Fibromyalgia: An Environmental Scan
Table of Contents
As with other chronic pain disorders, diagnosis of fibromyalgia is established by the physician on the basis of the patient history, clinical observations and the physical exam. Importantly, fibromyalgia is a syndrome with a number of presenting symptoms that exist on a continuum; therefore, it is not uncommon for a clinician to require patient observation over time in order to firmly establish a proper diagnosis. Fibromyalgia should be considered in any patient with widespread pain that is unexplained by a clear anatomical pathology. Specific to fibromyalgia is that the diagnosis depends on findings from the history and physical examination rather than on diagnostic testing. The criteria for classifying patients with fibromyalgia were established in 1990 but do not absolutely exclude patients who do not meet the criteria (Millea and Holloway 2000). A patient’s history is important given our understanding of possible triggers such as a trauma along with the impact of stress, medical illness, sleep disturbances or abnormalities, depression and anxiety. Furthermore, the tendency of fibromyalgia to run in families along with the increased likelihood of fibromyalgia and high prevalence of the presence of co-morbid conditions are all indicative of the necessity of a full and thorough patient history (Chakrabarty and Zoorob 2007).
Despite having no specific test or diagnostic procedure to definitively conclude an individual has fibromyalgia, the physical exam allows a clinician to conclude confidently that the patient exhibits significant signs of the syndrome. The physical exam consists of applying pressure to certain places on the body to detect the level of pain or tenderness. The American College of Rheumatology (ACR) has selected 18 sites used as indicators for specific association with fibromyalgia (See Appendix F and Appendix G). The classification of fibromyalgia requires that there must be tenderness on palpation at 11 of the 18 sites, a history of pain and other clinical manifestations for a minimum of 3 months and clinicians must look for widespread pain inclusive of both the upper and lower body along with pain on both sides or bilateral body pain. Skill in palpation of tender points is critical to establishing a diagnosis of fibromyalgia. Physical findings to consider during the physical exam are the soft tissues include tender points, changes in skin texture, increased resting muscle tension and changes in the texture of the subcutaneous tissue.
Some individuals with fibromyalgia will not meet this classification and tender points may change location and intensity of tenderness or pain levels over time. Importantly, all indications of pain and tenderness must be in the absence of inflammatory processes such as redness, swelling or heat in the joints and soft tissues of the body (Millea and Holloway 2000). Importantly, patients who do not meet the ACR criteria require a complete workup including laboratory tests to ensure accurate diagnosis as presenting symptoms can overlap with other conditions so it is paramount to rule out other conditions.