Improving the Recognition and Diagnosis of Fibromyalgia

doi:10.4065/mcp.2010.0738

Mayo Clinic Proceedings

Volume 86, Issue 5, May 2011, Pages 457-464

https://doi.org/10.4065/mcp.2010.0738 Get rights and content

Fibromyalgia (FM) is a chronic widespread pain disorder often seen in primary care practices. Advances in the understanding of FM pathophysiology and clinical presentation have improved the recognition and diagnosis of FM in clinical practice. Fibromyalgia is a clinical diagnosis based on signs and symptoms and is appropriate for primary care practitioners to make. The hallmark symptoms used to identify FM are chronic widespread pain, fatigue, and sleep disturbances. Awareness of common mimics of FM and comorbid disorders will increase confidence in establishing a diagnosis of FM.

Section snippets

UNDERDIAGNOSIS

Despite improved understanding of its pathologic processes, FM remains undiagnosed in as many as 3 out of 4 people with the condition (Data on file. Decision Resources report 2009. Pfizer, New York, NY). Diagnosis time averages 5 years,¹¹ resulting in delayed treatment and potentially suboptimal medical care. Women currently account for 80% to 90% of cases diagnosed using the American College of Rheumatology (ACR) 1990 criteria for FM (prevalence, 3.4% in women vs 0.5% in men).¹ Women are more

IMPORTANCE OF IMPROVED RECOGNITION AND DIAGNOSIS

Establishing the diagnosis of FM is an essential component of successful management.⁴ Many patients with FM have been living with chronic pain and other troubling and disabling symptoms for extended periods. Primary care practices undoubtedly see more patients with FM than is currently appreciated. When such patients are finally recognized and a diagnosis is confirmed, both clinician and patient clear a major hurdle to more effective management of the disorder.

Research shows that the diagnosis

A PRACTICAL APPROACH TO RECOGNITION AND DIAGNOSIS

Fibromyalgia is a clinical diagnosis based on the disorder's unique clinical characteristics and not solely a diagnosis of exclusion. Like other pain states (eg, migraine), FM is commonly diagnosed in the primary care setting on the basis of characteristic symptoms.

A focused history and physical examination are the cornerstones of FM recognition. No laboratory or radiologic testing is required to diagnose FM. Such tests are necessary only if clinically indicated to evaluate other potential

FORMAL CLASSIFICATION CRITERIA

The ACR criteria for FM (Figure 1) include a history of widespread pain lasting 3 months or longer.³¹ Widespread pain is defined as pain above and below the waist and on both sides of the body. In addition, axial skeletal pain (in the cervical spine, anterior chest, thoracic spine, or lower back) must be present. According to the ACR, a patient must have pain on digital palpation at 11 of 18 predesignated sites, commonly referred to as tender points, to be diagnosed as having FM. Approximately

DIFFERENTIAL DIAGNOSIS

Current medications should be identified and medication-related pain such as statin-induced muscle pain or opioid-induced hyperalgesia ruled out. Identification of disorders that can mimic FM (eg, hypothyroidism and inflammatory rheumatic diseases) or that are frequent comorbid conditions in patients with FM (eg, RA, osteoarthritis, systemic lupus erythematosus, spinal stenosis, neuropathies, sleep disorders such as sleep apnea, and mood and anxiety disorders) is essential so that appropriate

CONCLUSION

Fibromyalgia can have a profound effect on a patient's quality of life. Despite greater interest in and awareness of the disorder than ever before, FM remains underdiagnosed and undertreated. A greatly improved understanding of FM and its pathophysiologic underpinnings has helped explain the varied and often complex constellation of FM signs and symptoms, resulting in effective new treatment approaches.

Fibromyalgia is a clinical diagnosis that, similar to other chronic pain states such as

Acknowledgments

Editorial support was provided by Dr Gayle Scott, PharmD, of UBC Scientific Solutions and funded by Pfizer.

Questions About Fibromyalgia

1.
Which one of the following triad of symptoms is the most typical presentation of fibromyalgia (FM)?
- a.
  Pain, anorexia, and elevated creatine phosphokinase levels
- b.
  Pain, mild dysphasia, and ataxia
- c.
  Pain, disturbed sleep, and fatigue
- d.
  Pain, paresthesia, and depression
- e.
  Pain, swollen joints, and elevated erythrocyte sedimentation rate
2.
Which one of the following best describes the pathophysiology of FM pain?
- a.
  Aberrant processing of painful stimuli in the central nervous system
- b.
  Diffuse

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Cited by (167)

Do FIQR Severity Categories and Symptoms, Differentiate Between Continuous, Intermittent and Non-Opioid Users in the Treatment of Fibromyalgia?
2024, Pain Management Nursing
Many fibromyalgia patients utilize opioids to treat symptoms. It is important to better understand nuances regarding this treatment option and any stigma associated with this treatment modality.
This study: (1) assessed the prevalence of opioid use among continuous, intermittent, and non-opioid users in fibromyalgia patients; (2) determined whether the Revised Fibromyalgia Impact Questionnaire (FIQR) was useful in distinguishing opioid use and symptom burden; and (3) assessed whether fibromyalgia patients encountered stigma and/or invalidation.
A cross-sectional, observational study of 1,105 participants’ responses to validated fibromyalgia and invalidation scales and demographic questions.
The study employed online survey methodology.
A total of 45% of patients reported utilizing opioids (27% continuous, 18% intermittent, 55% non-users). FIQR disease categories (mild to most severe) strongly distinguished between opioid and non-opioid users with 59% of users falling in the most severe category and 68% of non-users falling in mild disease category (p < .0001). Interestingly, intermittent users were similar to non-users on FIQR severity (65.9 versus 65.7; p <0.60, 0-100) while continuous users reported greater severity than the former (73.9, p < .0001). Continuous users particularly reported more problems with daily activities (p < .0001), being overwhelmed (p < .0001), and being unable to accomplish goals (p < .0001). Stigma related to being ‘drug seeking’ and being ‘judged’. Invalidation was infrequent.
Opioid use is common in fibromyalgia and increases monotonically with FIQR severity. Multidisciplinary approaches which help patients perform daily activities, decrease feelings of overwhelm, accomplish goals, and reduce stigma may be beneficial.
Patient-journey of fibromyalgia patients: A scoping review
2024, Reumatologia Clinica
Fibromyalgia (FM) is a chronic disease characterized by widespread pain. Although much is known about this disease, research has focused on diagnosis and treatment, leaving aside factors related to patient's experience and the relationship with healthcare system.
The aim was to analyze the available evidence on the experience of FM patients from the first symptoms to diagnosis, treatment, and follow-up.
A scoping review was carried out. Medline and the Cochrane Library were searched for original studies or reviews dealing with FM and focusing on “patient journey”. Results were organized using a deductive classification of themes.
Fifty-four articles were included in the qualitative synthesis. Five themes were identified: the patient journey, the challenge for the health systems, a complex doctor–patient relationship, the importance of the diagnosis, and the difficulty of standardizing the treatment.
This scoping review confirms the negative impact of FM on the patient, their social environment, and health systems. It is necessary to minimize the difficulties encountered throughout the diagnosis and follow-up of patients with FM.
La fibromialgia (FM) es una enfermedad crónica caracterizada por dolor generalizado. Aunque se sabe mucho de esta enfermedad, la investigación se ha centrado en el diagnóstico y el tratamiento, sin valorar la experiencia del paciente y la relación con el sistema.
El objetivo fue analizar la evidencia sobre la experiencia de los pacientes con FM desde el inicio de los síntomas hasta el diagnóstico, el tratamiento y el seguimiento.
Se realizó una revisión de alcance. Se buscaron en Medline y en Cochrane Library estudios o revisiones sobre la FM y “patient journey”. Los resultados se clasificaron mediante deductiva de temas.
Se incluyeron 54 artículos en la síntesis cualitativa. Se identificaron cinco temas: el viaje del paciente, el reto para los sistemas sanitarios, la compleja relación médico-paciente, la importancia del diagnóstico, y la dificultad de estandarizar el tratamiento.
Esta revisión confirma el impacto negativo de la FM en pacientes, su entorno social y sistemas sanitarios. Es necesario minimizar las dificultades durante el diagnóstico y seguimiento de pacientes con FM.
Hierarchical Clustering Applied to Chronic Pain Drawings Identifies Undiagnosed Fibromyalgia: Implications for Busy Clinical Practice
2024, Journal of Pain
Currently-used assessments for fibromyalgia require clinicians to suspect a fibromyalgia diagnosis, a process susceptible to unintentional bias. Automated assessments of standard patient-reported outcomes (PROs) could be used to prompt formal assessments, potentially reducing bias. We sought to determine whether hierarchical clustering of patient-reported pain distribution on digital body map drawings predicted fibromyalgia diagnosis. Using an observational cohort from the University of Pittsburgh’s Patient Outcomes Repository for Treatment registry, which contains PROs and electronic medical record data from 21,423 patients (March 17, 2016–June 25, 2019) presenting to pain management clinics, we tested the hypothesis that hierarchical clustering subgroup was associated with fibromyalgia diagnosis, as determined by ICD-10 code. Logistic regression revealed a significant relationship between the body map cluster subgroup and fibromyalgia diagnosis. The cluster subgroup with the most body areas selected was the most likely to receive a diagnosis of fibromyalgia when controlling for age, gender, anxiety, and depression. Despite this, more than two-thirds of patients in this cluster lacked a clinical fibromyalgia diagnosis. In an exploratory analysis to better understand this apparent underdiagnosis, we developed and applied proxies of fibromyalgia diagnostic criteria. We found that proxy diagnoses were more common than ICD-10 diagnoses, which may be due to less frequent clinical fibromyalgia diagnosis in men. Overall, we find evidence of fibromyalgia underdiagnosis, likely due to gender bias. Coupling PROs that take seconds to complete, such as a digital pain body map, with machine learning is a promising strategy to reduce bias in fibromyalgia diagnosis and improve patient outcomes.
This investigation applies hierarchical clustering to patient-reported, digital pain body maps, finding an association between body map responses and clinical fibromyalgia diagnosis. Rapid, computer-assisted interpretation of pain body maps would be clinically useful in prompting more detailed assessments for fibromyalgia, potentially reducing gender bias.
The patient journey of fibromyalgia in Latin America
2024, Reumatologia Clinica
Explorar la experiencia de las personas con fibromialgia (FM) en países latinoamericanos con objeto de identificar problemas en la atención sanitaria y otros ámbitos potencialmente solucionables.
Estudio cualitativo con enfoque fenomenológico y de análisis de contenido a través de grupos focales y metodología de viaje del paciente (Ux del inglés User Experience). Se llevaron a cabo 9 grupos focales virtuales con pacientes con FM y profesionales sanitarios en Argentina, México y Colombia reclutados a partir de informantes clave y redes sociales.
Participaron 43 personas (33 clínicos y 10 pacientes). Los agentes que interaccionan con el paciente en la enfermedad se encuentran en 3 esferas: la de la atención sanitaria, la del apoyo y vida laboral y la del contexto socioeconómico. La línea del viaje presenta 2 grandes tramos, 2 bucles y una línea discontinua delgada. Los 2 grandes tramos representan los tiempos que van desde los primeros síntomas hasta la visita médica y desde el diagnóstico hasta el seguimiento. Los bucles incluyen: 1.°) sucesión de diagnósticos, tratamientos erróneos y derivaciones a especialistas y 2.°) nuevos síntomas cada cierto tiempo, visitas a especialistas y dudas diagnósticas. Pocos pacientes logran la fase final de autonomía.
El viaje de una persona con FM en Latinoamérica está lleno de obstáculos. La meta deseada es que todos los agentes entiendan que el automanejo por parte del paciente con FM es una parte indispensable del éxito, y solo se puede lograr accediendo a recursos de forma precoz y guiado por profesionales.
To explore the patient journey of people with fibromyalgia (FM) in Latin American countries in order to identify problems in health care and other areas that may be resolvable.
Qualitative study with phenomenological and content analysis approach through focus groups and patient journey (Ux; User Experience) methodology. Nine virtual focus groups were conducted with FM patients and healthcare professionals in Argentina, Mexico and Colombia recruited from key informants and social networks.
Forty-three people participated (33 were clinicians and 10 were patients). The agents interacting with the patient in their disease journey are found in three spheres: healthcare (multiple medical specialists and other professionals), support and work life (including patient associations) and socioeconomic context. The line of the journey presents two large sections, two loops and a thin dashed line. The two major sections represent the time from first symptoms to medical visit (characterized by self-medication and denial) and the time from diagnosis to follow-up (characterized by high expectations and multiple contacts to make life changes that are not realized). The two loop phases include (1) succession of misdiagnoses and mistreatments and referrals to specialists and (2) new symptoms every so often, visits to specialists, diagnostic doubts, and impatience. Very few patients manage to reach the final phase of autonomy.
The journey of a person with FM in Latin America is full of obstacles and loops. The desired goal is for all the agents involved to understand that self-management by the patient with FM is an essential part of success, and this can only be achieved with early access to resources and guidance from professionals.
High frequency of gastrointestinal complaints, but insignificant prevalence of gluten-sensitive enteropathies in Brazilian fibromyalgia patients
2023, Reumatologia Clinica
Coeliac disease (CD) and non-coeliac gluten sensitivity (NCGS) cause symptoms like those seen in patients with fibromyalgia (FM) and functional gastrointestinal disorders. There is no consistent data on frequency of these symptoms and no study performed duodenal biopsies to investigate CD/NCGS in Brazilian FM patients. Therefore, we sought to verify the prevalence of CD/NCGS in FM patients and the association between gastrointestinal manifestations and FM symptoms.
Sixty-two individuals with FM (ACR2010) were recruited from FM outpatient clinics of a tertiary hospital. Clinical evaluation included the Widespread Pain Index (WPI), Severity Symptom Scale (SS), Polysymptomatic Distress Scale (PDS), and Fibromyalgia Impact Questionnaire (FIQ). Subjects were screened for the presence of coeliac antibodies and upper gastrointestinal endoscopy (duodenal biopsies) was performed for diagnosis of CD/NCGS.
46 (74.2%) women reported at least one digestive symptom: constipation, abdominal distension, loss of weight/inappetence, and nausea/vomiting. Fourteen (31.8%) presented macroscopic duodenitis and 2(4.5%) had duodenal lymphocytic infiltrates, but none met CD criteria. In 1(1.6%) patient NCGS was confirmed. There was association between presence of any digestive symptom and WPI and SS (fatigue, waking up tired, cognition), but no difference on FIQ between patients with and without gastrointestinal symptoms.
Gastrointestinal complaints were frequent and associated with increased degree of polysymptomatic distress in FM patients, but presence of these symptoms was not related to overall impact of FM over different dimensions of the patient's life. Moreover, the prevalence of CD/NCGS was very low. This suggests that screening for CD in Brazilian FM patients might not be cost-effective, since the frequency of CD/NCGS was very low.
La enfermedad celíaca (EC) y la sensibilidad al gluten no celíaca (SGNC) causan síntomas similares a los observados en pacientes con fibromialgia (FM) y trastornos gastrointestinales funcionales. Ningún estudio realizó biopsias duodenales para investigar EC/SGNC en pacientes brasileños con FM. Por lo tanto, buscamos verificar la prevalencia de EC/SGNC en pacientes con FM y la asociación entre manifestaciones gastrointestinales y síntomas de FM.
Sesenta y dos mujeres con FM (ACR2010) fueron reclutadas de las consultas de FM de un hospital terciario. La evaluación incluyó el índice de dolor generalizado (IDG), la escala de gravedad de síntomas (SS), la escala de angustia polisintomática (EAP) y el cuestionario de impacto de la fibromialgia (FIQ). Los sujetos fueron examinados para la presencia de anticuerpos celíacos y se realizó una endoscopia gastrointestinal superior (biopsias duodenales) para el diagnóstico de EC/SGNC. Se investigaron las asociaciones estadísticas entre las molestias gastrointestinales y los síntomas de FM (p < 0,05).
Un total de 46 (74,2%) mujeres refirieron al menos un síntoma digestivo: estreñimiento, distensión abdominal, pérdida de peso/inapetencia y náuseas/vómitos. Catorce (31,8%) presentaban duodenitis macroscópica y 2 (4,5%) infiltrados linfocíticos duodenales, pero ninguno cumplía criterios de EC. En un (1,6%) paciente se confirmó SGNC. Hubo asociación entre la presencia de síntoma digestivo y IDG y SS (fatiga, despertarse cansado, cognición), pero no hubo diferencia en FIQ entre pacientes con y sin síntomas gastrointestinales.
A pesar de la alta prevalencia de síntomas digestivos y su asociación con el grado de amplificación del dolor central, la frecuencia de EC/SGNC fue insignificante. Además, no se observaron diferencias en el impacto de la FM en la calidad de vida (FIQ) en pacientes con y sin síntomas gastrointestinales.
Fibromyalgia: Recognition and Management in the Primary Care Office
2022, Rheumatic Disease Clinics of North America

View all citing articles on Scopus

Dr Arnold has received grants/research support from Eli Lilly and Company, Pfizer, Cypress Biosciences, Wyeth Pharmaceuticals, Boehringer Ingelheim, Allergan, and Forest Laboratories. She is a consultant for Eli Lilly and Company, Pfizer, Cypress Biosciences, Wyeth Pharmaceuticals, Boehringer Ingelheim, Forest Laboratories, Allergan, Takeda, UCB, Theravance, AstraZeneca, and sanofi-aventis. Dr Clauw has received grants/research support from Pfizer and Forest Laboratories. He is a consultant for Pfizer, Eli Lilly and Company, Forest Laboratories, Cypress Biosciences, Pierre Fabre Pharmaceuticals, UCB, and AstraZeneca. Dr Clauw is a member of the advisory boards for Pfizer, Eli Lilly and Company, Forest Laboratories, Cypress Biosciences, Pierre Fabre Pharmaceuticals, UCB, and AstraZeneca. Dr McCarberg has received honoraria from Cephalon, Eli Lilly and Company, Endo Pharmaceuticals, Forest Laboratories, Merck & Co., Pfizer, and Purdue Pharma. The FibroCollaborative group was sponsored by Pfizer.

A list of the additional members of the FibroCollaborative appears on page 464

A question-and-answer section appears at the end of this article.

Additional Members of the FibroCollaborative. Kenneth Barrow, PA-C, MHS, Independence Back Institute, Wilmington, NC; Lucinda Bateman, MD, Fatigue Consultation Clinic Inc, Salt Lake City, UT; Larry Culpepper, MD, MPH, Boston University, Boston, MA; Cassandra Curtis, MD, American Health Network, Greenfield, IN; Yvonne D'Arcy, MS, CRNP, CNS, Suburban Hospital-Johns Hopkins Medicine, Bethesda, MD; L. Jean Dunegan, MD, JD, Hillsdale Community Health Center, Brighton, MI; Kevin B. Gebke, MD, Indiana University, Indianapolis; Robert Gerwin, MD, Pain and Rehabilitation Medicine, Bethesda, MD; Don L. Goldenberg, MD, Newton-Wellesley Hospital, Newton, MA; James I. Hudson, MD, ScD, Harvard University, Belmont, MA; Rakesh Jain, MD, MPH, Clinical Research Center, Lake Jackson, TX; Arnold L. Katz, MD, Overland Park Regional Medical Center, Overland Park, KS; Andrew G. Kowal, MD, Tufts University, Burlington, MA; Charles Lapp, MD, Duke University, Charlotte, NC; Philip J. Mease, MD, Swedish Medical Center, Seattle, WA; Danielle Petersel, MD, Pfizer Inc, New York, NY; I. Jon Russell, MD, PhD, University of Texas, San Antonio; Stephen M. Stahl, MD, PhD, University of California, San Diego; Dennis C. Turk, PhD, University of Washington, Seattle; and Alvin F. Wells, MD, PhD, Rheumatology & Immunotherapy Center, Oak Creek, WI.

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CONCISE REVIEW FOR CLINICIANSImproving the Recognition and Diagnosis of Fibromyalgia

Section snippets

UNDERDIAGNOSIS

IMPORTANCE OF IMPROVED RECOGNITION AND DIAGNOSIS

A PRACTICAL APPROACH TO RECOGNITION AND DIAGNOSIS

FORMAL CLASSIFICATION CRITERIA

DIFFERENTIAL DIAGNOSIS

CONCLUSION

Acknowledgments

Questions About Fibromyalgia

Patient Educ Couns

Rheum Dis Clin North Am

Rheum Dis Clin North Am

Rheum Dis Clin North Am

Rheum Dis Clin North Am

Rheum Dis Clin North Am

Rheum Dis Clin North Am

Rheum Dis Clin North Am

J Pain

Rheum Dis Clin North Am

Psychiatr Clin North Am

Rheum Dis Clin North Am

The prevalence and characteristics of fibromyalgia in the general population

Arthritis Rheum

Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II

Arthritis Rheum

Guidelines for the management of fibromyalgia syndrome pain in adults and children. APS Clinical Practice Guidelines Series, No. 4

Management of fibromyalgia syndrome

JAMA

Characteristics and healthcare costs of patients with fibromyalgia syndrome

Int J Clin Pract

CONCISE REVIEW FOR CLINICIANS
Improving the Recognition and Diagnosis of Fibromyalgia