Fibromyalgia: more than just a musculoskeletal disease. (includes patient information sheet) Daniel J. Clauw Author's Abstract: COPYRIGHT American Academy of Family Physicians 1995 Fibromyalgia is a common condition characterized by diffuse musculoskeletal pain and fatigue. The syndrome is defined by the presence of musculoskeletal tender points on physical examination. Additionally, persons with this syndrome have a high incidence of headaches, ocular and vestibular complaints, paresthesias, esophageal dysmotility, "allergic" symptoms, irritable bowel syndrome, genitourinary symptoms and affective disorders. Recent research has revealed a number of objective biochemical, hormonal and neurotransmitter abnormalities associated with fibromyalgia, making it a clearly identifiable condition. These abnormalities may clarify our understanding of the pathogenesis and treatment of fibromyalgia. Full Text COPYRIGHT American Academy of Family Physicians 1995 Fibromyalgia is a common musculoskeletal syndrome characterized by generalized pain, fatigue and a variety of associated symptoms. Although the term "fibromyalgia" was not introduced until 1976, this symptom complex was described as muscular rheumatism, fibrositis, fibromyositis and psychogenic rheumatism as early as the 17th century.(1) Further complicating the diagnosis of fibromyalgia is the considerable overlap with conditions such as myofascial pain syndrome and chronic fatigue syndrome,(2) since some persons meet criteria for more than one of these diagnoses. The confusion surrounding the diagnosis of fibromyalgia was reduced considerably by a multicenter study sponsored by the American College of Rheumatology (ACR) that developed criteria for the diagnosis of fibromyalgia. These criteria, generally referred to as the 1990 ACR criteria,(3) are listed in Table 1. These criteria are particularly useful for the standardization of patient groups in studies examining the epidemiology or pathogenesis of fibromyalgia but, as with most diagnostic criteria, they should not be too rigidly applied when making a diagnosis. TABLE 1 1990 American College of Rheumatology Diagnostic Criteria for Fibromyalgia 1. History of widespread pain of at least 3 months' duration Pain must be present in the axial skeleton as well as all four quadrants of the body 2. Pain in at least 11 of 18 of the following paired tender points on digital palpation (approximately 4 kg of pressure should be applied with digit, and the patient must state that the palpation was painful): Occiput: at the suboccipital muscle insertions Cervical: at the anterior aspects of the intertransverse spaces at C5-C7 Trapezius: at the midpoint of the upper border Supraspinatus: at origins above the scapular spine near the medial border Second rib: at the second costochondral junctions Lateral epicondyle: 2 cm distal to epicondyles Gluteal: in upper outer quadrants of buttocks in anterior fold of muscle Greater trochanter: posterior to trochanteric prominences Knees: at the medial fat pad proximal to joint line Adapted from Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990; 33:160-72. Used with permission. Epidemiology Several breakthroughs in our understanding of fibromyalgia have been made in the past few years. Recent studies have examined the prevalence of fibromyalgia in the general population. All of these studies used the 1990 ACR criteria for diagnosis but used disparate methods for subject selection, and all reached similar conclusions.(4)(5)(6)(7) The data suggest that at a given point in time, 3 to 6 percent of the population (including children) meet criteria for this diagnosis. Since the ACR criteria indicate that pain must be present in all four quadrants of the body and that 11 of 18 tender points must be found at the time of examination, this figure probably represents a conservative estimate of the prevalence of fibromyalgia in the population. These studies also demonstrated that women are more likely to have fibromyalgia than men. However, studies show that at any given age women have a lower pain threshold than men, even if those with fibromyalgia are excluded from analysis.(4)(5) The other primary determinant of tenderness is age. Tenderness increases linearly with ages in both men and women.(4)(5) Persons with fibromyalgia who are identified through epidemiologic studies are older (mean age: 55 to 60 years) and generally have fewer concurrent symptoms (irritable bowel syndrome, sleep disturbance, affective disorders) than those who seek medical attention.(4)(8)(9) Clinical Features PAIN AND TENDER POINTS Widespread pain and tenderness are the cardinal features of fibromyalgia. Although to meet the 1990 ACR criteria pain must be present in all four quadrants of the body, many persons with unilateral pain or pain that only affects the upper or lower half of the body clearly have fibromyalgia. The pain in fibromyalgia tends to be migratory and to wax and wane. Stiffness in the morning or after remaining in one position for a prolonged period is common, and patients will frequently note that the pain is worsened by weather changes, physical activity, stress or menses. Although patients often report swelling in the regions of pain (a common report is that rings no longer fit), no objective evidence of swelling or synovitis is apparent on examination. A tender point is defined as an anatomic site where pain is elicited when 4 kg (approximately 9 lb) of pressure is applied (Figure 1). Although the presence of tender points on physical examination is the hallmark of fibromyalgia, it is not the entire clinical presentation (Figure 2). Several studies have suggested that persons with fibromyalgia are more sensitive to pain throughout the body, not simply in areas recognized as tender points.(10) In fact, visceral as well as peripheral pain sensitivity may be increased in fibromyalgia, as has been noted in related conditions such as irritable bowel syndrome.(11)(12) Also, it is normal to have some tenderness in these anatomic regions of the body, with a mean of 3.7 "positive" tender points in persons reporting no pain.(5) Finally, nociception is probably influenced by a number of factors besides the patient's age and sex, with aerobic fitness, poor sleep and depression probably having significant effects.(5)(13) Since so many variables influence nociception, diagnostic criteria that use tenderness as the principal determinant have limited specificity and sensitivity. FATIGUE Most patients with fibromyalgia complain of fatigue, but this symptom is not universal and is not required for diagnosis. In some persons, fatigue may be severe and debilitating, but in others it is either not present or it has been accepted because of its chronic nature. A careful sleep history should be obtained in patients who are suspected of having fibromyalgia, especially men, since some data suggest that a significant number of men with fibromyalgia may have underlying sleep apnea.(14) Early work by Moldofsky and colleagues(15) indicated that the fatigue associated with fibromyalgia, as well some of the other clinical symptoms, was thought to be due to a disruption of deep sleep. However, many persons with this condition have normal sleep patterns, and the sleep anomalies seen in some patients with fibromyalgia are also seen in some persons without fibromyalgia as well as in patients with other conditions.(16) In addition, only a small percentage of persons with primary sleep disorders (e.g., sleep apnea) have fibromyalgia, and improvement in fibromyalgia symptoms with pharmacologic treatment does not correlate with improvement in sleep.(17)(18) At present, the role of sleep disturbances in the pathogenesis of fibromyalgia is unclear. NEUROLOGIC SYMPTOMS Patients with fibromyalgia have a higher incidence of both tension and migraine headaches than normal persons. A number of other neurologic symptoms in this group of patients, however, are not as well recognized. Numbness or tingling is common and may occur anywhere in the body; it is typically fleeting in nature and does not follow a dermatomal distribution. In one series, 84 percent of persons with fibromyalgia complained of these paresthesias.(19) Hearing, ocular and vestibular abnormalities have also been noted, including a lowered tolerance for painful sound, exaggerated nystagmus and ocular dysmotility, and asymptomatic low-frequency sensorineural hearing loss.(20)(21) Cognitive complaints, especially difficulty with concentration and short-term memory, are also common. Results of standard neurologic examinations, nerve conduction tests and imaging studies are normal in these persons, but results of more subtle testing (including evoked responses and functional assessment) may be abnormal. Because of the variety of neurologic symptoms seen in patients with fibromyalgia, once a person is diagnosed it is prudent to use neurodiagnostic tests only when objective abnormalities are apparent on physical examination. "ALLERGIC" SYMPTOMS Patients with fibromyalgia display a wide array of "allergic" symptoms. These symptoms range from adverse reactions to drugs and environmental stimuli (many patients meet criteria for "multiple chemical hypersensitivity syndrome") to a higher-than-expected incidence of rhinitis, nasal congestion and lower respiratory symptoms.(22) It is unlikely that all of these symptoms have a true allergic basis; instead, these symptoms may be the result of the central nervous system activation seen in fibromyalgia. CARDIAC, PULMONARY AND GASTROINTESTINAL SYMPTOMS For many years it has been believed that patients with fibromyalgia have a number of symptoms of "functional" disorders of visceral organs, including a high incidence of recurrent noncardiac chest pain, heartburn, heart palpitations and irritable bowel syndrome. However, prospective studies of randomly selected patients with fibromyalgia have detected evidence of objective abnormalities of visceral organs, including a 75 percent incidence of echocardiographic evidence of mitral valve prolapse, a 40 to 70 percent incidence of esophageal dysmotility, and diminished static inspiratory and expiratory pressures on pulmonary function testing.(12)(23)(24) These studies suggest that the symptoms have a physiologic mechanism that is likely to be centrally mediated. GENITOURINARY SYMPTOMS Patients with fibromyalgia have a higher incidence of dysmenorrhea, urinary frequency and urgency than normal persons.(25) Fibromyalgia may also be associated with other genitourinary conditions such as interstitial cystitis, vulvar vestibulitis or vulvodynia (which are characterized by dyspareunia and sensitivity of the vulvar region).(26)(27) AFFECTIVE DISORDERS Patients with fibromyalgia have a higher incidence of psychiatric disorders, including current and lifetime major depression (20 percent and 50 percent, respectively). Considerable controversy surrounds the relationship between these psychiatric conditions and the concurrent physical symptoms. Some believe that fibromyalgia is primarily a psychiatric condition and that the related symptoms are the result of somatization, whereas others believe that psychiatric problems largely occur as a consequence of the chronic pain, fatigue and disability that these patients have. This debate becomes less relevant if the psychiatric disturbances are considered in the same light as physical symptoms in that there is a common neurotransmitter or hormonal imbalance responsible, and thus both occur in increased frequency in patients with fibromyalgia. Diagnosis Fibromyalgia can occur either in an isolated form (formerly termed "primary" fibromyalgia) or in association with other diseases (formerly termed "secondary" fibromyalgia). Table 2 lists conditions that may mimic fibromyalgia or that may occur in association with the syndrome. In many cases a triggering event can be identified, such as physical or emotional trauma or infection. Even in cases in which the full-blown syndrome develops after a triggering event, a premorbid history frequently suggests a high lifetime incidence of related conditions. This fact, in addition to studies suggesting familial aggregation of fibromyalgia and associated syndromes,(28) suggests that there may be a genetic tendency toward the development of this disorder, which may express itself following an inciting event either in childhood or later. TABLE 2 Conditions Simulating or Associated with Fibromyalgia Rheumatic Early rheumatoid arthritis(*) Polymyalgia rheumatica(*) Systemic lupus erythematosus Sjogren's syndrome Polymyositis/dermatomyositis Scleroderma Endocrine/metabolic Hypothyroidism(*) Hyperparathyroidism Hypoparathyroidism Hypercalcemia Alcoholic or metabolic myopathy Hypokalemia Osteomalacia Paget's disease Neoplastic Carcinomatosis Multiple myeloma Lymphoma Infectious Human immunodeficiency virus infection Viral hepatitis Parasitic infections Subacute bacterial endocarditis (*)--This disorder should always be excluded because of similarity of clinical features. The conditions listed in Table 2 should be considered in the differential diagnosis when a patient presents with symptoms suggestive of fibromyalgia. In general, a supportive history and a physical examination that is normal except for the presence of tender points are strongly suggestive of the diagnosis. Initial screening laboratory tests should include a complete blood count with differential, a chemistry and thyroid panel, and an erythrocyte sedimentation rate. Further testing (tests for antinuclear antibody and rheumatoid factor, or imaging studies such as magnetic resonance imaging [MRI]) should be avoided initially unless specifically indicated, not only because of the associated expense but because these tests are associated with false-positive results. It must be emphasized that it is common for fibromyalgia to coexist with other disorders. However, caution is urged before attributing the patient's symptoms to another coexisting disorder. For example, even if a patient is found to have abnormalities on skeletal MRI or plain radiographs, or if evidence of an inflammatory disorder (systemic lupus erythematosus, rheumatoid arthritis, Lyme disease) is found, fibromyalgia may be responsible for the majority of the symptoms. Pathophysiology Although the pathogenesis of fibromyalgia remains elusive, a review of the current knowledge may facilitate a better understanding of this disorder. Table 3 outlines the most pertinent neurotransmitter, hormonal and biochemical abnormalities in fibromyalgia. Insulin-like growth factor I (IGF I/somatomedin C) is a hormone produced in the liver, primarily in response to growth hormone. Most patients with fibromyalgia have low serum levels of IGF I, and this test has good specificity and sensitivity in detecting fibromyalgia.(29) TABLE 3 Hormonal, Neurotransmitter and Biochemical Abnormalities in Fibromyalgia Test Abnormality Sensitivity Specificity Serum insulin-like growth factor I Low High Moderate Cerebrospinal fluid substance P High High ? Serum serotonin Low Moderate Low Serum tryptophan Low Moderate Low Tissue magnesium Low High ? Hypothalamic-pituitary-adrenal axis Deranged Low Low Substance P is a neuropeptide stored in the secretory granules of sensory nerves and is released by axonal stimulation. Cerebrospinal fluid levels of substance P are quite high in patients with fibromyalgia, with little overlap between the levels seen in these patients and levels seen in normal control subjects. Serum levels of serotonin and its precursor, tryptophan, are low in persons with fibromyalgia.(30)(31) The hypothesis that low levels of serotonin may be responsible for fibromyalgia is intriguing because many of the associated conditions, including affective disorders, migraine headaches and irritable bowel syndrome, are known or thought to be due to low levels of serotonin. Low tissue levels of magnesium in fibromyalgia (despite normal serum levels) have been demonstrated,(32) and the efficacy of magnesium repletion is currently being tested. Abnormalities of the hypothalamic-pituitary-adrenal axis are seen in fibromyalgia and are likely responsible for the low IGF I noted, but these abnormalities are also seen in a number of other disorders, making the significance of this finding uncertain.(33) The data suggest that objective hormonal, biochemical and neurotransmitter abnormalities can be identified in patients with fibromyalgia. Which of these abnormalities are causal and which are "epiphenomena" is not clear at present. Although these tests should not be used for screening purposes, many of them compare favorably with commonly ordered tests such as rheumatoid factor, which has a sensitivity of 80 percent and a comparable specificity for the diagnosis of rheumatoid arthritis. Management Without an effective management plan, care for patients with fibromyalgia can be frustrating and time-consuming. With an effective management plan, clinicians can have a considerable positive impact on patients with fibromyalgia. EDUCATION At initial diagnosis the physician and patient must discuss the symptoms of fibromyalgia in depth. The physician should explain to the patient that death or organ or tissue damage will not occur as a result of this condition, but that there is no known cure and that the condition is likely to be chronic with a fluctuating course. Patients should be encouraged to take an active role in management of their condition. A passive approach by the patient is rarely successful in this disorder. A number of excellent pamphlets are available for patient education, including one from the Arthritis Foundation, 1314 Spring St. NW, Atlanta, GA 30309, or call 404-872-7100. BEHAVIOR MODIFICATION Some simple suggestions may make a tremendous difference for patients with fibromyalgia. The physician should emphasize the importance of sleep. Some patients chronically attempt to subsist on less sleep than their body requires, and pointing this out can be helpful. Patients should be informed that consumption of caffeinated or alcoholic beverages near bedtime may aggravate fibromyalgia because deep sleep is impaired. Emotional stress should be minimized. More formal behavioral modification such as pain programs may also be helpful, especially programs focusing on time-based pacing skills (many patients will do so much on a "good" day that they hurt for several days thereafter), scheduling pleasant activities that can act as distractors from chronic pain, or cognitive therapy to decrease victimization or "learned-helplessness" behavior. PHARMACOLOGIC THERAPY Drugs for the treatment of fibromyalgia that have been studied most are low nighttime doses of the tricyclic compounds amitriptyline (Elavil, Endep) and cyclobenzaprine (Flexeril). Although it is sometimes helpful to explain to patients that the clinical benefit from these drugs occurs as a result of improved deep sleep, this is not likely the reason that they are effective, since improvement in sleep status with these medications does not correlate with clinical improvement. With either of these medications, the starting dose should be 10 mg one to two hours before bedtime (or in patients who have had adverse reactions to many medications, perhaps half of a 10-mg tablet). This dose should be continued for at least one week before it is increased by 10 mg. The physician should explain that the first several nights that this medication is taken, or whenever the dose is increased, the patient is likely to have vivid dreams or nightmares, will need more than the usual amount of sleep and may feel "hungover" the following day (it is sometimes useful to suggest that medication be initiated on a Friday evening for this reason). It should also be explained that the improvement as a result of these medications may not occur for four to six weeks. Titration to the optimal dose is difficult. It is sometimes useful to use the sleep cycle to make this determination, with the goal being to identify the dose of either medication that is necessary to keep the patient sleeping soundly throughout the night but not "hungover." This dose may be increased up to a maximum of 70 to 80 mg of amitriptyline or up to 40 mg of cyclobenzaprine. Anticholinergic side effects occur with either of these medications and, if one medication is not well tolerated, the patient may respond to the other. Nonsteroidal anti-inflammatory drugs may be useful in this condition. However, if an empiric trial of a few drugs from this class is ineffective, then they probably should be discontinued. The selective serotonin reuptake inhibitors fluoxetine (Prozac), sertraline (Zoloft) and paroxetine (Paxil), as well as venlafaxine (Effexor), may also be of benefit in selected patients. It is possible that patients with concurrent depression may respond best to this class of drugs. Also, in patients who cannot tolerate therapeutic doses of a tricyclic compound, occasionally the addition of a selective serotonin reuptake inhibitor in a low dose may be of benefit. Benzodiazepines and narcotics should be avoided if possible in patients with fibromyalgia, not only because of the associated addictive potential but also because of the detrimental effect on deep sleep. If a hypnotic agent must be used, zolpidem (Ambien) may be a reasonable choice since it does not appear to impair deep sleep. EXERCISE It is helpful to explain that exercise is vital to improvement of symptoms of fibromyalgia, since it is rare for patients to have a lasting improvement unless they become involved in an aggressive program of low-impact aerobic and stretching exercises. Although exercise can be done with the help of a physical therapist, psychologically it may be useful to avoid using a therapist and encourage independence. Lowimpact aerobic exercises such as water exercise classes, stationary bicycling, rowing machines or cross-country skiing machines can be used. The patient should be instructed to begin at the level of exercise that results in mild tenderness on the following day, but no more. This level should be slowly and gradually increased, and the patient should be instructed that it may take several months until a benefit is seen. OTHER MODALITIES Injections of tender points with a topical anesthetic, either alone or in combination with corticosteroids, may be of benefit, especially when one region is particularly bothersome. Biofeedback, acupuncture, massage therapy and spinal manipulation may all be of benefit in selected patients. Final Comment Fibromyalgia is a common condition. Although the syndrome is defined by its musculoskeletal features, virtually any area of the body may be affected. If the conventional paradigm for the clinical expression of fibromyalgia is represented in Figure 1, Figure 2 represents a new paradigm. This disease causes decreased pain tolerance throughout the body, rather than only at tender points, and patients with fibromyalgia display a higher incidence of a number of other symptoms and syndromes than normal persons. Most of these allied conditions are characterized by dysmotility or abnormal tone in skeletal or smooth muscle and by increased peripheral or visceral nociception. A number of objective biochemical, hormonal and other abnormalities have been identified in patients with fibromyalgia, and it is likely that this syndrome and associated conditions, including affective disorders, have common centrally mediated causes. Although this condition has no cure, prompt recognition and proper management often lead to substantial symptomatic improvement. A patient information handout on fibromyalgia is provided on page 853. 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(25.)Wallace DJ. Genitourinary manifestations of fibrositis: an increased association with the female urethral syndrome. J Rheumatol 1990; 17:238-9. (26.)Koziol JA, Clark DC, Gittes RF, Tan EM. The natural history of interstitial cystitis: a survey of 374 patients. J Urology 1993; 149:465-9. (27.)Friedrich EG Jr. Vulvar vestibulitis syndrome. J Reprod Med 1987; 32:110-4. (28.)Stormorken H, Brosstad F. Fibromyalgia: family clustering and sensory urgency with early onset indicate genetic predisposition and thus a "true" disease [Letter]. Scand J Rheumatol 1992; 21:207 [Published erratum appears in Scand J Rheumatol 1992; 21:264!. (29.)Bennett RM, Clark SR, Campbell SM, Burckhardt CS. Low levels of somatomedin C in patients with the fibromyalgia syndrome. A possible link between sleep and muscle pain. Arthritis Rheum 1992; 35:1113-6. (30.)Yunus MB, Dailey JW, Aldag JC, Masi AT, Jobe PC. Plasma tryptophan and other amino acids in primary fibromyalgia: a controlled study. J Rheumatol 1992; 19:90-4. (31.)Russell IJ, Michalek JE, Vipraio GA, Fletcher EM, Javors MA, Bowden CA. Platelet 3H-imipramine uptake receptor density and serum serotonin levels in patients with fibromyalgia/fibrositis syndrome. J Rheumatol 1992; 19:104-9. (32.)Clauw D, Blank CA, Hewett-Meulman J, Katz P. Low tissue levels of magnesium in fibromyalgia [Abstract]. Arthritis Rheum 1993; 36(Suppl):161. (33.)Griep EN, Boersma JW, de Kloet ER. Altered reactivity of the hypothalamic-pituitary-adrenal axis in the primary fibromyalgia syndrome. J Rheumatol 1993; 20:469-74. RELATED ARTICLE: Fibromyalgia: What It Is and How to Manage It What is fibromyalgia? Fibromyalgia is a common condition that causes pain in the muscles, joints, ligaments and tendons. The pain occurs in certain parts of the body, and these painful areas are called tender points. The drawing below shows areas where tender points are common. Fibromyalgia affects 2% to 6% of the population, including children. This disorder might be hereditary, so you may have family members with similar symptoms. How can my doctor tell that I have fibromyalgia? Increased sensitivity to pain is the main symptom of fibromyalgia. Many other symptoms also occur in patients with this disorder. Symptoms may come and go. You may have some degree of constant pain, but the severity of pain may vary in response to activity, stress, weather changes and other factors. You may have a deep ache or a burning pain. You may have muscle tightening or spasms. Many patients have migratory pain (pain that moves around the body). Most people with fibromyalgia feel tired or out of energy. This fatigue may be mild or very severe. You may also have trouble sleeping, and this may add to the fatigue. You may have feelings of numbness or tingling in parts of your body, or a sensation of poor blood flow in some areas. Many patients are very sensitive to odors, bright lights, loud noises and even medicines. Headaches and jaw pain are also common. In addition, you may have dry eyes or difficulty focusing on nearby objects. Problems with dizziness and balance may also occur. Some patients have chest pain, heart palpitations or shortness of breath. Digestive symptoms are also common in fibromyalgia and include difficulty swallowing, heartburn, gas, cramping abdominal pain, and alternating diarrhea and constipation. Some patients have urinary complaints, including frequent urination, a strong urge to urinate and pain in the bladder area. Women with fibromyalgia often have pelvic symptoms, including pelvic pain, painful menstrual periods and painful sexual intercourse. Depression or anxiety may occur as a result of the chronic pain and fatigue, or the frustration you feel with the condition. It is also possible that the same chemical imbalances in the brain that are responsible for fibromyalgia might also cause depression and anxiety. Although fibromyalgia causes symptoms that can be very uncomfortable, your muscles and organs are not being damaged. This condition is not life-threatening, but it is chronic, or ongoing. There is no cure, but you can do many things to help you feel better. Is there any medicine I can take to help my symptoms? Several medicines can help relieve symptoms of fibromyalgia. Many of these medicines (such as amitriptyline [Elavil, Endep] or cyclobenzaprine [Flexeril]) are taken before bedtime and improve your sleep. They also help the pain and other symptoms. When you begin taking these medicines, it is common to feel very groggy the following morning. Other possible side effects include dry eyes and mouth, nightmares, constipation and increased appetite. These side effects are worse when you first begin taking the medicine and improve with time. You will probably begin to notice the benefits of these medicines in about six to eight weeks. What else can I do to relieve my symptoms? One of the most effective treatments for fibromyalgia is low-impact aerobic exercise. Examples of this type of exercise include swimming or water exercise, stationary bicycling and exercising on ski-type machines. You may need to begin at a very low level of exercise (five minutes every other day is helpful at first). Continue to increase the length and frequency of exercise until you are exercising at least 20 to 30 minutes on at least four occasions per week. Once you reach this point, you can consider switching to high-impact exercises, like walking, jogging and tennis. The symptoms of fibromyalgia are made worse by stress and poor sleep. It is important to cut stress out of your life whenever possible and to get as much sleep as your body needs. Since alcohol and caffeine cause poor sleep quality, try to avoid these substances near bedtime. Other simple lifestyle changes may be helpful. Many people with fibromyalgia try to do as much as possible on "good" days, which leads them to have several "bad" days. If you keep your activity level even, you may not have as many bad days. In many cities, there are fibromyalgia patient groups that can provide both information and support. The Arthritis Foundation also has some information you may be interested in reading. In addition, a national fibromyalgia support group publishes a newsletter on this disorder. For more information, contact the Fibromyalgia Network Newsletter, P.O. Box 31750, Tucson, AZ 85751, or call 602-290-5508. This information provides a general overview on fibromyalgia and may not apply to everyone. Talk to your family doctor to find out if this information applies to you and to get more information on this subject.