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.^{[100, 101]}

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%).^{[100, 101]}

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.^{[100, 101]}

Differential Diagnoses

Workup

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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.

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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