Recognizing and Diagnosing Fibromyalgia
Larry Culpepper, MD, MPH
Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
AV 1. Current Understanding of the Pathophysiology of Fibromyalgia (00:45)
Fibromyalgia affects an estimated 2% of the American population.1 Current understanding explains it as a neurologic disorder of central pain processing that causes the perception of pain in response to stimuli that would not be painful in healthy individuals (). Fibromyalgia is associated with a genetically determined predisposition and hypothalamic-pituitary-adrenal axis dysregulation.2–5 Most patients present with the “fibromyalgia triad” of pain, sleep dysfunction, and mood disorders6,7 (). While pain is often the initial symptom in adults, those older than 70 years might present with sleep dysfunction followed by the development of chronic pain.
AV 2. Common Characteristics of Fibromyalgia (00:19)
Characteristics of Fibromyalgia
Widespread pain, often described as a deep aching pain, is characteristic of fibromyalgia, and patients usually report little relief from NSAIDs and other common analgesics, including opiates. The onset of pain is gradual, with many patients reporting feeling out of sorts for months followed by the slow onset of pain.6–8 Patients commonly report a sleep pattern of sleeping for 2 to 3 hours, then awakening in the middle of the night for 1 to 2 hours, followed by resumption of sleep and exhaustion and fatigue throughout the next day.9 Depression and anxiety each occur in about 40% of fibromyalgia patients and often are comorbid with each other; however, many patients with fibromyalgia do not have an associated mood disorder.6,8 Fibromyalgia patients often have other somatic concerns such as chronic headaches, irritable bowel or bladder, and temporomandibular joint disorder. Trauma, infections, and psychological events have been reported as precipitating events, but no evidence supports causality in such cases; instead, these events may serve to bring the patient to medical attention.6,8
Practical Approaches to Diagnosing Fibromyalgia
AV 3. 3-Point Bilateral Examination to Diagnose Fibromyalgia (00:25
The classic diagnostic criteria of fibromyalgia require pain to be of greater than 3 months duration, to be elicited at 11 of 18 tender points, to be present on both sides of the body and above and below the waist, and to include axial skeletal pain (cervical spine, anterior chest, thoracic spine, or low back pain).10 However, the use of a tender point examination is based on criteria used to qualify patients for research studies and is often omitted from the physical examination, even by specialists in the area. A more clinically practical approach is to demonstrate pain above and below the waist and on both sides of the body by eliciting pain at 3 points bilaterally: (1) the lateral border of the trapezius, (2) the lateral epicondyle or lateral upper arm, and (3) the anterior thigh (). A common examination technique is for the examiner to press his or her thumb at these points with just enough force to blanch the nail bed, which will evoke allodynia (the report of pain to a stimulus that would not normally be painful) in fibromyalgia patients.6,11
AV 4. Fibromyalgia as a Potential First Diagnosis (00:47)
The recognition of fibromyalgia can lead to effective treatment with significant improvement in functioning. However, one of the major impediments to appropriate diagnosis and care is the attitude of many health care professionals who reject fibromyalgia as a valid diagnosis or avoid patients with it.12 Because of the chronic nature of the pain condition and associated counterproductive behaviors and disability, patients and physicians may rapidly become frustrated with each other and abandon the pursuit of adequate diagnosis and treatment. However, if the physician instead recognizes the diagnostic pattern of pain, often associated with sleep dysfunction and mood disorders, and appreciates the real nature of the underlying pathology, then he or she can be of great benefit to patients and their families in managing this chronic disease7 ().
For Clinical Use
- Complete an examination of 3 points bilaterally (the lateral border of the trapezius, the lateral epicondyle or lateral upper arm, and the anterior thigh) to identify fibromyalgia; a complete tender point examination is not always necessary
- If you and the patient commit to a treatment plan, you may be able to help your patient experience significant functional improvement
FDA = Food and Drug Administration
NSAIDs = nonsteroidal anti-inflammatory drugs
All videos are derived from the Webcast "Debates and Directions in Fibromyalgia: Recognizing Signs and Selecting the Appropriate Paths, Part 1," held in January 2010 by the University of North Texas Health Science Center and featuring Larry Culpepper, MD, MPH, Boston University Medical Center, and Raymond Pertusi, DO, Harvard Vanguard Medical Associates. © 2010 University of North Texas Health Science Center, Fort Worth.
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- Abeles AM, Pillinger MH, Solitar BM, et al. Narrative review: the pathophysiology of fibromyalgia. Ann Intern Med. 2007;146(10):726–734.
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- Moldofsky H. The significance of the sleeping-waking brain for the understanding of widespread musculoskeletal pain and fatigue in fibromyalgia syndrome and allied syndromes. Joint Bone Spine. 2008;75(4):397–402.
- Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia: Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990;33(2):160–172.
- Tunks E, McCain GA, Hart LE, et al. The reliability of examination for tenderness in patients with myofascial pain, chronic fibromyalgia and controls. J Rheumatol. 1995;22(5):944–952.
- Alghalyini B. That sinking feeling: a patient-doctor dialogue about rescuing patients from fibromyalgia culture. Can Fam Physician. 2008;54(11):1576–1577.