Fibromyalgia Clinical Presentation

  • Author: John Buckner Winfield, MD; Chief Editor: Herbert S Diamond, MD   more...
 
Updated: Dec 20, 2011
 

History

Fibromyalgia (FM) is a disorder of chronic widespread pain lasting more than 3 months, with associated fatigue, poor sleep, stiffness, cognitive difficulties, multiple somatic symptoms, and, not infrequently, anxiety and/or depression. Patients with fibromyalgia may meet criteria for 3 or more central sensitivity syndromes.[1] Most patients do not appear chronically ill, although they may look fatigued or agitated.

Assessment strategy

Although insurance reimbursement and other aspects of the medical infrastructure are often barriers to giving patients the necessary assessment time, a thorough and detailed history saves time in the long run, reduces the potential for litigation, helps prevent incorrect diagnosis, and eliminates inappropriate or unnecessary treatments. Without a thorough history, it is impossible to develop a complete list of comorbid illnesses, with the inevitable result that treatment is incomplete and often inappropriate.

Patients with fibromyalgia do significantly better when they receive a comprehensive, individualized treatment regimen than when they do not. A thorough history is the first step toward developing such a regimen. Start the evaluation by identifying the chief complaint, which usually is pain. However, avoid treating patients based on the chief complaint alone. Premature treatment may lead to symptom chasing and ineffective treatment. Patients with fibromyalgia experience changes in symptoms from day to day, a feature that may not reflect the global nature of their disorder. This waxing and waning or fluctuating pattern of symptoms is common in fibromyalgia.

Because many patients do not understand that their symptoms are connected, they provide a fragmented history. The physician must ask the right questions to develop a complete understanding of the patient's distribution of pain and pattern of illness.

Pain

The chief complaint in patients with fibromyalgia is often "I hurt all over all the time." The quality of this constant pain is described as burning, aching, and soreness. They may feel as if they are bruised all over, even though there are no physical signs of this. The pain radiates diffusely from the axial skeleton over large areas of the body, predominantly involving muscles and musculoskeletal junctions, but also in joints (arthralgia without actual synovitis) The pain may also be multifocal and can wax and wane in a migratory fashion.

Although pain is constant, the location tends to migrate and the intensity varies. Many patients may complain of only a single painful area, such as the low back or neck. On the other hand, patients may initially complain of pain at one site because they are primarily concerned about their worst pain. A careful history often reveals that the individual's pain is global, not focal, in its distribution.

Multifocal pain or recurrent episodes of regional pain are essentially equivalent to the classic "pain all over" description. Regional pains in fibromyalgia may include, but are not limited to, the following:

  • Noncardiac chest pain
  • Dyspepsia
  • Headache
  • Scalp tenderness
  • Abdominal cramping (irritable bowel syndrome)
  • Temporomandibular pain
  • Chronic pelvic pain
  • Dysmenorrhea

Ask about the duration and onset of the pain. Patients can usually remember the onset of pain if it was sudden. If the pain began gradually, determining the exact time of onset is difficult. Inquire about aggravating and alleviating factors for the pain. Record the description or characteristics of the pain (eg, ask whether the pain is migratory, burning, tender, sore, aching, sharp, or radiating).

Flare-ups

The severity of fibromyalgia may vary, with patients experiencing few symptoms one day and many the next. Patients may experience flare-ups, with an acute, intense increase in symptoms that last more than a day. The pain may reach such intense levels that the patient becomes bedridden. Flares-ups usually are triggered by a stressor, such as infection, trauma, or changes in medication, sleep, or exercise. Onset of allergies, changes in diet, and a change in usual activity may bring on a flare-up.

Sleep

Patients generally do not volunteer a history of a sleeping disorder, but a carefully taken history reveals unrefreshing sleep in about 65% of patients and morning fatigue in about 80%. Patients awaken as tired as they were before sleeping. Most patients awaken frequently throughout the night, and some have difficulty falling asleep. They finally fall asleep in the early morning hours, describing this as their best sleep.

Many patients deny sleep-onset problems and report only infrequent awakenings. However, they fall asleep immediately, and sleep onset this rapid is abnormal and should not be overlooked.[32]

Question the patient about sleep habits and environment. If possible, ask the patient's sleeping partner whether the patient snores or kicks while asleep. Ask how long it takes for the patient to fall asleep and how many times he/she awakens. Ask the patient how he/she feels in the morning.

Most patients complain of morning stiffness of variable duration. Question the patient's sleeping partner about leg movements. Approximately 20% of persons with fibromyalgia have concomitant restless legs syndrome, which may lead the physician to choose or add medications other than antidepressants.

Fatigue

Many patients with fibromyalgia report that fatigue is second only to pain as a source of distress. The fatigue is worse in the morning and early evening. By 10 or 11 o'clock in the morning, the fatigue subsides somewhat.

Several investigators, including this author, have found that poor sleep, physical activity, and diet can worsen the patient's fatigue. Most patients with fibromyalgia also meet the classification criteria for chronic fatigue syndrome.

Cognitive problems

Cognitive problems (known as "fibrofog") may be a primary symptom of fibromyalgia.[71] Cognitive symptoms associated with fibromyalgia are exacerbated by pain, mood and anxiety disorders, and poor sleep.

Cognitive symptoms include confusion and forgetfulness, an inability to concentrate and recall simple words and numbers, and the transposition of words and numbers. Cognitive functions are often so impaired that patients cannot perform the activities of daily living (ADL); they may become lost in familiar places or lose the ability to communicate effectively. Patients who work may fear losing their job, and many pediatric patients drop out of school because of their inability to complete their schoolwork.

Other features

Other common symptoms associated with fibromyalgia include the following:

  • Weight fluctuations
  • Allergic symptoms (eg, nasal congestion) and hypersensitivity to environmental stimuli (eg, odors, bright lights, loud noises) and medications
  • Syncope or dizziness
  • Shortness of breath
  • Urinary frequency and urgency (female urethral syndrome, interstitial cystitis)

Approximately 40% of patients with fibromyalgia describe having alternating bouts of diarrhea and constipation and also experience bloating, cramping, and an increased urge to defecate. These symptoms are most likely related to irritable bowel syndrome.

Approximately 50% of patients with fibromyalgia present with complaints of tissues feeling swollen and of numbness and tingling in the extremities. These symptoms generally are more common in the upper extremities than in the lower ones. Objective swelling, sensory changes, and other neurologic findings are usually absent.

Information on medications, exercise, and fatigue is important. List any allergies and perpetuating factors.

Patients may not admit to feeling depressed or anxious; therefore, the physician must inquire about these conditions. The source of the patient's emotional stress may be multifactorial.

Social and developmental history

The social and developmental history is of particular relevance in fibromyalgia. The clinician should elicit details regarding the following:

  • Abuse
  • Alcoholism in a parent during childhood
  • Past and ongoing stressors
  • Exposure to violence[72]
  • Beliefs regarding triggers of illness
  • Ongoing compensation claims
  • Work status

It is also important to review any previous treatment modalities and their efficacy, as well as whether the patient is or has been prescribed opioids.

Associated conditions

A number of medical conditions and diseases frequently occur with fibromyalgia. Yunus has proposed that these syndromes are interconnected, similar, and overlapping, with a probable common pathophysiologic mechanism.[73, 74] Ironically, they have been described as functional syndromes. This is a misnomer, because their pathophysiology is based on the dysfunction of the neuroendocrine system. Central sensitization is likely the common pathophysiologic pathway.

These coexisting conditions can aggravate and perpetuate the patient's symptoms. If they go unrecognized, the physician might inadvertently prescribe an ineffective or even harmful treatment regimen, leading to costly and unnecessary testing.

Among the conditions most commonly associated with fibromyalgia include the following:

  • Irritable bowel syndrome
  • Nondermatomal paresthesia
  • Temporomandibular joint syndrome
  • Mitral valve prolapse
  • Vulvar vestibulitis
  • Hypermobility syndrome
  • Restless legs syndrome
  • Multiple chemical sensitivity syndrome
  • Enthesopathies
  • Vestibular disorders
  • Esophageal dysmotility
  • Ocular disturbances
  • Anxiety disorders
  • Raynaud phenomenon
  • Thyroid dysfunction
  • Lyme disease
  • Silicone breast implant syndrome
  • Rheumatoid arthritis
  • Systemic lupus erythematosus
  • Sjogren syndrome
  • Osteoarthritis
  • Carpal tunnel syndrome
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Physical Examination

The goal of the physical examination is to confirm the diagnosis, rule out concomitant systemic diseases, and recognize common coexisting conditions. Except for painful tender points and, perhaps, signs of deconditioning, physical examination findings are normal in patients with fibromyalgia. The tender-point examination should be performed first during the physical examination, because a number of factors may influence the sensitivity of the tender points during the examination.

Pain, not just tenderness, is present at multiple fibromyalgia tender points (see the image below) when pressure (approximately 4 kg/cm2) is applied manually, with pressure increasing gradually at the rate of 1 kg per second over 4 seconds, as depicted in the image below. The pressure should cause no referred pain.

Tender points in fibromyalgia. Tender points in fibromyalgia.

However, pain upon light pressure may not be restricted to specific tender points. Many patients feel pain virtually anywhere that pressure is applied, including control areas (eg, forehead, thumbnail) that are relatively insensitive to pain in healthy patients.

Tender-point examination procedure

The thumb pad of the examiner's dominant hand is used to apply pressure to the evaluation sites during the tender-point examination. This allows the examiner to use important tactile cues and is as reliable as the use of a dolorimeter (see Pressure algometry, below). The procedure is as follows: First, visually locate the evaluation site. Then, with the thumb pad, press perpendicularly into the evaluation site for 4 seconds. Apply 4 kg of pressure to the site; this is enough force to blanch the examiner's nail bed. Press the site only once, to avoid sensitization.

The patient should respond with a "yes" or "no" if he/she has any pain at the site being examined. If the patient's response is "yes," have the individual rate the pain on a scale of 0 (no pain) to 10 (worst pain), and record each response.

Site locations

The 18 possible tender points exist as 9 pairs (in addition to 3 control sites; see below), 4 on the anterior of the body and 5 on the posterior of the body.[7] Tender points may be found in any palpable muscle, but 18 sites are consistently present in patients with fibromyalgia. The sites are as follows:

  • 1, control site - Forehead
  • 2 and 3 diagnostic sites - Occiput at the nuchal ridge
  • 4 and 5 diagnostic sites - Trapezius
  • 6 and 7 diagnostic sites - Supraspinatus
  • 8 and 9 diagnostic sites - Gluteal
  • 10 and 11 diagnostic sites - Low cervical
  • 12 and 13 diagnostic sites - Second rib
  • 14 and 15 diagnostic sites - Lateral epicondyle
  • 16, control site - Distal middle third of the right forearm
  • 17, control site - Nail of the left thumb
  • 18 and 19 diagnostic sites - Greater trochanter
  • 20 and 21 diagnostic sites - Medial knee

The American College of Rheumatology (ACR) specifies the location of tender points on the anterior body as follows:

  • At the fifth through seventh intertransverse spaces of the cervical spine
  • In the pectoral muscle, at the second costochondral junctions
  • Approximately 3 finger breadths (2 cm) below the lateral epicondyle
  • At the medial fat pad, proximal to the joint line

The ACR specifies the location of tender points on the posterior body as follows:

  • At the upper border of the shoulder in the trapezius muscle, midway from the neck to the shoulder joint
  • At the craniomedial border of the scapula, at the origin of the supraspinatus
  • In the upper outer quadrant of the gluteus medius
  • Just posterior to the prominence of the greater trochanter at the piriformis insertion

Revised American College of Rheumatology (ACR) criteria for fibromyalgia have recently been developed and accepted by the ACR.[75, 76] These criteria do not use tender points. There are many pitfalls with the use of tender points, not the least of which is that few physicians, including rheumatologists, know how to test for them. Testing for 1-2 tender points may be useful, but testing for all 18 is unnecessary and causes undue pain for the patient.

Pressure algometry

A useful device for rough quantitation of pain perception and pain tolerance is a pressure algometer, or dolorimeter, as depicted in the image below. Pressure algometry (dolorimetry) provides a simple determination of pressure pain thresholds at 4 tender points associated with fibromyalgia (ie, both lateral epicondyles, midpoints of the trapezii). Normal values are 4 kg/cm2 or greater.

Pressure algometer (dolorimeter). Pressure algometer (dolorimeter).

Pressure algometry can also serve as a useful tool for educating the patient regarding the nature of altered central nociceptive processing, allodynia (pain with stimuli that should not cause pain, such as gentle touching) and hyperalgesia (amplification of pain experienced from peripheral stimuli that are expected to be painful). On follow-up visits, it can provide a semiquantitative guide to therapy

Other evaluations

After completing the tender-point examination, the physician should include neurologic, joint, and musculoskeletal evaluations. Note the presence of swelling, deformities, and erythema. Examine the patient's gait, joint range of motion (ROM), and posture for structural asymmetry and skeletal deficiencies. Palpate the soft issues for tone or spasm.

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Complications

Potential complications of fibromyalgia include the following:

  • Extreme allodynia with high levels of distress
  • Opioid or alcohol dependence
  • Marked functional impairment
  • Severe depression and anxiety
  • Obesity and physical deconditioning
  • Metabolic syndrome
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Contributor Information and Disclosures
Author

John Buckner Winfield, MD  Herman and Louise Smith Distinguished Professor of Medicine in Arthritis Emeritus, Department of Medicine, Senior Member, Neurosensory Disorders Center, University of North Carolina at Chapel Hill; Consulting Rheumatologist, Appalachian Regional Rheumatology

John Buckner Winfield, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Immunologists, American Clinical and Climatological Association, American College of Rheumatology, American Federation for Clinical Research, American Pain Society, American Society for Clinical Investigation, Association of American Physicians, and North Carolina Medical Society

Disclosure: Pfizer Honoraria Speaking and teaching; Forest Honoraria Speaking and teaching

Chief Editor

Herbert S Diamond, MD  Adjunct Professor of Medicine, Division of Rheumatology, University of Pittsburgh School of Medicine; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital

Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, and Phi Beta Kappa

Disclosure: Merck Ownership interest Other; Smith Kline Ownership interest Other; Zimmer Ownership interest Other

Additional Contributors

Lawrence H Brent, MD Associate Professor of Medicine, Jefferson Medical College of Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center

Lawrence H Brent, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American College of Physicians, and American College of Rheumatology

Disclosure: Genentech Honoraria Speaking and teaching; Genentech Grant/research funds Other; Amgen Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Abbott Immunology Honoraria Speaking and teaching; Takeda Honoraria Speaking and teaching; UCB Speaking and teaching; Omnicare Consulting fee Consulting; Centocor Consulting fee Consulting

Kristine M Lohr, MD, MS Professor, Department of Internal Medicine, Center for the Advancement of Women's Health and Division of Rheumatology, Director, Rheumatology Training Program, University of Kentucky College of Medicine

Kristine M Lohr, MD, MS is a member of the following medical societies: American College of Physicians and American College of Rheumatology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Additional Contributors

Lawrence H Brent, MD Associate Professor of Medicine, Jefferson Medical College of Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center

Lawrence H Brent, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American College of Physicians, and American College of Rheumatology

Disclosure: Genentech Honoraria Speaking and teaching; Genentech Grant/research funds Other; Amgen Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Abbott Immunology Honoraria Speaking and teaching; Takeda Honoraria Speaking and teaching; UCB Speaking and teaching; Omnicare Consulting fee Consulting; Centocor Consulting fee Consulting

Kristine M Lohr, MD, MS Professor, Department of Internal Medicine, Center for the Advancement of Women's Health and Division of Rheumatology, Director, Rheumatology Training Program, University of Kentucky College of Medicine

Kristine M Lohr, MD, MS is a member of the following medical societies: American College of Physicians and American College of Rheumatology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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A neurophysiologist's view of pain. Courtesy of Alan R. Light, PhD.
Tender points in fibromyalgia.
Pressure algometer (dolorimeter).
Biopsychosocial model of fibromyalgia.
 
 
 
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