Date
Dear Patient,
The Arthritis Center is committed to diagnosing and treating patients with musculoskeletal
complaints. If Fibromyalgia (FM) is your primary diagnosis, you will be diagnosed, treated and
given information on how to best manage this condition. Most Fibromyalgia patients will be
seen once or twice and then referred back to the primary care physician (your family doctor)
for future treatment and prescription refills. We are providing you with this information so that
you may easily transfer your care to the doctor you choose. We can answer your questions by
phone and provide limited prescription refills until you arrange for another medical provider.
It is important that you share with your primary care physician (family doctor or internist) the
information we provide you about your diagnosis. This includes the following:
A copy of your initial visit and subsequent clinic note(s), including any tests done
at our site (we encourage you to keep a personal file or “chart” with your medical
information regarding your care and test results);
The attached Fibromyalgia Guide: a summary of what FM is, how is it treated,
etc;
o Guidelines for the treatment of Fibromyalgia;
o Sleep Hygiene: information on better sleep;
o Guidelines for the treatment of Pain and Sleep. These are “maps” you can
use to evaluate your symptoms and how to best managed them;
We are grateful for the opportunity to evaluate and treat you and wish you well.
Sincerely,
FIBROMYALGIA GUIDE
DEFINITION: Fibromyalgia (FM) is a very common condition. It is sometimes called fibrositis or
myofascial pain syndrome. Primary symptoms are widespread muscle and/or joint pains, marked
fatigue and poor sleep. The pain is usually over “soft tissues” around or near joints, often over tender
areas called “trigger points.” Many FM patients have been diagnosed with “chronic fatigue syndrome.”
CAUSE: The cause is unknown. Some cases have no obvious trigger or “initial event.” In others, FM
may be brought on by pain or trauma (such as car accident, back surgery or arthritis), stress (ie, death
of a loved one), depression, poor health/fitness, or chronic insomnia (poor sleep). These events begin a
vicious cycle of poor sleep, leading to more pain, then worse sleep, etc. The net result is a lowering of
your pain threshold that increases your overall pain level. Hence, activities and simple things that
never used to cause pain, now causes pain, stiffness and muscle soreness in the FM patient. Most of
your pains comes from muscle spasm and pain around the joints (tendons). FM does not damage the
joints or lead to deformity or disability.
WHO GETS FIBROMYALGIA? FM affects between 5-7 million Americans. Over 80% of Fibromyalgia
patients are female. The average age is between 30-50 years, but Fibromyalgia may affect the very
young or the very old. FM may also secondarily affect those with other forms of “arthritis,” such as
rheumatoid arthritis, lupus, and Sjogren’s syndrome.
WHAT ARE THE SYMPTOMS? Most people with FM complain of “pain all over” - in the joints or
muscles, in the upper and lower body, and both sides of the body. The intensity and sites of pain may
vary day to day. Pain often affects the neck, shoulders, between the shoulder blades (upper back), low
back or hips. Other painful areas include the elbows, knees, jaw or chest. The most painful areas are
called “trigger points” or “tender joints” (see figure on next page) – these painful areas are near or
around the joints and are due to muscle and tendon spasm. On exam, the joints are usually normal. FM
patients often complain of severe fatigue, malaise, and joint stiffness that may for last hours. Also,
chronic pain and poor sleep lead to fatigue and numerous other bothersome symptoms in FM patients.
Sleep problems: may appear as problems falling asleep, staying asleep, waking up many
times during the night (often with problems falling back to sleep), restless or jerking legs, or
waking up very early in the morning. Most people with FM only sleep for a short period of time
during the night and feel worse or more tired when they wake in the morning. Non-restorative
or non-restful sleep worsens the pain and lessens the chance of normal sleep the next night.
Poor sleep can cause more pain, fatigue, headaches, poor memory and even unexplained
numbness. Many people with FM have poor sleep habits (eg, sleep hygiene). If you sleep
badly, you will feel bad. If you sleep fair, you will feel fair. To feel great, you must sleep great!
Other symptoms: Many people with FM will often have major fatigue and malaise and past
or current complaints of migraine, headaches, irritable bowl syndrome (alternating
diarrhea/constipation), premenstrual syndrome (PMS), chronic fatigue syndrome, depression,
anxiety multiple drug allergies, unexplained numbness, chronic TMJ syndrome, restless leg
syndrome, poor memory or concentration and problems with thinking (“Fibro-Fog”). Many of
these symptoms are worsened by poor sleep.
How is FM diagnosed? There is no diagnostic lab or test for FM. This diagnosis is easily made on the
basis of a careful medical history and physical examination. X-rays and lab tests are usually normal
and usually not necessary. Consultation with a Rheumatologist may to establish an accurate diagnosis
and treatment plan. Once diagnosed, a treatment plan tailored to your specific needs. The following
pages describe the key symptoms of FM, how FM is treated, sleep hygiene advice and how to manage
poor sleep.
Diagnosing Fibromyalgia
Key Findings in
Fibromyalgia
Widespread
pain
Problems with
sleep
No joint swelling
or damage
Multiple tender
Trigger points
FM TRIGGER POINTS
Other problems seen
with fibromyalgia
Chronic
headaches
Unexplained
numbness
Muscle and
joints pains
TMJ
(Jaw) pain
Depression
Anxiety
Irritable bowel
syndrome
Chronic
sinusitis
Sensitivity to
many drugs
Atypical
chest pain
Poor memory/
concentration
Severe
premenstrual
syndrome
Chronic
fatigue
4 Cornerstones to
FM Treatment :
 Pain Control
 Improved
Sleep
 Stretching &
Pool Exercise
 Treat
Depression
Treatment of FM: There is no single drug or treatment that can cure FM.
A combination of
treatments is necessary to help this condition. The 4 cornerstones of treatment are:
1. Pain Control: There is no single pain pill that will stop the pain. Pain pills alone may help your pain
by only 10-35%. Many different types of medicine can be used to lessen your pain:
- Tylenol Arthritis (acetaminophen) 650 mg: 2-3 tabs twice a day OR
Ibuprofen (Advil, Nuprin, Motrin IB) 200 mg: 2-3 tabs 2 or 3 times daily (with meals) OR
Aleve (naproxen) 250 mg 1-2 tabs twice a day (with meals). OR
Prescription NSAIDs (anti-inflammatory pills): Celebrex, Mobic, Relafen, Daypro, Lodine
( These NSAIDs may upset your stomach or cause bleeding; watch for heartburn or nausea) OR
- Lyrica (once or twice daily) is FDA approved for FM. OR
- Weak narcotics (eg, tramadol) may be needed to lessen pain (especially at bedtime)
- Strong narcotic pills like Vicodin, Lortab, Norco, Percocet and steroids (like prednisone) are
usually not helpful, may have harmful side effects and should be avoided.
2. Sleep Control: The goal is to fall asleep easily, stay asleep throughout the night and feel refreshed
in the morning. Talk to your doctor about your sleep habits (see SLEEP HYGIENE on the next
page). If needed, there are many sleeping aids/pills you can use that are usually not addictive.
These can be used safely each night if prescribed by your doctor.
a. Antidepressant pills like Trazodone, Elavil (amitriptyline), or Pamelor may be helpful. They
help FM patients to fall asleep and stay asleep. The doses used are often too low to treat
depression, but are helpful with sleep problems, pain, and muscle spasm.
b. Sleep aids like Ambien, Lunesta, Restoril (temazepam), Sonata, or muscle relaxants with
sedating side effects (like Flexeril, Soma, or Norflex) can also be used alone or in
combination. If worried about side effects or if sleep medicines are too strong for you, you
can start with half the usual dose of Ambien, Sonata, Elavil, Doxepin, Restoril or Soma.
c. OTC sleep aides include Tylenol PM, Advil PM, Melatonin or Valerian root or magnesium
powders (such as Calm) (no prescription needed).
d. If sleep problems persist, an evaluation by sleep specialist can help. Let your doctor know if
you have problems with falling asleep, staying asleep, early waking, snoring, night pain,
sleep apnea (sudden stops in breathing – more common in obese or men) or restless legs.
3. Exercises: You must begin a regular stretching and pool exercise program - 3 to 5 times a week.
Regular exercise can improve sleep and reduce pain. The BEST exercise for FM patients:
- Swimming: water exercise in WARM (not cold) water is advised. This includes swimming, water
walking and water aerobics (aquasize) classes. For water programs near you, call the Arthritis
Foundation (214-826-4361) OR the YMCA. Hot tubs or Jacuzzi’s help for a short time, but pool
exercise is better by providing therapeutic stretch while exercising your muscles and joints.
-Yoga (or Tai Chi, Pilates): all 3 are excellent forms of “stretching” exercise to help relieve or
prevent muscle spasm/pain, while improving overall health. It is better to join a
class/program/club to learn about yoga (or Pilates or Tai Chi).
- Find these by checking colleges/schools, YMCA, physical therapists, hospitals, Yellow pages
- Wii Fit (costs $300) or YouTube videos: search “stretching & neck, shoulder, hip, back etc.
- Walking is good for overall health, but often does not help FM symptoms, fatigue or aching.
- Weight lifting is not advised and may aggravate your problems.
- Physical Therapy (PT) may help (stretching, massage therapy, heat packs, ultrasound,
biofeedback) and Cognitive Behavioral Therapy may also improve your pain.
4. Treat Depression or Anxiety (if present): If depression or anxiety is a problem, then consultation
and care by a psychologist or psychiatrist is necessary; especially if the above therapies don’t work.
Other sources of information on FM: local Arthritis Foundation (214-826-4361), Fibromyalgia
Association (714-921-0150), The Fibromyalgia Network (800-853-2929), public library, NIH.gov, etc.
Sleep Hygiene
12 Steps for Good Sleep
1. You need great sleep every night – at least 7 hours for most people.
Do not over sleep - Too much sleep is not a good idea. Extra sleep (especially during the day) weakens
the refreshing power of a good nights sleep and may interfere with good sleep the next night. Sleep only
as much as you need to feel well rested during the following day.
2. Develop and keep a regular sleep schedule and routine.
Go to bed and get up at the same time every day (including weekends, holidays). Do not take daytime
naps. This will “steal” from your night time sleep. If you must, limit afternoon “power naps” to 30-50
minutes. Get plenty of morning and/or afternoon sunlight. If you work nights – maintain the same sleep
schedule – even on your days off.
3. Do not struggle at falling asleep or get frustrated when falling asleep.
Don’t go to bed until you are drowsy. Use TV, reading or hot baths to wind down and make yourself sleepy.
If you can’t fall asleep, go to another room where you can relax. Return to bed when drowsy.
4. Establish a constant sleep environment.
Keep your bedroom quiet, dark, and at a comfortable sleeping temperature. Position the bedroom clock so
it will not bother or wake you. Sleep in your bed and not on the sofa or recliner.
5. Your bed is your special place for sleep only.
Do not read or watch TV in bed. Your bed should be free of books, magazines, remote controls,
computers, cell phones, food, children, pets, snoring spouses. Your bedroom is NOT a place to hangout; it
is NOT your office; and it is NOT “command central” for you or your family.
6. Do not go to bed hungry, as hunger may disturb sleep.
You may sleep better with a light carbohydrate snack at bedtime. However, avoid eating large meals
before bedtime.
7. Tell your doctor about specific sleep problems.
Your doctor needs to know if you snore, sleep walk, have nightmares, restless legs, sleep apnea, nighttime pain, heartburn, narcolepsy, etc. Also let us know if you do not tolerate sleeping medicines.
8. Avoid bedtime stimulants!
AVOID caffeine (tea, coffee, soda, etc), alcohol (no “nightcap”!), smoking/tobacco, and stressful/stimulating
books, TV shows, phone calls or confrontations. These will interfere with falling and staying asleep.
9. Exercise everyday and try to live an active life.
Exercise will promote and enhance your sleep.
10. Avoid excessive fluid intake in the evenings.
Many visits to the bathroom will interrupt, frustrate and decrease your sleep. Limit your fluid intake after
6PM. Also, if you are on water pills (diuretics) talk to your primary care doctor about decreasing, stopping,
or substituting these medications.
11. Improve your sleep comfort.
Your bed (mattress, pillows), bed clothes, (blankets, comforters, sheets) and sleepwear (pajamas) should
be of high quality and comfort. You should look forward to using these and getting great sleep every
night!
12. Consider using bedtime relation techniques.
Warm bath, massage, imagery and muscle relaxation can be used to relax your brain and muscles. Avoid
stressful tasks or activities (bill-paying, arguments), stimulating books or television before bedtime.
FM: Treating Poor Sleep
Fibromyalgia Patients
Require Great Sleep!
Yes
Do you have
good sleep
habits?
Continue
same plan
Read about
Sleep Hygiene
No
What is your
sleep problem?
Are Restless
Legs (RLS)
a problem?
Problem
falling
asleep
Avoid alcohol,
caffeine,
tobacco
1st wind down
Hot baths, heat
exercise
massage
Bedtime
narcotic or
analgesic
RLS Meds:
Requip Sinemet
Mirapex Permex
Ask MD about
other problems
Problem
staying
asleep
Due to pain
Frequent
urination
Frequent waking, can’t
fall back asleep
Bedtime
analgesics,
narcotics
Limit
liquids
after 6PM
Stress
Management
(wind down or relax)
Stop water
pill
(diuretic)
Maximize dose of
prescribed sleep aid
(warm bath, read)
Consider OTC
Unisom,Tylenol
PM, etc
Consider
Ambien, Sonata,
Lunesta
Consider Restoril,
Klonopin,
Remeron
Referral to
Urologist for
bladder, prostate
problems
Add in:
Trazodone,
Elavil, Doxepin
Legs jerking
or restless
Early
morning
awakening
Stress
management
Treat
depression
(if present)
Maximize
prescribed
sleep aid
Try Soma, Flexeril,
Neurontin, Lunesta
If not improved, consider referral and
evaluation by a sleep specialist or
sleep clinic
Cramps or
Spasms
Snoring,
apnea
Sleep
medicine
intolerance
Is pain
under
control?
Fibromyalgia: Treating Pain
No
Yes
Caution:
Do not chase or
overtreat pain.
The goal is to
lessen pain
Measures
to treat
pain:
Continue current
regimen, good
sleep, exercise
Tylenol
650mg 2-3
tabs bid
Continue
current
regimen
NSAIDs
(OTC or
prescription)
Pain Meds
(tramadol,
Lyrica, etc)
Local heat/ice,
Trigger point
injection
If pain is
still poorly
controlled
Evaluate for
poor sleep
Is
depression
present?
Prescribe sleep
aid or sleep
clinic referral
Consider Trazodone,
Cymbalta, Remeron,
Effexor, Zoloft
Encourage
water
exercise, yoga
Consider
Physical therapy
referral
If pain still
poorly
controlled:
Refer to
Sleep clinic
Yes
Refer to
Psychiatry
Is pain
controlled?
Refer to
Pain clinic
No
Consult a
Rheumatologist