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Diagnosing fibromyalgia: Moving away from tender points

Diagnosing fibromyalgia: Moving away from tender points

Fibromyalgia syndrome (FMS) is not a novel entity—there has been interest in unexplained pain syndromes since antiquity (Figure 1). The earliest research focused on the symptom of “muscle hardenings,” which may be the equivalent of musculoskeletal symptoms that patients with FMS describe today. More recently, the concept of FMS diagnosis has undergone several changes, including a shift in focus from tender point evaluation to identifying “areas of pain” and from assessment of specific symptoms to looking at the “whole patient.”

As in all other illnesses, clinicians should actively seek a diagnosis of recognition to facili- tate better overall management. A multimodal approach to therapy should be executed in parallel rather than in tandem to achieve optimal benefit.

In this article, we review early and recent developments in the diagnosis of FMS. We also discuss key treatment issues: the importance of patient education, the role of aerobic exercise, and the use of therapeutic agents in optimizing sleep and in managing depression and pain.

EVOLUTION OF THE DIAGNOSTIC CONCEPT

Initial criteria

In 1976, Hench1 clinically defined FMS on the basis of 2 criteria, pain and no physiological explanation for pain. Since this initial description, FMS has evolved into a diagnosis of inclusion rather than exclusion. In other words, physicians should make a diagnosis of FMS on the basis of its clinical presentation rather than on a battery of tests that are not useful in the diagnosis of this condition and may be potentially misleading because of the detection of incidental findings. Because FMS does not offer immunity to other diseases, however, a reasonable clinically indicated workup is not unjustified.

In 1979, Smythe2 proposed diagnostic criteria for FMS as 12 of 14 tender anatomical points (tender with application of 4 kg of pressure), diffuse pain of at least 3 months’ duration, disturbed sleep, skin roll tenderness at the upper trapezius border, and normal laboratory test results. In 1981, Yunus and associates3 included diffuse pain of 3 months’ duration, lack of other obvious causes, and 5 of 40 tender points along with 10 other minor criteria. These criteria gave tender points and other FMS symptoms and signs equal weight.

In 1990, the American College of Rheumatology (ACR) set criteria for FMS on the basis of a study of 293 patients deemed to have FMS compared with 265 control patients matched for age, sex, and rheumatologic diagnoses.4 The combination of criteria of widespread pain of at least 3 months’ duration with 11 of 18 tender points provided a sensitivity of 88% and specificity of 81%. On the basis of the ACR criteria, 19% of patients with 11 tender points did not have FMS. This criteria set ignored the myriad other symptoms and signs that are part of FMS, including fatigue; cognitive problems; sleep difficulties; feeling unrefreshed in the morning; hypersensitivity to light, odor, and sound; and generalized weakness.

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