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Diagnosing
Fibromyalgia
The diagnosis
of fibromyalgia is currently based on the
Classification Criteria developed by The American College of
Rheumatology in 1990. These diagnostic recommendations are
based on 2 features:
1. A history
of widespread pain of 3 months or more. Widespread is
defined as pain in an axial distribution plus pain of both left
and right sides of the body, and pain above and below the
waist.
Thus, a patient with axial pain, plus pain in 3 body
segments would qualify - as seen below.
2. The palpation of 18 specified locations of tenderness (so
called “tender points”). To make a diagnosis of fibromyalgia
there needs to be pain on digital palpation of 11 or more out of
the18 specified tender points. The recommendations specify that
the palpation be at a final force of 4 kg (the amount of
pressure required to blanch a thumbnail) starting at 1 kg and
incrementing by 1 kg at a rate of 1 kg per second. The
anatomical locations of the tender point locations are as
follows
1. Occiput:
Bilateral, at the suboccipital muscle insertions.
2. Low cervical: bilateral, at the anterior aspects of
the
intertransverse spaces at C5-C7.
3. Trapezius: bilateral, at the midpoint of the upper
border.
4. Supraspinatus: bilateral, at origins, above the
scapula spine
near the medial border.
5. Second rib: bilateral, at he second costochondral
junctions,
just lateral to the junctions on upper surfaces.
6. Lateral epicondyle: bilateral, 2 cm distal to the
epicondyles.
7. Gluteal: bilateral, in upper outer quadrants of
buttocks in
anterior fold of muscle.
8. Greater trochanter: bilateral, posterior to the
trochanteric
prominence.
9. Knee: bilateral, at the medial fat pad proximal to
the joint line.
Here are the approximate tender point locations on a mannequin:
Other
common symptoms
Symptoms such as sleep disturbance, fatigue, stiffness, skin
fold tenderness, and cold intolerance, are common in
fibromyalgia patients, but their inclusion did not improve
diagnostic accuracy. The recommended number of tender points --
i.e., 11 or greater -- was originally derived from a
receiver
operating curve and relates to the number giving the best
sensitivity and specificity.
Fibromyalgia
pain typically waxes and wanes in intensity; flares are
associated with unaccustomed exertion, soft tissue injuries,
lack of sleep, cold exposure, and psychological stressors.
Although most patients have widespread body pain, there are
typically one or two locations that are the major foci. These
pain foci often shift to other locations -- often in response to
new biomechanical stresses or trauma. Fibromyalgia is more than
a muscle pain syndrome, as most patients have an array of other
somatic complaints. Nearly all fibromyalgia patients have
severe fatigue, poor sleep, and post-exertional pain. Other
symptoms include: tension type headaches, cold intolerance, dry
mouth, unexplained bruising, poor memory and concentration,
fluid retention, chest pain, jaw pain, dyspnea, dizziness,
abdominal pain, paresthesiae, and low grade depression and
anxiety. Some symptoms relate to specific syndromes whose
prevalence appears to be increased; these include: irritable
bowel syndrome, irritable bladder syndrome migraine,
premenstrual syndrome, Raynaud’s and restless leg syndrome.
Do you need blood tests and imaging tests to diagnose
fibromyalgia?
The 1990 ACR
recommendations state that "fibromyalgia is not a diagnosis of
exclusion". This means that you do not need special tests to
rule out other conditions. If a patient meets the historic
and exam findings of tender points they can be diagnosed as
having FM. This is an important concept, as some physicians only
consider a diagnosis of FM after they have done exhaustive
testing to rule out other conditions.
However, it is
equally important to understand that FM often accompanies
other conditions such as osteoarthritis, lupus (SLE), rheumatoid
arthritits and multiple sclerosis. Thus, depending on the
history and physical exam, further testing is often quite
appropriate. In fact a careful evaluation for all other
conditions that may be contributing to pain is an essential part
of an informed treatment plan. However, I stress that the
finding of another condition does not necessarily rule out a
diagnosis of FM.
Acceptance of Fibromyalgia as a valid Diagnosis
The publication
of the ACR criteria led to widespread interest and research into
this disorder. For instance, the US Government provided research
funding for fibromyalgia through the NIH, and both the Social
Security Administration and the Veterans Administration
recognize fibromyalgia as a potential cause for disability.
More recently, the American Boards of Internal Medicine have
included questions on fibromyalgia in their certifying
examinations. Interestingly many soldiers suffering from
“Gulf-War Syndrome” have been found to have fibromyalgia.
Here are some
links to Government and other influential organizations that
recognize fibromyalgia:
http://www.ama-cmeonline.com/pain_mgmt/module08/06fibro/02_01.htm
The Social
Security Administration recognizes fibromyalgia as a potential
cause of disability -
http://www.myalgia.com/SSA_FM
The American
Boards of Internal Medicine requires that physicians taking
their recertification examination be familiar with fibromyalgia
-
http://www.superscore.com/abim_recertification_exam_course.htm
The Veterans
Administration recognizes fibromyalgia as a potential cause of
disability -
http://www.myalgia.com/vah
disability.htm
The Mayo Clinic
recognizes fibromyalgia as a common cause of pain -
http://www.mayoclinic.com/invoke.cfm?id=DS00079
The Cleveland
Clinic contributes to the WebMD website on fibromyalgia -
http://www.clevelandclinic.org/arthritis/treat/facts/fibromyalgia.htm
The National
Institutes of Health recognize fibromyalgia as a common problem
-
http://www.niams.nih.gov/hi/topics/fibromyalgia/fibrofs.htm
The National
Institutes of Health supports research on fibromyalgia -
http://www.niams.nih.gov/rtac/funding/grants/ep3.htm
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