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Listen to the full interview with Dr. Andrew Holman in Episode 175 of the Fibromyalgia Podcast®
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Originally shared in Episode 175 of the Fibromyalgia Podcast®, this article has been adapted for readers of The Fibro Compass℠.
Many people with fibromyalgia live in a body that feels constantly on edge — exhausted, overstimulated, and unable to fully rest. In this conversation, board-certified rheumatologist Dr. Andrew Holman shares what he observed after treating thousands of fibromyalgia patients, and how patterns involving sleep, pain, and the autonomic nervous system changed the way he understood the condition. What follows is a guided interview exploring why the nervous system matters — and what becomes possible when we pay attention to it.
When the nervous system stays stuck in fight-or-flight, pain is amplified, sleep is disrupted, and healing becomes much harder — even when you’re doing everything right.
About Dr. Andrew Holman
Dr. Andrew Holman is a board-certified rheumatologist with over 25 years of clinical experience. After treating thousands of people with fibromyalgia and autoimmune conditions, he became especially interested in how stress biology, sleep, and autonomic nervous system regulation influence healing and recovery.
He is the co-founder of Inmedix, the company behind CloudHRV — an FDA-cleared clinical technology that measures autonomic nervous system activity through heart rate variability (HRV). His work has helped bring greater attention to the role of nervous system regulation in rheumatology and complex chronic illness care.
Why Dr. Holman Took Fibromyalgia Seriously
You’ve treated thousands of fibromyalgia patients over several decades. What first made you realize there were real, consistent patterns here — and that this wasn’t “nothing”?
Dr. Andrew Holman:
Early on, what stood out to me was that patients were telling remarkably similar stories — even though they were coming from different places, backgrounds, and circumstances. It wasn’t as if they had all gotten together beforehand to compare notes. Yet the same themes kept showing up again and again.
The symptoms weren’t random. Pain, non-restorative sleep, heightened sensitivity, and poor recovery consistently appeared together.
One of the most important lessons I’ve learned in medicine is that patients tell the truth. When large numbers of people describe the same experience, it’s not imaginary — even if we don’t yet have the tools to fully explain it.
Over time, it became clear that fibromyalgia wasn’t just about pain by itself. What I kept seeing, over and over, were problems with sleep — especially non-restorative sleep — along with amplified tenderness and heightened responses to things that normally shouldn’t hurt as much.
I also began to notice other recurring physical patterns. Quite a few patients had hypermobility — joints that moved more than you’d normally expect — and many of those patients also had symptoms pointing to autonomic nervous system involvement. Seeing those patterns together reinforced for me that this wasn’t a localized pain problem, but something involving broader regulation in the body.
When you see that combination repeatedly across thousands of patients, you start to realize something more global is going on. It isn’t random, and it isn’t imagined. There’s a system in the body that isn’t regulating the way it should.
That realization changed how I thought about fibromyalgia. Rather than treating pain as an isolated symptom, I had to account for what was happening with sleep, sensitivity, and regulation more broadly.
When you put those pieces together, it becomes clear that you can’t treat fibromyalgia by focusing on pain alone. If you only focus on pain, you miss what’s driving the process.
Why Sleep Matters So Much In Fibromyalgia
Sleep is foundational. If you don’t sleep normally, the body doesn’t repair itself the way it’s supposed to.
You’ve emphasized that non-restorative sleep is central to fibromyalgia. Why is sleep such a critical piece of the puzzle?
Dr. Andrew Holman:
In fibromyalgia, non-restorative sleep is something you see over and over again. Patients may be sleeping for many hours, but the sleep isn’t doing what it’s supposed to do.
One of the most important findings in this area came from studies where healthy volunteers were selectively deprived of deep sleep. Within four nights, they developed fibromyalgia-like symptoms — including widespread pain, tenderness, fatigue, and cognitive issues. When deep sleep was restored, those symptoms resolved within a couple of days. [1]
When you can induce fibromyalgia-like symptoms simply by disrupting deep sleep — and then reverse them by restoring it — that tells you how important sleep is in this condition. It isn’t just something that gets disrupted along the way.
Clinically, you see this all the time. Many patients are in bed long enough, but they’re not getting the kind of deep sleep that allows the system to reset. When that doesn’t happen, pain sensitivity goes up and recovery slows.
This is also why it’s so important not to miss sleep disorders in fibromyalgia. Conditions like sleep apnea — as well as movement-related sleep disruptions — repeatedly fragment sleep and interfere with deep, restorative sleep. Even when patients aren’t aware of waking during the night, the disruption is enough to matter.
If you don’t address sleep, treatments don’t work the way you expect them to. Pain medications, physical therapy, and other interventions all depend on recovery. Without restorative sleep, that recovery is limited.
Tami’s note: A 2017 study examining the connection between fibromyalgia and obstructive sleep apnea (OSA) found that about half of people with fibromyalgia also have sleep apnea — far higher than in the general population, where recent meta-analyses place OSA rates between 9% and 38%, depending on diagnostic criteria. [2, 3]
This is an important statistic to share with your doctor — many aren’t aware of how common sleep apnea is in fibromyalgia, or how crucial it is to be screened. My own sleep study revealed 45 breathing events an hour — meaning my breathing was being disrupted about every 80 seconds throughout the night. No wonder I was tired!
The Autonomic Nervous System — and Why It Matters in Fibromyalgia
What I kept seeing was a nervous system that wasn’t regulating normally.
You’ve described seeing autonomic imbalance in many fibromyalgia patients. How did the autonomic nervous system help explain what you were observing clinically?
Dr. Andrew Holman:
The autonomic nervous system controls a lot of basic functions we don’t consciously think about — things like heart rate, blood pressure, digestion, temperature regulation, and sleep. It’s constantly adjusting to help the body function appropriately.
In fibromyalgia, I often saw an imbalance between activation and recovery. Even at night, when the body should be shifting into a restorative state, that downshift wasn’t happening the way it should.
When the autonomic nervous system doesn’t downshift appropriately, deep sleep is harder to access. Pain sensitivity increases, and recovery is slower.
What Autonomic Imbalance Looks Like Physiologically
How does that imbalance show up in measurable ways?
Dr. Andrew Holman:
In healthy individuals, the time between heartbeats naturally changes from moment to moment. That’s what we mean by heart rate variability, or HRV. In fibromyalgia, you often see less of that normal variation — the heart rhythm becomes more rigid. That pattern suggests the autonomic nervous system isn’t regulating normally.
This doesn’t mean someone is consciously stressed or anxious.
It’s a physiologic pattern, not a psychological one.
Many patients feel calm but still show signs of autonomic imbalance when you measure it.
Research has also shown that this imbalance can be especially pronounced at night. In studies led by Dr. Martinez-Lavin, people with fibromyalgia showed increased sympathetic nervous system activity — essentially a heightened stress response — during sleep, particularly between midnight and 4 AM. That’s a time when the body should normally be in a deeply restorative, parasympathetic state.
Even when people aren’t fully waking up, that ongoing nighttime activation can fragment sleep and interfere with recovery. The nervous system remains more activated than it should be during the night, which helps explain why someone can spend hours in bed and still wake up exhausted.
When this kind of autonomic activation happens night after night, it becomes something we can actually observe and quantify — which is where heart rate variability measurement becomes useful.
What Heart Rate Variability Tells Us
What does heart rate variability actually tell us about autonomic function?
Dr. Andrew Holman:
Heart rate variability (HRV) gives us a window into autonomic function. It helps us see how the sympathetic and parasympathetic systems are interacting — and whether the system is regulating the way it should.
If you’re being chased by a bear, a heightened response makes sense. The problem is when the system doesn’t turn itself off afterward. In fibromyalgia, what I was seeing was a nervous system that stayed activated when it shouldn’t.
HRV isn’t measuring stress hormones like cortisol. It reflects the effects of autonomic activity on the heart. What’s helpful about HRV is that it makes something that’s otherwise invisible visible — instead of guessing what the nervous system is doing, you can actually see it.
That need for objective, usable measurement is what led us to develop CloudHRV. In clinical practice, we didn’t have a practical, standardized way to assess autonomic function during a routine office visit. We were often inferring what the nervous system was doing based on symptoms, but that only gets you so far.
CloudHRV was designed to measure heart rate variability in a consistent, reproducible way in a medical setting. It doesn’t diagnose fibromyalgia — it measures autonomic nervous system balance. But having that information allows clinicians and patients to move beyond guesswork and actually observe how the nervous system is responding over time as care is adjusted.
Tami’s note: Dr. Holman goes into more detail about CloudHRV in the full interview — including how it works, why it’s different from wearables (like your Apple Watch), and how clinicians use it in practice. Unlike fitness trackers, CloudHRV is a clinical tool used in medical settings to assess autonomic nervous system function in a standardized way.
To learn more, listen to our full conversation in Episode 175 of the Fibromyalgia Podcast® or watch the interview on our YouTube channel here.
Resources To Share With Your Doctor
During our conversation, Dr. Holman referenced many of the studies that shaped his understanding of fibromyalgia, sleep, heart rate variability (HRV), the autonomic nervous system, and positional cervical cord compression (PC3).
Dr. Holman has compiled a list of the key research papers discussed in this interview so you can easily review them yourself or share them with your healthcare providers.
Clinical HRV vs Wearables
Many patients are now seeing HRV data from consumer wearables — such as smartwatches and fitness trackers. How do you think about that kind of data compared to clinical HRV testing?
Dr. Andrew Holman:
Wearables can be helpful for tracking trends over time — comparing someone to themselves rather than to a population average. That kind of longitudinal data can give patients useful feedback about pacing, recovery, and overall load.
Clinical-grade HRV testing goes a step further. It allows you to assess different components of autonomic function with much greater precision. In a clinical setting, that information can guide decision-making and help explain why certain treatments aren’t working as expected.
Both have value, as long as the data is used appropriately and not as a source of judgment or pressure.
What Changed When Autonomic Balance Was Addressed
What did you start to notice once you began paying attention to autonomic nervous system balance in your patients?
Dr. Andrew Holman:
When we began accounting for autonomic function — along with sleep, immune activity, and other physiologic factors — outcomes improved.
In rheumatology research, addressing autonomic imbalance was associated with higher remission rates. Patients were more stable, treatments worked more predictably, and in some cases, medication needs decreased over time.
What that showed was that if the nervous system is under ongoing strain, it limits how well other treatments can work. When regulation is supported, the rest of the system responds more effectively.
It’s similar to blood pressure. You can treat the blood pressure itself, but if someone remains under constant stress, that treatment can only go so far — the underlying strain still matters.
What Clinicians Learned When Autonomic Function Was Measured
You’ve pointed to rheumatoid arthritis research as an example of what can change when autonomic function is taken seriously. Can you share what stood out there?
Dr. Andrew Holman:
In rheumatoid arthritis research where autonomic function was evaluated alongside standard treatment, remission rates were markedly higher than what is typically seen with medication alone.
In the studies I referenced, remission rates increased from roughly 25% to about 79% when autonomic imbalance was addressed as part of the overall picture. That’s a substantial difference.
What’s important is not the specific disease, but the principle. Rheumatoid arthritis is a condition where inflammation is front and center, yet the nervous system still plays a significant role in how the body responds to treatment.
When the autonomic nervous system is under constant strain, it constrains outcomes — even when appropriate medications are being used. When regulation is supported, treatments tend to work more predictably.
That doesn’t mean the same numbers apply to fibromyalgia. But it does reinforce the idea that ignoring autonomic function can quietly limit how well care works across conditions.
What Patients (and Providers) Often Miss
What do you think both patients and providers often miss when it comes to fibromyalgia care?
Dr. Andrew Holman:
One of the most common issues is focusing on pain as if it’s the primary problem to solve. Pain is real, but it’s often the downstream result of other physiologic processes rather than the root cause.
When care focuses only on pain relief, treatments may not work the way you expect them to.
Medications may help some, but not enough. Physical therapy can be difficult to tolerate. Other interventions don’t seem to stick. That doesn’t mean the treatments are wrong — it often means the system isn’t in a state where it can respond well.
Another thing that gets missed is assuming autonomic imbalance is the same as feeling stressed or anxious. It isn’t. This is a physiologic pattern. Many patients feel emotionally calm but still have a nervous system that isn’t regulating normally when you measure it.
What makes the biggest difference is paying attention to regulation. Sleep quality, autonomic balance, and overall recovery capacity shape how well the body tolerates stress and responds to treatment. If those foundations aren’t addressed, even appropriate care has limits.
That doesn’t mean pain management isn’t important. It means pain management works best when it’s part of a broader physiologic approach, rather than the only focus.
Another contributor that can be overlooked in some patients is the cervical spine — particularly how the spinal cord responds to neck position. Most standard imaging is done with the neck in a neutral position, which means certain types of spinal cord irritation may not be seen. In select cases, imaging the cervical spine during flexion and extension can reveal mechanical stress on the cord, which can play a role in ongoing autonomic nervous system activation and interfere with sleep and recovery.
This doesn’t apply to everyone with fibromyalgia, and it doesn’t mean surgery is the answer. But for a subset of patients, identifying a mechanical factor helps explain why the nervous system remains so activated — and helps guide more appropriate evaluation and management.
Want to explore the research behind positional cervical cord compression (PC3)? Dr. Holman's Key Fibromyalgia References Guide includes the studies discussed in this interview and is designed to be shared with your doctor.
Tami’s note: If this topic is new to you, I encourage you to listen to the full interview in Episode 175 of the Fibromyalgia Podcast®. Dr. Holman goes into much more detail about the connection between neck position, the spinal cord, and fibromyalgia — including how it is evaluated and the types of treatment approaches that may be considered. You can also watch the interview on our YouTube channel here.
A Different Way to Think About Fibromyalgia Care
Conversations like this one with Dr. Holman help explain why fibromyalgia so often feels confusing — and why people can do “all the right things” and still struggle to feel better.
When care focuses only on pain, it misses the broader physiologic context pain lives in. Sleep quality, autonomic regulation, recovery capacity, and overall load quietly shape how the body responds to treatment. When those foundations are strained, even appropriate care has limits.
What’s encouraging is that this doesn’t mean fibromyalgia is mysterious or untreatable. It means the body is responding predictably to ongoing physiologic stress — and that when regulation is supported, the system often responds more consistently.
That doesn’t require chasing perfect metrics or pushing harder. It starts with understanding what’s actually happening beneath the surface, and why symptoms behave the way they do.
For patients, this perspective can be validating. For providers, it can open new avenues for care. And for anyone who’s been told “nothing is wrong” despite very real symptoms, it offers a framework that makes sense of the experience.
Fibromyalgia care works best when it reflects how the body truly functions — not just where the pain shows up.
Action Steps: One Small Step Forward
Reading can bring insight — but change happens when you do something with what you’ve learned. You don’t need to tackle everything at once. One tiny, baby step is enough.
1. Talk to Your Doctor About a Sleep Study
Research shows that about half of people with fibromyalgia also have sleep apnea, often without obvious symptoms like loud snoring or daytime sleepiness. While non-restorative sleep is a hallmark of fibromyalgia, many sleep disorders are very treatable.
At your next appointment, you might simply say:
“I have fibromyalgia, and I’ve learned that sleep apnea is very common in people with fibro — even when it isn’t obvious. Would it make sense for me to have a sleep study?”
You’re not asking for a diagnosis — just appropriate screening.
(If you had a sleep study years ago, especially an in-home study, it may be worth revisiting the results with fresh eyes.)
2. Broaden the Conversation Beyond Pain
Living with fibromyalgia means your nervous system has likely been under ongoing strain — even when you don’t feel emotionally stressed. As Dr. Holman explains, “It’s a physiologic pattern, not a psychological one. Many patients feel calm but still show signs of autonomic imbalance when you measure it.”
Bringing that context into your care can shift how symptoms are understood and treated.
At your next appointment, you might ask:
“Are there ways we can look at sleep quality or nervous system regulation — not just pain — as part of my care?”
This isn't about abandoning pain management. It's about looking beyond pain to address other factors that may be contributing to your symptoms. As Dr. Holman said: "addressing autonomic imbalance is associated with higher remission rates."
Want help starting that conversation with your doctor? Download Dr. Holman's Key Fibromyalgia References Guide and bring it with you to your next appointment. You'll also receive guidance on how to use the guide as a conversation starter with your doctor.
3. Use HRV Information Gently — If You Have It
If you use a wearable that tracks HRV:
- Compare yourself to yourself, not to averages
- Look for patterns over time, not daily scores
- Use the data as information, not judgement or pressure
You may choose to experiment with gentle ways of supporting regulation — like consistent sleep, reducing overall load, paced breathing, or true recovery time — and simply notice what helps your system.
I've noticed an improvement in my own HRV using my Apollo® wearable. If you're curious, I share my experience with it — and why it earned a place on my list — in Tami's Favorite Things 2025.
And remember: not everyone’s HRV responds easily or dramatically. If yours doesn’t, that’s not a failure — it reflects how your nervous system is wired.
The goal isn’t to chase numbers.
It’s to learn what helps your system feel safer, calmer, and more resilient.
Remember: Your Symptoms Make Sense
If you’ve ever been told “nothing is wrong” — yet your body feels anything but okay — this framework offers a different explanation. Understanding what’s happening beneath the surface can help you make more informed, compassionate choices about your care.
If you’d like to go deeper, I invite you to listen to Episode 175 of the Fibromyalgia Podcast® — or catch the interview on YouTube — where Dr. Andrew Holman and I explore these ideas in more detail, including what nervous system regulation can look like in real life.
You don’t have to do everything at once.
One small step is enough to begin.
Not Sure What To Focus On Next?
There may be important factors affecting your symptoms that nobody has looked at yet.
But when you're living with fibromyalgia, it can be difficult to know which factors may be contributing to your symptoms.
This is where working with a Certified Fibromyalgia Coach® can be especially helpful — having someone who understands fibromyalgia and can help you identify what may be most relevant to your situation.
You don’t have to walk this path alone. Schedule your consultation with me or a Certified Fibromyalgia Coach® today, and discover how having someone who truly understands fibromyalgia can make all the difference.
[1] Moldofsky H, Scarisbrick P, England R, Smythe H. Musculosketal symptoms and non-REM sleep disturbance in patients with "fibrositis syndrome" and healthy subjects. Psychosom Med. 1975;37(4):341-351. doi:10.1097/00006842-197507000-00008.
[2] Köseoğlu Hİ, İnanır A, Kanbay A, et al. Is There a Link Between Obstructive Sleep Apnea Syndrome and Fibromyalgia Syndrome?. Turk Thorac J. 2017;18(2):40-46. doi:10.5152/TurkThoracJ.2017.16036
[3] Senaratna CV, Perret JL, Lodge CJ, et al. Prevalence of obstructive sleep apnea in the general population: A systematic review. Sleep Med Rev. 2017;34:70-81. doi:10.1016/j.smrv.2016.07.002
Cover Photo by Martin Adams
About Tami Stackelhouse
Tami Stackelhouse is an award-winning author, founder of the International Fibromyalgia Coaching Institute (IFCI), and one of the most influential voices in fibromyalgia today, having helped hundreds of thousands of people worldwide rethink what is possible with fibromyalgia. Through her signature Fibromyalgia Wellness Framework℠, Tami is helping transform the way fibromyalgia is understood, supported, and lived — moving people beyond symptom management and into a future they once believed was out of reach.
Photo by Emily Broadbent
