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Medical Articles »Matthew Duncan, M.D.
Fibromyalgia Syndrome
Matthew Duncan, M.D.
Internal Medicine & Rheumatology
Causation
Aside from arthritic conditions, one of the most frequent inquiries of a Rheumatologist is the analysis of any causal connection of fibromyalgia in work related injuries. I offer an excerpt from "Controversies in Fibromyalgia and Related Conditions," Rheumatic Disease Clinics of North America, May 1996 that may provide the most current research on causality.
"A number of reports have dealt with fibromyalgia developing in the work disability or compensation setting. Although almost no data are available on the issue of casual relationships between work or trauma and fibromyalgia, the association between work disability or compensation and fibromyalgia is well established. A recent fibromyalgia consensus report on disability stated: "The clinical dilemma, whether an injury or work place stress caused the patient’s fibromyalgia, a ‘retrodictive (or It Did) causal proposition,’ can rarely be determined to be certainly true or certainly false. Evidence that trauma can cause fibromyalgia, a ‘potential (or It Can) causal proposition’ comes from a few case series or case reports, and is insufficient to establish causal relationships. That trauma might cause fibromyalgia "sometimes," a ‘predictive (or It Will) causal proposition,’ can only be addressed by epiderniological studies which measure the risk of potential exposures on the development of fibromyalgia.
Epidemiologic studies of trauma and fibromyalgia needed to address potential or predictive causality are currently not available. The fibromyalgia causality issue…injury-related syndromes may be further complicated by the potential influence of the availability of compensation for the syndrome. In settings where compensation is widely available illnesses similar to fibromyalgia have been shown to increase in apparent prevalence, as measured by physician visits, then to fall when compensation availability declines.
Overall, then, data from the literature are insufficient to indicate whether causal relationships exist between trauma and fibromyalgia. The absence of evidence, however, does not mean that causality does not exist, but instead that appropriate studies have not been performed.
The issue of causality is at the base of the myriad of workers’ compensation and automobile accident claims concerning fibromyalgia. These issues are not different from those addressed by Hadler concerning low back pain and upper extremity problems and they remain unresolved."
Diagnosis
Often, fibromyalgia is misdiagnosed; listed below are some guidelines I follow in determining a fibromyalgia diagnosis.
I. Definition: Fibromyalgia is a syndrome of generalized pain associated with evidence of widespread localized tenderness.
II. Cardinal Features: Objective Findings
A. Core features: Generalized pain & widespread tenderness
B. Characteristic features: Fatigue, non-refreshed or disturbed sleep, morning stiffness (75% of patients)
C. Common features: Irritable bowel syndrome, Raynaud’s, headache, subjective swelling, paresthesias, psychological abnormality & functional disability (occurs more than 25% of the time)
D. Coexisting Disorders Arthritis: Low back & cervical disorders, tendonitis, etc. Symptoms intertwine & overlap with those of fibromyalgia
III. Diagnostic Criteria for Primary Fibromyalgia
A. Major (Required)
1. Widespread pain for at least 3 months
2. Multiple tender points in at least 6 specified anatomic sites
3. Absence of underlying disease as cause for fibromyalgia
B. Minor
1. Alpha intrusion in non-REM sleep EEG
2. Non-restorative sleep
3. Overnight increase in morning stiffness & fatigue
4. Daytime fatigue or tenderness
5. Subjective swelling or dysesthesias
6. Aggravation with cold, stress or activities
7. Improved with rest, heat, increased level of physical fitness
8. Chronic headache (migraine, tension headache)
9. Functional bowel disorder (Irritable colon)
IV. Classification of Fibromyalgia
A. Primary: Characteristic features of fibromyalgia without recognizable cause
B. Secondary: Characteristic features secondary to known cause or underlying disease or so closely associated with other disease conditions as to appear as manifestations of the associated disease, and with the amelioration of fibromyalgia symptoms with treatment of primary or closely associated disease
C. Localized / Regional: Localized myofascial pain associated with trigger points, usually secondary to muscle strain (occupational, repetitive) similar to local regional or specific myofascial pain syndrome, does not satisfy accepted criteria for fibromyalgia
D. Elderly: Similar to primary and / or secondary fibromyalgia, special attention directed toward diagnosis of polymyalgia rheumatica, neurologic disease, osteoporosis, Parkinson’s disease, organic brain syndrome, post-viral fatigue syndrome
E. Juvenile: Similar to primary fibromyalgia rheumatica in the juvenile patient
V. Fibromyalgia: Subjective Complaints
A. Subjective Factors
1. Aching & stiffness for more than 3 months
2. No restorative sleep
3. Fatigue & poor work tolerance
4. Morning aching & stiffness
5. Modulating factors
6. Temporary relief with heat
B. Aggravating Factors
1. Cold or humid weather
2. Non-restorative sleep
3. Physical / mental fatigue
4. Excessive physical activity
5. Physical inactivity
6. Excessive anxiety / stress
C. Relieving Factors
1. Warm dry weather
2. Hot showers or baths
3. Restful sleep
4. Moderate activity, stretching exercises & massage
VI. Physical Exam: Require 11 of 18 tender points present for diagnosis
A. Positive Findings
1. Multiple tender points
2. Mild soft tissue swelling
3. Skin pinch tenderness
4. Hyperemia of the skin
5. Tenderness of peripheral nerves
B. Negative Findings Exclude Other Conditions
1. General physical exam
2. Joint exam
3. Neurologic exam
4. Muscle strength exam
C. Common Tender Points
1. Trapezius muscle, midpoint of upper fold
2. Costochondral junction, just lateral to junctions
3. Lateral epicondylitis "tennis elbow" sites, 1 to 2 cm distal to epicondyles
4. Supraspinitus muscle, at origins, above scapular spine near medial border
5. Low cervical interspinous ligaments in midline, C4 to C6
6. Low lumbar interspinous ligaments in midline, L4 to S1
7. Gluteus medius muscle, upper outer quadrants of buttocks
8. Medial fat pad (knee) overlying medial collateral ligament of the knee,
proximal to the joint line
9. Suboccipital muscle, base of skull posteriorly
10. Rhomboid muscle, medial to medial border of scapula
11. Greater trochanter
VII. Laboratory Studies to Exclude of Other Disorders
A. CBC, Sedimentation Rate, Muscle enzymes, TSH, Rheumatoid Factor, Antinuclear antibody, radiographs, EMG
VIII. Differential Diagnosis of Fibromyalgia Patient
A. Primary fibromyalgia syndrome
B. Myofascial pain syndrome
C. Temporomandibular joint disorder (TMJD)
D. Non-articular (soft tissue) rheumatism coexisting at multiple sites
E. Polymyalgia rheumatica/giant cell arteritis
F. Polymyositis / dermatomyositis
IX. Practical Differential Diagnosis of the Fibromyalgia Patient
A. Endocrine myopathies: Hypothyroidism, hyperthyroidism, hyperparathyroidism, hypoparathyroidism, adrenal insufficiency
B. Metabolic myopathy (alcohol)
C. Neuroses (Anxiety / depression)
D. Metastatic Carcinoma
E. Chronic Fatigue Syndrome: Epstein Barr virus, other viral infections, unknown
F. Parkinsonism
X. Medical Treatment Options for Fibromyalgia Syndrome
A. Medicinal: Amitriptyline, Cyclobenzaprine, Regional sympathetic blockade, Flexeril, Naproxen (NSAID)
B. Cardiovascular Fitness training
C. Biofeedback
D. Other non-medicinal treatments of lessor effectiveness
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