Lee S. Simon, MD: Hello, I am Lee Simon. I am a rheumatologist and pain specialist. I am also an Associate Clinical Professor of Medicine at Harvard Medical School and at the Beth Israel Deaconess Medical Center in Boston, Massachusetts. I would like to welcome you to this Medscape Rheumatology CME/CE Video Lecture, entitled "Differential Diagnosis and Management of Fibromyalgia Syndrome."

The objectives for this program are to review the epidemiology, etiology, and pathogenesis of the fibromyalgia syndrome, and to also identify the criteria for differential diagnosis of fibromyalgia in rheumatology practice. We also want to discuss selecting the nonpharmacologic and pharmacologic treatments for fibromyalgia, which would consider the benefits and limitations of each of those therapies.

In this slide, I would like to introduce you to the problem of fibromyalgia and how it relates to other systemic syndromes. As you can see in the top left-hand corner, fibromyalgia represents about 2% to 4% of the population, really defined specifically by widespread chronic pain and tenderness. However, as you can see on this very complicated Venn diagram, there are also other syndromes that, in fact, are systemic in nature. There is multiple chemical sensitivity syndrome; the chronic fatigue syndrome; down in the right-hand corner, the somatoform disorders; and on the left, the exposure syndromes. It is likely that all of these syndromes in some way, shape, and form -- in the right genetic host -- manifest themselves based on different ways that the host actually deals with the external stimuli or the environment.

As you can see on this slide, which is also quite complicated, if you look and spend a few minutes, you can see that this is one way to be able to differentially diagnose fibromyalgia. It allows a very reasonable simple work-up to understand what to do next when you actually have a patient complaining of significant pain for a period of time. At the top of this slide, fibromyalgia-like symptoms of greater than 3 months would lead you to evaluate for all kinds of disorders, including systemic disease, so you do a complete physical exam and take a complete history. You check for sed rates, CRPs [C-reactive proteins], CBC [complete blood count], chemistry panel, and TSH, which is the thyroid-stimulating hormone. You would likely not, because we are rheumatologists, actually measure an antinuclear antibody or a rheumatoid factor unless for some reason you are suspicious about that.

If, in fact, you have an abnormal work-up -- as you can see in the red-orange to the right of this slide -- then, in fact, we are not talking about fibromyalgia. If all of those things are normal, like shown on the left, then you are going down and really dealing with a disease that would be fulfilling the issues associated with the systemic painful syndrome of fibromyalgia. You can actually see that you can talk to the patient about this particular problem, and that is really critical. Educating the patient about the condition, telling them that, in fact, they have something that is relatively benign, yes, they are quite symptomatic but, in fact, they don't have a lethal disease. Then you also need to make sure that you have enough time to speak to the patient and discuss these particular issues. You also need to offer reputable resources that are actually going to help support the patient, including exercise programs and other programs that we will talk about in a little bit.

And then, you also evaluate for comorbidities particularly seen in fibromyalgia, such as reactive depression associated with dealing with chronic pain, for quite some time, and then you may have some choices of either nonpharmacologic or in combination with pharmacologic therapy, and you would then treat the patient.

We are going to introduce a polling question on this next slide, and we would like you to take a moment to register your choice of answer, and we will see how the rest of the readers have answered as well. In this question, we are asking which of these conditions are you most likely to encounter in your own clinical practice. As rheumatologists, we tend to think of ourselves as taking care of patients with inflammatory diseases that may have pain, but also pain as an important part. As you can see there, the first answer might be rheumatoid arthritis; the second one might be fibromyalgia; the third one might be lupus; and the fourth one might be chronic fatigue syndrome.