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CME

Enhancing the Diagnosis and Assessment of Fibromyalgia

  • Authors: Lesley M. Arnold, MD
  • THIS ACTIVITY HAS EXPIRED FOR CREDIT
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Target Audience and Goal Statement

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.

Upon completion of this activity, participants will demonstrate the ability to:

  1. Describe data on the latest concepts of the pathophysiologic underpinnings of fibromyalgia and the role of neuronal mechanisms
  2. Apply knowledge of current diagnostic criteria to diagnose patients with fibromyalgia
  3. Describe evidence-based data on the use of pharmacologic and nonpharmacologic treatment approaches for fibromyalgia


Disclosures

The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of Johns Hopkins University School of Medicine name implies review of educational format design and approach. Please review the complete prescribing information of specific drugs or combination of drugs, including indications, contraindications, warnings and adverse effects before administering pharmacologic therapy to patients.

As a provider approved by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the Johns Hopkins University School of Medicine Office of Continuing Medical Education (OCME) to require signed disclosure of the existence of financial relationships with industry from any individual in a position to control the content of a CME activity sponsored by OCME. Members of the Planning Committee are required to disclose all relationships regardless of their relevance to the content of the activity. Faculty are required to disclose only those relationships that are relevant to their specific presentation. The following relationships have been reported for this activity:


CME Author(s)

  • Kirsten R. Ambrose, MS

    Center for Neurosensory Disorders, School of Dentistry, University of North Carolina at Chapel Hill, North Carolina

    Disclosures

    Disclosure: Kirsten R. Ambrose, MS, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for Algynomics, Inc.
    Owns stock, stock options, or bonds from Algynomics, Inc.

    Kristen Ambrose does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

    Kristen Ambrose does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

  • Lesley M. Arnold, MD

    Lesley M. Arnold, MD, Professor of Psychiatry and Behavioral Neuroscience; Director, Women’s Health Research Program, University of Cincinnati College of Medicine, Cincinnati, Ohio

    Disclosures

    Disclosure: Lesley M. Arnold, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for Daiichi Sankyo, Inc.; Forest Laboratories, Inc.; Grünenthal; Pfizer Inc.
    Received grants for clinical research from Boehringer Ingelheim Pharmaceuticals, Inc.; Cypress Bioscience, Inc.; Eli Lilly and Company; Forest Laboratories, Inc.; Novartis Pharmaceuticals Corporation; Pfizer Inc; Takeda Pharmaceuticals North America, Inc.

    Dr Arnold does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

    Dr Arnold does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

  • Don L. Goldenberg, MD

    Chief of Rheumatology, University of Wisconsin, Madison, Wisconsin; Chief of Rheumatology, Newton-Wellesley Hospital, Newton, Massachusetts

    Disclosures

    Disclosure: Don L. Goldenberg, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for Eli Lilly and Company; Forest Laboratories, Inc.; Pfizer Inc. Received grants for clinical research from: Pfizer Inc.

    Dr Goldenberg does intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

    Dr Goldenberg does intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

  • Richard H. Gracely, PhD

    Professor, Center of Neurosensory Disorders; Department of Endodontics, School of Dentistry, University of North Carolina at Chapel Hill, North Carolina

    Disclosures

    Disclosure: Richard H. Gracely, PhD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for Eli Lilly and Company.
    Owns stock, stock options, or bonds from Algynomics, Inc.

    Dr. Gracely does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

    Dr. Gracely does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

Planning Committee

  • Lesley M. Arnold, MD

    Lesley M. Arnold, MD, Professor of Psychiatry and Behavioral Neuroscience; Director, Women’s Health Research Program, University of Cincinnati College of Medicine, Cincinnati, Ohio

    Disclosures

    Disclosure: Lesley M. Arnold, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for Daiichi Sankyo, Inc.; Forest Laboratories, Inc.; Grünenthal; Pfizer Inc.
    Received grants for clinical research from Boehringer Ingelheim Pharmaceuticals, Inc.; Cypress Bioscience, Inc.; Eli Lilly and Company; Forest Laboratories, Inc.; Novartis Pharmaceuticals Corporation; Pfizer Inc; Takeda Pharmaceuticals North America, Inc.

Course Director(s)

  • Michael Clark, MD, MPH, MBA

    Associate Professor, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University; Director, Chronic Pain Treatment Program, Johns Hopkins Hospital, Baltimore, Maryland

    Disclosures

    Disclosure: Michael R. Clark, MD, MPH, MBA, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Eli Lilly and Company; Depomed, Inc.

Editor(s)

  • Shari Weisenfeld, MD

    Scientific Director, Medscape, LLC

    Disclosures

    Disclosure: Shari Weisenfeld, MD, has disclosed no relevant financial relationships.

  • Laura Feiker

    Clinical Editor, Medscape, LLC

    Disclosures

    Disclosure: Laura Feiker has disclosed no financial relationships.

Content Reviewer(s)

  • Nafeez Zawahir, MD

    CME Clinical Director, Medscape, LLC

    Disclosures

    Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

No other planners have indicated that they have any financial interests or relationships with a commercial entity.

CONFIDENTIALITY DISCLAIMER FOR CME CONFERENCE ATTENDEES

I certify that I am attending a Johns Hopkins University School of Medicine CME activity for accredited training and/or educational purposes.

I understand that while I am attending in this capacity, I may be exposed to "protected health information," as that term is defined and used in Hopkins policies and in the federal HIPAA privacy regulations (the "Privacy Regulations").  Protected health information is information about a person’s health or treatment that identifies the person.

I pledge and agree to use and disclose any of this protected health information only for the training and/or educational purposes of my visit and to keep the information confidential.

I understand that I may direct to the Johns Hopkins Privacy Officer any questions I have about my obligations under this Confidentiality Pledge or under any of the Hopkins policies and procedures and applicable laws and regulations related to confidentiality.  The contact information is:  Johns Hopkins Privacy Officer, telephone: 410-735-6509, e-mail: [email protected].

“The Office of Continuing Medical Education at the Johns Hopkins University School of Medicine, as provider of this activity, has relayed information with the CME attendees/participants and certifies that the visitor is attending for training, education and/or observation purposes only.”

For CME Questions, please contact the CME Office at (410) 955-2959 or e-mail [email protected].
For CME Certificates, please call (410) 502-9634.

Johns Hopkins University School of Medicine
Office of Continuing Medical Education
Turner 20/720 Rutland Avenue
Baltimore, Maryland 21205-2195

Reviewed & Approved by:
General Counsel, Johns Hopkins Medicine (4/1/03)
Updated 4/09

To participate in additional CME activities presented by the Johns Hopkins University School of Medicine Continuing Medical Education Office, please visit www.hopkinscme.edu


Accreditation Statements

    For Physicians

  • The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

    The Johns Hopkins School of Medicine designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Estimated Time to Complete This Activity: 1 hour

    The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

    Johns Hopkins Privacy Policy
    The Office of Continuing Medical Education (CME) at the Johns Hopkins University School of Medicine is committed to protect the privacy of its members and customers. Johns Hopkins University SOM CME maintains its Internet site as an information resource and service for physicians, other health professionals and the public. Continuing Medical Education at the Johns Hopkins University School of Medicine will keep your personal and credit information confidential when you participate in a CME Internet based program. Your information will never be given to anyone outside of the Johns Hopkins University School of Medicine's CME program. CME collects only the information necessary to provide you with the services that you request.

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.

CME

Enhancing the Diagnosis and Assessment of Fibromyalgia

Authors: Lesley M. Arnold, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED FOR CREDIT

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Introduction

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]

Diagnostic Criteria for Fibromyalgia

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]

An Approach to Diagnosing Fibromyalgia

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]

Diagnostic Screening Tool for Fibromyalgia

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.
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