evaluate mechanisms of flares.

Introduction

Fibromyalgia is a complex disorder characterized by chronic, widespread pain, fatigue, cognitive complaints, poor sleep, and mood difficulties. While these symptoms are characteristic of fibromyalgia, patients frequently report a host of other, less well-defined symptoms that occur with varying degrees of severity, including headache, gastrointestinal symptoms, dizziness, heat/cold intolerance, numbness or tingling, and low-grade fevers [1–3]. These symptoms, along with others of fibromyalgia, appear to undergo periods of exacerbation or worsening, often colloquially referred to as “flares” by patients and their health care providers.

Despite clinical observation supporting the presence of flares, no research has purposefully evaluated the presence and characteristics of flares in fibromyalgia and only a couple of publications provide even brief description of flares [4–6]. In one qualitative study, participants stated that over-doing it on a “good day” could lead to fibromyalgia symptom worsening. No further description of how a flare differed from typical or “normal” fibromyalgia symptoms was provided [4]. In a second qualitative study, participants describe flares as a “sudden increase in symptoms, usually to the point where everyday tasks become impossible” [5]. For some patients, flares were characterized by a worsening of existing symptoms (increased or altered pain), whereas others reported new symptoms (flu-like symptoms). In a third study, patients reported that fibromyalgia flares were associated with activity and weather changes [6]. These studies indicate that periods of symptom worsening or flares may be present in fibromyalgia, however, none of the above studies describe whether there are symptoms that are unique to flares or how flares differ from typical fibromyalgia symptoms.

The purpose of this qualitative descriptive study was to describe fibromyalgia flares in a well-characterized sample of patients with fibromyalgia. Using open-ended questions, we sought to understand how patients perceived fibromyalgia flares and what triggers and alleviating factors patients identified for their own symptoms (if any).

Methods

To obtain patient descriptions of fibromyalgia flares, patients were asked to respond to seven open-ended questions assessing quality, severity, and duration. The questions asked about symptoms that may appear during a flare that are not present at other times, how a flare differs from a patient’s typical fibromyalgia experience, flare triggers, and how patient’s cope with fibromyalgia flares (Table 1). Patients were each paid $20.00 for their time and participation. This study was reviewed and approved by the Mayo Clinic Institutional Review Board and all participants provided written informed consent.

Table 1

Open-ended items included on the qualitative questionnaire

Questionnaire Items
If you were describing a fibromyalgia flare to someone who had never experienced one, how would you describe it? 
Do you experience any new symptoms during a fibromyalgia flare that are not typical of your everyday fibromyalgia symptoms? Please describe 
How is a fibromyalgia flare different from your everyday experience of fibromyalgia symptoms? 
Do you find that there are things or events that trigger a fibromyalgia flare for you? If so, please explain 
How do you cope with a fibromyalgia flare? 
What, if anything, reduces the symptoms of a fibromyalgia flare? 
Is there any additional information you would like us to know about your fibromyalgia flares? 
Questionnaire Items
If you were describing a fibromyalgia flare to someone who had never experienced one, how would you describe it? 
Do you experience any new symptoms during a fibromyalgia flare that are not typical of your everyday fibromyalgia symptoms? Please describe 
How is a fibromyalgia flare different from your everyday experience of fibromyalgia symptoms? 
Do you find that there are things or events that trigger a fibromyalgia flare for you? If so, please explain 
How do you cope with a fibromyalgia flare? 
What, if anything, reduces the symptoms of a fibromyalgia flare? 
Is there any additional information you would like us to know about your fibromyalgia flares? 

Table 1

Open-ended items included on the qualitative questionnaire

Questionnaire Items
If you were describing a fibromyalgia flare to someone who had never experienced one, how would you describe it? 
Do you experience any new symptoms during a fibromyalgia flare that are not typical of your everyday fibromyalgia symptoms? Please describe 
How is a fibromyalgia flare different from your everyday experience of fibromyalgia symptoms? 
Do you find that there are things or events that trigger a fibromyalgia flare for you? If so, please explain 
How do you cope with a fibromyalgia flare? 
What, if anything, reduces the symptoms of a fibromyalgia flare? 
Is there any additional information you would like us to know about your fibromyalgia flares? 
Questionnaire Items
If you were describing a fibromyalgia flare to someone who had never experienced one, how would you describe it? 
Do you experience any new symptoms during a fibromyalgia flare that are not typical of your everyday fibromyalgia symptoms? Please describe 
How is a fibromyalgia flare different from your everyday experience of fibromyalgia symptoms? 
Do you find that there are things or events that trigger a fibromyalgia flare for you? If so, please explain 
How do you cope with a fibromyalgia flare? 
What, if anything, reduces the symptoms of a fibromyalgia flare? 
Is there any additional information you would like us to know about your fibromyalgia flares? 

Participants

Participants for this study were recruited from an existing, national registry of patients with fibromyalgia who have been seen at Mayo Clinic in Rochester, MN [7]. Patients in the fibromyalgia registry were seen at Mayo Clinic between January 1, 2000 and December 31, 2012 and had a diagnosis of fibromyalgia that was confirmed via medical record review. At the time of enrollment in the registry, all participants completed the Fibromyalgia Research Survey Criteria [8]. To be eligible for this qualitative study, registry participants were between the ages of 18 and 69 years, met Fibromyalgia Research Survey Criteria at the time of enrollment, able to read and write English, and provided an email address by which we could contact them with the electronic survey.

Procedure

The survey was administered electronically using the Research Electronic Data Capture (REDCap) Survey tool [9]. Patients were selected so that the female to male ratio was 4:1. Patients were divided into the following three age groups: 18–35, 36–53, and 54–69. A random number generator was used to select 24 women and 6 men from each of the age groups (total 90 invited). Of those, 44 agreed to participate and completed the study questionnaire.

Analysis

Content analysis [10] was used to analyze the text. Participant responses to each question were read for overall understanding of the content. Responses to the survey questions were analyzed and sorted into categories that described the meaning of the text. After all text was coded, the investigators independently reviewed the coding scheme to ensure the themes and subthemes were accurate. The few discrepancies and the final scheme was determined by consensus.

Results

A total of 44 participants completed the survey. The majority of participants were female (77%) and non-Hispanic white (93%). Fifty-seven percent of participants were married, 9% were divorced, and 34% were single. The average age of participants was 45.5 (standard deviation 14.6). Responses to the seven questions were found to demonstrate three main content areas: causes of flares, flare symptoms, and dealing with a flare. Content analysis of participant responses identified several key themes within each of these content areas. Each of these are detailed below and summarized in Table 2.

Table 2

Content areas and themes identified using content analysis

Content Areas
Themes
Frequency (%)
Causes of flares  “Stress, Stress, Stress!”  28 (63.6) 
“Overdoing It”  19 (43.2) 
“Poor Sleep”  11 (25.0) 
“Weather Changes”  11 (25.0) 
Flare symptoms  “Flu-like Symptoms”  14 (31.8) 
“Pain”  38 (86.4) 
“Fatigue”  15 (34.1) 
“Other Symptoms”*  49 (>100) 
Dealing with a flare  “Treatments”  33 (75.0) 
“Rest”  25 (56.8) 
“Avoid Everything”  10 (22.7) 
“Wait It Out”  8 (18.2) 
Content Areas
Themes
Frequency (%)
Causes of flares  “Stress, Stress, Stress!”  28 (63.6) 
“Overdoing It”  19 (43.2) 
“Poor Sleep”  11 (25.0) 
“Weather Changes”  11 (25.0) 
Flare symptoms  “Flu-like Symptoms”  14 (31.8) 
“Pain”  38 (86.4) 
“Fatigue”  15 (34.1) 
“Other Symptoms”*  49 (>100) 
Dealing with a flare  “Treatments”  33 (75.0) 
“Rest”  25 (56.8) 
“Avoid Everything”  10 (22.7) 
“Wait It Out”  8 (18.2) 

Table 2

Content areas and themes identified using content analysis

Content Areas
Themes
Frequency (%)
Causes of flares  “Stress, Stress, Stress!”  28 (63.6) 
“Overdoing It”  19 (43.2) 
“Poor Sleep”  11 (25.0) 
“Weather Changes”  11 (25.0) 
Flare symptoms  “Flu-like Symptoms”  14 (31.8) 
“Pain”  38 (86.4) 
“Fatigue”  15 (34.1) 
“Other Symptoms”*  49 (>100) 
Dealing with a flare  “Treatments”  33 (75.0) 
“Rest”  25 (56.8) 
“Avoid Everything”  10 (22.7) 
“Wait It Out”  8 (18.2) 
Content Areas
Themes
Frequency (%)
Causes of flares  “Stress, Stress, Stress!”  28 (63.6) 
“Overdoing It”  19 (43.2) 
“Poor Sleep”  11 (25.0) 
“Weather Changes”  11 (25.0) 
Flare symptoms  “Flu-like Symptoms”  14 (31.8) 
“Pain”  38 (86.4) 
“Fatigue”  15 (34.1) 
“Other Symptoms”*  49 (>100) 
Dealing with a flare  “Treatments”  33 (75.0) 
“Rest”  25 (56.8) 
“Avoid Everything”  10 (22.7) 
“Wait It Out”  8 (18.2) 

Causes of Flares

Participants hypothesized the causes of flares. Most stated a cause with only a few saying they were unable to identify a particular cause. Subthemes describing the causes of flares include stress, overdoing it, poor sleep, and weather changes.

 “Stress, Stress, Stress!”

When asked to identify causes of flares, stress was a common theme. This relationship is captured well by one participant’s comment, “Stress I would say is my BIGGEST trigger. There are days that stress makes my life awful.” Most participants used the term stress, but some also used anxiety to describe emotional turmoil related to a flare. Stress of any sort, including work and life stresses were reported. Specific examples included deadlines, emotional extremes, or upsets such as grief, family concerns, preparing to travel, and holiday stress. This is highlighted by one participant, “I find that for me I have flare ups in times of high stress with work or life.” Reactions to stress were also reported to influence flares; one participant stated that for her, flares were influenced by “extreme emotions such as grief. For instance when my best friend’s dad passed away I had a flare from the sadness I felt.”

 “Overdoing it”

Another key theme identified from participant responses was “overdoing it.” Overdoing it included physical exertion as well as variations in normal activity patterns (e.g., trips, social events). Work activity was cited as one source of overexertion, in addition to work at home that included things like yard work, cleaning, and vacuuming. Increased social activity was also described as a source of overextension. For example, one participant stated “If I am over-exerting at work, physically, or socially, I can flare.” Participants also highlighted the influence that overdoing their activities 1 day could have on the following day, for example, one participant stated “I’m an all or nothing gal. I do too much one day and can’t do anything the next.” In addition to overdoing activities, overdoing it in combination with inadequate rest was also cited as a cause by several participants. For example, one participant stated “I can induce a flare pretty easily if I work too much and don’t rest enough. If I push myself too hard … I can expect a flare in the coming days.”

 “Poor Sleep”

Difficulty sleeping or poor quality sleep was another theme identified from participant responses. One participant stated, “low sleep over a course of a couple of days or more can do it.” The relationship between poor sleep and fibromyalgia flares is obfuscated by the fact that when a patient is experiencing a flare, quality sleep often becomes more difficult to obtain. This circuitous relationship was described well by one participant, “If I don’t get enough sleep that will cause a flare-up, but it also causes me to not be able to sleep at the same time.”

 “Weather Changes”

Another common theme identified in participant responses was weather changes. Drops in barometric pressure, heat, and storms were implicated in development of a flare. Sudden changes in weather, in particular, seemed to be more problematic. One participant stated, “the changing of seasons when the weather swings really hard.” Another participant described how rapid weather fluctuations could induce rapid symptom changes, “It seems like whenever the barometric pressure changes drastically, the symptoms come on quickly and leave just as quickly.”

Flare Symptoms

When asked how flares differ from everyday symptoms of fibromyalgia, participants reported that although they may experience symptoms that are unique to a flare (e.g., flu-like body aches and exhaustion), their flare experience was largely an increased intensity of usual symptoms to the point “where it feels disabling.” “My flares are different because the pain is more intense and is continual. It carries on even after I have rested or taken medication. That’s how I distinguish between the daily fibromyalgia and a flare.” As the symptoms were more intense, they were also more difficult to manage, “I can normally work a regular 40 hour week, complete chores and errands and have somewhat of a social life with ‘normal’ fibromyalgia. With a bad flare, that’s not possible.” Common subthemes that emerged from patient-reported flare symptoms are detailed below.

 “Flu-like symptoms”

Participant responses often included description of the severe “full body aching and exhaustion” experienced during flares as akin to a severe flu and different from usual fibromyalgia symptoms. As described by one participant, “If you’ve ever had a flu sneak up on you after you went to sleep one night and you wake up with your entire body aching, you’ve got an inkling of what a flare is. It’s not gradual.” Similarly, other participants described flares as “the worst flu you’ve ever had,” “it feels like I have the flu in my bones really bad.”

 “Pain”

The pain experienced during a flare was also described as different and more severe than typical pain. According to one participant, flare pain is “intense pain that makes me not want to move or be touched.” The intensity of this pain is almost palpable in another participant’s description, “it feels like someone is taking a carrot peeler to my bones … like a giant wearing a mountain-boot is standing on that part of my body.”

 “Fatigue”

Similar to extreme pain experienced during a flare, the fatigue characteristic of a fibromyalgia flare is severe and debilitating. Participants described the fatigue as “complete exhaustion” that resulted in being “too tired to move,” which in turn severely impacted function. This was so extreme that, according to one participant, even “lifting a finger was exhausting.”

 “Other Symptoms”

In addition to flu-like symptoms, pain, and fatigue, participants reported experiencing a wide variety of other symptoms. One such symptom was decreased concentration. Participants noted, “I find my concentration is less than normal” and “[have] fogginess in my head.” Muscle tightness was another symptom reported by several participants. They stated “my legs feel like they are extremely tight” such that “nearly every major muscle is tight and locked up.” Additionally, participants reported “severe headaches/migraines,” “sensitivity to touch,” and feeling as although their “hands and feet are swollen,” which necessitated “significantly scaling back on activities during flares.” In addition to worsening of physical symptoms, patients reported an increased intensity of emotional responses and significant difficulty with mood. The “emotional and psychological repercussions are more intense,” “[flares] make me feel depressed and not want to be around other people.”

Dealing with a Flare

The third theme included strategies used by participants to prevent or manage flares (Table 3). Participants listed a wide variety of strategies, and from these four subthemes were identified: treatments, rest, avoiding everything, and waiting it out.

Table 3

Strategies adopted by patients to deal with flares

Strategies
Frequency (%)
Physical therapy  2 (4.5) 
Hydrotherapy  1 (2.3) 
Meditation  7 (15.9) 
Breathing exercises  8 (18.2) 
Massage  10 (22.7) 
Hot or cold therapy  6 (13.6) 
Medications  34 (77.3) 
Strategies
Frequency (%)
Physical therapy  2 (4.5) 
Hydrotherapy  1 (2.3) 
Meditation  7 (15.9) 
Breathing exercises  8 (18.2) 
Massage  10 (22.7) 
Hot or cold therapy  6 (13.6) 
Medications  34 (77.3) 

Table 3

Strategies adopted by patients to deal with flares

Strategies
Frequency (%)
Physical therapy  2 (4.5) 
Hydrotherapy  1 (2.3) 
Meditation  7 (15.9) 
Breathing exercises  8 (18.2) 
Massage  10 (22.7) 
Hot or cold therapy  6 (13.6) 
Medications  34 (77.3) 
Strategies
Frequency (%)
Physical therapy  2 (4.5) 
Hydrotherapy  1 (2.3) 
Meditation  7 (15.9) 
Breathing exercises  8 (18.2) 
Massage  10 (22.7) 
Hot or cold therapy  6 (13.6) 
Medications  34 (77.3) 

 “Treatments”

Despite the questions’ focus on coping strategies, participants identified a number of treatments used to cope with or manage symptoms, which included pharmacological and nonpharmacological modalities. Acetaminophen and ibuprofen were the most commonly used medications. In addition to medications, participants reported using physical modalities such as massage, heat/cold, hydrotherapy, and gentle exercise. Meditation, deep breathing, prayer, and humor were also used.

 “Rest”

The majority of participants described getting more rest or staying home, particularly in bed, as the major coping strategy for a flare. This is well captured in the response of one participant, “I recognize my body isn’t able to handle/cope with things as usual, so I try to slow my pace, rest if needed, take shorter walks, and just be good to myself.” Another participant described how she limited her activities during a flare to rest, “[I] collapsed on the couch in my old living room and cut out extra social engagements, errands that could wait, cooking (just ate out or made simple meals like sandwiches etc.), because I had no energy for those things.” This rest often required limiting work and social engagements, including doctor’s appointments. Another participant stated, “[I] stay at home, sleep (if I can), rest in my big recliner. I usually just phone and cancel appointments for doctors and meetings with friends.”

 “Avoid Everything”

Beyond simple rest, avoidance of all activities and social interactions was described as a protective coping strategy to prevent untoward outcomes. As one participant stated, a severe flare was “similar to a migraine, when you don’t want to see or hear from anyone.” Another participant stated, “all I want to do is crawl in bed and sleep until it’s over.” During a flare, “social contact and other activity is limited or nonexistent.” For some participants, social interactions were emotionally and physically challenging, “[I] just try to avoid dealing with people as I feel grumpy and get mad more easily.”

 “Wait it out”

Flares were described as a part of the fibromyalgia experience to be waited out and tolerated as best possible. Participants described how reminding themselves that a flare will pass served as a coping strategy. Ignoring the symptoms and “pushing through it” were the associated strategies. One participant stated, “I try to remind myself that it will pass, it’s temporary, and just keep moving forward and do what needs to be done.” Other participants “cope by giving [themselves] time and permission to take it slow” and acknowledging that “it will subside and there is nothing you can do about it.” Instead of avoiding everything, some participants agreed that you “just have to go with it.”

Discussion

This qualitative study is the first of its kind to describe a patient’s experience of a fibromyalgia flare. Despite the term “flare” being used frequently by health care providers and patients, little research has purposefully evaluated the presence and characteristics of fibromyalgia flares. Using content analysis, we identified themes in three content areas related to the causes, symptoms, and methods for dealing with a flare. This study provides the first step toward better defining flares so that they may be systematically studied.

Our results are consistent with the few previous papers that mention fibromyalgia flares, such as the one that describes activity and weather changes as potential causes of flares [6], but significantly add to the knowledge of what a flare looks and feels like for a patient with fibromyalgia. This study suggests that fibromyalgia symptoms do flare or fluctuate over time and that patients report that flares are often triggered by stress, overdoing it, and lack of sleep. As in previous studies, stress was identified as a trigger of flare-ups and the symptoms were interrelated; flare-ups of one symptom often exacerbated another (vicious cycle) [3].

In addition to exacerbation of common fibromyalgia symptoms, there seem to be symptoms that are unique to a flare, in particular, flu-like achiness. In one previous study of the patient experience of fibromyalgia, a woman reported feeling “feverish … almost like I have the flu.” [6], which is consistent with the description several study participants provided. The flu-like like achiness during a flare often makes the flare debilitating, severely impacting home and work life and social activity, which was also consistent with what participants reported in this study.

Although most of the study findings were consistent with what we observe clinically, we were somewhat surprised to find that in addition to rest and medical treatment, one of the most common methods of dealing with a flare was avoidance of physical, social, and psychological stimulation. Avoiding everything may indicate a lack of knowledge of or ability to use healthy coping strategies, and therefore, future research could evaluate the potential effects of teaching patients healthy coping strategies as one method to deal with symptom flares.

While the findings of this exploratory study shed light on the experience of a fibromyalgia flare as experienced by patients, there are inherent limitations. First, the data are collected by text response to survey questions. The use of interview or focus group might allow for deeper understanding of the experience. Second, while the sample of patients was randomly selected from a large, national fibromyalgia registry, it includes patients from only one academic medical center, and therefore, the results may not be generalizable to other patients with fibromyalgia. Third, in this study, we did not specifically conceptualize flares in terms of pain or fatigue, key symptoms of fibromyalgia, but allowed patients to report their experience regarding all symptoms that they have during a flare. Therefore, it is possible that comorbid depression or untreated sleep disorders could have contributed to a patient’s flare experience. Future research is needed to evaluate flare characteristics in a larger, more diverse sample of patients with fibromyalgia.

Conclusions

This study is the first of its kind to qualitatively explore patient perspectives regarding characteristics, causes, and management strategies of fibromyalgia flares. The presence of exacerbation or “flare” is a phenomenon readily described by these 44 patients diagnosed with fibromyalgia. Based on patient descriptions, a flare can be differentiated from typical or every day symptoms of fibromyalgia. The causes of flares are attributed to a wide variety of stressors. Strategies aimed at managing flare symptoms largely focus on rest and not “overdoing”. Future research assessing symptoms over time would be valuable in quantitatively characterizing the frequency of fibromyalgia flares and the changes in fibromyalgia symptoms that occur before, during, and after a flare.

Acknowledgments

Study data were collected and managed using REDCap electronic data capture tools hosted at Mayo Clinic REDCap (Research Electronic Data Capture) is a secure, web-based application designed to support data capture for research studies, providing 1) an intuitive interface for validated data entry; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for importing data from external sources.

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Author notes

© 2015 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: [email protected]

Fibromyalgia Flares: A Qualitative Analysis | Pain Medicine

Abstract

Objective. Patients with fibromyalgia report periods of symptom exacerbation, colloquially referred to as “flares” and despite clinical observation of flares, no research has purposefully evaluated the presence and characteristics of flares in fibromyalgia. The purpose of this qualitative study was to describe fibromyalgia flares in a sample of patients with fibromyalgia.

Methods. Using seven open-ended questions, patients were asked to describe how they perceived fibromyalgia flares and triggers and alleviating factors associated with flares. Patients were also asked to describe how a flare differs from their typical fibromyalgia symptoms and how they cope with fibromyalgia flares. Content analysis was used to analyze the text.

Results. A total of 44 participants completed the survey. Responses to the seven open-ended questions revealed three main content areas: causes of flares, flare symptoms, and dealing with a flare. Participants identified stress, overdoing it, poor sleep, and weather changes as primary causes of flares. Symptoms characteristic of flares included flu-like body aches/exhaustion, pain, fatigue, and variety of other symptoms. Participants reported using medical treatments, rest, activity and stress avoidance, and waiting it out to cope with flares.

Conclusions. Our results demonstrate that periods of symptom exacerbation (i.e., flares) are commonly experienced by patients with fibromyalgia and symptoms of flares can be differentiated from every day or typical symptoms of fibromyalgia. Our study is the first of its kind to qualitatively explore characteristics, causes, and management strategies of fibromyalgia flares. Future studies are needed to quantitatively characterize fibromyalgia flares and evaluate mechanisms of flares.

Introduction

Fibromyalgia is a complex disorder characterized by chronic, widespread pain, fatigue, cognitive complaints, poor sleep, and mood difficulties. While these symptoms are characteristic of fibromyalgia, patients frequently report a host of other, less well-defined symptoms that occur with varying degrees of severity, including headache, gastrointestinal symptoms, dizziness, heat/cold intolerance, numbness or tingling, and low-grade fevers [1–3]. These symptoms, along with others of fibromyalgia, appear to undergo periods of exacerbation or worsening, often colloquially referred to as “flares” by patients and their health care providers.

Despite clinical observation supporting the presence of flares, no research has purposefully evaluated the presence and characteristics of flares in fibromyalgia and only a couple of publications provide even brief description of flares [4–6]. In one qualitative study, participants stated that over-doing it on a “good day” could lead to fibromyalgia symptom worsening. No further description of how a flare differed from typical or “normal” fibromyalgia symptoms was provided [4]. In a second qualitative study, participants describe flares as a “sudden increase in symptoms, usually to the point where everyday tasks become impossible” [5]. For some patients, flares were characterized by a worsening of existing symptoms (increased or altered pain), whereas others reported new symptoms (flu-like symptoms). In a third study, patients reported that fibromyalgia flares were associated with activity and weather changes [6]. These studies indicate that periods of symptom worsening or flares may be present in fibromyalgia, however, none of the above studies describe whether there are symptoms that are unique to flares or how flares differ from typical fibromyalgia symptoms.

The purpose of this qualitative descriptive study was to describe fibromyalgia flares in a well-characterized sample of patients with fibromyalgia. Using open-ended questions, we sought to understand how patients perceived fibromyalgia flares and what triggers and alleviating factors patients identified for their own symptoms (if any).

Methods

To obtain patient descriptions of fibromyalgia flares, patients were asked to respond to seven open-ended questions assessing quality, severity, and duration. The questions asked about symptoms that may appear during a flare that are not present at other times, how a flare differs from a patient’s typical fibromyalgia experience, flare triggers, and how patient’s cope with fibromyalgia flares (Table 1). Patients were each paid $20.00 for their time and participation. This study was reviewed and approved by the Mayo Clinic Institutional Review Board and all participants provided written informed consent.

Table 1

Open-ended items included on the qualitative questionnaire

Questionnaire Items
If you were describing a fibromyalgia flare to someone who had never experienced one, how would you describe it? 
Do you experience any new symptoms during a fibromyalgia flare that are not typical of your everyday fibromyalgia symptoms? Please describe 
How is a fibromyalgia flare different from your everyday experience of fibromyalgia symptoms? 
Do you find that there are things or events that trigger a fibromyalgia flare for you? If so, please explain 
How do you cope with a fibromyalgia flare? 
What, if anything, reduces the symptoms of a fibromyalgia flare? 
Is there any additional information you would like us to know about your fibromyalgia flares? 
Questionnaire Items
If you were describing a fibromyalgia flare to someone who had never experienced one, how would you describe it? 
Do you experience any new symptoms during a fibromyalgia flare that are not typical of your everyday fibromyalgia symptoms? Please describe 
How is a fibromyalgia flare different from your everyday experience of fibromyalgia symptoms? 
Do you find that there are things or events that trigger a fibromyalgia flare for you? If so, please explain 
How do you cope with a fibromyalgia flare? 
What, if anything, reduces the symptoms of a fibromyalgia flare? 
Is there any additional information you would like us to know about your fibromyalgia flares? 

Table 1

Open-ended items included on the qualitative questionnaire

Questionnaire Items
If you were describing a fibromyalgia flare to someone who had never experienced one, how would you describe it? 
Do you experience any new symptoms during a fibromyalgia flare that are not typical of your everyday fibromyalgia symptoms? Please describe 
How is a fibromyalgia flare different from your everyday experience of fibromyalgia symptoms? 
Do you find that there are things or events that trigger a fibromyalgia flare for you? If so, please explain 
How do you cope with a fibromyalgia flare? 
What, if anything, reduces the symptoms of a fibromyalgia flare? 
Is there any additional information you would like us to know about your fibromyalgia flares? 
Questionnaire Items
If you were describing a fibromyalgia flare to someone who had never experienced one, how would you describe it? 
Do you experience any new symptoms during a fibromyalgia flare that are not typical of your everyday fibromyalgia symptoms? Please describe 
How is a fibromyalgia flare different from your everyday experience of fibromyalgia symptoms? 
Do you find that there are things or events that trigger a fibromyalgia flare for you? If so, please explain 
How do you cope with a fibromyalgia flare? 
What, if anything, reduces the symptoms of a fibromyalgia flare? 
Is there any additional information you would like us to know about your fibromyalgia flares? 

Participants

Participants for this study were recruited from an existing, national registry of patients with fibromyalgia who have been seen at Mayo Clinic in Rochester, MN [7]. Patients in the fibromyalgia registry were seen at Mayo Clinic between January 1, 2000 and December 31, 2012 and had a diagnosis of fibromyalgia that was confirmed via medical record review. At the time of enrollment in the registry, all participants completed the Fibromyalgia Research Survey Criteria [8]. To be eligible for this qualitative study, registry participants were between the ages of 18 and 69 years, met Fibromyalgia Research Survey Criteria at the time of enrollment, able to read and write English, and provided an email address by which we could contact them with the electronic survey.

Procedure

The survey was administered electronically using the Research Electronic Data Capture (REDCap) Survey tool [9]. Patients were selected so that the female to male ratio was 4:1. Patients were divided into the following three age groups: 18–35, 36–53, and 54–69. A random number generator was used to select 24 women and 6 men from each of the age groups (total 90 invited). Of those, 44 agreed to participate and completed the study questionnaire.

Analysis

Content analysis [10] was used to analyze the text. Participant responses to each question were read for overall understanding of the content. Responses to the survey questions were analyzed and sorted into categories that described the meaning of the text. After all text was coded, the investigators independently reviewed the coding scheme to ensure the themes and subthemes were accurate. The few discrepancies and the final scheme was determined by consensus.

Results

A total of 44 participants completed the survey. The majority of participants were female (77%) and non-Hispanic white (93%). Fifty-seven percent of participants were married, 9% were divorced, and 34% were single. The average age of participants was 45.5 (standard deviation 14.6). Responses to the seven questions were found to demonstrate three main content areas: causes of flares, flare symptoms, and dealing with a flare. Content analysis of participant responses identified several key themes within each of these content areas. Each of these are detailed below and summarized in Table 2.

Table 2

Content areas and themes identified using content analysis

Content Areas
Themes
Frequency (%)
Causes of flares  “Stress, Stress, Stress!”  28 (63.6) 
“Overdoing It”  19 (43.2) 
“Poor Sleep”  11 (25.0) 
“Weather Changes”  11 (25.0) 
Flare symptoms  “Flu-like Symptoms”  14 (31.8) 
“Pain”  38 (86.4) 
“Fatigue”  15 (34.1) 
“Other Symptoms”*  49 (>100) 
Dealing with a flare  “Treatments”  33 (75.0) 
“Rest”  25 (56.8) 
“Avoid Everything”  10 (22.7) 
“Wait It Out”  8 (18.2) 
Content Areas
Themes
Frequency (%)
Causes of flares  “Stress, Stress, Stress!”  28 (63.6) 
“Overdoing It”  19 (43.2) 
“Poor Sleep”  11 (25.0) 
“Weather Changes”  11 (25.0) 
Flare symptoms  “Flu-like Symptoms”  14 (31.8) 
“Pain”  38 (86.4) 
“Fatigue”  15 (34.1) 
“Other Symptoms”*  49 (>100) 
Dealing with a flare  “Treatments”  33 (75.0) 
“Rest”  25 (56.8) 
“Avoid Everything”  10 (22.7) 
“Wait It Out”  8 (18.2) 

Table 2

Content areas and themes identified using content analysis

Content Areas
Themes
Frequency (%)
Causes of flares  “Stress, Stress, Stress!”  28 (63.6) 
“Overdoing It”  19 (43.2) 
“Poor Sleep”  11 (25.0) 
“Weather Changes”  11 (25.0) 
Flare symptoms  “Flu-like Symptoms”  14 (31.8) 
“Pain”  38 (86.4) 
“Fatigue”  15 (34.1) 
“Other Symptoms”*  49 (>100) 
Dealing with a flare  “Treatments”  33 (75.0) 
“Rest”  25 (56.8) 
“Avoid Everything”  10 (22.7) 
“Wait It Out”  8 (18.2) 
Content Areas
Themes
Frequency (%)
Causes of flares  “Stress, Stress, Stress!”  28 (63.6) 
“Overdoing It”  19 (43.2) 
“Poor Sleep”  11 (25.0) 
“Weather Changes”  11 (25.0) 
Flare symptoms  “Flu-like Symptoms”  14 (31.8) 
“Pain”  38 (86.4) 
“Fatigue”  15 (34.1) 
“Other Symptoms”*  49 (>100) 
Dealing with a flare  “Treatments”  33 (75.0) 
“Rest”  25 (56.8) 
“Avoid Everything”  10 (22.7) 
“Wait It Out”  8 (18.2) 

Causes of Flares

Participants hypothesized the causes of flares. Most stated a cause with only a few saying they were unable to identify a particular cause. Subthemes describing the causes of flares include stress, overdoing it, poor sleep, and weather changes.

 “Stress, Stress, Stress!”

When asked to identify causes of flares, stress was a common theme. This relationship is captured well by one participant’s comment, “Stress I would say is my BIGGEST trigger. There are days that stress makes my life awful.” Most participants used the term stress, but some also used anxiety to describe emotional turmoil related to a flare. Stress of any sort, including work and life stresses were reported. Specific examples included deadlines, emotional extremes, or upsets such as grief, family concerns, preparing to travel, and holiday stress. This is highlighted by one participant, “I find that for me I have flare ups in times of high stress with work or life.” Reactions to stress were also reported to influence flares; one participant stated that for her, flares were influenced by “extreme emotions such as grief. For instance when my best friend’s dad passed away I had a flare from the sadness I felt.”

 “Overdoing it”

Another key theme identified from participant responses was “overdoing it.” Overdoing it included physical exertion as well as variations in normal activity patterns (e.g., trips, social events). Work activity was cited as one source of overexertion, in addition to work at home that included things like yard work, cleaning, and vacuuming. Increased social activity was also described as a source of overextension. For example, one participant stated “If I am over-exerting at work, physically, or socially, I can flare.” Participants also highlighted the influence that overdoing their activities 1 day could have on the following day, for example, one participant stated “I’m an all or nothing gal. I do too much one day and can’t do anything the next.” In addition to overdoing activities, overdoing it in combination with inadequate rest was also cited as a cause by several participants. For example, one participant stated “I can induce a flare pretty easily if I work too much and don’t rest enough. If I push myself too hard … I can expect a flare in the coming days.”

 “Poor Sleep”

Difficulty sleeping or poor quality sleep was another theme identified from participant responses. One participant stated, “low sleep over a course of a couple of days or more can do it.” The relationship between poor sleep and fibromyalgia flares is obfuscated by the fact that when a patient is experiencing a flare, quality sleep often becomes more difficult to obtain. This circuitous relationship was described well by one participant, “If I don’t get enough sleep that will cause a flare-up, but it also causes me to not be able to sleep at the same time.”

 “Weather Changes”

Another common theme identified in participant responses was weather changes. Drops in barometric pressure, heat, and storms were implicated in development of a flare. Sudden changes in weather, in particular, seemed to be more problematic. One participant stated, “the changing of seasons when the weather swings really hard.” Another participant described how rapid weather fluctuations could induce rapid symptom changes, “It seems like whenever the barometric pressure changes drastically, the symptoms come on quickly and leave just as quickly.”

Flare Symptoms

When asked how flares differ from everyday symptoms of fibromyalgia, participants reported that although they may experience symptoms that are unique to a flare (e.g., flu-like body aches and exhaustion), their flare experience was largely an increased intensity of usual symptoms to the point “where it feels disabling.” “My flares are different because the pain is more intense and is continual. It carries on even after I have rested or taken medication. That’s how I distinguish between the daily fibromyalgia and a flare.” As the symptoms were more intense, they were also more difficult to manage, “I can normally work a regular 40 hour week, complete chores and errands and have somewhat of a social life with ‘normal’ fibromyalgia. With a bad flare, that’s not possible.” Common subthemes that emerged from patient-reported flare symptoms are detailed below.

 “Flu-like symptoms”

Participant responses often included description of the severe “full body aching and exhaustion” experienced during flares as akin to a severe flu and different from usual fibromyalgia symptoms. As described by one participant, “If you’ve ever had a flu sneak up on you after you went to sleep one night and you wake up with your entire body aching, you’ve got an inkling of what a flare is. It’s not gradual.” Similarly, other participants described flares as “the worst flu you’ve ever had,” “it feels like I have the flu in my bones really bad.”

 “Pain”

The pain experienced during a flare was also described as different and more severe than typical pain. According to one participant, flare pain is “intense pain that makes me not want to move or be touched.” The intensity of this pain is almost palpable in another participant’s description, “it feels like someone is taking a carrot peeler to my bones … like a giant wearing a mountain-boot is standing on that part of my body.”

 “Fatigue”

Similar to extreme pain experienced during a flare, the fatigue characteristic of a fibromyalgia flare is severe and debilitating. Participants described the fatigue as “complete exhaustion” that resulted in being “too tired to move,” which in turn severely impacted function. This was so extreme that, according to one participant, even “lifting a finger was exhausting.”

 “Other Symptoms”

In addition to flu-like symptoms, pain, and fatigue, participants reported experiencing a wide variety of other symptoms. One such symptom was decreased concentration. Participants noted, “I find my concentration is less than normal” and “[have] fogginess in my head.” Muscle tightness was another symptom reported by several participants. They stated “my legs feel like they are extremely tight” such that “nearly every major muscle is tight and locked up.” Additionally, participants reported “severe headaches/migraines,” “sensitivity to touch,” and feeling as although their “hands and feet are swollen,” which necessitated “significantly scaling back on activities during flares.” In addition to worsening of physical symptoms, patients reported an increased intensity of emotional responses and significant difficulty with mood. The “emotional and psychological repercussions are more intense,” “[flares] make me feel depressed and not want to be around other people.”

Dealing with a Flare

The third theme included strategies used by participants to prevent or manage flares (Table 3). Participants listed a wide variety of strategies, and from these four subthemes were identified: treatments, rest, avoiding everything, and waiting it out.

Table 3

Strategies adopted by patients to deal with flares

Strategies
Frequency (%)
Physical therapy  2 (4.5) 
Hydrotherapy  1 (2.3) 
Meditation  7 (15.9) 
Breathing exercises  8 (18.2) 
Massage  10 (22.7) 
Hot or cold therapy  6 (13.6) 
Medications  34 (77.3) 
Strategies
Frequency (%)
Physical therapy  2 (4.5) 
Hydrotherapy  1 (2.3) 
Meditation  7 (15.9) 
Breathing exercises  8 (18.2) 
Massage  10 (22.7) 
Hot or cold therapy  6 (13.6) 
Medications  34 (77.3) 

Table 3

Strategies adopted by patients to deal with flares

Strategies
Frequency (%)
Physical therapy  2 (4.5) 
Hydrotherapy  1 (2.3) 
Meditation  7 (15.9) 
Breathing exercises  8 (18.2) 
Massage  10 (22.7) 
Hot or cold therapy  6 (13.6) 
Medications  34 (77.3) 
Strategies
Frequency (%)
Physical therapy  2 (4.5) 
Hydrotherapy  1 (2.3) 
Meditation  7 (15.9) 
Breathing exercises  8 (18.2) 
Massage  10 (22.7) 
Hot or cold therapy  6 (13.6) 
Medications  34 (77.3) 

 “Treatments”

Despite the questions’ focus on coping strategies, participants identified a number of treatments used to cope with or manage symptoms, which included pharmacological and nonpharmacological modalities. Acetaminophen and ibuprofen were the most commonly used medications. In addition to medications, participants reported using physical modalities such as massage, heat/cold, hydrotherapy, and gentle exercise. Meditation, deep breathing, prayer, and humor were also used.

 “Rest”

The majority of participants described getting more rest or staying home, particularly in bed, as the major coping strategy for a flare. This is well captured in the response of one participant, “I recognize my body isn’t able to handle/cope with things as usual, so I try to slow my pace, rest if needed, take shorter walks, and just be good to myself.” Another participant described how she limited her activities during a flare to rest, “[I] collapsed on the couch in my old living room and cut out extra social engagements, errands that could wait, cooking (just ate out or made simple meals like sandwiches etc.), because I had no energy for those things.” This rest often required limiting work and social engagements, including doctor’s appointments. Another participant stated, “[I] stay at home, sleep (if I can), rest in my big recliner. I usually just phone and cancel appointments for doctors and meetings with friends.”

 “Avoid Everything”

Beyond simple rest, avoidance of all activities and social interactions was described as a protective coping strategy to prevent untoward outcomes. As one participant stated, a severe flare was “similar to a migraine, when you don’t want to see or hear from anyone.” Another participant stated, “all I want to do is crawl in bed and sleep until it’s over.” During a flare, “social contact and other activity is limited or nonexistent.” For some participants, social interactions were emotionally and physically challenging, “[I] just try to avoid dealing with people as I feel grumpy and get mad more easily.”

 “Wait it out”

Flares were described as a part of the fibromyalgia experience to be waited out and tolerated as best possible. Participants described how reminding themselves that a flare will pass served as a coping strategy. Ignoring the symptoms and “pushing through it” were the associated strategies. One participant stated, “I try to remind myself that it will pass, it’s temporary, and just keep moving forward and do what needs to be done.” Other participants “cope by giving [themselves] time and permission to take it slow” and acknowledging that “it will subside and there is nothing you can do about it.” Instead of avoiding everything, some participants agreed that you “just have to go with it.”

Discussion

This qualitative study is the first of its kind to describe a patient’s experience of a fibromyalgia flare. Despite the term “flare” being used frequently by health care providers and patients, little research has purposefully evaluated the presence and characteristics of fibromyalgia flares. Using content analysis, we identified themes in three content areas related to the causes, symptoms, and methods for dealing with a flare. This study provides the first step toward better defining flares so that they may be systematically studied.

Our results are consistent with the few previous papers that mention fibromyalgia flares, such as the one that describes activity and weather changes as potential causes of flares [6], but significantly add to the knowledge of what a flare looks and feels like for a patient with fibromyalgia. This study suggests that fibromyalgia symptoms do flare or fluctuate over time and that patients report that flares are often triggered by stress, overdoing it, and lack of sleep. As in previous studies, stress was identified as a trigger of flare-ups and the symptoms were interrelated; flare-ups of one symptom often exacerbated another (vicious cycle) [3].

In addition to exacerbation of common fibromyalgia symptoms, there seem to be symptoms that are unique to a flare, in particular, flu-like achiness. In one previous study of the patient experience of fibromyalgia, a woman reported feeling “feverish … almost like I have the flu.” [6], which is consistent with the description several study participants provided. The flu-like like achiness during a flare often makes the flare debilitating, severely impacting home and work life and social activity, which was also consistent with what participants reported in this study.

Although most of the study findings were consistent with what we observe clinically, we were somewhat surprised to find that in addition to rest and medical treatment, one of the most common methods of dealing with a flare was avoidance of physical, social, and psychological stimulation. Avoiding everything may indicate a lack of knowledge of or ability to use healthy coping strategies, and therefore, future research could evaluate the potential effects of teaching patients healthy coping strategies as one method to deal with symptom flares.

While the findings of this exploratory study shed light on the experience of a fibromyalgia flare as experienced by patients, there are inherent limitations. First, the data are collected by text response to survey questions. The use of interview or focus group might allow for deeper understanding of the experience. Second, while the sample of patients was randomly selected from a large, national fibromyalgia registry, it includes patients from only one academic medical center, and therefore, the results may not be generalizable to other patients with fibromyalgia. Third, in this study, we did not specifically conceptualize flares in terms of pain or fatigue, key symptoms of fibromyalgia, but allowed patients to report their experience regarding all symptoms that they have during a flare. Therefore, it is possible that comorbid depression or untreated sleep disorders could have contributed to a patient’s flare experience. Future research is needed to evaluate flare characteristics in a larger, more diverse sample of patients with fibromyalgia.

Conclusions

This study is the first of its kind to qualitatively explore patient perspectives regarding characteristics, causes, and management strategies of fibromyalgia flares. The presence of exacerbation or “flare” is a phenomenon readily described by these 44 patients diagnosed with fibromyalgia. Based on patient descriptions, a flare can be differentiated from typical or every day symptoms of fibromyalgia. The causes of flares are attributed to a wide variety of stressors. Strategies aimed at managing flare symptoms largely focus on rest and not “overdoing”. Future research assessing symptoms over time would be valuable in quantitatively characterizing the frequency of fibromyalgia flares and the changes in fibromyalgia symptoms that occur before, during, and after a flare.

Acknowledgments

Study data were collected and managed using REDCap electronic data capture tools hosted at Mayo Clinic REDCap (Research Electronic Data Capture) is a secure, web-based application designed to support data capture for research studies, providing 1) an intuitive interface for validated data entry; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for importing data from external sources.

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Author notes

© 2015 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: [email protected]

The Connection between Fibromyalgia and Fever

Fibromyalgia is a chronic disease that has many different characteristics such as pain in the spine, hips, shoulders, neck, and yes- even a low grade fever. Fibromyalgia can occur in all individuals, regardless of age or gender, but does occur more often in women between the ages of 30 and 59. The exact cause of fibromyalgia is not known, which has made it very difficult to figure out a cure for it. Another thing that complicates this is the fact that some fibromyalgia symptoms are also present in other diseases/disorders.

Fibromyalgia and fever are actually related because an individual who is suffering from fibromyalgia can actually have a low grade fever at any given time. There isn’t really any specific evidence that connects the two but there is that possibility that fibromyalgia can cause a fever.

Individuals who have fibromyalgia also have a very weak immune system and infections can be easily picked up while symptoms are flared up. These infections can actually lead to a much higher fever. Additionally, the severe muscle pain/tingling that is common in individuals with fibromyalgia can cause fever. Your skin will get very hot and you may or may not start sweating. Additionally, though you may feel hot and think you have a fever, the thermometer will read normal. So, you could feel hot- but not really have a fever.

Fever related to fibromyalgia symptoms can also cause your glands to swell up. This happens in both individuals with fibromyalgia and those who are only experiencing a fever. Additionally, joint pain could flare up if you’re experiencing a mild fever.

However, typically the fevers are very mild and is not the main reason for discomfort in individuals with fibromyalgia. In fact, most individuals don’t even realize that they do have a fever, but are more focused on their symptoms that are causing them the most extreme discomfort.

In some cases, individuals with fibromyalgia could start shivering before, during, or after experiencing a fever. There isn’t really any known medication that can curb a fever with fibromyalgia, so the individual will have to continue with their normal course of treatment, despite having a low grade (or high grade) fever.

The only way to avoid having a fever with fibromyalgia symptoms is by taking care to reduce the other symptoms of your fibromyalgia. Make sure to take part in regular physical exercise in order to reduce muscle stiffness. Additionally, make sure that you are consuming a proper diet that will give you plenty of energy. You will also want to make sure that you get adequate sleep, which will help you to be relaxed and help to reduce the symptoms of fatigue and such.

Consuming a balanced diet- as in consuming lots of fruits and vegetables especially- can help to reduce the symptoms of fibromyalgia and fever. Vegetables have lots of fiber, which is essential for increasing metabolism and fruits have vitamins and minerals that help with repair and rebuilding of the muscles. As an individual with fibromyalgia, you should take care to avoid caffeine, processed foods, soft drinks, refined carbohydrates, and other junk food.

For those individuals who are suffering from not sleeping and high levels of stress, medications that facilitate sleep and relaxation methods can be wonderful in reducing those symptoms of fibromyalgia, which can contribute to feeling feverish.

Both not getting adequate sleep and levels of stress are related because people who are stressed out don’t get the proper amount of sleep. The less sleep you’re able to get, the more likely you are to react negatively to stress. Therefore, relaxation methods, such as massage will help you to relax, which will help you to sleep much better.

Additionally, massage can help serve to decrease pain, which helps to alleviate other symptoms. In times of extreme lack of sleep, you can use sleep medication, but be sure that you don’t become dependent upon them entirely as a way to get some sleep. Also, keep in mind that sleeping pills do come with some undesirable side effects.

In order to relive the fever that results from the pain and other symptoms of fibromyalgia, you could consider acupuncture as an option. This will typically relive the pain in the tender spots and may very well serve to reduce stress. Both massage and physical therapy actually regulates the neurotransmitters in the brain, which help your body to actually have a much higher pain threshold. This also leads to the individual to be able to more effectively overcome stress and pain.

Individuals who have fibromyalgia are prone to experiencing both spells of fever and spells of chills on occasion. In some cases, the individuals will have a fever the entire time that they’re suffering from fibromyalgia, most will actually never once experience a fever. Physicians say that individuals who are in the more advanced stages of fibromyalgia are less affected by fever and chills, and those in the early stages are more likely to be affected.

In conclusion, fibromyalgia is a chronic disease that has many different characteristics such as pain in the spine, hips, shoulders, neck, and yes- even a low grade fever. Fibromyalgia can occur in all individuals, regardless of age or gender, but does occur more often in women between the ages of 30 and 59. The exact cause of fibromyalgia is not known, which has made it very difficult to figure out a cure for it. Another thing that complicates this is the fact that some fibromyalgia symptoms are also present in other diseases/disorders.

Fibromyalgia and fever are actually related because an individual who is suffering from fibromyalgia can actually have a low grade fever at any given time. There isn’t really any specific evidence that connects the two but there is that possibility that fibromyalgia can cause a fever.

Fibromyalgia Symptoms You Might Be Ignoring

If you’ve had a nagging sore throat, your doctor may take a swab to check for strep. If you’re suffering from a high fever and bad cough, your doctor may order a chest X-ray to look for pneumonia. But not all diagnoses are that straightforward.

Case in point: Fibromyalgia, a condition that causes widespread chronic pain pain — as well as fatigue, sleep disturbances, and cognitive difficulties — is often challenging for a physician to pinpoint.

“Fibromyalgia can be difficult to diagnose because there’s no gold standard test like an X-ray or blood work,” says Lenore Brancato, MD, a board-certified rheumatologist at NYU Langone Ambulatory Care in New Hyde Park, New York. “It’s a diagnosis of exclusion, which means you first have to rule out other diseases that may be causing symptoms. It’s not a cookie-cutter condition.”

Fibromyalgia is also a diagnosis that’s been subject to change. Back in 1990, when the first diagnostic criteria were set by the American College of Rheumatology (ACR), a doctor had to find the following elements in order to say their patient had fibromyalgia: pain in at least 11 of 18 designated “tender points” throughout the body, plus a history of widespread pain lasting more than three months.

In 2010, however, those diagnostic criteria for fibromyalgia were updated to eliminate the tender point requirement and instead focus on findings that a patient has widespread pain, as well as sleep disruptions, fatigue, and cognitive difficulties.

Whereas the validity of fibromyalgia as a diagnosis was once questioned in the medical community — leading to a stigma it’s still overcoming — ongoing research has led to a number of possible explanations for physical causes of fibromyalgia (ranging from genetics to physical triggers) and mechanisms (involving the central nervous system).

What we know for sure is that fibromyalgia affects approximately 2 percent of adults in the United States, and your risk of developing the condition increases if you are middle-aged or older and have been diagnosed with lupus or rheumatoid arthritis, says the Centers for Disease Control and Prevention (CDC). You may also be at a higher risk if you are female (most fibromyalgia patient are women), have suffered a trauma or repetitive injury, or if you are obese.

But statistics and risk factors can’t describe how fibromyalgia actually feels to the person living with it. What follows are the descriptions doctors hear patients use when they talk about both usual and less common symptoms of fibromyalgia.

 

Widespread pain

While every fibromyalgia patient is different, their descriptions of overwhelming, debilitating pain throughout the entire body are very common. “My patients report feeling sore and stiff with an achy pain that goes from the top of their head to their toenails,” says Christopher Morris, MD, a board-certified rheumatologist with Arthritis Associates in Kingsport, Tennessee, and a fellow of the American College of Rheumatology. “They tell me the pain is in the muscles and soft tissues rather than joints.” Dr. Brancato hears similar concerns, with some of her patients saying the pain is lacerating, “like being cut by knives.”

 

Sensitivity to touch

Fibromyalgia could also make you overly sensitive to touch and temperature. “If you’re a patient with fibromyalgia, and someone brushes up against you in a crowded room it can be very painful,” says Dr. Brancato. “I’ll hear that my female patients can’t tolerate a massage.” Even though the stimulus is taken away, like removing your hand from a hot stove, the pain can continue, she explains.

 

Sleep issues

If you have fibromyalgia, you may have trouble falling asleep or staying asleep. “My patients say they toss and turn, or their mind wanders,” Dr. Brancato says. “I’ll hear that my patients wake up throughout the night and end up feeling as tired as when they went to bed,” Dr. Morris adds.

 

Daytime fatigue

One of the most common issues for fibromyalgia patients is fatigue. “It’s exhausting for them,” says Dr. Brancato. “If you ask a patient how they feel in the morning, you’ll hear they felt awful, they never feel ready to go, they feel like they can’t get their head above water.”

 

Cognitive problems

“My patients describe having a ‘fibro fog,’” says Dr. Morris. “They have a hard time concentrating.” For her part, Dr. Brancato sees a lot of memory problems. “If you tell a fibromyalgia patient three things during an office visit, then ask them to recall them later during the same visit, they have difficulty,” she explains. “With fibromyalgia, short-term recall can be very poor.”

 

Depression and anxiety

For many patients, fibromyalgia may also bring feelings of sadness and other negative moods. Some researchers suspect a connection between fibromyalgia and certain types of chronic anxiety and depression.

 

Headaches

Though less common, headaches can occur among fibromyalgia symptoms. “Stress- and tension-type headaches tend to travel with fibromyalgia,” Dr. Brancato reports, adding that they can be triggered differently than in patients without fibromyalgia. “These headaches can be induced by regular sounds, background music, or even odors like perfumes.”

 

Digestive issues

Fibromyalgia can sometimes occur alongside digestive problems, such as bloating, constipation, abdominal pain, and irritable bowel syndrome (IBS), says the CDC.

 

Pelvic floor dysfunction

Some patients with fibromyalgia might also have an increased incidence of interstitial cystitis, says Dr. Brancato. This condition can cause chronic pain or pressure in the bladder and pelvis.

 

Jaw and facial pain

It’s possible for fibromyalgia to be linked to pain in the muscles of the jaw and face (temporomandibular joint disorder) or to myofascial (skeletal muscle) pain in one part of the body. Such occurrences could be considered forms of regional or localized or incomplete fibromyalgia.

 

Fibromyalgia and Arthritis: What’s the Link?

The relationship between fibromyalgia and different types of arthritis can be complicated. For one thing, there’s misdiagnosis: Depending on how your symptoms present, you could be told you have fibromyalgia when you actually have a kind of arthritis, or vice versa. Read about how ankylosing spondylitis and fibromyalgia can be mistaken for each other, for example.

At the same time, having a painful chronic disease like arthritis may in turn trigger the onset of fibromyalgia. Inflammatory diseases like arthritis can affect the way your central nervous system processes pain, creating a double-whammy of having both diseases at the same time.

If you suspect your combination of symptoms could be fibromyalgia, it’s a good idea to start with your primary care doctor. Because fibromyalgia is a diagnosis of exclusion, you’ll likely need a through physical exam, blood tests, and imaging tests to figure out what could be causing your symptoms. Ask about seeing a rheumatologist. These are doctors who specialize in diagnosing and treating musculoskeletal and related diseases.

 

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Managing Your Symptoms With Fibromyalgia Syndrome

If you feel pain after an injury, the reason behind the pain is fairly logical—there is a cause and effect relationship that can be observed clear as day. But in some cases, such as Fibromyalgia Syndrome (FMS), the origin of pain is not obvious at all. The American College of Rheumatology defines FMS as the presence of widespread aching and pain that has been present for at least 3 months, and tenderness with pressure in at least 11 of 18 sites across the body. For many years, FMS has incited considerable debate and controversy. What does the precise definition of the condition really mean for patients, and why would they care if all they know is that they are in pain? Due to FMS’s mysterious onset, it is safe to say there are a good number of people who haven’t been diagnosed or received adequate treatment for the condition.
Much like treatment for many musculoskeletal pain disorders, the optimal treatment for FMS includes an advanced therapeutic exercise program of physical activity. Because FMS can greatly affect physical and mental capacities, appropriate pharmacological management is also needed in many cases. Symptoms may include any of the following:

  • Pain and morning stiffness
  • Swollen joints
  • Temporomandibular dysfunction (TMJ)
  • Numbness of the extremities or face
  • Restless leg syndrome
  • Leg and foot cramps
  • Weight gain
  • Low grade fever
  • Lowered immunity to infections
  • Night sweats
  • Sensitivity to temperature changes

FMS can also have a severe impact on mental health. It can lead to overwhelming fatigue, irritability, apathy, impaired memory and concentration, insomnia or non-restorative sleep, anxiety, depression, and even suicidal thoughts.
With so many different symptoms, it can be difficult and overwhelming for individuals to figure out a proper plan of care. That being said, there are vast amounts of research available to support the use of strengthening programs and aerobic programs in treatments, along with education about FMS, to help patients manage symptoms and enjoy a greater quality of life. Regular exercise can boost your body’s endorphins, decrease stress, and improve energy levels, flexibility, and strength. Other benefits may include decreased mental stress and a lower risk of anxiety and depression.
Types of exercise that have been proven to treat chronic symptoms include:

  • Aerobic exercise, which is non-impactful, low resistance, and high repetition, such as:
    • Pool exercises
    • Brisk walks
    • Bike riding
    • Tai Chi
  • Flexibility and low resistance strength training in the following muscle groups:
    • Upper trapezius
    • Levator scapulae
    • Scalenes
    • Pectorals
    • Quadriceps
    • Hamstrings
    • Gluteus maximus

Patients with FMS have up to 18 tender points, so training usually has to address many different areas of the body. As with any exercise program, make sure your training is tailored to your individual needs before beginning a new regimen.
Physical exercise is not the only important component of managing chronic pain due to FMS. Two major keys to overall care include goal-setting activities and pacing. Goals should be realistic and meaningful. They should be specific, and not an umbrella goal of experiencing zero pain whatsoever. Lifestyle goals such as traveling to visit family or friends could be the initial focus. If you begin by putting too much pressure on yourself to achieve difficult or impossible goals, you might become quickly discouraged. Having a number of smaller but meaningful goals will help you continue along the path to recovery. Pacing is also incredibly important, and patients should remember to set tasks in a graded manner so you can build confidence and tolerance along the way. Remember, too much inactivity can be debilitating and could lead to more pain – however, overdoing it can be just as harmful.
As physical therapists, we are trained to properly evaluate, assess, and implement a proper therapy plan of care that can incorporate all facets of physical activities needed to alleviate symptoms of FMS. With the help of skilled professionals, plans of care can be properly organized and tailored to each individual’s needs, and realistic goals can be set so you can ultimately improve your quality of life. If you have further questions about Fibromyalgia and PT, contact your local Foothills Sports Medicine Physical Therapy clinic today!
 

90,000 Get diagnosed and treated for fibromyalgia in Moscow

03.11.2021

The article was checked by the therapist-rheumatologist Borodin OO. is for general informational purposes only and does not replace specialist advice.
For recommendations on diagnosis and treatment, a doctor’s consultation is required.

Fibromyalgia is a complex disease associated with musculoskeletal pain and a number of other disorders.Despite the fact that up to 4% of the population suffers from fibromyalgia, such a diagnosis is rarely made, due to the lack of clear diagnostic criteria.

A distinctive feature of fibromyalgia is a large number of subjective complaints of patients with a fairly limited number of objective manifestations of the disease.

Doctors of the Clinical Hospital on Yauza are engaged in the diagnosis and treatment of fibromyalgia in close cooperation with each other. This approach helps in making the correct diagnosis and developing an optimal treatment program.

Fibromyalgia Symptoms

The main symptom of fibromyalgia is musculoskeletal pain that is common throughout the body. Patients may complain of pain in any part of the body. Plus, patients may complain of a feeling of stiffness in movements, general weakness, tingling (feeling of “goose bumps”), feelings as if the limbs are swelling.
These symptoms are aggravated by changes in weather, great emotional and physical stress.

However, there are a number of complaints that are typical for patients with fibromyalgia:

  • Sleep Disorders
  • fast fatigability
  • frequent headaches
  • depression
  • manic-depressive states
  • Vestibular Disorders
  • fluid retention syndrome and others

Fibromyalgia is characterized by the presence of so-called painful points on the body.This distinguishes this disease from others, which are also accompanied by musculoskeletal pain.

Causes and pathogenesis of fibromyalgia

Scientists have not yet come to a consensus as to what causes fibromyalgia. The factors provoking the onset of the disease can be viral infections, stress, prolonged psychological stress, physical trauma, but the mechanism of the formation of fibromyalgia is not clear.

A number of doctors associate the onset of fibromyalgia with damage to the nervous system or with a decrease in the level of pain threshold.However, all these hypotheses have not yet been proven.

Diagnostics and treatment of fibromyalgia at the Clinical Hospital on Yauza

Fibromyalgia is a disease that is difficult to diagnose.
There are a number of criteria that need to be ascertained from the patient: pain points, general fatigue, stiffness after sleep, depression, anxiety disorders, etc.
As a treatment, patients are prescribed antidepressants, local anesthetics, anticonvulsants, and other drugs.

Prices for services You can look at the price list or specify by phone, indicated on the website.

Literature:

  1. Alekseev E.I., Litvitsky P.F. Juvenile rheumatoid arthritis: etiology, pathogenesis, clinic, diagnostic and treatment algorithms // Vedi. 2007.

  2. Noskov S.M. Conservative treatment of osteoarthritis // GEOTAR-Media. 2014.

90,000 Muscle pain – consultations and treatment

MUSCLE PAIN TREATMENT AVAILABLE IN BRANCHES:

Treatment of muscle pain in the Primorsky district

Address: St. Petersburg , Primorsky district, st. Repishcheva, 13

Treatment of muscle pain in the Petrogradsky district

Address: g.St. Petersburg , Petrogradskiy district, st. Lenin, 5

Muscle pain can negatively affect the daily functioning of the body and significantly reduce our quality of life. The factors that cause muscle pain are quite varied. This can be the result of physical exertion, mechanical injury, or a symptom of an infection.

Why do muscles hurt?

Pain caused by excessive exertion

As a result of increased physical activity, muscle pain occurs, which is often mistakenly associated with the accumulation of lactic acid.Intense exercise can damage muscle fibers. In this case, the pain can last for several days after training. The pain associated with a high concentration of lactic acid in the muscles lasts only for several hours after training. Pain caused by overuse is usually treated with appropriate analgesics and anti-inflammatory drugs.

  • Muscle pain as a complication of certain diseases

There are situations in which muscle pain occurs as a complication of various diseases and acute viral infections.

Muscle pain can often indicate problems with the spine (hernia, osteochondrosis). Pain in the calf muscle, for example, may indicate a blood vessel disorder (varicose veins).

Pain can also result from certain medications that, with prolonged use, damage muscle cells.

  • Muscle pain as a result of inflammation

Various inflammatory conditions can also cause muscle pain.Very often this happens with colds and flu, which are accompanied by a high fever and muscle pain throughout the body.

Muscle pain is often reported by patients suffering from rheumatoid arthritis or bone tumors. The pain in such cases is caused by the action of inflammatory substances that enter the muscle cells with the bloodstream.

Inflammatory processes in the esophagus, thyroid gland or trachea can cause pain in the front of the neck.And the cause of pain in the femoral muscle is often inflammation of the sciatic nerve.

It happens that muscle pain can signal fibromyalgia. It is a chronic disease that manifests itself as persistent pain in muscles and joints. This condition may be accompanied by other symptoms such as fatigue, body tension, dizziness, constipation, diarrhea, sleep problems, and mood disorders. Such a wide range of symptoms are similar to those in other diseases, which greatly complicates the diagnosis and effective treatment of fibromyalgia.

Remember that severe and persistent muscle pain should never be underestimated. They can be a symptom of a serious medical condition that may require medical advice.

If you have pain in the muscles of your legs, back, neck, in our clinic you can make an appointment with specialists of different directions, who will prescribe you an examination and select the right treatment.

Appointments are carried out by doctors:

Select the branch “Dynasty” on Novocherkassky avenue, Krasnogvardeisky district “Dynasty” on Lenina, Petrogradsky district “Dynasty” on Repishcheva, Primorsky district “Dynasty” in Vsevolozhsk

Muscle pain treatment cost:

Name of services Price in rubles
St. Petersburg Vsevolozhsk
First stage rheumatologist appointment

1850

Reappointment of a rheumatologist of the 1st stage

1650

Initial appointment with a rheumatologist, leading specialist

2500

2000

Follow-up appointments with a rheumatologist, leading specialist

2300

1800

HANDLING
Capillaroscopy

1500

RECORD FOR MUSCLE PAIN TREATMENT

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Everything you need to know about shingles [Herpes Zoster]

Shingles is a neuropathic condition that truly lives up to its name. Shingles, also known as shingles, causes a characteristic, painful skin rash in the affected nerve area (dermatome).

The diagnosis is related to reactivation of the varicella-zoster virus called Varicella-zoster . The condition can cause severe nerve pain and is due to the fact that the virus physically travels along the nerves to the nerve endings on the skin and causes infectious blisters (which can cause chickenpox in those who are not sick – it cannot be infected with shingles).

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In this article we will consider:

  • Tile symptoms
  • The reason why you are receiving shingles
  • Treatment of herpes zoster

+ Medicines for shingles

+ Shingles vaccine

In this article you can learn more about shingles and the reasons for the diagnosis, symptoms, prevention, diagnosis and treatment of this clinical condition.

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Shingles Symptoms (Shingles)

The condition usually starts when you feel that a patch of skin hurts or burns in your skin. This may continue for two to four days before the rash appears. In some people, these pains can be severe and cause nerve pain that accompanies the entire affected nerve.

Previous, nonspecific symptoms of shingles may include headaches, mild fever, and fatigue. Before symptoms develop into more specific symptoms such as:

  • Burning pains
  • Hypersensitive skin
  • itchy
  • insensitivity
  • tingling
  • Acute, stabbing nerve pain along the nerve root

It is important to note that shingles affects one dermatome (the area innervated by one nerve) and only one side of the body. This means that the rash will only appear in this area, which is characteristic and unique to shingles.

For example, shingles in the C8 nerve root can cause a rash on the arm, but mostly in one lower half of the arm (see picture). The rash will gradually break down and disappear. However, in some more serious cases, physical scars may remain.

Source: Birgitt Lersch-Barlach.

The most common condition is that the condition affects the chest or face. But in theory, the diagnosis can be made on any dermatome, including:

  • Eye
  • ear
  • mouth
  • Language

We’ll talk more about this later in this article.

Diagnosis of herpes zoster

Because the clinical manifestations and rash are so unique (dermatomal conditions), diagnosis usually requires only a visual examination by a physician.But there are also laboratory tests, such as the Tsank test, that can help identify the disease.

Different pain from person to person

It is important to remember that shingles can affect strength and strength in different ways for different people. Some people may have significant, severe nerve pain – when others have only some discomfort in the affected area of ​​the nerve, approximately as at the time of diagnosis neck tension .

The condition usually lasts two to four weeks – but in some people it can last for several months. If it does, it is known as postherpetic neuralgia .

Read more: – What you need to know about neck tension and tense neck muscles

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Shingles on the face and eye

Shingles can also cause dermatomes on the face. The trigeminal nerve is most susceptible to shingles of the face.

A branch of this nerve is called the ophthalmic nerve. If shingles occurs in this nerve branch (shingles), serious symptoms can occur – which in the worst case can lead to visual impairment. With this diagnosis, a rash may appear on the forehead, eyelid, or in the eye socket itself.

Ophthalmic herpes zoster accounts for approximately 10-25% of shingles outbreaks – and can, as mentioned, lead to severe visual complications in the form of inflammation (uveitis, keratitis, conjunctivitis) or damage to the optic nerve.These complications can lead to chronic inflammation of the optic nerve, poor vision, and severe pain.

Shingles in the ear and mouth

If shingles occurs in the ear, the medical name is Ramsey-Hunt syndrome type 2. This diagnosis can occur if the virus spreads from the facial nerve (cerebral nerve number seven) to the vestibulochlear nerve. Symptoms may include hearing loss and dizziness (vertigo).

Shingles can also affect the mouth if the branches of the maxillary nerve or the mandibular nerve belonging to the trigeminal nerve are affected. In these cases, a rash may occur in the mouth – for example, on the palate, in the mouth, on the tongue, or on the gums.

Shingles in the mouth is relatively rare – this means that patients often mistakenly think that it is due to the teeth, and therefore go to the dentist. Without help.

Read more: – 7 natural treatments for psoriatic arthritis

Reason: Why are you getting shingles?

Varicella-zoster virus reactivation is particularly associated with a weakened immune system, the fact that you are older and had chickenpox before you were 18 months old.

Even today it is not entirely clear how the varicella-zoster virus remains in the body or how it is reactivated. However, it is known to be related to the varicella-zoster virus, which is related to the herpes simplex virus, but not the same virus. The virus enters the body with chickenpox. Usually at a young age.

Reactivation of the varicella-zoster virus can practically only occur when the immune system is weakened. If the immune system is strong and activated as usual, it should prevent herpes outbreaks and characteristic rashes.

But there are several factors that can cause you to have a temporarily weakened immune system – this could include:

  • Cytotoxic or radiation therapy
  • Long-term illness
  • Drug side effects
Who is affected by shingles?

Research has shown that up to one third of us suffer from shingles. The diagnosis is therefore relatively common.

Fortunately, the condition usually does not occur multiple times during a person’s life. In fact, only about 5% of those affected will experience it.

The risk of developing shingles increases with age. Those over 65, who also have a weakened immune system, are particularly affected.

Read more: – This You Should Know About Osteoarthritis of the Neck

Wondering if you suffer from osteoarthritis of the neck? Read more in the article above.

Prevention and treatment of shingles

In this part of the article, we will give you more information on how vaccination can work against shingles – and what drugs are used against this diagnosis.

Shingles vaccine

There are several different vaccines that can be used to reduce the risk of shingles. Research has shown that they can be very effective – with efficiency rates ranging from 50 to 90%.

Vaccines can also reduce the incidence of postherpetic neuralgia and, if shingles occurs, reduce both its duration and severity.

Medicines and medicines for shingles

If you suffer from shingles, you should be aware that there are medications that can help you relieve both the symptoms and the intensity of the pain.

Antivirals, such as acyclovir , are used against certain viral infections (including shingles) – and have been clinically shown to be effective when used within 72 hours of rash onset.

Read more: – 7 ways to reduce inflammation in osteoarthritis

Summarize pt

Shingles is a painful diagnosis that results in a rash in the affected dermatome (nerve area). The condition is relatively common and affects about 33% of us. A strong immune system is the best way to prevent the onset of the disease, but there are also effective vaccines for people with weakened immune systems.

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Next page: – 7 Known Fibromyalgia Triggers: They May Increase Your Pain

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Frequently Asked Questions About Herpes Zoster

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90,000 Treatment of fibromyalgia in Yekaterinburg – New Hospital

Or “everything hurts and nothing helps!”

It is with this phrase that a patient with fibromyalgia most often enters the doctor’s office: this is how this disease can be characterized.

He is already, as a rule:

  • visited many doctors (according to statistics – at least four),
  • 90,023 he underwent a huge number of studies (on average, at least three only instrumental studies – MRI, CT, fibrocolonoscopy, etc.),

  • a large number of “on-duty diagnoses” were exposed, each of which does not represent “anything special” according to the doctor, several groups of drugs are tried in the treatment,
  • and still the pain remains the same.

This process of going to examinations and doctors to consultants takes on average two years, until some of them have the idea of ​​fibromyalgia.


Fibromyalgia symptoms

In order to understand what kind of disease it is, first we will focus on the fact that the leading symptom of fibromyalgia is generalized pain, i.e.i.e. pain in at least four of the five regions, which include the two upper, two lower limbs and the patient’s body. And here you need to delve into the process of the emergence and perception of pain.

It turns out to be not so simple: pain can occur on several levels. The first – quite understandable – is irritation of peripheral nerve endings. Suppose a person is cut or burned, or his joint is inflamed or an ulcer has formed in his stomach, – in all cases, the painful endings will irritate him.This is nociceptive pain, the name of which comes from nocens “harmful”. But this pain is not so harmful – it warns us of danger. A feature of nociceptive pain is that the patient clearly localizes it, and it is directly related to the area of ​​damage, inflammation.
Another type of pain is neuropathic. Our nerves are uniquely structured; many of them resemble electrical wires. In the center of the nerve there is a conductor, along which, just like in wires, an electrical impulse passes, and the entire nerve is covered with an “insulator” – a myelin sheath, which prevents loss of electricity and the development of “short circuits”.In the case of damage to the nerve itself or the myelin sheath, when the nerve becomes “exposed”, it is also possible to develop pain.

However, with neuropathic pain, no visible changes are observed, movements in the joints are often completely preserved, but in the zones of innervation, hypersensitivity may develop, or, on the contrary, it decreases. A feature of this type of pain is its clear correspondence with the location of the nerve structures.


A classic example of neuropathic pain is peripheral neuropathy, when the pain syndrome develops symmetrically in a “gloves and socks” pattern.Such damage can be observed with diabetes or alcoholism.

Another example is radiculopathy, where a nerve root is compressed, often at the lumbar level. Then the pain literally “shoots” all over the leg, for example, on its outer surface, reaching the heel. And another classic example of neuropathic pain is carpal tunnel syndrome associated with compression of the median nerve at the level of the palmar surface of the wrist. In this case, the patient will go to the doctor with complaints of “burning” in the I-IV fingers of the hand, again without any external changes in the joints.


The third type of pain is dysregulatory. Previously it was also called psychogenic pain, but this name did not justify itself, because it is not always the case that the patient has some kind of psyche. To understand the reason for the development of this type of pain, you need to remember that all our sensations are analyzed at the level of the brain.

So if the eyes see some object, then the visual analyzer recognizes that it is, for example, a table made of wood, located three meters from a person.In the same way, the auditory analyzer recognizes the melody, hears the play of individual musical instruments. Similarly, at the level of the brain, there is an analyzer of pain signals from our body. And due to various circumstances, there may be an increase in the activity of this zone, which is why there is a feeling of generalized pain.

Disputes about the causes of this phenomenon do not stop. There is an indication of understandable “organic” reasons. For example, there may be a change in the activity of blood flow in certain areas of the brain, and therefore pain throughout the body (fibromyalgia) is so characteristic of older people.

Organic reasons also include changes in the concentration of mediators: it is known that serotonin is a hormone of pleasure, and norepinephrine is a hormone of stress and decreased sensitivity to pain. Violation of the concentration of these substances will also lead to pain syndrome, although at the level of examinations we will not be able to confirm this, because the concentration of hormones in the peripheral blood does not correspond to their concentration in the brain.

But there is another theory that explains the development of generalized pain through various psychological disorders.It is well known that with anxiety and depression, body pain is very common.

Unfortunately, there is one more category – patients of a hysterical disposition, who talk about the presence of pain in the whole body and, due to this, try to manipulate the environment (relatives, less often co-workers) in order to get a “benefit” from their illness. The “benefit” may be avoiding domestic or professional responsibilities. Such patients, and more often patients, also try to manipulate the doctor so that he “showed” her relatives how sick she is.


But fibromyalgia isn’t just common body pain. Fibromyalgia is often associated with other symptoms. The patient may feel severe fatigue, may wake up absolutely not rested overnight.

Gradually there is an increase in cognitive impairment: the patient has problems with memory, performing some kind of mental operations. And, as a rule, body pain is accompanied by many other symptoms: abdominal discomfort (which is why gastroenterologists often diagnose irritable bowel syndrome), headache, numbness, dizziness, dry eyes, constipation, nausea, loss of appetite, painful urination, etc.

Fibromyalgia occurs very often: at a rheumatologist’s appointment it is every eighth to tenth patient.

Such a high frequency is due to the fact that fibromyalgia does not exclude, but, on the contrary, may accompany other diseases, for example, rheumatoid arthritis, osteoarthritis.


Fibromyalgia Treatment

In general, the treatment of fibromyalgia includes several areas: a warm shower or bath in the morning (this is done with great enthusiasm by patients), sports activities.Despite the fact that during physical activity the hormones of pleasure – endorphins and enkephalins – are produced, many patients actively resist physical education, from which they “only get worse”, which is most typical for the hysteroid variant of the disease.

The arsenal of medicines is not that great. Patients often need to prescribe antidepressants – there is no need to be afraid of these drugs, they do not cause addiction, any psychotic effects, but they significantly change the view of the world, painting it in brighter colors.Antidepressants begin to work two months after their appointment, they should be taken for at least a year, until the patient develops some kind of hobby that will bring him no less joy than antidepressants. Another class of drugs are anticonvulsants. They originated from the drugs that treat epilepsy, in which, as you know, there are areas of high excitability in the brain. With the appointment of anticonvulsants, there is a rapid effect in the form of pain relief.Finally, the third group of drugs is opioids – powerful analgesics that can enter the brain.

Having recognized fibromyalgia, the doctor tries to identify the main causes of its development, because the preferred choice of drug therapy will depend on this. So, if there is a pronounced anxiety behind fibromyalgia, then it is necessary to establish its roots. Most often it turns out to be cancerophobia, and behind each painful sensation the patient sees a growing oncological process. In this case, it is possible to cope without medication at all, for example, by making a plan for a regular medical examination that will eliminate the most common causes of cancer.

And the doctor will behave in a completely different way with hysteroid patients. This is the most difficult category, which is generally not in the mood to be treated, because the elimination of pain will immediately deprive it of the manipulative mechanism.

Fibromyalgia is so multifaceted. It cannot be said that rheumatologists “love” this disease, because these patients can talk about their complaints for a very long time, and it will take a lot of time for the doctor to “pick up the key” for each patient who is firmly convinced that he is “very sick”.But a competent rheumatologist with fibromyalgia is sometimes akin to a “magician” who, in 40-60 minutes of admission, answers a riddle, the answer to which the patient has been looking for for several years .