Diagnostic Considerations

Although no basis for many of the multiple symptoms of patients with fibromyalgia will be found upon physical examination or laboratory testing, the physician must remain alert for organic illness (eg, colon carcinoma in a patient with irritable bowel syndrome).

The clinical assessment may reveal objective evidence for a discrete illness, such as hypothyroidism, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), polymyalgia rheumatica, or another inflammatory or autoimmune disorder. Such findings do not exclude comorbid fibromyalgia. Indeed, approximately 25% of patients with RA and approximately 50% of patients with SLE also have fibromyalgia, and the provision of optimum care in such cases impels recognition and treatment of both illnesses.

It is important to recognize that treatment of an autoimmune disorder in a patient with comorbid fibromyalgia usually does not improve fibromyalgia symptoms. Recognition and treatment of fibromyalgia in these patients is vitally important to avoid overtreatment with immunosuppressive drugs, which can result when providers falsely ascribe symptoms of fibromyalgia to the autoimmune condition.

Other problems to consider in the differential diagnosis of fibromyalgia include the following:

Atypical chest pain
Chronic fatigue syndrome
Multiple chemical sensitivity
Sick building syndrome
Vulvodynia
Vulvar vestibulitis

Because complaints of chest pain, shortness of breath, and palpitations are common, serious cardiac problems should be considered and may require extensive evaluation. Many symptoms in patients with fibromyalgia can be related to mitral valve prolapse syndrome.

Fibromyalgia Rapid Screening Tool

A self-administered questionnaire developed by French researchers, the Fibromyalgia Rapid Screening Tool (FiRST) consists of six questions regarding the presence or absence of the following dimensions of fibromyalgia:

Widespread pain
Fatigue
Pain characteristics
Nonpainful abnormal sensations
Functional somatic symptoms
Sleep and cognitive problems

Questions require only a "yes" or "no" answer, with each "yes" answer worth 1 point. A score of 5 or more has the highest sensitivity and specificity for fibromylagia.^[102]

Although initially used only to discriminate between fibromyalgia and other painful conditions, FiRST has also proved useful in helping detect concomitant fibromyalgia in patients with inflammatory rheumatic disorders. In a study of patients presenting for treatment of rheumatoid arthritis, spondyloarthritis, or connective tissue disease, and whose pain had persisted for at least 3 months, FiRST screening detected concomitant fibromyalgia in 143 of 586 patients (24.4%).^[102]

By comparison, use of American College of Rheumatology 1990 criteria detected only 52 cases of fibromyalgia (8.6%), and assessment by a rheumatologist, 93 cases (15.4%). The study authors conclude that FiRST can be used by rheumatologists in clinical practice to rule out fibromyalgia as a possible explanation for apparent treatment failure in other rheumatologic disorders.^[102]

Differential Diagnoses

Workup

López-Pousa S, Garre-Olmo J, de Gracia M, Ribot J, Calvó-Perxas L, Vilalta-Franch J. Development of a multidimensional measure of fibromyalgia symptomatology: The comprehensive rating scale for fibromyalgia symptomatology. J Psychosom Res. 2013 May. 74(5):384-92. [QxMD MEDLINE Link].
Giorgi V, Bazzichi L, Batticciotto A, Pellegrino G, Di Franco M, Sirotti S, et al. Fibromyalgia: one year in review 2023. Clin Exp Rheumatol. 2023 Jun. 41 (6):1205-1213. [QxMD MEDLINE Link].
Borchers AT, Gershwin ME. Fibromyalgia: A Critical and Comprehensive Review. Clin Rev Allergy Immunol. 2015 Oct. 49 (2):100-51. [QxMD MEDLINE Link].
Yunus MB. Fibromyalgia and overlapping disorders: the unifying concept of central sensitivity syndromes. Semin Arthritis Rheum. 2007 Jun. 36(6):339-56. [QxMD MEDLINE Link].
Sawaddiruk P, Paiboonworachat S, Chattipakorn N, Chattipakorn SC. Alterations of brain activity in fibromyalgia patients. J Clin Neurosci. 2017 Apr. 38:13-22. [QxMD MEDLINE Link].
Gracely RH, Petzke F, Wolf JM, Clauw DJ. Functional magnetic resonance imaging evidence of augmented pain processing in fibromyalgia. Arthritis Rheum. 2002 May. 46(5):1333-43. [QxMD MEDLINE Link].
Wolfe F, Cathey MA, Kleinheksel SM. Fibrositis (Fibromyalgia) in rheumatoid arthritis. J Rheumatol. 1984 Dec. 11(6):814-8. [QxMD MEDLINE Link].
Buskila D, Press J, Abu-Shakra M. Fibromyalgia in systemic lupus erythematosus: prevalence and clinical implications. Clin Rev Allergy Immunol. 2003 Aug. 25(1):25-8. [QxMD MEDLINE Link].
Thompson ME, Barkhuizen A. Fibromyalgia, hepatitis C infection, and the cytokine connection. Curr Pain Headache Rep. 2003 Oct. 7(5):342-7. [QxMD MEDLINE Link].
Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990 Feb. 33(2):160-72. [QxMD MEDLINE Link].
Katz RS, Wolfe F, Michaud K. Fibromyalgia diagnosis: a comparison of clinical, survey, and American College of Rheumatology criteria. Arthritis Rheum. 2006 Jan. 54(1):169-76. [QxMD MEDLINE Link].
Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010 May. 62(5):600-10. [QxMD MEDLINE Link].
Observations with cases illustrative of a new, simple, and expeditious mode of curing rheumatism and sprains. Balfour W. J Lond Med Phys. 1824. 51:446-62.
Beard G. Neurasthenia, or nervous exhaustion. J Boston Med Surg. 1869. 80:217-22.
Gowers WR. Lumbago: Its lessons and analogues. Br Med J. 1904. 1:117-21.
Chaitow L. Fibromyalgia and Muscle Pain. Thorsons Pub; 1995. 1-205.
Yunus M, Masi AT, Calabro JJ, Miller KA, Feigenbaum SL. Primary fibromyalgia (fibrositis): clinical study of 50 patients with matched normal controls. Semin Arthritis Rheum. 1981 Aug. 11(1):151-71. [QxMD MEDLINE Link].
Schmidt-Wilcke T, Diers M. New Insights into the Pathophysiology and Treatment of Fibromyalgia. Biomedicines. 2017 May 13. 5 (2):[QxMD MEDLINE Link]. [Full Text].
Clauw DJ. Fibromyalgia: more than just a musculoskeletal disease. Am Fam Physician. 1995 Sep 1. 52(3):843-51, 853-4. [QxMD MEDLINE Link].
Merskey H. Classification of chronic pain: Description of chronic pain syndromes and definitions of pain terms. Pain. 1986. Suppl 3:S217.
Pillemer SR, Bradley LA, Crofford LJ, Moldofsky H, Chrousos GP. The neuroscience and endocrinology of fibromyalgia. Arthritis Rheum. 1997 Nov. 40(11):1928-39. [QxMD MEDLINE Link].
Crofford LJ. The hypothalamic-pituitary-adrenal stress axis in fibromyalgia and chronic fatigue syndrome. Z Rheumatol. 1998. 57 Suppl 2:67-71. [QxMD MEDLINE Link].
Martinez-Lavin M. Biology and therapy of fibromyalgia. Stress, the stress response system, and fibromyalgia. Arthritis Res Ther. 2007. 9(4):216. [QxMD MEDLINE Link].
Tanriverdi F, Karaca Z, Unluhizarci K, et al. The hypothalamo-pituitary-adrenal axis in chronic fatigue syndrome and fibromyalgia syndrome. Stress. 2007 Mar. 10(1):13-25. [QxMD MEDLINE Link].
van Middendorp H, Lumley MA, Jacobs JW, Bijlsma JW, Geenen R. The effects of anger and sadness on clinical pain reports and experimentally-induced pain thresholds in women with and without fibromyalgia. Arthritis Care Res (Hoboken). 2010 Oct. 62(10):1370-6. [QxMD MEDLINE Link].
Jones KD, Deodhar P, Lorentzen A, Bennett RM, Deodhar AA. Growth hormone perturbations in fibromyalgia: a review. Semin Arthritis Rheum. 2007 Jun. 36(6):357-79. [QxMD MEDLINE Link].
Umeda M, Corbin LW, Maluf KS. Preliminary investigation of absent nociceptive flexion reflex responses among more symptomatic women with fibromyalgia syndrome. Rheumatol Int. 2013 Apr 4. [QxMD MEDLINE Link].
Clauw DJ. Fibromyalgia: update on mechanisms and management. J Clin Rheumatol. 2007 Apr. 13(2):102-9. [QxMD MEDLINE Link].
Staud R, Robinson ME, Vierck CJ Jr, et al. Diffuse noxious inhibitory controls (DNIC) attenuate temporal summation of second pain in normal males but not in normal females or fibromyalgia patients. Pain. 2003 Jan. 101(1-2):167-74. [QxMD MEDLINE Link].
Staud R, Spaeth M. Psychophysical and neurochemical abnormalities of pain processing in fibromyalgia. CNS Spectr. 2008 Mar. 13(3 Suppl 5):12-7. [QxMD MEDLINE Link].
Wood PB, Schweinhardt P, Jaeger E, et al. Fibromyalgia patients show an abnormal dopamine response to pain. Eur J Neurosci. 2007 Jun. 25(12):3576-82. [QxMD MEDLINE Link].
Sarchielli P, Di Filippo M, Nardi K, Calabresi P. Sensitization, glutamate, and the link between migraine and fibromyalgia. Curr Pain Headache Rep. 2007 Oct. 11(5):343-51. [QxMD MEDLINE Link].
Diatchenko L, Slade GD, Nackley AG, et al. Genetic basis for individual variations in pain perception and the development of a chronic pain condition. Hum Mol Genet. 2005 Jan 1. 14(1):135-43. [QxMD MEDLINE Link].
Docampo E, Escaramís G, Gratacòs M, Villatoro S, Puig A, Kogevinas M, et al. Genome-wide analysis of single nucleotide polymorphisms and copy number variants in fibromyalgia suggest a role for the central nervous system. Pain. 2014 Jun. 155 (6):1102-9. [QxMD MEDLINE Link].
Clauw DJ. Pharmacotherapy for patients with fibromyalgia. J Clin Psychiatry. 2008. 69 Suppl 2:25-9. [QxMD MEDLINE Link].
Winfield JB. Psychological determinants of fibromyalgia and related syndromes. Curr Rev Pain. 2000. 4(4):276-86. [QxMD MEDLINE Link].
Tander B, Gunes S, Boke O, et al. Polymorphisms of the serotonin-2A receptor and catechol-O-methyltransferase genes: a study on fibromyalgia susceptibility. Rheumatol Int. 2008 May. 28(7):685-91. [QxMD MEDLINE Link].
Russell IJ, Orr MD, Littman B, et al. Elevated cerebrospinal fluid levels of substance P in patients with the fibromyalgia syndrome. Arthritis Rheum. 1994 Nov. 37(11):1593-601. [QxMD MEDLINE Link].
Griep EN, Boersma JW, de Kloet ER. Altered reactivity of the hypothalamic-pituitary-adrenal axis in the primary fibromyalgia syndrome. J Rheumatol. 1993 Mar. 20(3):469-74. [QxMD MEDLINE Link].
Crofford LJ. Neuroendocrine aspects of fibromyalgia. J Musculoskelet Pain. 1994. 2:125-33.
Cuatrecasas G, Riudavets C, Güell MA, Nadal A. Growth hormone as concomitant treatment in severe fibromyalgia associated with low IGF-1 serum levels. A pilot study. BMC Musculoskelet Disord. 2007 Nov 30. 8:119. [QxMD MEDLINE Link]. [Full Text].
Albrecht DS, Forsberg A, Sandström A, Bergan C, Kadetoff D, Protsenko E, et al. Brain glial activation in fibromyalgia - A multi-site positron emission tomography investigation. Brain Behav Immun. 2018 Sep 14. [QxMD MEDLINE Link]. [Full Text].
Glass JM. Fibromyalgia and cognition. J Clin Psychiatry. 2008. 69 Suppl 2:20-4. [QxMD MEDLINE Link].
Glass JM, Williams DA, Fernandez-Sanchez ML, Kairys A, Barjola P, Heitzeg MM, et al. Executive function in chronic pain patients and healthy controls: different cortical activation during response inhibition in fibromyalgia. J Pain. 2011 Dec. 12(12):1219-29. [QxMD MEDLINE Link].
Lue FA. Sleep and fibromyalgia. J Musculoskelet Pain. 1994. 2:89-100.
WebSciences International and Sleep Research Society (United States). Basics of Sleep Behavior. Sleep Research Society. Available at http://www.sleepsources.org/uploads/sleepsyllabus/. 1997; Accessed: September 5, 2018.
Goebel A, Krock E, Gentry C, Israel MR, Jurczak A, Urbina CM, et al. Passive transfer of fibromyalgia symptoms from patients to mice. J Clin Invest. 2021 Jul 1. 131 (13):[QxMD MEDLINE Link].
Tracey KJ. From human to mouse and back offers hope for patients with fibromyalgia. J Clin Invest. 2021 Jul 1. 131 (13):[QxMD MEDLINE Link].
Pinto AM, Luís M, Geenen R, Palavra F, Lumley MA, Ablin JN, et al. Neurophysiological and psychosocial mechanisms of fibromyalgia: A comprehensive review and call for an integrative model. Neurosci Biobehav Rev. 2023 Aug. 151:105235. [QxMD MEDLINE Link].
Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977 Apr 8. 196(4286):129-36. [QxMD MEDLINE Link].
Arnold LM, Hudson JI, Hess EV, Ware AE, Fritz DA, Auchenbach MB, et al. Family study of fibromyalgia. Arthritis Rheum. 2004 Mar. 50(3):944-52. [QxMD MEDLINE Link].
Olson J. Mapping Genes for Fibromyalgia. National Institute of Arthritis and Musculoskeletal and Skin Diseases; Aug 2004. Spotlight on Research, Fibromyalgia: Summaries of Research. [Full Text].
Diatchenko L, Nackley AG, Slade GD, et al. Idiopathic pain disorders--pathways of vulnerability. Pain. 2006 Aug. 123(3):226-30. [QxMD MEDLINE Link].
Buskila D, Sarzi-Puttini P. Biology and therapy of fibromyalgia. Genetic aspects of fibromyalgia syndrome. Arthritis Res Ther. Jul 28 2006. 8(5):218.
Ovrom EA, Mostert KA, Khakhkhar S, McKee DP, Yang P, Her YF. A Comprehensive Review of the Genetic and Epigenetic Contributions to the Development of Fibromyalgia. Biomedicines. 2023 Apr 7. 11 (4):[QxMD MEDLINE Link]. [Full Text].
Offenbaecher M, Bondy B, de Jonge S, Glatzeder K, Krüger M, Schoeps P, et al. Possible association of fibromyalgia with a polymorphism in the serotonin transporter gene regulatory region. Arthritis Rheum. 1999 Nov. 42(11):2482-8. [QxMD MEDLINE Link].
Diatchenko L, Nackley AG, Slade GD, Bhalang K, Belfer I, Max MB, et al. Catechol-O-methyltransferase gene polymorphisms are associated with multiple pain-evoking stimuli. Pain. 2006 Dec 5. 125(3):216-24. [QxMD MEDLINE Link].
Fillingim RB, Maixner W. Gender differences in the responses to noxious stimuli. Pain Forum. 1995. 4:209-221.
Moldofsky H, Scarisbrick P, England R, et al. Musculosketal symptoms and non-REM sleep disturbance in patients with "fibrositis syndrome" and healthy subjects. Psychosom Med. 1975 Jul-Aug. 37(4):341-51. [QxMD MEDLINE Link].
Schrader H, Obelieniene D, Bovim G, Surkiene D, Mickeviciene D, Miseviciene I, et al. Natural evolution of late whiplash syndrome outside the medicolegal context. Lancet. 1996 May 4. 347(9010):1207-11. [QxMD MEDLINE Link].
Buskila D, Neumann L, Vaisberg G, Alkalay D, Wolfe F. Increased rates of fibromyalgia following cervical spine injury. A controlled study of 161 cases of traumatic injury. Arthritis Rheum. 1997 Mar. 40(3):446-52. [QxMD MEDLINE Link].
Obelieniene D, Schrader H, Bovim G, Miseviciene I, Sand T. Pain after whiplash: a prospective controlled inception cohort study. J Neurol Neurosurg Psychiatry. 1999 Mar. 66(3):279-83. [QxMD MEDLINE Link].
Tishler M, Levy O, Maslakov I, Bar-Chaim S, Amit-Vazina M. Neck injury and fibromyalgia-- are they really associated?. J Rheumatol. 2006 Jun. 33(6):1183-5. [QxMD MEDLINE Link].
Shir Y, Pereira JX, Fitzcharles MA. Whiplash and fibromyalgia: an ever-widening gap. J Rheumatol. 2006 Jun. 33(6):1045-7. [QxMD MEDLINE Link].
Van Houdenhove B, Egle UT. Fibromyalgia: a stress disorder? Piecing the biopsychosocial puzzle together. Psychother Psychosom. 2004 Sep-Oct. 73(5):267-75. [QxMD MEDLINE Link].
Van Houdenhove B, Luyten P. Beyond dualism: the role of life stress in chronic pain. Pain. 2005 Jan. 113(1-2):238-9; discussion 240-2. [QxMD MEDLINE Link].
Wolfe F, Ross K, Anderson J, Russell IJ, Hebert L. The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum. 1995 Jan. 38(1):19-28. [QxMD MEDLINE Link].
Moldofsky H, Scarisbrick P. Induction of neurasthenic musculoskeletal pain syndrome by selective sleep stage deprivation. Psychosom Med. 1976 Jan-Feb. 38(1):35-44. [QxMD MEDLINE Link].
Crombez G, Eccleston C, Van den Broeck A, et al. Hypervigilance to pain in fibromyalgia: the mediating role of pain intensity and catastrophic thinking about pain. Clin J Pain. 2004 Mar-Apr. 20(2):98-102. [QxMD MEDLINE Link].
Keefe FJ, Lefebvre JC, Maixner W, Salley AN Jr, Caldwell DS. Self-efficacy for arthritis pain: relationship to perception of thermal laboratory pain stimuli. Arthritis Care Res. 1997 Jun. 10(3):177-84. [QxMD MEDLINE Link].
Gracely RH, Geisser ME, Giesecke T, Grant MA, Petzke F, Williams DA, et al. Pain catastrophizing and neural responses to pain among persons with fibromyalgia. Brain. 2004 Apr. 127:835-43. [QxMD MEDLINE Link].
Bradley LA. Psychiatric comorbidity in fibromyalgia. Curr Pain Headache Rep. 2005 Apr. 9(2):79-86. [QxMD MEDLINE Link].
Arnold LM, Hudson JI, Keck PE, Auchenbach MB, Javaras KN, Hess EV. Comorbidity of fibromyalgia and psychiatric disorders. J Clin Psychiatry. 2006 Aug. 67(8):1219-25. [QxMD MEDLINE Link].
Giesecke T, Williams DA, Harris RE, Cupps TR, Tian X, Tian TX, et al. Subgrouping of fibromyalgia patients on the basis of pressure-pain thresholds and psychological factors. Arthritis Rheum. 2003 Oct. 48(10):2916-22. [QxMD MEDLINE Link].
Giesecke T, Gracely RH, Williams DA, Geisser ME, Petzke FW, Clauw DJ. The relationship between depression, clinical pain, and experimental pain in a chronic pain cohort. Arthritis Rheum. 2005 May. 52(5):1577-84. [QxMD MEDLINE Link].
Fassbender K, Samborsky W, Kellner M, Müller W, Lautenbacher S. Tender points, depressive and functional symptoms: comparison between fibromyalgia and major depression. Clin Rheumatol. 1997 Jan. 16(1):76-9. [QxMD MEDLINE Link].
Hoffman DL, Dukes EM. The health status burden of people with fibromyalgia: a review of studies that assessed health status with the SF-36 or the SF-12. Int J Clin Pract. 2008 Jan. 62(1):115-26. [QxMD MEDLINE Link].
Hassett AL. Psychosocial aspects of fibromyalgia: psychological stress, psychiatric morbidity, and personality subgroups. 2008. pp 55-61.
McBeth J, Macfarlane GJ, Benjamin S, Morris S, Silman AJ. The association between tender points, psychological distress, and adverse childhood experiences: a community-based study. Arthritis Rheum. 1999 Jul. 42(7):1397-404. [QxMD MEDLINE Link].
Buchwald D, Umali P, Umali J, Kith P, Pearlman T, Komaroff AL. Chronic fatigue and the chronic fatigue syndrome: prevalence in a Pacific Northwest health care system. Ann Intern Med. 1995 Jul 15. 123(2):81-8. [QxMD MEDLINE Link].
Pawlikowska T, Chalder T, Hirsch SR, Wallace P, Wright DJ, Wessely SC. Population based study of fatigue and psychological distress. BMJ. 1994 Mar 19. 308(6931):763-6. [QxMD MEDLINE Link].
White LA, Birnbaum HG, Kaltenboeck A, et al. Employees with fibromyalgia: medical comorbidity, healthcare costs, and work loss. J Occup Environ Med. 2008 Jan. 50(1):13-24. [QxMD MEDLINE Link].
Arnold LM, Crofford LJ, Mease PJ, et al. Patient perspectives on the impact of fibromyalgia. Patient Educ Couns. 2008 Oct. 73(1):114-20. [QxMD MEDLINE Link]. [Full Text].
Vincent A, Lahr BD, Wolfe F, et al. Prevalence of fibromyalgia: a population-based study in Olmsted County, Minnesota, utilizing the Rochester Epidemiology Project. Arthritis Care Res (Hoboken). 2013 May. 65(5):786-92. [QxMD MEDLINE Link].
Branco JC, Bannwarth B, Failde I, et al. Prevalence of fibromyalgia: a survey in five European countries. Semin Arthritis Rheum. 2010 Jun. 39(6):448-53. [QxMD MEDLINE Link].
Guermazi M, Ghroubi S, Sellami M, et al. [Fibromyalgia prevalence in Tunisia]. Tunis Med. 2008 Sep. 86(9):806-11. [QxMD MEDLINE Link].
White KP, Speechley M, Harth M, Ostbye T. The London Fibromyalgia Epidemiology Study: the prevalence of fibromyalgia syndrome in London, Ontario. J Rheumatol. 1999 Jul. 26(7):1570-6. [QxMD MEDLINE Link].
Assumpção A, Cavalcante AB, Capela CE, et al. Prevalence of fibromyalgia in a low socioeconomic status population. BMC Musculoskelet Disord. 2009 Jun 8. 10:64. [QxMD MEDLINE Link]. [Full Text].
Santos AM, Burti JS, Lopes JB, Scazufca M, Marques AP, Pereira RM. Prevalence of fibromyalgia and chronic widespread pain in community-dwelling elderly subjects living in São Paulo, Brazil. Maturitas. 2010 Nov. 67(3):251-5. [QxMD MEDLINE Link].
Gansky SA, Plesh O. Widespread pain and fibromyalgia in a biracial cohort of young women. J Rheumatol. 2007 Apr. 34(4):810-7. [QxMD MEDLINE Link].
Neumann L, Buskila D. Ethnocultural and educational differences in Israeli women correlate with pain perception in fibromyalgia. J Rheumatol. 1998 Jul. 25(7):1369-73. [QxMD MEDLINE Link].
Felson DT. Comparing the prevalence of rheumatic diseases in China with the rest of the world. Arthritis Res Ther. 2008. 10(1):106. [QxMD MEDLINE Link]. [Full Text].
Ferrari R, Russell AS. A questionnaire using the modified 2010 American College of Rheumatology criteria for fibromyalgia: specificity and sensitivity in clinical practice. J Rheumatol. 2013 Sep. 40(9):1590-5. [QxMD MEDLINE Link].
Michels H, Gerhold K, Hafner R, et al. [Juvenile fibromyalgia syndrome]. Schmerz. 2008 Jun. 22(3):339-48. [QxMD MEDLINE Link].
Palstam A, Bjersing JL, Mannerkorpi K. Which aspects of health differ between working and nonworking women with fibromyalgia? A cross-sectional study of work status and health. BMC Public Health. 2012 Dec 14. 12:1076. [QxMD MEDLINE Link]. [Full Text].
Turk DC, Okifuji A, Sinclair JD, et al. Pain, disability, and physical functioning in subgroups of patients with fibromyalgia. J Rheumatol. 1996 Jul. 23(7):1255-62. [QxMD MEDLINE Link].
Turk DC, Okifuji A, Sinclair JD, et al. Differential responses by psychosocial subgroups of fibromyalgia syndrome patients to an interdisciplinary treatment. Arthritis Care Res. 1998 Oct. 11(5):397-404. [QxMD MEDLINE Link].
Dreyer L, Kendall S, Danneskiold-Samsoe B, Bartels EM, Bliddal H. Mortality in a cohort of Danish patients with fibromyalgia: increased frequency of suicide. Arthritis Rheum. 2010 Oct. 62(10):3101-8. [QxMD MEDLINE Link].
Stephens RJ, Hopwood P, Girling DJ, Machin D. Randomized trials with quality of life endpoints: are doctors' ratings of patients' physical symptoms interchangeable with patients' self-ratings?. Qual Life Res. 1997 Apr. 6(3):225-36. [QxMD MEDLINE Link].
Wolfe F, Clauw DJ, Fitzcharles MA, et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol. 2011 Jun. 38(6):1113-22. [QxMD MEDLINE Link].
Okifuji A, Turk DC, Sinclair JD, Starz TW, Marcus DA. A standardized manual tender point survey. I. Development and determination of a threshold point for the identification of positive tender points in fibromyalgia syndrome. J Rheumatol. 1997 Feb. 24(2):377-83. [QxMD MEDLINE Link].
Fan A, Tournadre A, Pereira B, Tatar Z, Couderc M, Malochet-Guinamand S, et al. Performance of Fibromyalgia Rapid Screening Tool (FiRST) to detect fibromyalgia syndrome in rheumatic diseases. Rheumatology (Oxford). 2016 Jun 15. [QxMD MEDLINE Link]. [Full Text].
Pincus T, Yazici Y, Bergman M. Development of a multi-dimensional health assessment questionnaire (MDHAQ) for the infrastructure of standard clinical care. Clin Exp Rheumatol. 2005 Sep-Oct. 23(5 Suppl 39):S19-28. [QxMD MEDLINE Link].
[Guideline] Fitzcharles MA, Ste-Marie PA, Goldenberg DL, Pereira JX, Abbey S, Choinière M, et al. 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary. Pain Res Manag. 2013 May-Jun. 18 (3):119-26. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Macfarlane GJ, Kronisch C, Dean LE, Atzeni F, Häuser W, Fluß E, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 2017 Feb. 76 (2):318-328. [QxMD MEDLINE Link].
Wood PB. Treating comorbidities in fibromyalgia. Pain Pract. 2008. 18(1):pp 42-53.
Turk DC, Vierck CJ, Scarbrough E, et al. Fibromyalgia: combining pharmacological and nonpharmacological approaches to treating the person, not just the pain. J Pain. 2008 Feb. 9(2):99-104. [QxMD MEDLINE Link].
Staud R. Treatment of fibromyalgia and its symptoms. Expert Opin Pharmacother. 2007 Aug. 8(11):1629-42. [QxMD MEDLINE Link].
Sarzi-Puttini P, Buskila D, Carrabba M, et al. Treatment strategy in fibromyalgia syndrome: where are we now?. Semin Arthritis Rheum. 2008 Jun. 37(6):353-65. [QxMD MEDLINE Link].
Carville SF, Arendt-Nielsen S, Bliddal H, et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis. 2008 Apr. 67(4):536-41. [QxMD MEDLINE Link].
Goldenberg DL. Pharmacological treatment of fibromyalgia and other chronic musculoskeletal pain. Best Pract Res Clin Rheumatol. 2007 Jun. 21(3):499-511. [QxMD MEDLINE Link].
Goldenberg DL. Multidisciplinary modalities in the treatment of fibromyalgia. J Clin Psychiatry. 2008. 69 Suppl 2:30-4. [QxMD MEDLINE Link].
Burckhardt CS. Multidisciplinary approaches for management of fibromyalgia. Curr Pharm Des. 2006. 12(1):59-66. [QxMD MEDLINE Link].
Häuser W, Bernardy K, Arnold B, Offenbächer M, Schiltenwolf M. Efficacy of multicomponent treatment in fibromyalgia syndrome: a meta-analysis of randomized controlled clinical trials. Arthritis Rheum. 2009 Feb 15. 61(2):216-24. [QxMD MEDLINE Link].
Benca RM, Ancoli-Israel S, Moldofsky H. Special considerations in insomnia diagnosis and management: depressed, elderly, and chronic pain populations. J Clin Psychiatry. 2004. 65 Suppl 8:26-35. [QxMD MEDLINE Link].
Bigatti SM, Hernandez AM, Cronan TA, et al. Sleep disturbances in fibromyalgia syndrome: relationship to pain and depression. Arthritis Rheum. 2008 Jul 15. 59(7):961-7. [QxMD MEDLINE Link].
Moldofsky H. The significance, assessment, and management of nonrestorative sleep in fibromyalgia syndrome. CNS Spectr. 2008 Mar. 13(3 Suppl 5):22-6. [QxMD MEDLINE Link].
Cheng YC, Hsiao CY, Su MI, Chiu CC, Huang YC, Huang WL. Treating fibromyalgia with electrical neuromodulation: A systematic review and meta-analysis. Clin Neurophysiol. 2023 Apr. 148:17-28. [QxMD MEDLINE Link].
Stephens S, Feldman BM, Bradley N, Schneiderman J, Wright V, Singh-Grewal D, et al. Feasibility and effectiveness of an aerobic exercise program in children with fibromyalgia: results of a randomized controlled pilot trial. Arthritis Rheum. 2008 Oct 15. 59(10):1399-406. [QxMD MEDLINE Link].
Kashikar-Zuck S, Cunningham N, Sil S, Bromberg MH, Lynch-Jordan AM, Strotman D, et al. Long-term outcomes of adolescents with juvenile-onset fibromyalgia in early adulthood. Pediatrics. 2014 Mar. 133(3):e592-600. [QxMD MEDLINE Link].
Kelly J. Teenagers With Fibromyalgia Unlikely to 'Outgrow' the Pain. Medscape Medical News. Available at http://www.medscape.com/viewarticle/821275. Accessed: March 1, 2014.
Upadhyaya HP, Arnold LM, Alaka K, Qiao M, Williams D, Mehta R. Efficacy and safety of duloxetine versus placebo in adolescents with juvenile fibromyalgia: results from a randomized controlled trial. Pediatr Rheumatol Online J. 2019 May 28. 17 (1):27. [QxMD MEDLINE Link]. [Full Text].
Thieme K, Flor H, Turk DC. Psychological pain treatment in fibromyalgia syndrome: efficacy of operant behavioural and cognitive behavioural treatments. Arthritis Res Ther. 2006. 8(4):R121. [QxMD MEDLINE Link].
Thieme K, Turk DC, Flor H. Responder criteria for operant and cognitive-behavioral treatment of fibromyalgia syndrome. Arthritis Rheum. 2007 Jun 15. 57(5):830-6. [QxMD MEDLINE Link].
Häuser W, Bernardy K, Uçeyler N, Sommer C. Treatment of fibromyalgia syndrome with antidepressants: a meta-analysis. JAMA. 2009 Jan 14. 301(2):198-209. [QxMD MEDLINE Link].
Arnold LM, Sarzi-Puttini P, Arsenault P, Khan T, Bhadra Brown P, Clair A, et al. Efficacy and Safety of Pregabalin in Patients with Fibromyalgia and Comorbid Depression Taking Concurrent Antidepressant Medication: A Randomized, Placebo-controlled Study. J Rheumatol. 2015 Jul. 42 (7):1237-44. [QxMD MEDLINE Link].
Jones KD, Adams D, Winters-Stone K, Burckhardt CS. A comprehensive review of 46 exercise treatment studies in fibromyalgia (1988-2005). Health Qual Life Outcomes. 2006 Sep 25. 4:67. [QxMD MEDLINE Link].
Busch AJ, Schachter CL, Overend TJ, et al. Exercise for fibromyalgia: a systematic review. J Rheumatol. 2008 Jun. 35(6):1130-44. [QxMD MEDLINE Link].
Munguía-Izquierdo D, Legaz-Arrese A. Assessment of the effects of aquatic therapy on global symptomatology in patients with fibromyalgia syndrome: a randomized controlled trial. Arch Phys Med Rehabil. 2008 Dec. 89(12):2250-7. [QxMD MEDLINE Link].
Sawynok J, Lynch ME. Qigong and Fibromyalgia circa 2017. Medicines (Basel). 2017 Jun 6. 4 (2):[QxMD MEDLINE Link]. [Full Text].
Wang C, Schmid CH, Fielding RA, Harvey WF, Reid KF, Price LL, et al. Effect of tai chi versus aerobic exercise for fibromyalgia: comparative effectiveness randomized controlled trial. BMJ. 2018 Mar 21. 360:k851. [QxMD MEDLINE Link]. [Full Text].
Living with Fibromyalgia, Drugs Approved to Manage Pain. U.S. Food and Drug Administration. Available at http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm107802.htm#approved. January 31, 2014; Accessed: July 30, 216.
Lee YH, Song GG. Comparative efficacy and tolerability of duloxetine, pregabalin, and milnacipran for the treatment of fibromyalgia: a Bayesian network meta-analysis of randomized controlled trials. Rheumatol Int. 2016 May. 36 (5):663-72. [QxMD MEDLINE Link].
Cuatrecasas G, Alegre C, Casanueva FF. GH/IGF1 axis disturbances in the fibromyalgia syndrome: is there a rationale for GH treatment?. Pituitary. 2013 Apr 9. [QxMD MEDLINE Link].
Winfield JB. Pain and arthritis. N C Med J. 2007 Nov-Dec. 68(6):444-6. [QxMD MEDLINE Link].
MacLean AJ, Schwartz TL. Tramadol for the treatment of fibromyalgia. Expert Rev Neurother. 2015 May. 15 (5):469-75. [QxMD MEDLINE Link].
Peng X, Robinson RL, Mease P, Kroenke K, Williams DA, Chen Y, et al. Long-term evaluation of opioid treatment in fibromyalgia. Clin J Pain. 2015 Jan. 31 (1):7-13. [QxMD MEDLINE Link].
Scharf MB, Hauck M, Stover R, et al. Effect of gamma-hydroxybutyrate on pain, fatigue, and the alpha sleep anomaly in patients with fibromyalgia. Preliminary report. J Rheumatol. 1998 Oct. 25(10):1986-90. [QxMD MEDLINE Link].
Russell IJ, Perkins AT, Michalek JE. Sodium oxybate relieves pain and improves function in fibromyalgia syndrome: a randomized, double-blind, placebo-controlled, multicenter clinical trial. Arthritis Rheum. 2009 Jan. 60(1):299-309. [QxMD MEDLINE Link].
Gendreau RM, Thorn MD, Gendreau JF, Kranzler JD, Ribeiro S, Gracely RH, et al. Efficacy of milnacipran in patients with fibromyalgia. J Rheumatol. 2005 Oct. 32(10):1975-85. [QxMD MEDLINE Link].
Arnold LM, Rosen A, Pritchett YL, D'Souza DN, Goldstein DJ, Iyengar S, et al. A randomized, double-blind, placebo-controlled trial of duloxetine in the treatment of women with fibromyalgia with or without major depressive disorder. Pain. 2005 Dec 15. 119(1-3):5-15. [QxMD MEDLINE Link].
Arnold LM, Pritchett YL, D'Souza DN, Kajdasz DK, Iyengar S, Wernicke JF. Duloxetine for the treatment of fibromyalgia in women: pooled results from two randomized, placebo-controlled clinical trials. J Womens Health (Larchmt). 2007 Oct. 16(8):1145-56. [QxMD MEDLINE Link].
Arnold LM. Duloxetine and other antidepressants in the treatment of patients with fibromyalgia. Pain Med. 2007 Sep. 8 Suppl 2:S63-74. [QxMD MEDLINE Link].
Russell IJ, Mease PJ, Smith TR, Kajdasz DK, Wohlreich MM, Detke MJ, et al. Efficacy and safety of duloxetine for treatment of fibromyalgia in patients with or without major depressive disorder: Results from a 6-month, randomized, double-blind, placebo-controlled, fixed-dose trial. Pain. 2008 Jun. 136(3):432-44. [QxMD MEDLINE Link].
Farag HM, Yunusa I, Goswami H, Sultan I, Doucette JA, Eguale T. Comparison of Amitriptyline and US Food and Drug Administration-Approved Treatments for Fibromyalgia: A Systematic Review and Network Meta-analysis. JAMA Netw Open. 2022 May 2. 5 (5):e2212939. [QxMD MEDLINE Link]. [Full Text].
Goldenberg D, Mayskiy M, Mossey C, Ruthazer R, Schmid C. A randomized, double-blind crossover trial of fluoxetine and amitriptyline in the treatment of fibromyalgia. Arthritis Rheum. 1996 Nov. 39 (11):1852-9. [QxMD MEDLINE Link].
Nelson LS, Erdman AR, Booze LL, Cobaugh DJ, Chyka PA, Woolf AD, et al. Selective serotonin reuptake inhibitor poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007 May. 45 (4):315-32. [QxMD MEDLINE Link].
Besson JM, Chaouch A. Peripheral and spinal mechanisms of nociception. Physiol Rev. 1987 Jan. 67 (1):67-186. [QxMD MEDLINE Link].
Colpaert FC, Tarayre JP, Koek W, Pauwels PJ, Bardin L, Xu XJ, et al. Large-amplitude 5-HT1A receptor activation: a new mechanism of profound, central analgesia. Neuropharmacology. 2002 Nov. 43 (6):945-58. [QxMD MEDLINE Link].
Arnold LM, Goldenberg DL, Stanford SB, et al. Gabapentin in the treatment of fibromyalgia: a randomized, double-blind, placebo-controlled, multicenter trial. Arthritis Rheum. 2007 Apr. 56(4):1336-44. [QxMD MEDLINE Link].
Crofford LJ, Rowbotham MC, Mease PJ, Russell IJ, Dworkin RH, Corbin AE, et al. Pregabalin for the treatment of fibromyalgia syndrome: results of a randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2005 Apr. 52(4):1264-73. [QxMD MEDLINE Link].
Crofford LJ, Mease PJ, Simpson SL, et al. Fibromyalgia relapse evaluation and efficacy for durability of meaningful relief (FREEDOM): a 6-month, double-blind, placebo-controlled trial with pregabalin. Pain. 2008 Jun. 136(3):419-31. [QxMD MEDLINE Link].
Mease PJ, Farmer MV, Palmer RH, Gendreau RM, Trugman JM, Wang Y. Milnacipran combined with pregabalin in fibromyalgia: a randomized, open-label study evaluating the safety and efficacy of adding milnacipran in patients with incomplete response to pregabalin. Ther Adv Musculoskelet Dis. 2013 Jun. 5 (3):113-26. [QxMD MEDLINE Link]. [Full Text].
Simpson DA. Gabapentin and venlafaxine for the treatment of painful diabetic neuropathy. J Clin Neuromuscul Dis. 2001 Dec. 3 (2):53-62. [QxMD MEDLINE Link].
Sadreddini S, Molaeefard M, Noshad H, et al. Efficacy of Raloxifen in treatment of fibromyalgia in menopausal women. Eur J Intern Med. 2008 Jul. 19(5):350-5. [QxMD MEDLINE Link].
Broughton RJ, Fleming JA, George CF, et al. Randomized, double-blind, placebo-controlled crossover trial of modafinil in the treatment of excessive daytime sleepiness in narcolepsy. Neurology. 1997 Aug. 49(2):444-51. [QxMD MEDLINE Link].
Schwartz TL, Rayancha S, Rashid A, et al. Modafinil treatment for fatigue associated with fibromyalgia. J Clin Rheumatol. 2007 Feb. 13(1):52. [QxMD MEDLINE Link].
Habib G, Artul S. Medical Cannabis for the Treatment of Fibromyalgia. J Clin Rheumatol. 2018 Aug. 24 (5):255-258. [QxMD MEDLINE Link].
Hershkovich O, Hayun Y, Oscar N, Shtein A, Lotan R. The role of cannabis in treatment-resistant fibromyalgia women. Pain Pract. 2023 Feb. 23 (2):180-184. [QxMD MEDLINE Link]. [Full Text].
Skrabek RQ, Galimova L, Ethans K, et al. Nabilone for the treatment of pain in fibromyalgia. J Pain. 2008 Feb. 9(2):164-73. [QxMD MEDLINE Link].
Walitt B, Klose P, Fitzcharles MA, Phillips T, Häuser W. Cannabinoids for fibromyalgia. Cochrane Database Syst Rev. 2016 Jul 18. 7 (7):CD011694. [QxMD MEDLINE Link]. [Full Text].
Rooks DS. Fibromyalgia treatment update. Curr Opin Rheumatol. 2007 Mar. 19(2):111-7. [QxMD MEDLINE Link].
Bootzin RR, Lahmeyer HW, Lilie JK. Easy Steps to Help You Sleep. Chicago, Ill: Searle Pharmaceuticals; 1994. 1-34.
Choy EH. Current treatments to counter sleep dysfunction as a pathogenic stimulus of fibromyalgia. Pain Manag. 2016 May. 6 (4):339-46. [QxMD MEDLINE Link].
Holman AJ, Myers RR. A randomized, double-blind, placebo-controlled trial of pramipexole, a dopamine agonist, in patients with fibromyalgia receiving concomitant medications. Arthritis Rheum. 2005 Aug. 52(8):2495-505. [QxMD MEDLINE Link].
Logan AC. Is there a fibromyalgia diet. Fibromyalgia Aware. Dec 2004-Mar 2005. 8:46-9.
Sanada K, Díez MA, Valero MS, Pérez-Yus MC, Demarzo MM, García-Toro M, et al. Effects of non-pharmacological interventions on inflammatory biomarker expression in patients with fibromyalgia: a systematic review. Arthritis Res Ther. 2015 Sep 26. 17:272. [QxMD MEDLINE Link]. [Full Text].
Ciappuccini R, Ansemant T, Maillefert JF, Tavernier C, Ornetti P. Aspartame-induced fibromyalgia, an unusual but curable cause of chronic pain. Clin Exp Rheumatol. 2010 Nov-Dec. 28 (6 Suppl 63):S131-3. [QxMD MEDLINE Link].
Smith JD, Terpening CM, Schmidt SO, Gums JG. Relief of fibromyalgia symptoms following discontinuation of dietary excitotoxins. Ann Pharmacother. 2001 Jun. 35 (6):702-6. [QxMD MEDLINE Link].
Cairns BE. Influence of pro-algesic foods on chronic pain conditions. Expert Rev Neurother. 2016. 16 (4):415-23. [QxMD MEDLINE Link].
Yang CC, Tsai ST, Ting B, Cheng YC, Wang CK, Chang JP, et al. Psychological Outcomes and Quality of Life of Fibromyalgia Patients with Vitamin D Supplementation-A Meta-Analysis. J Clin Med. 2023 Apr 6. 12 (7):[QxMD MEDLINE Link]. [Full Text].
Callahan LF, Freburger JK, Mielenz TJ, Wiley-Exley EK. Medical skepticism and the use of complementary and alternative health care providers by patients followed by rheumatologists. J Clin Rheumatol. 2008 Jun. 14(3):143-7. [QxMD MEDLINE Link].
[Guideline] Yokota S, Kikuchi M, Miyamae T. Juvenile fibromyalgia: Guidance for management. Pediatr Int. 2013 Aug. 55 (4):403-9. [QxMD MEDLINE Link].
[Guideline] Draheim N, Ebinger F, Schnöbel-Müller E, Wolf B, Häuser W. [Definition, diagnostics and therapy of chronic widespread pain and the (so-called) fibromyalgia syndrome in children and adolescents : Updated guidelines 2017]. Schmerz. 2017 Jun. 31 (3):296-307. [QxMD MEDLINE Link].
[Guideline] Sommer C, Alten R, Bär KJ, Bernateck M, Brückle W, Friedel E, et al. [Drug therapy of fibromyalgia syndrome : Updated guidelines 2017 and overview of systematic review articles]. Schmerz. 2017 Jun. 31 (3):274-284. [QxMD MEDLINE Link].
[Guideline] Schiltenwolf M, Eidmann U, Köllner V, Kühn T, Offenbächer M, Petzke F, et al. [Multimodal therapy of fibromyalgia syndrome : Updated guidelines 2017 and overview of systematic review articles]. Schmerz. 2017 Jun. 31 (3):285-288. [QxMD MEDLINE Link].
[Guideline] Fitzcharles MA, Ste-Marie PA, Goldenberg DL, Pereira JX, Abbey S, Choinière M, et al. Canadian Pain Society and Canadian Rheumatology Association recommendations for rational care of persons with fibromyalgia: a summary report. J Rheumatol. 2013 Aug. 40 (8):1388-93. [QxMD MEDLINE Link].
[Guideline] Petzke F, Brückle W, Eidmann U, Heldmann P, Köllner V, Kühn T, et al. [General treatment principles, coordination of care and patient education in fibromyalgia syndrome : Updated guidelines 2017 and overview of systematic review articles]. Schmerz. 2017 Jun. 31 (3):246-254. [QxMD MEDLINE Link].
[Guideline] Ablin JN, Amital H, Ahrenfeld M, et al. Guidelines for the diagnosis and treatment of the fibromyalgia syndrome (Hebrew). Harefuah. Available at http://www.ima.org.il/Ima/FormStorage/ Type7/clinical 68 fibrom.pdf. 2013; Accessed: September 14, 2021.
Arnold LM, Russell IJ, Diri EW, Duan WR, Young JP Jr, Sharma U, et al. A 14-week, randomized, double-blinded, placebo-controlled monotherapy trial of pregabalin in patients with fibromyalgia. J Pain. 2008 Sep. 9(9):792-805. [QxMD MEDLINE Link].

Media Gallery

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

of 4

Author

Chad S Boomershine, MD, PhD, CPI, CPT Assistant Clinical Professor, Department of Medicine, Vanderbilt University School of Medicine; Principal Investigator, Clinical Research Solutions; Medical Director, Boomershine Wellness Centers, Elite Healthcare Alliance, Platinum Medical Group, and Spectrum Pain Clinic

Chad S Boomershine, MD, PhD, CPI, CPT is a member of the following medical societies: American College of Rheumatology, American Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Pfizer;<br/>Serve(d) as a speaker or a member of a speakers bureau for: Pfizer;.

Chief Editor

Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; 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, Phi Beta Kappa

Disclosure: Nothing to disclose.

Acknowledgements

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

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