Evaluating the Patient With Fibromyalgia
Larry Culpepper, MD, MPH
Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
Pain, specifically bilateral pain both above and below the waist, that has continued for more than 3 months should make the clinician suspect that the patient may have fibromyalgia.1,2 Once the physician has identified fibromyalgia as a potential diagnosis, further evaluation is warranted, both to understand the full dimensions of fibromyalgia, if it proves to be the diagnosis, and to evaluate other potential causes of the patient’s symptoms.3 For example, mood disorders, sleep disorders, and daytime fatigue are often present in patients with fibromyalgia and often are closely related to pain.
Identifying Comorbid Conditions
Mood disorders may be evaluated by screening for both depression and anxiety. The first 2 questions of the PHQ-9 and the first 2 questions of the GAD-7 constitute such a screen if the physician chooses to use instruments for this purpose.4,5 Clinical interviews can then confirm mood-related diagnoses. The physician should recognize that the patient with fibromyalgia may have minor depression or dysthymia rather than major depressive disorder and that these mild depressions may contribute substantially to disability and impairment in functioning. Evaluating the severity of depression might also be helpful in understanding the patient’s current state and in establishing a baseline to later assess the effectiveness of therapy. While mood disorders are often associated with pain syndromes, the pattern of pain characteristic of fibromyalgia is distinctive and warrants establishing the diagnosis of fibromyalgia as well as comorbid depression. Similarly, the Insomnia Severity Index (5 questions) and the Fatigue Severity Index (9 questions) are brief instruments that might be of help in measuring problems with sleep and fatigue.6,7 It is important to establish mood- and sleep-related diagnoses in addition to the diagnosis of fibromyalgia since additional treatment, patient education, and counseling are necessary.
AV 1. Conditions That Can Be Mistaken for Fibromyalgia (00:24)
In addition to the complications bestowed by comorbid psychiatric disorders or sleep issues, a number of conditions can mimic fibromyalgia and must be considered in the patient’s evaluation (). These include endocrine conditions, such as hypothyroidism, primary hyperparathyroidism, and vitamin D deficiency; neurologic conditions, including multiple sclerosis, myasthenia gravis, and polyneuropathy; and musculoskeletal conditions, such as the early stages of rheumatoid arthritis, systemic lupus erythematosus, psoriatic arthritis, ankylosing spondylitis, polymyositis, and polymyalgia rheumatica. The myalgia sometimes associated with statin medications may mimic fibromyalgia, as can the side effects of aromatase inhibitors and antiepileptics. Some chronic infections, such as HIV and hepatitis C, and some cancers, such as multiple myeloma, also might be the source of pain symptoms that can be confused with fibromyalgia.1–3
AV 2. Recognizing Conditions that Mimic Fibromyalgia (00:57)
In patients with suspected fibromyalgia, taking a complete medical history and performing a thorough physical examination can be very helpful in confirming the diagnosis or establishing an alternate diagnosis by evaluating the course of symptoms and associated physical findings (). In many patients, a complete laboratory assessment will be of help, although no laboratory test is required to establish the fibromyalgia diagnosis. Laboratory assessments that might be of help in completing a differential diagnosis include complete blood cell count, erythrocyte sedimentation rate, C-reactive protein levels, thyrotropin levels, creatine kinase levels, vitamin D levels, and other tests as indicated by the patient’s history and physical examination. In addition, the physician should consider performing all screening and prevention appropriate for the individual patient, which will help determine the patient’s current health status and be of potential use should additional symptoms develop.3,7,8
Assessing Function and Attitudes
Beyond establishing the diagnosis of fibromyalgia and potential comorbidities, the initial evaluation should include assessing the patient’s current level of functioning (within the family and in social and work settings), coping strategies and resources, beliefs about the condition, and past treatment experiences. Often, patients have had multiple frustrating medical encounters and sources of care before the diagnosis of fibromyalgia is established, and these experiences may negatively influence the patient’s receptiveness to the diagnosis and treatment recommendations. Most patients with untreated fibromyalgia are sedentary and may have significant deconditioning. Similarly, self-medication for pain and insomnia, including both substance use and herbal and alternative therapies, may require the clinician’s attention.1,9,10
AV 3. Adjusting Clinicians' Attitudes About Fibromyalgia (00:45)
AV 4. Online Resources for Further Information on Fibromyalgia and Chronic Pain
After evaluating the patient as described above, the physician will then be positioned to positively establish the diagnosis of fibromyalgia as well as any comorbidities (). An understanding of the patient’s current limitations and strengths and past experiences will be helpful in guiding the education and treatment required. The physician might find the online resources of professional groups involved with the diagnosis and management of fibromyalgia helpful (), including the American College of Rheumatology (www.rheumatology.org), the American Pain Society (www.ampainsoc.org), and the European League Against Rheumatism (www.eular.com).
For Clinical Use
- Complete a full psychological and physical assessment of the patient with suspected fibromyalgia, which can help the physician evaluate other potential causes of the patient’s symptoms, understand the full dimensions of that patient’s fibromyalgia if that diagnosis is confirmed, and assess for co-occurring mood and sleep disorders
- Take a complete medical history and perform a thorough physical examination, including a complete laboratory assessment, to confirm the diagnosis or establish an alternate diagnosis by evaluating the course of symptoms and associated physical findings
FDA = Food and Drug Administration
GAD-7 = 7-item Generalized Anxiety Disorder scale
PHQ-9 = 9-item Patient Health Questionnaire
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.
- Chakrabarty S, Zoorob R. Fibromyalgia. Am Fam Physician. 2007;76(2):247–254.
- Mease P. Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment. J Rheumatol Suppl. 2005;75:6–21.
- Russell IJ. Fibromyalgia syndrome: presentation, diagnosis, and differential diagnosis. Prim Psychiatry. 2006;13(9):40–45.
- Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613.
- Kroenke K, Spitzer RL, Williams JB, et al. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146(5):317–325.
- Krupp LB, LaRocca NG, Muir-Nash J, et al. The fatigue severity scale: application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol. 1989;46(10):1121–1123.
- Bastien CH, Vallières A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001;2(4):297–307.
- Fitzcharles MA, Esdaile JM. The overdiagnosis of fibromyalgia syndrome. Am J Med. 1997;103(1):44–50.
- Arnold LM, Bradley LA, Clauw DJ, et al. Multidisciplinary care and stepwise treatment for fibromyalgia. J Clin Psychiatry. 2008;69(12):e35.
- Hassett AL, Gevirtz RN. Nonpharmacologic treatment for fibromyalgia: patient education, cognitive-behavioral therapy, relaxation techniques, and complementary and alternative medicine. Rheum Dis Clin North Am. 2009;35(2):393–407.