Fibromyalgia – Understanding the Pain, Regaining Control

A Research-Based Clinical Guide: Mechanisms, Diagnosis, Treatment, and Daily Management

 

Fibromyalgia is a chronic pain syndrome that combines widespread pain with fatigue, non-restorative sleep, cognitive impairment ("fibro-fog"), and additional somatic symptoms. Contrary to outdated myths, it is a real and recognized medical condition with well-explained neurobiological mechanisms.

 

The good news: through correct diagnosis, Pain Education, precise manual therapy, graded exercise, and load management—it is possible to significantly reduce pain and improve quality of life.

 

What is Fibromyalgia?

Fibromyalgia is characterized by Widespread Pain (WPI) lasting over three months. It often involves a "brain fog"—decreased concentration and memory. While more common in women, it affects men and adolescents as well.

Key Distinction: Fibromyalgia is not an "inflammation of the muscles." It is a disorder of pain regulation within the nervous system. Blood tests and imaging are typically normal; the diagnosis is clinical, based on defined criteria.

 

Pain Mechanisms: Central Sensitization and Nociplastic Pain

The pathophysiological core of Fibromyalgia is Central Sensitization—a state where the Central Nervous System (CNS) is "tuned too high." Sensory signals are processed as more threatening, the stimulus threshold is lowered, and non-painful stimuli are experienced as painful (Allodynia).

This is categorized as Nociplastic Pain—pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage.

  • Background Factors: Genetics, previous infections, physical or emotional trauma, and chronic stress.
  • Neurochemical Mediators: Alterations in the balance of Descending Inhibition (serotonin/norepinephrine) and dopamine.
  • The Kinetic Chain: Compensatory movement patterns and increased muscle tone maintain the painful experience.

 

Diagnosis and Comorbidities

Diagnosis is based on the updated ACR criteria (2016), involving the Widespread Pain Index (WPI) and the Symptom Severity Scale (SSS). It is crucial to rule out "mimics" such as hypothyroidism, inflammatory diseases, or major nutritional deficiencies.

Common Comorbidities:

  • Chronic Fatigue Syndrome (CFS)
  • Irritable Bowel Syndrome (IBS)
  • Migraines and TMD (Jaw pain)
  • Anxiety and Depression

 

The Pain Cycle: How It Feels

The pain is often "migratory" and fluctuates daily. Non-restorative sleep leads to fatigue, which lowers load tolerance. This creates a Pain Cycle:

Pain → Decreased Activity → Deconditioning → Increased Fatigue → Avoidance. Breaking this cycle is the primary goal of rehabilitation by gradually increasing the body's Capacity.

 

Treatment Principles: Multidisciplinary and Graded

There is no "magic pill." Success lies in a tailored intervention mix:

Pain Education: Understanding central sensitization reduces fear and restores a sense of agency.

Graded Exercise Therapy (GET): Low-impact aerobic activity + gentle strengthening.

Manual Therapy (STB): To reduce local hypertonicity, improve movement flow, and restore trust in the body.

CBT/Mindfulness: Tools for stress regulation and sleep hygiene.

The Role of Precise Manual Therapy

Manual therapy in Fibromyalgia focuses on reducing the "peripheral input" (noise) sent to the brain. In the STB (Soft Tissue Balance) approach, we map the compensatory patterns along the kinetic chain.

  • Fascial/Trigger Point Release: To lower protective guarding.
  • Joint Mobilizations: To improve fluid movement.
  • The Advantage: Provides a "therapeutic window" of reduced pain, allowing the patient to begin active exercise with more confidence.

 

Graded Exercise – Doing it Right

Exercise is one of the most effective interventions, provided it is consistent and paced:

Activity TypeRecommendationProgression

AerobicWalking/Swimming 10–20 min, 3–5x weekIncrease 10% every 1–2 weeks

Strengthening2–3x week, large muscle groups, low weightFocus on quality over load

Mobility/Yoga10–15 min daily, synchronized breathingFocus on reducing systemic tone

The Golden Rule: "Walk on the edge" without crossing it. If pain flares significantly 24 hours later, take a half-step back but remain consistent.

 

Managing Flares ("Flares")

Flares happen—even with a good plan. It doesn't mean the progress is lost.

  • Step back: Reduce load by 20–40% for 3–7 days; keep moving gently.
  • Regulate: Use diaphragmatic breathing and warmth.
  • Gentle Touch: Use light STB techniques to signal safety to the nervous system.

 

6-8 Week Action Plan

  • Weeks 1–2: Pain Education, daily breathing, 10 min walking, 1–2 STB sessions.
  • Weeks 3–4: 15–20 min aerobic, gentle strengthening 2x week, sleep hygiene focus.
  • Weeks 5–6: Increase volume by 10%, dynamic posture drills, graded exposure to "scary" movements.

  • Weeks 7–8: Consolidation, independence in exercise, and long-term maintenance.

By: Giveon Peled

Founder of the STB Method and

Pain Management Specialist

Do you want to learn how to diagnose, map compensations, and treat chronic pain (including Fibromyalgia) using a precise, evidence-based approach?

Join the STB Manual Therapy Course
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Recommended Research and Literature

Clauw DJ. Fibromyalgia: A Clinical Review. JAMA, 2014.

Wolfe F, et al. 2010/2016 ACR Diagnostic Criteria for Fibromyalgia. Arthritis Care & Research.

Macfarlane GJ, et al. EULAR recommendations for fibromyalgia management. Ann Rheum Dis.

Busch AJ, et al. Exercise for treating fibromyalgia. Cochrane Review.

Bernardy K, et al. Cognitive-behavioural therapies for fibromyalgia. Cochrane Review.

Fitzcharles M-A, et al. Pharmacological management of fibromyalgia. Drugs.