Fibromyalgia

In fibromyalgia the nervous system amplifies pain signals. Widespread pain, unrefreshing sleep, fatigue and difficulty concentrating occur together. Tissue examination and scans are typically normal, and this is frequently misread as meaning nothing is wrong.

Something is wrong. The problem is in how pain is processed rather than in the tissue being examined, and treatment is directed at that.

The common pattern is boom and bust: a good day leads to doing too much, which produces several bad days, which produces avoidance, which reduces capacity further. Over months this shrinks what the person can do considerably more than the pain itself does.

Graded activity breaks the cycle. Activity is set at a level that can be sustained on a bad day and increased slowly, deliberately below the level that provokes a flare. It is counter-intuitive and it is what the evidence supports.

Graded aerobic and strengthening exercise, pacing training, sleep management, and education about pain mechanisms — which is a genuine intervention in this condition rather than an add-on. Hydrotherapy is often the easiest place to start because warm water reduces the initial pain barrier.

The outcome we track is function and activity tolerance rather than pain score alone, because pain score alone improves last and would understate the change.

Fibromyalgia is diagnosed clinically, from widespread pain lasting more than three months together with fatigue, unrefreshing sleep and cognitive difficulty 2. There is no blood test or scan that confirms it.

What tests do is exclude conditions that can look similar — inflammatory arthritis, thyroid disease, vitamin D deficiency, sleep apnoea. Getting this right matters, because a missed inflammatory arthritis treated as fibromyalgia loses time that cannot be recovered, and the reverse produces years of unnecessary investigation.

Unrefreshing sleep both results from and drives the pain, and in most people it is the leverage point. Addressing it — sleep timing, screens, caffeine, untreated apnoea where present — often produces more change than anything aimed directly at pain.

This is why the assessment asks about sleep in detail rather than in passing, and why a programme that ignores it tends to stall.

The common pattern is boom and bust: a good day is used to catch up on everything, which produces several bad days, which produces guilt and then another overdone good day. Pacing breaks that cycle by setting activity at a level that can be sustained on a bad day and increased slowly.

Graded aerobic and strength work is the best-supported intervention, and it must start below what feels achievable. Starting at the level that seems reasonable is the single most common reason people conclude exercise makes them worse.

We do not describe fibromyalgia as curable, and we do not offer treatments marketed as resetting or rebalancing the nervous system. The evidence supports graded exercise, sleep work, pacing and psychological approaches to pain — not the more elaborate claims made around this condition.

What a good programme delivers is a meaningful reduction in symptom burden and a return of function and predictability. That is worth having and it is what we measure.