COMMENTARY
Fibromyalgia and Chronic Fatigue Syndrome
Arya B. Mohabbat, MD; Nikita Maria L. Mohabbat, PT, DPT; and Elizabeth C. Wight, MD
From the Division of General
Internal Medicine (A.B.M.,
E.C.W.) and Department of
Physical Medicine and Reha-
bilitation (N.M.L.M.), Mayo
Clinic, Rochester, MN.
764
www.mcpiqojournal.org
in the Age of COVID-19
S
evere acute respiratory syndrome coro-
navirus 2 (SARS-CoV-2) infection,
which leads to the condition known
as coronavirus disease 2019 (COVID-19), is
unlike anything that we, as a society, have
seen in our lifetime. The COVID-19 pandemic
will forever serve as a historical marker. With
more than 10.5 million documented infected
cases globally and more than 500,000 deaths1
in a short period of time, SARS-CoV-2 has left
a lasting impact on our global society in un-
precedented ways.
It has been demonstrated that clinical out-
comes of COVID-19 are significantly worse in
persons with advanced age and those with
“traditional” medical comorbidities (cardiovas-
cular disease, pulmonary disease, diabetes,
malignancy, and immunosuppression).2 But
what about the ever-increasing group of peo-
ple in our society, many of whom do not
have “traditional” medical comorbidities, who
suffer chronically from pain, fatigue, and func-
tional decline? We are referring to patients
with fibromyalgia (FM) and chronic fatigue
syndrome (CFS): 2 conditions that, although
medically distinct, share a common patho-
physiological etiology: central sensitization
(CS).3-6
Fibromyalgia is a chronic centralized pain-
sensitivity disorder characterized by diffuse,
migratory, waxing, and waning pain; fatigue;
sleep disturbance; mood symptoms; and
many other somatic complaints. At present,
the estimated prevalence of FM ranges from
2% to 8% of the US population.3 Statistically,
approximately 1 of every 12 people whom you
encounter has FM. Stated yet another way,
based on current US census data, estimating
a US population of 330,000,000 people, 8%
(the upper estimate of FM prevalence) of the
US population would equal 26,400,000 peo-
ple: more than the entire population of the
state of Florida.7
Mayo Clin Proc Inn Qual Out n December 2020;4(6):764-766 n https://doi.org/10.1016/j.mayocpiqo.2020.08.002
n ª 2020 THE AUTHORS. Published by Elsevier Inc on behalf of Mayo Foundation for Medical Education and Research. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Chronic fatigue syndrome is a condition
characterized by chronic fatigue, lasting at
least 6 months, that impairs one’s ability to
perform daily activities; demonstrates postex-
ertional malaise and unrefreshed sleep; and ex-
hibits either cognitive impairment or
orthostatic intolerance.4 According to the
Institute of Medicine (IOM), although approx-
imately 2.5 million Americans (just under the
entire population of the city of Chicago7) are
diagnosed with CFS, it is estimated that 84%
to 91% of persons suffering from CFS are
currently undiagnosed.4
Based on our clinical experience, we
suspect this cohort (patients with FM or
CFS) to be an extremely vulnerable popula-
tion in the setting of COVID-19. First, this
cohort is by no means exempt from SARS-
CoV-2 infection, sharing the same concerns
we all have living through these uncertain
times.
Second, it is increasingly acknowledged
that stressors (whether physical, mental,
emotional, or financial) directly and negatively
affect the underlying process of CS, which, in
turn, worsens symptoms. As a review, CS is
the pathophysiological process underlying
many different conditions in which structural,
functional, and chemical changes in the cen-
tral nervous system lead to alterations in
how the brain and spinal cord process pain
and other sensory stimuli.3,5,6 These maladap-
tive processing changesdin conjunction with
neuroplastic changes in the central and pe-
ripheral nervous systems, hypothalamic-
pituitary-adrenal axis changes, sympathetic
nervous system hyperactivity, and endogenous
opioid system hyperactivitydcollectively
cascade into developing chronic symptoms
and conditions. The additional COVID-
19eassociated stressors are likely to affect
the underlying CS negatively, leading to wors-
ening symptoms in persons with FM and CFS.
FIBROMYALGIA IN THE AGE OF COVID-19
This potential impact should be further inves-
tigated in well-designed prospective studies.
Third, given the highly comorbid nature of
mood disorders in patients with FM or CFS,
we fear that this pandemic will have detri-
mental impact on mood. Further limbic-
system dysregulation in centrally sensitized
patients can intensify symptoms of depression
and anxiety acutely. Furthermore, for many of
these patients, who already experience signifi-
cant psychosocial difficulties, further mood
dysregulationdas a result of pandemic-
associated stressorsdcould lead to increased
suicidal ideations, a trend that is already being
seen during the COVID-19 pandemic in the
general population, with an exponential rise
in national suicide hotline calls.8
Fourth, it is widely known that the finan-
cial and societal impact associated with condi-
tions such as FM and CFS are staggering.6
With predicted worsening of symptoms, we
foresee greater health care utilization, direct
medical expenses, indirect societal costs, and
further loss of productivity. In the age of
COVID-19, in which layoffs, furloughs, and
financial uncertainties are all around us, the
majority of these patients are not in a position
to “weather this storm.”
This brings us to the ultimate question:
What can we offer to help stave off these pre-
dicted outcomes? Patients with chronic medical
conditions need routine checkins; patients with
FM or CFS should be treated no differently. We
recommend routine follow-up visits, whether
done virtually (telehealth options) or in person.
These visits can be performed by any member
of the health care team and should be time-
limited, focused, and scheduled regularly.
These encounters will allow for assessing cur-
rent symptoms, adherence to medication regi-
mens, and the presence of any red-flag
concerns. Furthermore, these encounters will
help to foster a supportive and healing environ-
ment, given that patients routinely tell us that
“being heard” and “acknowledged” are
extremely therapeutic. As such, for patients
with FM or CFS, we recommend simply reach-
ing out, offering support, and not allowing
isolation during these uncertain times.
In addition, health care professionals
should take the opportunity to further rein-
force the utility of effective nonpharmacologic
treatment options.3-6,9 Nonpharmacologic
n n
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treatment recommendations should include
graded exercise, healthy lifestyle, meditation
and meditative movement activities (tai chi
and yoga), mindfulness activities, paced dia-
phragmatic breathing, supportive counseling,
cognitive behavioral therapy, biofeedback
therapy, sleep hygiene, and ongoing patient
education. Given the physical distancing chal-
lenges during the pandemic, it should be
noted that many of these therapeutic modal-
ities are available digitially (online and app-
based offerings). Patients should be made
aware of these convenient options, encouraged
to participate, and appropriate clinical referrals
should be facilitated.
In summary, we are in the midst of an un-
precedented pandemic. We can only speculate
on the long-term effects and implications of
COVID-19. Among persons with FM and
CFS, we anticipate the consequences of
pandemic-associated stressors, isolation, and
uncertainties to further dysregulate the under-
lying CS. Consequently, the health of these
people could be profoundly and negatively
affected. In the midst of everything, please
do not overlook this vulnerable group.
Abbreviations and Acronyms: CFS = chronic fatigue syn-
drome; COVID-19 = coronavirus disease-2019; CS = central
sensitization; FM = fibromya
Correspondence: Address to Arya B. Mohabbat, MD, Divi-
sion of General Internal Medicine, Mayo Clinic, 200 First
Street SW, Rochester, MN 55905 (Mohabbat.arya@mayo.
edu).
ORCID
Elizabeth C. Wight: https://orcid.org/0000-0002-4283-
0358
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