Friday, March 31, 2023
This activity is intended for rheumatologists, psychiatrists, neurologists, and primary care providers who treat patients with FM. There are no prerequisites.
The goal of this activity is improve the recognition, diagnosis, and treatment of fibromyalgia.
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Fibromyalgia (FM) is a common chronic widespread pain disorder that has a worldwide prevalence of between 0.5% and 5%.[1-2] Although common, fibromyalgia may be difficult to diagnose. In a study by Choy and colleagues, patients with fibromyalgia reported that it took an average of 2.3 years and assessment by an average of 3.7 physicians before they received a diagnosis of fibromyalgia.[3] Patients with fibromyalgia are often referred to multiple specialists and undergo several investigations before a diagnosis of fibromyalgia is established.[3,4]
Because of the growing number of patients requesting an evaluation for fibromyalgia, it has become important to develop strategies to help clinicians identify fibromyalgia and commonly associated conditions and to differentiate fibromyalgia from other chronic pain disorders. The goal is to identify fibromyalgia and initiate treatment as early as possible, even if further evaluation is needed to diagnose comorbidities that may also require management. Early identification and treatment of fibromyalgia may help prevent the potentially debilitating effects of the disorder.[4-5]
The establishment of the 1990 American College of Rheumatology (ACR) criteria for the classification of fibromyalgia helped to increase the recognition of the disorder and stimulate research.[6] The ACR criteria required at least 3 months of widespread pain defined as axial pain and pain above and below the waist and on the right and left sides of the body. In addition, the criteria required pain in 11 of 18 tender point sites determined by digital palpation with an approximate force of 4 kg, which usually results in a whitening of the examiner’s nail bed. Although the ACR criteria made no exclusions for the presence of concomitant radiographic or laboratory abnormalities, it was implicit that clinical examination and judgment be used to exclude other causes of chronic widespread pain.
In 2010, the ACR accepted a clinical case definition that did not include a physical or tender point examination, but required that other disorders that would otherwise explain the pain be ruled out.[7] The proposed criteria take into account other fibromyalgia symptoms besides pain and are intended to also assess fibromyalgia symptom-related severity (Table 1).[7]
Table 1. 2010 ACR Diagnostic Criteria for FM [a]
This content is no longer available.
To administer the Widespread Pain Index (WPI) and Symptom Severity (SS) scale, the patient reports the location of pain over the prior week at 19 sites including areas of the shoulders, arms, hips, legs, jaws, chest, abdomen, back and neck. The SS scale focuses on 3 physical symptoms, as well as somatic symptoms in general. Fatigue, waking unrefreshed, and cognitive symptoms are rated based on the level of severity over the prior week.
Notably, neither the 1990 nor the 2010 ACR revised criteria provide guidance about which painful conditions to rule out or the tests to perform to rule them out. This column discusses an approach to the diagnosis of fibromyalgia that includes the collection of pertinent information from the patient history, and physical examination to identify fibromyalgia and differentiate it from other painful conditions.[8]
The patient history. Fibromyalgia is a diagnosis that is based on the disorder’s clinical characteristics and is not solely a diagnosis of exclusion. The primary, hallmark symptom of fibromyalgia is chronic widespread pain of long duration greater than or equal to 3 months. The pain associated with fibromyalgia can wax and wane, and vary in intensity from day to day and by physical location. Other key symptoms suggestive of fibromyalgia along with chronic widespread pain include fatigue and sleep disturbance.[8] Other commonly associated symptoms include tenderness, stiffness, mood disturbances (eg depression and/or anxiety) and cognitive difficulties (eg, trouble concentrating, forgetfulness, and disorganized thinking).[9] Patients with fibromyalgia frequently report impairment in multiple areas of function, especially physical function.[5]
The presence of common comorbidities associated with fibromyalgia can also help identify patients with fibromyalgia. The lifetime prevalence of mood or anxiety disorders with fibromyalgia is high, with 1 study reporting anxiety disorders in 56%, major depressive disorder in 62%, and bipolar disorder in 11% of patients with fibromyalgia.[10] Underlying pathophysiologic abnormalities common to mood and anxiety disorders and fibromyalgia may account for the high level of co-occurrence of these disorders.[10]
Other common comorbid disorders in patients with fibromyalgia include regional pain syndromes that may have overlapping pathophysiologic features with fibromyalgia, such as irritable bowel syndrome, headache/migraine, interstitial cystitis, prostadynia, temporomandibular disorder, chronic pelvic pain, and others.[11] If a patient presents with 1 of these disorders, it is important to ask the patient whether the pain is limited to a region of the body or if it is more widespread, which suggests the presence of comorbid fibromyalgia.
There are risk factors for fibromyalgia that should be considered when evaluating the patient’s history. Evidence suggests that fibromyalgia is familial, which is likely due to both genetic and environmental factors.[12] Family members of patients with fibromyalgia are also likely to have a lifetime history of major mood disorders, supporting the possibility that mood disorders and fibromyalgia may share genetic risk factors.[12] Environmental risk factors associated with fibromyalgia include physical trauma or injury, infections, psychosocial stressors, and history of abuse.[13] Being overweight or obese, both of which are associated with increased pain sensitivity, may also be risk factors for the development or persistence of fibromyalgia. Obesity (body mass index [BMI] greater than or equal to 30) is present in 32% to 50% of patients with fibromyalgia and an additional 21% to 28% of patients are overweight (BMI greater than or equal to 25).[14] Higher BMIs in patients with fibromyalgia are correlated with decreased physical function, diminished quality of life, and sleep problems.[14] Finally, gender appears to be a risk factor, with women receive a fibromyalgia diagnosis approximately 7 times more often than men using the 1990 ACR criteria.[2] Women are about 10 times more likely to have a positive tender point examination and about 2 times more likely than men to report chronic, widespread pain.[15] The reasons for the gender disparity in fibromyalgia are still unknown, but may, in part, be related to biological differences in pain sensitivity between the sexes .[16]
The patient history is also essential for the differential diagnosis of fibromyalgia. A review of current medications may reveal potential problems, such as statin-induced muscle pain or opioid-induced hyperalgesia.[17] Disorders with symptoms that can mimic fibromyalgia include hypothyroidism, rheumatic diseases (eg, rheumatoid arthritis [RA], osteoarthritis, systemic lupus erythematosus [SLE], spinal stenosis, inflammatory myopathies), neuropathies, multiple sclerosis, hepatitis, myofascial pain syndrome, sleep disorders (eg, sleep apnea), and mood and anxiety disorders.[8,18] It is important to recognize that the presence of these disorders does not necessarily exclude a diagnosis of fibromyalgia, which may co-occur with other medical and psychiatric disorders. Persistence of widespread pain and tenderness or other symptoms that persist after the treatment of identified medical or psychiatric disorders may indicate comorbid fibromyalgia that requires additional management.
The physical examination The diagnostic evaluation of fibromyalgia includes a physical examination for diffuse tenderness which is typically accomplished with the ACR tender point examination in the clinic. The physical examination also aids in the differential diagnosis of fibromyalgia by identifying associated or comorbid disorders.[8,18] The differential diagnostic examination may involve a joint examination to assess for signs of inflammation, such as swelling, tenderness, redness, and heat, as well as an assessment of range of motion and presence of crepitus. A neurological examination based on the patient’s symptoms may include an evaluation for numbness, objective weakness, or other signs of neuropathy. If the history is suggestive, the physical examination may contain an evaluation for signs of connective tissue disease such as rash, skin ulcers, and alopecia or signs of other disorders such as an infectious etiology or other medical disorders.[8,18]
<Level 3>Laboratory testing A diagnosis of fibromyalgia can be made based on the history and physical examination with the selective use of laboratory testing to evaluate for other possible causes of the patient’s symptoms. These tests include erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP), complete blood cell, comprehensive metabolic panel, and thyroid function tests. Routine testing for rheumatoid factor and/or antinuclear antibodies is not recommended unless the patient has signs or symptoms suggesting an autoimmune disorder, or if initial inflammatory indices (ie, ESR and/or CRP) are abnormal (with the recognition that some patients with RA or SLE may have normal inflammatory indices).Depending on history and physical examination, other tests may be indicated, such as ferritin, iron-binding capacity and percentage of saturation, vitamin B12, and vitamin D levels.[8,19]
To address the need for a valid and easy tool to help clinicians identify fibromyalgia and commonly associated conditions, Arnold and colleagues developed a diagnostic screening tool (Fibromyalgia Diagnostic Screen) for use in primary care settings to improve the assessment of patients with fibromyalgia. This screening tool was found to accurately screen for fibromyalgia in patients who present with pain duration greater than 30 days. The Fibromyalgia Diagnostic Screen was designed to guide clinicians in the differential diagnosis of fibromyalgia, focusing on the more common medical disorders that may present with symptoms that overlap with fibromyalgia.[19]
The Fibromyalgia Diagnostic Screen includes a patient self-reported questionnaire and an abbreviated physical examination with targeted laboratory tests to assist in evaluating the differential diagnosis of fibromyalgia (Table 2).[19]
Table 2. Fibromyalgia Diagnostic Screen -- Patient[a,b]
| 1. Pain location: Check the box next to EACH OF THE PLACES that best matches your experience with PAIN in these locations DURING THE PAST WEEK: | |||||
| 0 | 1 | 2 | 3 | 4 | |
| None | Mild | Moderate | Severe | Very Severe | |
| Area 1 | |||||
| Low back | □ | □ | □ | □ | □ |
| Neck | □ | □ | □ | □ | □ |
| Upper back | □ | □ | □ | □ | □ |
| Chest | □ | □ | □ | □ | □ |
| Area 2 | |||||
| Right shoulder | □ | □ | □ | □ | □ |
| Right upper arm | □ | □ | □ | □ | □ |
| Right lower arm | □ | □ | □ | □ | □ |
| Area 3 | |||||
| Right hip | □ | □ | □ | □ | □ |
| Right upper leg | □ | □ | □ | □ | □ |
| Right lower leg | □ | □ | □ | □ | □ |
| Area 4 | |||||
| Left shoulder | □ | □ | □ | □ | □ |
| Left upper arm | □ | □ | □ | □ | □ |
| Left lower arm | □ | □ | □ | □ | □ |
| Area 5 | |||||
| Left hip | □ | □ | □ | □ | □ |
| Left upper leg | □ | □ | □ | □ | □ |
| Left lower leg | □ | □ | □ | □ | □ |
| 2. Pain history: Circle YES or NO for each of the following questions: | |||||
| Duration of pain 3 months or longer? | YES | NO | |||
| Does the pain get WORSE with physical activity or exercise? | YES | NO | |||
| 3. Symptoms: Check the box next to EACH OF THE SYMPTOMS that best matches your experience DURING THE PAST WEEK: | |||||
| 0 | 1 | 2 | 3 | 4 | |
| None | Mild | Moderate | Severe | Very Severe | |
| Tenderness to touch | □ | □ | □ | □ | □ |
| Tiredness or fatigue | □ | □ | □ | □ | □ |
| Unrefreshing sleep | □ | □ | □ | □ | □ |
| Memory problems or forgetfulness | □ | □ | □ | □ | □ |
| Sadness or depression | □ | □ | □ | □ | □ |
| Anxiety or worry | □ | □ | □ | □ | □ |
aData were derived from Arnold LM, et al. J Womens Health (Larchmt). 2012;21:231-239.
b Scoring of the Fibromyalgia Diagnostic Screen-Patient: Positive screen for fibromyalgia if “yes” to all of the following: (1) at least mild pain in at least 1 site within at least 3 out of 5 areas of the body, (2) duration of pain 3 months or longer,(3) pain gets worse with physical activity or exercise, (4) sum of 8 or more in symptom severity.
Based on the findings of the validation study, the patient self-reported questionnaire has a sensitivity of 78% and a specificity of 78% and may be used alone to screen patients for fibromyalgia.[19] Clinician-rated items may be added to the patient-rated screen to aid in the evaluation of patients if desired by the clinician (Table 3).[19] These screening tools were developed to increase awareness of fibromyalgia and facilitate the identification of patients with fibromyalgia.
Table 3. Fibromyalgia Diagnostic Screen – Cliniciana,b
| 1. Tender Point Evaluation: To the 8 sites listed below, apply perpendicular pressure using the thumb pad of your dominant hand. Apply pressure slowly and steadily until your thumb nail bed whitens. Instruct the patients to state “yes” or “no” if there is any pain with the palpation. Circle the response to each site. | ||
| Trapezius muscle (midpoint of the upper border): | ||
| Right | Yes | No |
| Left | Yes | No |
| Supraspinatus muscle (above the scapular spine near the medial border of the scapula): | ||
| Right | Yes | No |
| Left | Yes | No |
| Second rib (at the second costochondral junction, just lateral to the junction, on the upper surface): | ||
| Right | Yes | No |
| Left | Yes | No |
| Gluteal muscle (in upper outer quadrant of the buttock in the anterior fold of muscle): | ||
| Right | Yes | No |
| Left | Yes | No |
| 2. Joint Evaluation: Check for swollen or boggy joints on bilateral exam. Check “yes” if there is bilateral joint swelling at the sites. | ||
| Elbows | Yes | No |
| Wrists | Yes | No |
| Metacarpophalangeal joints | Yes | No |
| Proximal interphalangeal joints | Yes | No |
| 3. Blood Tests: | ||
| Erythrocyte sedimentation rate < 40 | Yes | No |
| Thyroid stimulating hormone (TSH) < 1.5 times the upper limit of normal (ULN) | Yes | No |
aData were derived from Arnold LM, et al. J Womens Health (Larchmt). 2012;21:231-239.
b Scoring of the Fibromyalgia Diagnostic Screen -- Clinician: A positive Fibromyalgia Diagnostic Screen -- Patient plus positive screen on each of the components selected for administration by the clinician. These components include a tender point evaluation (must have at least 2 out of 8 positive tender points), joint evaluation (must have negative examination for bilateral swelling), ESR (must be less than 40), and/or TSH (must be less than 1.5 times the ULN). Clinicians may select the components that they deem the most useful for aiding their diagnosis or they may administer the Fibromyalgia Diagnostic Screen -- Patient alone.
