Fibromyalgia and Myofascial Pain Syndrome

Ross Hauser MD,

Fibromyalgia syndrome (FMS) is a chronic disorder affecting mostly women. The condition is characterized by widespread musculoskeletal pain, fatigue, poor sleeping patterns and multiple tender points that occurs in precise, localized areas, particularly in the neck, spine, shoulders and hips.

The long and winding road of Fibromyalgia

In December 2022, Professor Anne Marit Mengshoel of the University of Oslo wrote in the International journal of qualitative studies on health and well-being (1): “Fibromyalgia is a contested (controversial) illness with unknown (origins) and poorly understood development. (The aim of this study) is to explore the pre-diagnostic illness trajectory narrated by individuals recently diagnosed with fibromyalgia.” In other words, what medical journey did these patients go on and what challenges did they face until they were eventually diagnosed with fibromyalgia? In this paper “Individual interviews about the course of the illness were conducted with seven women and three men (age from early 20s to 50s) who had recently been diagnosed with fibromyalgia.”

Results: The findings are expressed by three storylines.

In summary: “The three storylines portray a long, winding trajectory of suffering starting before the onset of illness, and unfolding illness gradually becoming persistent and overwhelming. Finally, a diagnosis of fibromyalgia is arrived at, but how the situation will evolve is uncertain.”

When a fibromyalgia patient first seeks help for pain, a diagnosis such as tendinitis is generally given. When the pain continues, an MRI scan or some such study will be ordered. The diagnosis then changes to a “disc problem.” After more unsuccessful treatments, the pain sufferer will be sent to a pain center where the diagnosis of depression will be made. (See our article when depression and anxiety prevent healing). After several thousands of dollars of treatment, diagnostic tests, and a lot of frustration and misery, the person will be given that all-inclusive, “so everyone will know I’m not crazy” diagnosis: fibromyalgia. Nearly anyone who has had pain long enough and seeks enough medical opinions will eventually be labeled with this diagnosis. The diagnosis of fibromyalgia, chronic pain syndrome, or myofascial pain syndrome does not determine the etiology and, thus, the cure for the condition.

The 18 trigger points of Fibromyalgia

Fibromyalgia and myofascial pain syndrome are often diagnosed in the same patient. Myofascial pain syndrome (MPS) is a common painful muscle disorder caused by taut bands or trigger points in the muscles. Myofascial trigger points are tender areas in muscles causing local and referred muscle pain. Trigger points may cause the tight muscles and tight muscles may cause trigger points.

To make the diagnosis of fibromyalgia, one of the cardinal features is tenderness over specific points on the body. The diagnosis is made when at least 11 of the 18 points are tender. The unilateral sites are the occiput (insertion of the suboccipital muscles), inter-transverse ligaments C5 through C7, trapezius muscle, origin of the supraspinatous muscle, second costochondral junction (ligament), lateral epicondyle (wrist extensor muscle insertions), gluteal area (gluteus maximus muscle), greater trochanter (gluteus medius muscle insertion), and the medial fat pad of the knee (medial collateral ligament).

In essence, 14 of the 18 points are located where either a ligament, tendon, or muscle inserts and the remaining four are in the middle of a particular muscle. As we discuss below, Prolotherapy injections helps to promote ligament, tendon, and muscle tissue growth where they attach to the bone, alleviating and prossibly eliminating trigger points and the pain of fibromyalgia.

“Our findings also suggest avoiding repeated or unnecessary rule-out tests and the over diagnosis of psychiatric disorders is necessary.”

overdiagnosis of psychiatric disorders

Let’s look at the December 2022 statements of doctors in Finland writing about their experiences with fibromyalgia patients in the medical journal The European journal of general practice. (2)

“Fibromyalgia is a functional syndrome. Despite recent findings, there is still considerable uncertainty about its diagnostic process. . .  The main unifying entities (characteristics among patients) were the uncertainty and contradictions fibromyalgia patients faced on several occasions (Confusing diagnosis). Physicians sometimes offered other diagnoses – like depression – as an explanation for the symptoms, or used repetitive tests to eliminate other possible diagnoses. Furthermore, patients expressed their wishes for a holistic, empathetic, and up-to-date approach to their symptoms. . . . In our interviews, a good doctor-patient relationship and continuity of care were necessary, as were the physician’s attitude and knowledge of fibromyalgia. Our findings also suggest avoiding repeated or unnecessary rule-out tests and the overdiagnosis of psychiatric disorders is necessary.”

The diagnosis of fibromyalgia remains controversial “that still lack either a gold standard or at least supportive laboratory findings.”

As we see, in recent research, the medical community acknowledges that the diagnosis of fibromyalgia remains controversial. Further that offering a diagnosis of fibromyalgia may lead to a patients’ “over-medicalization,” whereas others have raised concerns of under-diagnosing Fibromyalgia and under treatment for patients.

In a November 2020 paper in the International journal of molecular sciences (3) Dr. Massimo E. Maffei of the Department of Life Sciences and Systems Biology, University of Turin wrote: “Diagnosis of fibromyalgia is based on clinical feature and criteria that still lack either a gold standard or at least supportive laboratory findings. Fibromyalgia diagnostic criteria may include heterogeneous (a mixed group without an obvious connection to the cause of their symptoms) patients also in clinical trials and this may impair evaluation of clinically meaningful treatment effect.”

The review of the literature suggests that a multidisciplinary therapeutic approach, based on the combination of pharmacologic and alternative therapy (including thermal, light, electrostimulatory and body exercise treatments) could improve the quality of life and reduce pain and other symptoms related to fibromyalgia. However, sometimes the ability of patients to participate to alternative therapies is impeded by the level of pain fatigue, poor sleep, and cognitive dysfunction. These patients may need to be managed with medications before initiating nonpharmacologic therapies.”

In other words, fibromylagia is hard to diagnose and it is better to talk to the patient and be proactive in treatment while neither overmedicating nor undertreating, however, medications may be necessary.

In the image below, the common symptoms of fibromyalgia are shown. The symptoms are listed below and linked to other articles on our site that address these problems.


the common symptoms of fibromyalgia

Many of these symptoms are also seen in patients with cervical spine instability, the links will take you to articles that may explain this connections. I will also discuss this subject further below.


Loss of memory and cognitive performance in women with fibromyalgia. By the time of diagnoses, how much cognitive decline is there?

During COVID-19, many patients, and in the case of this study, women, could not get a diagnostic evaluation for their symptoms. A September 2022 paper in the journal Applied neuropsychology. Adult (4) aimed to obtain evidence of the role of pain and the effect of time since FMS diagnosis and cognitive performance using a novel online protocol of neuropsychological evaluation. This novel or online approach was developed during the COVID-19 pandemic. A sample of 70 adult women was evaluated (50 with fibromyalgia and 19 controls) using online questionnaires that evaluated pain and executive functioning (impulsivity, inhibition control, monitoring, and planning). Afterward, participants were evaluated by trained neuropsychologists in a 30 min online session using virtually adapted cognitive tests.

Delayed diagnosis did matter

In their results the researchers found: “the role of pain as a mediator on cognitive performance, specifically in executive functions which are directly affected by the cumulative effect of the time of diagnosis. Furthermore, the importance of considering a broader perspective for assessment and treatment including novel procedures via tele-neuropsychology.”

Long-Term Effects of Fibromyalgia Pain – Changes in the brain

Long-Term Effects of Fibromyalgia Pain - Changes in the brain

Recent research is showing that living with fibromyalgia pain is not a viable option. In fact, it is now known that living with fibromyalgia causes significant changes in the brain. Let’s start with a 2007 study and work our way forward. In this study researchers at McGill University’s McGill Centre for Research on Pain wrote in The Journal of neuroscience (12) compared brain images of 10 women with fibromyalgia to 10 women without fibromyalgia. Results showed that there was a significantly lower amount of gray matter in the brain in women with fibromyalgia. The researchers wrote: “The longer the individuals had had fibromyalgia, the greater the gray matter loss, with each year of fibromyalgia being equivalent to 9.5 times the loss in normal aging.” Gray matter plays an integral role in the central nervous system. Although gray matter loss naturally occurs with age, it appears to occur three times faster in people with fibromyalgia. The researchers stated: “In particular, fibromyalgia appears to be associated with an acceleration of age-related changes in the very substance of the brain. . . These findings reveal for the first time that patients with fibromyalgia have brain gray matter atrophy. Interestingly, the normal age-related decrease in gray matter was accelerated in fibromyalgia patients and related to disease duration.”

Chronic pain, as demonstrated in Fibromyalgia, can cause cognitively impaired

This research was used as reference material in the following studies, in February 2022 a paper in the Journal of the American Geriatrics Society (13). In this study the association between the persistence of pain and its relationship to cognitive problems in older adults such as cognitive performance, cognitive impairment, and subjective memory decline. What the researchers found was “Persistence of pain presence was associated with an increased risk of cognitive impairment. Only persistence of pain interference (chronic, stubborn pain), not pain intensity (severity), was significantly associated with poorer cognitive performance or being classified as cognitively impaired. (In other words no matter the intensity of pain, chronic long-term pain was significantly associated with cognitive impairment.)


Most doctors don’t believe that there is a single cause of fibromyalgia

Most doctors don’t believe that there is a single cause of fibromyalgia. Rather, medicine points to a number of different factors and this is what makes isolating a single diagnose that can be treated with a single protocol impossible and creates the difficulty in offering a treatment program.

Although these are all possible contributors to the condition, we find that the many of people suffering from fibromyalgia experience this pain as a result of ligament weakness from degenerative diseases like osteoarthritis, injury or repetitive use damage.

In compensating for the ligament weakness, other areas of the body, including tendons and muscles, can be afflicted with referred pain. In this case, the fatigue, poor sleeping patterns and tender points associated with this condition are results of the ligament damage rather than causes of the condition.

Fibromyalgia, one terrible condition among many

This is an email we received, it has been edited:

“I have been diagnosed with hEDS, POTS, Dysautonomia, MCAS, fibromyalgia, CFS, IBS, migraines, allergies/food intolerances, exercise intolerance, light/noise/smell/chemical sensitivity, balance/gait problems, neuropathy, neck and left shoulder injuries, multiple motor vehicle accidents . . . I want to get rid of constant neck pain and headaches. I have been referred to the neurologist,surgery the say will not help. Here I am more than a year later still looking for treatments that help.”

Self-stretching for fibromyalgia and myofascial pain syndrome

The illustration shows the upper trapezius muscles.

In an October 2022 study (15) researchers assessed a clinical trial of self-stretching with and without mindful breathing (an eyes closed period before and after the self-stretching while concentrating on deep breathing) and the intervention’s immediate effect on pressure pain and range of motion in myofascial pain syndrome. Stretching poses were performed at least four times repeatedly and held for 150 seconds per each pose.

Results: Both groups (stretching alone and stretching with breathing) showed that the pressure pain threshold (PPT) at upper trapezius muscles significantly increased after performing the stretching. The cervical neck range of motion in the stretching / breathing group significantly increased in extension, left and right lateral flexion, and left rotation. The researchers concluded: “Since this treatment is a non-pharmacological intervention and was considered as part of active self-care, we suggest that this therapy could be used as alternative therapy for patients with myofascial pain syndrome.”

Fibromyalgia and Neck Instability

Fibromyalgia is the name for a condition associated with widespread pain in the body and tenderness in multiple joints, muscles, and other soft tissue. Most doctors don’t believe there is one single cause of fibromyalgia. Therefore many treatment options exist, although most of them are symptom management and not curative treatment.

Research is showing a connection between difficult to treat symptoms of fibromyalgia and neck and whiplash injuries, meaning a  large number of fibromyalgia patients have neck instability and cervical spine injury causing their problem.

In a study from the University of Aberdeen, one hundred and two neck injury patients were examined. Researchers found that 21.6% were later diagnosed with fibromyalgia syndrome. On average the fibromyalgia symptoms occurred just 3.2 months after injury and they were accompanied with poorer quality of life and an increase in physical functioning.4

Confirming this research, another study showed that 326 patients with three months of persistent pain following a whiplash injury found a greater proportion of neck/shoulder tender points .

When this study compared whiplash injury patients to other non-whiplash fibromyalgia patients seeking treatment, they found that the whiplash patients had the same amount of neck and shoulder girdle tender points but less tender points in other parts of the body.

This suggests a localized injury rather than widespread condition ruling out the fibromyalgia diagnosis.5

The role of anxiety and depression – “the behavior of avoiding activity due to pain-induced fear exacerbates the pain and even contributes to its chronicity”

A September 2022 paper in the journal Medicine (9) aimed to determine whether there is a relationship between fibromyalgia and depression, anxiety, anxiety sensitivity, fear-avoidance beliefs, and quality of life in female patients with a diagnosis of fibromyalgia. The researchers wrote: “In fibromyalgia patients, it has been determined that anxiety, depression and perceived pain severity reduce social functionality and quality of life in areas such as mental health, physical function, and emotional role difficulties. It was determined that the functionality and quality of life of patients diagnosed with fibromyalgia decreased in daily life. An important contribution of the study to the literature is that it shows that the behavior of avoiding activity due to pain-induced fear exacerbates the pain and even contributes to its chronicity. These results, which show the effects of anxiety, depression, anxiety sensitivity, and fear-avoidance behavior on the prognosis of the disease in the behavior of avoiding activity due to pain-induced fear exacerbates the pain and even contributes to its chronicity patients, indicate that psychiatric evaluation and treatment in FM patients is an important factor that determines the functionality and quality of life.”

Amitriptyline and Duloxetine

A May 2022 study in the JAMA network open (14), a companion journal to the Journal of the American Medical Association (JAMA) compared Amitriptyline (a depression and nerve pain medication which is also an off-label treatment for fibromyalgia and current US Food and Drug Administration-Approved Treatments for Fibromyalgia:  pregabalin, duloxetine, and milnacipran. A total of 36 studies (11,930 patients) were included.

In this study following doses were compared:

Average patient profile:

Compared with placebo:

The role of chronic opioid therapy in the treatment of Fibromyalgia

A person writes us an email: It has been edited for clarity:

“My goals are to come off of my current medications, eventually, I know this may be a long-term goal. I would like to feel mentally sharper, more like my old self.”

In October 2016, (5) Doctors from the University for Washington published new findings on chronic pain-killer medications and fibromyalgia:

Medications often given to treat fibromyalgia such as NSAIDs and narcotics inhibit the normal inflammatory healing cascade. They prevent healing.

Why fibromyalgia patients stopped taking opioids: side-effects and the opioids was not helping their pain.

A July 2022 paper in the International Association for the Study of Pain’s journal Pain Reports (6) , wrote: “Many consider chronic opioid therapy to be ineffective for fibromyalgia, but empirical (the observable benefit seen in patients) evidence is limited. Among patients identified as initiating chronic opioid therapy, (the researchers) examined whether fibromyalgia was associated with different relationships of opioid use to pain and activity interference outcomes 12 months later. (In other words, what was the opioid usage compared to perceived pain in the fibromyalgia patients? Did fibromyalgia patients need more? Less opioids?)

The researchers examined the medical records of 429 patients diagnosed with fibromyalgia. They looked at the patients pain symptoms and opioid response at baseline, four and 12 months.

It is difficult to tell if exercise is working for fibromyalgia patients.

Woman doing tai chi exercise.

It is difficult to tell if exercise is working for fibromyalgia patients

Intuitively some patients know if exercise is helping because they feel better. Doctors however have a hard time making these feel better results show up in data. This is expressed by Greek doctors and researchers writing in November 2022 in the medical journal Rheumatology international (7)

“For many years, pharmaceutical management of pain was the mainstay of treatment. In the latest decade, conventional low-impact aerobic exercise and complementary and alternative medical (CAM) exercise have become important when structuring a personalized therapeutic plan, since side effects are practically inexistent. Heterogenous (mixed group) studies with different methodological approaches have failed to display a clear clinical effect.”

In this study, the researchers conducted a systematic review with meta-analysis of clinical trials putting emphasis on standardized measurable outcomes (Fibromyalgia Impact Questionnaire, FIQ). The wanted to put numbers with symptom improvement to show complementary and alternative medical (CAM) exercise exercise’s effect.

After analyzing 14 studies, including 886 patients, the researchers demonstrated that complementary and alternative medical (CAM) exercise had a beneficial effect on patients’ Fibromyalgia Impact Questionnaire, FIQ score reports. Dance and Tai chi, had a more profound effect. “However, the risk of bias was overall medium to high and statistical heterogeneity (too mixed to make definitive conclusions) was very high. . . Even though more experimental studies should be done on this subject, CAM exercise seems beneficial for patients with Fibromyalgia.

A November 2022 paper in the journal Rheumatology international (8) tested the effects of different programs of physical exercise on fibromyalgia symptoms.

In reviewing 16 previously published studies on the subject of exercise and fibromyalgia, the researchers noted that exercise showed good evidence for providing reduction in the Fibromyalgia Impact Questionnaire, FIQ score. They suggested that exercise programs lasting 13-24 weeks should be used to reduce pain, and each session should last between 30 and 60 minutes. In addition, the intensity should always be carried out gradually and progressively.

Pain, fear of pain, fibromyalgia and obesity

A September 2022 study published in the Journal of pain research (10) evaluated the role of pain catastrophizing, kinesiophobia (fear of movement), and pain acceptance as mediators of the association between perceived pain severity and physical functioning in individuals with fibromyalgia and obesity.

Conclusion: Pain acceptance, kinesiophobia, and pain catastrophizing should be addressed in rehabilitative intervention to improve physical functioning. Interestingly, the subjective and objective aspects of physical functioning are influenced by different factors. Therefore, interventions for women with fibromyalgia and obesity should focus on factors related to both subjective and performance-based physical functioning.

Hyperbaric oxygen treatment

A March 2021 study in the journal Diving and hyperbaric medicine (11) wrote: “A broad spectrum of conditions including neuropathic pain, complex regional pain syndrome (CRPS) and fibromyalgia, have been implicated as causes of chronic pain. There is a need for new and effective treatments that patients can tolerate without significant adverse effects. One potential intervention is hyperbaric oxygen treatment (HBOT).” In a case report of a patients with complex regional pain syndrome (CRPS) was shown successful as a treatment.

Prolotherapy for Fibromyalgia Pain

The most common reason for chronic pain is joint instability caused by chronic ligament laxity. The second most common reason is chronic insomnia. Other causes of diffuse chronic body pain are multiple chemical sensitivities, hypoglycemia, hypothyroidism, hypoadrenocortisolism, viral infection, yeast infection, increased gut permeability, nutrient deficiency, and poor tissue oxygenation. To cure fibromyalgic-type complaints, these conditions must be evaluated and treated. For this reason, it is recommended that the person suffering from diffuse body pain see a Natural Medicine physician. Prolotherapy is an effective treatment for people suffering from diffuse body pain when tenderness is elicited over muscle, ligament, and tendon attachments to the bone.

Prolotherapy is not an isolated treatment. The physician must investigate all possible factors which may be involved with a person experiencing diffuse body pain.

Car accidents and fibromyalgia

One study showed a relationship between car accidents and chronic widespread pain, that is pain that occurs at various points throughout the body.(10) Of the 2,069 patients questioned, 11.6% of them (241) reported cases of chronic widespread pain following a car accident. Researchers stated that, “persons exposed to an RTA [road traffic accident], but not those exposed to other traumatic events, experienced an increase in the likelihood of CWP [chronic widespread pain] onset. . . .We have demonstrated that persons with new-onset CWP are 34% more likely to report a prior, recent, and traumatic event than individuals who remain without CWP.”(11)

This is of interest because many car accidents cause some sort of trauma, namely whiplash, that potentially leads to a ligament injury. Ligament injury is a source of many chronic pain conditions and therefore is best treated with Prolotherapy to strengthen the injured ligament and alleviate pain.

Prolotherapy for treatment for fibromyalgia related to whiplash injury

Seeing that most tender points following whiplash tend to be located in the neck and shoulder girdle indicate cervical instability caused from the trauma of the whiplash.

The most effective treatment for cervical instability, or any joint instability, is Prolotherapy. Prolotherapy is an injection technique that stimulates a mild inflammation in the injured area. This inflammation mimics the body’s natural healing process.

While the diagnosis may be controversial, the pain is real and patients suffering from symptoms of whiplash injury are looking for a cure. Prolotherapy could be the cure for many of these patients.


As we read this study we thought of the many people who just live with their pain. The thought that not dealing with pain doesn’t cause any harm is simply wrong. Not only should you seek help for your pain so that you can live life, you should also seek a cure for your pain to prevent serious health risks. A Prolotherapist’s approach to fibromyalgia involves a multi-layered approach depending on the individual patient. Prolotherapy is almost always part of the treatment as it addresses the underlying ligament laxity behind chronic joint pain. Some Prolotherapy offices have the capability to address hormone levels, diet for fibromyalgia and sleep problems. Resigning to live with your pain clearly has undesirable long-term effects. Chronic use of pain medications also has undesirable long-term effects. A better option is to consider an experienced Prolotherapist who can address the whole patient and underlying causes of fibromyalgia.

Fibromyalgia and myofascial pain syndrome may be diagnosed in the same patient due to their overlapping and vague descriptions, both involving pain throughout specific tender areas or trigger points that cause both local and referred pain. Digging a little deeper into a patient’s health can help the clinician and the patient understand if the pain is due to issues that can be helped with Natural Medicine, such as food sensitivities, low hormones, poor sleep, and/or infections, among others. On the other hand, the physical exam may demonstrate undiagnosed joint instability in the areas exhibiting tender muscles and trigger points. The latter cases have good success with Prolotherapy as a standalone treatment. Oftentimes, a combined approach is necessary to help the patient fully recover. As the joints repair, the muscles can relax and the pain is alleviated. With the pain-relief, sleep is improved and the vicious cycle is stopped.



1 Mengshoel AM. A long, winding trajectory of suffering with no definite start and uncertain future prospects–narratives of individuals recently diagnosed with fibromyalgia. International Journal of Qualitative Studies on Health and Well-being. 2022 Dec 31;17(1):2056956.
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This article was updated January 13, 2023



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