How to Diagnose Fibromyalgia ?

• History
• Personal history
• Family history

• Physical examination
• Diagnostic criteria : ACR 1990 or ACR 2010
• Tender-point evaluation

• Laboratory examination
• To exclude other conditions such as: Osteoarthritis, rheumatoid
arthritis, hypothyroidism, lupus, and Sjögren’s syndrome

Mease. J Rheumatol. 2005;32:6-21. Wolfe et al. Arthritis Rheum. 1990;33:160-172.

 DIAGNOSTIC CRITERIA
ACR 2010 Criteria

A patient satisfies diagnostic criteria for fibromyalgia if the following 3

conditions are met:

1.Widespread pain index (WPI) ≥ 7 and symptom severity scale (SS)

score ≥ 5, or WPI 3–6 and SS scale score 9.

2.Symptoms have been present at a similar level for at least 3 months.

3.The patient does not have a disorder that would otherwise explain the
pain.
 Widespread Pain Index (WPI)

• Note the number of areas in which the patient has had pain over the last week.
Score will be between 0 and 19.
• To be used in conjunction with the Symptom Severity (SS) scale

Upper extremity Lower extremity Front Back

Shoulder girdle, left Hip (buttock, trochanter), left Jaw, left Upper back
Shoulder girdle, right Hip (buttock, trochanter, right) Jaw, right Lower back
Upper arm, left Upper leg, left Chest Neck
Upper arm, right Upper leg, right Abdomen
Lower arm, left Lower leg, left
Lower arm, right Lower leg, right
(6) (6) (4) (3)

25
Wolfe F, et al. Arthritis Care Res (Hoboken) 2010;62:600-610.
 Symptom Severity (SS) scale score
For each of 3 symptoms : fatigue, waking unrefreshed and cognitive
indicate level of severity over the past week using the following scale:
 0 = no problem
 1 = slight or mild problems, generally mild or intermittent
 2 = moderate, considerable problems, often present and/or at a moderate level
 3 = severe: pervasive, continuous, life-disturbing problems

Considering somatic symptoms in general, indicate whether patient has:

 0 = no symptoms
 1 = few symptoms
 2 = a moderate number of symptoms
 3 = a great deal of symptoms

Wolfe F, et al. Arthritis Care Res (Hoboken) 2010;62:600-610

 Somatic symptoms to be considered
• Muscle pain - Irritable bowel syndrome - Fatigue/tiredness
• Headache - Muscle weakness - Abdominal pain
• Numbness/tingling - Dizziness - Insomnia
• Depression - Constipation - Nausea
• Nervousness - Chest pain - Fever
• Seizures - Blurred vision - Diarrhea
• Dry mouth - Itching - Wheezing
• Hives/welts - Ringing in ears - Heartburn
• Vomiting - Oral ulcers - Dry eyes
• Rash - Sun sensitivity - Hearing difficulties
• Easy bruising - Hair loss - Frequent urination
• Painful urination - Bladder spasms
• Thinking or remembering problem - Loss of taste
• Raynaud’s phenomenon - Loss of appetite
• Shortness of breath - Upper abdominal pain
Summary of ACR 2010 criteria

WPIWPI
≥ ≥77and SS ≥ 5
AND SS ≥ 5

or
OR
WPI 3–6 AND SS ≥ 9
WPI= 3–6 and SS =9

This case definition of fibromyalgia correctly classifies 88% of

cases classified by existing ACR 1990 classification criteria, but
does not require a tender point examination
Wolfe F, et al. Arthritis Care Res (Hoboken) 2010;62:600-610.
 FM Diagnosis Algorithm

History of widespread pain for ≥3 months

Rule out other conditions presenting with chronic widespread pain

General physical exam, neurologic exam, selected laboratory testing

Use Diagnostic Criteria ACR 1990 or ACR 2010

Confirm diagnosis of fibromyalgia

Modified from Goldenberg JAMA 2004  29

 Differential Diagnosis
• Symptoms of Fibromyalgia may overlap with other conditions, including:
• Chronic fatigue syndrome – Endocrine disorder
• Rheumatoid arthritis (hypothyroidism)
• Systemic lupus erythematosus – Medications
• Sleep apnea – Polymyalgia rheumatica
• Parvovirus – Hepatitis
• Cervical stenosis/Chiari – Malignancy
malformation – Osteoarthritis
• Lyme disease
– Major depressive disorder

• Patients with Fibromyalgia are more likely than non-Fibromyalgia

patients to have comorbidities such as painful neuropathies and
circulatory disorders
Wolfe et al. Arthritis Rheum. 1995;38:19-28.
Wolfe et al. Arthritis Rheum. 1990;33:160-172.
Berger et al. Int J Clin Pract. 2007; 61:1498-1508.
Jain et al. J Musculoskeletal Pain. 2003;11:3-107.
Burckhardt et al. APS Clinical Practice Guideline Series, No. 4.
Carville et al. Ann Rheum Dis. doi:10.1136/ard.2007.071522.
MANAGEMENT
 TREATMENT of FIBROMYALGIA

• No known cure or universally accepted treatment for fibromyalgia

• Treatment is typically aimed at symptom management to alleviate

pain and other fibromyalgia-related symptoms
 Treatment Approach

1. Multidisciplinary therapy
2. Individualized to patients’ symptoms and presentation
3. Integrated Multimodal therapy: : combination of
a) Pharmacologic therapy
b) Nonpharmacologic therapy
 Exercise and Physical therapy
 Psychologic therapy

Mease P. Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment. J Rheumatol. 2005;32(suppl 75):6-21.
Carville, Arendt-Nielsen, Bliddal, et al. EULAR evidence based recommendations for the management of fibromyalgia syndrome [published online ahead of print July 20, 2007]. Ann Rheum Dis.
Doi:10.1136/ard.2007.071522.
Goldenberg et al. JAMA. 2004;292:2388-2395.
Clauw DJ, Crofford LJ. Chronic widespread pain and fibromyalgia: what we know, and what we need to know. Best Pract Res Clin Rheumatol. 2003;17:685-701.
Arnold LM, Goldenberg DL, Stanford SB, et al. Gabapentin in the treatment of fibromyalgia: a randomized, double-blind, placebo-controlled, multicenter trial. Arthritis Rheum. 2007;56:1336-1344.
Multidisciplinary Pain Management

Integrated Coordinated

Pain Specialist
Nurses
Psychiatrist Rheumatologist
Primary
Neurologist Clinician Pharmacist
Physiatrist Social Worker

Psychologist Anesthesiologist
Occupational Therapist Physician Assistant
Physical Therapist
 PHARMACOLOGIC THERAPY

1. Antidepressants.
 Tricyclic antidepressants (Amitriptylin) : effective
 Selective serotonin reuptake inhibitors (SSRIs)
 Serotonin-norepinephrine reuptake inhibitors (SNRIs)
 SSRI and SNRI have lower effects.

2. Anticonvulsants
 Pregabalin : for diabetic polyneuropathic pains, and fibromyalgia
 Gabapentin : approved for use in neuropathic pain but not
fibromyalgia.
PHARMACOLOGIC THERAPY (cont’d)

3. Dopamine agonists
 Pramipexole (Mirapex)
 Ropinirole (ReQuip)
May give some improvement in a minority of patients

Three medications have been approved by the FDA for

treatment of Fibromyalgia:
 Pregabalin (June, 2007)
 Duloxetine (June, 2008 )
 Milnacipran (January, 2009.)
 PHARMACOLOGIC THERAPY (cont’d)

4. Muscle relaxants
 Cyclobenzaprine
 Tizanidine
5. Opioids
 Tramadol / + acetaminophen : Less evidence to support the
efectiveness.
 Opioids other than Tramadol : Have not had random controlled trials.
6. NSAIDs
 Generally ineffective
7. Benzodiazepines
 Diazepam, clonazepam
 For restless leg syndrome or very severe sleep disturbance
NONPHARMACOLOGIC THERAPY

 Aerobic exercise
 Cognitive behavioral therapy
 Patient education
 Strength training
 Acupuncture
 Biofeedback
 Balneotherapy
 Hypnotherapy
Pharmacotherapy : Efficacy
• Strong evidence for efficacy
– Pregabalin, 300-450 mg/day
– Amitriptyline, 25-50 mg at bedtime
– Cyclobenzaprine, 10-30 mgs at bedtime
– Duloxetine, 60-120 mg/day
– Milnacipran, 100-200 mg/day

• Modest evidence for efficacy

– Tramadol, 200-300 mg/day
– SSRIs (fluoxetine, sertraline)

• Weak evidence for efficacy: pramipexole, gamma hydroxybutyrate, growth hormone, 5-

hydroxytryptamine, tropisetron, s-adenosyl-methionine

• No evidence: opioids, NSAIDS, benzodiazepene and nonbenzodiazepene hypnotics, melatonin,

magnesium, DHEA, thyroid hormone, OTC including guaifenesin

Modified from Goldenberg, et al: Management of fibromyalgia syndrome. JAMA 2004; 292:2388-95.
 Non-Pharmacologic Therapy

Strong Evidence Modest Evidence

Exercise Strength training
Physical and psychological benefits Acupuncture
May increase aerobic performance and tender Hypnotherapy
point pain pressure threshold, EMG biofeedback
and improve pain Balneotherapy (medicinal bathing)
Efficacy not maintained if exercise stops Transcranial electrical stimulation
Cognitive-behavioral therapy
Weak Evidence
Improvements in pain, fatigue, mood,
Chiropractic
and physical function
Manual and massage therapy
Improvement often sustained for months
Ultrasound
Patient education/self-management
Improves pain, sleep, fatigue, and
quality of life No Evidence
Tender-point injections
Combination (multidisciplinary therapy)
Flexibility exercise

Goldenberg DL, et al. JAMA. 2004;292:2388-2395; Williams DA, et al. J Rheumatol. 2002;29:1280-
1286; Busch AJ, et al. Cochrane Database Syst Rev. 2002
Conclusions
• Fibromyalgia is a debilitating chronic widespread pain condition with increased pain
sensitivity—the extreme end of a spectrum of abnormal pain perception /
processing – and has a negative impact on patients' quality of life
• More understanding and awareness of fibromyalgia is needed for early detection
and treatment
• Early and accurate diagnosis helps patients with fibromyalgia and may reduce
healthcare costs
• Fibromyalgia management may be improved using a multidisciplinary approach