Diagnosis There are no standard laboratory tests or other diagnostic tests that can be used to diagnose fibromyalgia, so the diagnosis must be determined on the basis of patient symptoms and physical examination. It is common for individuals to consult a variety of physicians and therapists before receiving a diagnosis. Unfortunately, in this process, some doctors conclude that a patient’s pain is psychosomatic or tell the patient there is nothing they can do. In addition, an incorrect diagnosis is often made because the symptoms of fibromyalgia overlap with those of other conditions. For example, in one study, about 70 percent of patients who have the diagnostic symptoms of chronic fatigue syndrome also meet the criteria for diagnosis of fibromyalgia.8 Other complex conditions with similar clusters of symptoms that may be misdiagnosed are chronic myofascial pain syndrome and post- traumatic stress disorder. Clinicians may also pursue potential allergies as a diagnosis, especially because the symptoms of fibromyalgia fluctuate, suggesting that the problems experienced are not systemic but result from environmental factors. For a clinician who is familiar with fibromyalgia, though, a diagnosis can be made on the basis of two criteria established by the American College of Rheumatology in 1990: 9 ● Widespread pain lasting more than three months. To be considered “widespread,” pain must occur on both the right and left sides of the body, above and below the waist, and near the spine. ● Pain upon digital palpation with a force of about 4 kg in at least 11 of the 18 tender points (see figure 3). Treatment Managing the pain and dysfunction related to fibromyalgia is challenging and frustrating for patients and clinicians alike. In 2004, a group of experts reviewed all published scientific research on fibromyalgia and concluded that, on the basis of the evidence, a treatment program for fibromyalgia should emphasize education, certain medications, exercise, cognitive therapy, or all four approaches. 10 Education and coping skills Recognizing the need for lifestyle adaptation is one of the most important factors in improving the symptoms of fibromyalgia. In addition to educating themselves about fibromyalgia, patients should provide information to their family, friends and coworkers. Educational classes and support groups available through organizations such as the Arthritis Foundation and the American Chronic Pain Association can provide information and put individuals in touch with others who have had similar experiences and understand what they are going through. Essential education to help patients in appropriate self-care for fibromyalgia should include sleep habits, stress reduction, exercise and a healthy diet. Medications Medications typically used to treat musculoskeletal pain, such as nonsteroidal anti-inflammatory drugs and aspirin, are not usually effective in relieving the pain of fibromyalgia. Narcotic-based drugs, including codeine, morphine and methadone, sometimes provide pain relief for a small subgroup of severely afflicted patients, but individuals with fibromyalgia are especially sensitive to the side effects of these drugs (nausea, constipation, itching and mental blurring), and often decide not to use them for the long term. Several classes of antidepressants have been found to be the most useful medication for treating fibromyalgia. Although they don’t work for all fibromyalgia patients, they have been shown to help relieve pain, fatigue and insomnia in about 25 percent of patients. 11 Tricyclic antidepressants taken at bedtime can help promote restorative sleep, help relax painful muscles and increase the effects of endorphins, the body’s natural pain-killing substances. The newer class of antidepressants,
Some physicians consider these criteria too rigid and believe a diagnosis of fibromyalgia can be made even when individuals do not have the required minimum number of 11 tender points. Figure 3. The Location of the Nine Paired Tender Points that Comprise the 1990 American College of Rheumatology Criteria for Fibromyalgia.
Illustration Sources: National Institute of Arthritis and Musculoskeletal and Skin Diseases
selective serotonin reuptake inhibitors (SSRIs), seems to be more effective for many people with fibromyalgia, but SSRIs don’t help everyone. Results of a study using a dual-action antidepressant, duloxetine, demonstrated that it was effective in improving symptoms and relieving pain of fibromyalgia. 12 Duloxetin works by increasing the availability in the brain of both serotonin and norepinephrine, as do some other antidepressants such as Effexor. Compared with the control group, the patients given duloxetine had significant reduction in both generalized and tender-point pain, as well as significant improvement in general activity, mood, walking ability, normal work, sleep, and enjoyment of life as measured by standardized tests. Corticosteroids, such as prednisone, have not been shown to be effective in treating fibromyalgia. Exercise For exercise, the basic approach recommended for patients with fibromyalgia is called graded exercise , which uses strength training and regular low-impact aerobic exercise starting at a low level and building to higher intensity and length of time. Both of these types are important for raising the pain threshold, although it may take months for the individual to recognize the benefits. Walking, swimming, water aerobics and using stationary bicycles are typical beginning points in graded exercise. Because of pain, individuals with fibromyalgia are not able to begin at a level that would be considered normal for a healthy person. For example, one program started patients out with two weekly sessions of six minutes each. By week 12, the exercise sessions lasted 25 minutes each. This gradual approach is necessary because patients who try strenuous exercise too early have an increase in pain, leading them to be discouraged about exercise and to stop doing it. Individuals should do stretching exercises for about 10 minutes before they begin aerobic exercise.
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