Understanding Fibromyalgia; How Experts are Diagnosing and Treating Their Patients - Episode 5
Experts discuss the common characteristics of fibromyalgia (FM) and related symptoms.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Any further comments on this section before we move ourselves on to the diagnosis of fibromyalgia? Any parting words? Then let's move on now, and let's talk about diagnosing fibromyalgia. We've already talked a little bit about this, but let's kind of put it into a succinct conversation. And what are the characteristic features of fibromyalgia?
Kostas Botsoglou, MD: The original ACR criteria included widespread pain for at least 3 months and the presence of at least 11 tender points out of 18 sites. But the revised criteria, we don't require the tender points for diagnosis, but the presence of generalized widespread pain for at least 3 months, and scale based on the degree of fatigue, adjusting non-restorative sleep, as well as any cognitive symptoms, which is more practical as well in the office setting.
Benjamin Natelson, MD: I would think it's simpler to just assess for widespread pain to find this four-quadrant pain and then multiple tender points. In our center we use that. And then of course we very carefully look for the criteria for chronic fatigue syndrome which in the new case definition of FM overlaps. And, we do that specifically to try to force the groups apart for research purposes.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Anything else to add to that, Dr Clauw, or do you think we've covered the characteristic features?
Daniel Clauw, MD: No. I think it's important because, again, the criteria that are generally recommended are the new criteria that are entirely self-report. No one knows how to do a tender point count correctly, even if those criteria made sense in the first place. And so, it is important to know there's two elements. There's the widespread pain index, and that is just adding up a total of 19 sites of pain, and that that's scored from 0 to 19 depending on how many sites someone has. And then on the other side is the symptom severity component of that which scores sleep memory and fatigue problems, 0 to 3. And then there's three points for headache, IBS, and depression. But it's a total of 31 points and a score of 13 or higher with various combinations is now considered to be diagnostic of fibromyalgia. But I don't think people should in any way rigidly adhere to those criteria. There's not anything about them that’s definitive. And in all the research we've done in 30 years of pathophysiology, you should think of it as a continuum and that these individuals are at the end of a continuum.
Benjamin Natelson, MD: I agree with that, in that there's probably a skewed bell-shaped curve of severity and symptoms with individuals who have body wide achiness pretty much alone, and then individuals where they get more perhaps related to the pain interfering with sleep or other mechanisms.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: And we see that same spectrum in headache disorders, tension, migraine, and cluster with a lot of overlap. And certainly, there are diagnostic criteria for it, but there's also a lot of overlap and nothing really kind of fits. A lot of people don't fit into one of the criteria. It's a great way to think of it. For our colleagues who are unaware, there is a downloadable printable version of a tool that can be used in a primary care clinic that reiterates this criteria for those people who just don't make this diagnosis a lot. It's available online and you can download it and print it out.
Daniel Clauw, MD: Can I just mention one other sort of clinical pearl that is sometimes helpful is that these individuals on brain imaging, quantitative sensory testing are more sensitive to any type of sensory stimuli, the brightness of light, the loudness of noises, odors. They have a lot of adverse effects of drugs that are hypersensitivities, not true allergies. And when you see someone clinically that you think might have fibromyalgia based on the other part of the profile, and then you ask them just offhand, 'Are you bothered by bright lights or noises?' And they go, 'Yeah, absolutely.' That helps you really sort of localize that this is sort of like an amplifier volume control problem, which is really what we think nociplastic pains, central sensitization fibromyalgia is this that in the central nervous system, the amplifiers turned up too high. But it's not just painful signals that are amplified, other sensory information like light and noises and things like that are also amplified. So, I think it is helpful clinically to tell people to ask that set of questions because it just helps close the loop when someone says, 'Oh my, I didn't ever put together that my pain sensitivity could be related to by wearing sunglasses all the time.'
Transcript edited for clarity.