Diagnosis of Fibromyalgia
The ACR criteria for fibromyalgia were never intended to be strict
diagnostic criteria for use in clinical practice. Many individuals who clearly
have fibromyalgia will not have pain throughout their entire body, or will not
have 11 tender points. Figure 7 illustrates the algorithm for the diagnosis of
fibromyalgia.
Figure 7. Algorithm for the diagnosis and treatment of fibromyalgia.
History Pain. In clinical practice, practitioners should suspect fibromyalgia
in individuals with multifocal pain that cannot be explained on the basis of
damage or inflammation in those regions of the body. In most cases,
musculoskeletal pain is the most prominent feature, but because pain pathways
throughout the body are amplified, pain can be perceived more generally. Thus,
chronic headaches, sore throats, chest pain, abdominal pain, and pelvic pain are
very common in individuals with fibromyalgia, and patients with chronic regional
pain in any of these locations are more likely to have fibromyalgia.
Because pain is a defining feature of fibromyalgia, it is helpful to focus on
the features of the pain that can help distinguish it from other disorders. The
pain of fibromyalgia is typically diffuse or multifocal, often waxes and wanes,
and is frequently migratory in nature. These characteristics of "central pain"
are quite different from "peripheral" pain, where both the location and severity
of pain are typically more constant. Patients may complain of discomfort when
they are touched or when wearing tight clothing, and may experience dysesthesias
or paresthesias that accompany the pain.
Nonpain symptoms. Aside from pain, a number of seemingly nonrelated symptoms
may develop and persist. These include fatigue, sleep difficulties, weakness,
problems with attention or memory, unexplainable weight fluctuations, and heat
and cold intolerance. "Allergies" are reported much more commonly in
fibromyalgia patients, although these excess symptoms are better considered
hypersensitivities than true IgE-mediated immunologic reactions. These patients
are also more prone to nonallergic rhinitis, sinus and nasal congestion, and
lower respiratory symptoms, all of which, again, may be primarily attributable
to neural mechanisms. Distortions in hearing, vision, and vestibular symptoms
are often reported, as are sicca symptoms (sometimes so prominent that these
individuals will overlap with those with Sjogren's syndrome).
"Functional disorders" involving visceral organs have long been noted to be
more common in fibromyalgia. These include noncardiac chest pain, heartburn and
palpitations, as well as the frequent comorbidity of irritable bowel syndrome.
Thus, there are reports of increased echocardiographic evidence of mitral valve
prolapse and esophageal dysmotility, as well as reduced static inspiratory and
expiratory pressure on pulmonary function tests. The latter might be explained
by pain in respiratory muscles. Syncope and hypotension are symptoms that may
occur in fibromyalgia, and in some cases will be accompanied by neurally
mediated hypotension or postural orthostatic tachycardia. Pelvic complaints are
common, including not only pain but also urinary frequency and urgency. In
females the frequent comorbid diagnoses are dysmenorrhea, interstitial cystitis,
endometriosis, and sensitivity disorders like vulvar vestibulitis and
vulvodynia; whereas in males these same symptoms are
sometimes diagnosed as nonbacterial prostatitis.
Physical Examination and Laboratory Investigations Physical examination is
often unremarkable, except for the presence of tenderness. As previously
discussed, tenderness may be generalized and thus present anywhere in the body.
Laboratory testing is generally not useful, except for the purpose of
differential diagnosis. One factor that can help guide the intensity of the
diagnostic work-up is the length of time the patient has had symptoms. If the
patient's symptoms have persisted for several years, minimal testing is
required, whereas a more aggressive strategy should be employed for acute or
subacute onset of symptoms. Simple testing should be limited to complete blood
count and routine serum chemistries, along with thyroid-stimulating hormone
(TSH) and erythrocyte sedimentation rate (ESR).
Serologic studies such as antinuclear antibody (ANA) and rheumatoid factor
assays should generally be avoided unless there are historical features not seen
in fibromyalgia or abnormalities on physical examination. Such studies represent
a problem in clinical practice, because several autoimmune disorders share
overlapping symptomatology with fibromyalgia. These include not only fatigue,
arthralgias, and myalgias, but also such symptoms as morning stiffness and
subjective swelling of the hands and feet. Certain dermatologic features
commonly seen in fibromyalgia, including malar flushing, livedo reticularis, and
Raynaud's-like reddening of the hands, also mimic symptoms of autoimmune
disorders. This overlap sometimes results in patients with fibromyalgia being
misdiagnosed as having an autoimmune disorder such as systemic lupus
erythematosus.
Aside from the many comorbid conditions already discussed, fibromyalgia may
present similarly to a number of disorders or concurrently with other disorders
that may confuse the diagnosis (Table 2). Hypothyroidism and polymyalgia
rheumatica can be differentiated from fibromyalgia by results of TSH and ESR.
Sleep apnea and hepatitis C also simulate fibromyalgia and tend to present more
often in men than women.
Table 2. Conditions That Simulate Fibromyalgia Common Less Common
Hypothyroidism Hepatitis C Polymyalgia rheumatica Sleep apnea Early in
course of autoimmune disorders, eg, rheumatoid arthritis or SLE Chiari
malformation Sjogren's syndrome




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