FM :: Fibromyalgia  Signs, Symptoms, Diagnostics

THE FIBROMYALGIA SYNDROME: A CLINICAL CASE DEFINITION FOR PRACTITIONERS
Anil Kumar Jain , Dan S. Heffez , Bruce M. Carruthers , Frances Y.-K. Leung , Marjorie I. van de Sande , Daniel G. Malone , Stephen R. Barron , Thomas J. Romano , C. C. Stuart Donaldson , I. Jon Russell , James V. Dunne , David Saul , Emerson Gingrich , Donald G. Seibel.

DIAGNOSITIC PROTOCOL

A. Canadian Clinical Working Case Definition of FMS

The two compulsory pain criteria [adopted from the American College of Rheumatology 1990 Criteria (1)] are merged with Additional Clinical Symptoms & Signs to expand the classification of FMS into a Clinical Working Case Definition of FMS.

1. Compulsory HISTORY of widespread pain. Pain is considered widespread when all of the following are present for at least three months:
· pain in both sides of the body
· pain above and below the waist [including low back pain]
· axial skeletal pain [cervical spine, anterior chest, thoracic spine or low back]. Shoulder and buttock involvement counts for either side of the body. "Low back" is lower segment.

2. Compulsory PAIN ON PALPATION at 11 or more of the 18 defined tender point sites.[see Figure 1]
· Occiput [1,2]­ at the suboccipital muscle insertions [see Figure 1]
· Low cervical [3,4] ­at the anterior aspects of the intertransverse spaces [the spaces between the transverse processes] at C5-C7
· Trapezius [5,6] ­at the midpoint of the upper border
· Supraspinatus [7,8] ­at origins, above the scapular spine near its medial border
· Second rib [9,10] ­just lateral to the second costochondral junctions, on the upper rib surfaces
· Lateral epicondyle [11,12] ­2 cm distal to the epicondyles [in the brachioradialis muscle]
· Gluteal [13,14] ­in upper outer quadrants of buttocks in the anterior fold of muscle
· Greater trochanter [15,16] ­posterior to the trochanteric prominence
· Knee [17,18] ­at medial fat pad proximal to the joint line (and condyle)

Notes Regarding Application of the Compulsory Criteria

· Digital palpation. The palpation examina-tion should be performed with an approximate force of 4 kg/1.4 cm2 [pressure required to partially blanch the blood from under the thumbnail]. This force can be standardized by pressing thumb on a weight scale. For a tender point to be considered "positive" the subject must state that the palpation was painful. "Tender" is not to be considered "painful."

FIGURE 1. Location of Fibromyalgia Syndrome Tender Points [TrPs]

· Validity. The two compulsory pain criteria were validated as classification criteria applicable to groups of subjects for the purpose of research study. In that setting, they yielded 88.4 percent sensitivity and 81.1 percent specificity for a research classification of FMS. They have not yet been validated for clinical diagnosis of symptomatic individuals in a medical care setting.

3. Additional clinical symptoms & signs. In addition to the compulsory pain and tenderness required for research classification of FMS, many additional clinical symptoms and signs can contribute importantly to the patients' burden of illness. Two or more of these features are present in most FMS patients by the time they seek medical attention. On the other hand, it is uncommon for any individual FMS patient to have all of the associated symptoms or signs. As a result, the clinical presentation of FMS may vary somewhat, and the patterns of involvement may eventually lead to the recognition of FMS clinical subgroups. These additional clinical symptoms and signs are not required for the research classification of FMS but they are still clinically important. For these reasons, the following clinical symptoms and signs are itemized and described in an attempt to expand the compulsory pain criteria into a proposed Clinical Case Definition of FMS [see Appendix 2, p. 79].

· Neurological manifestations: Neurological difficulties are often present such as hypertonic and hypotonic muscles; musculoskeletal asymmetry and dysfunction involving muscles, ligaments and joints; atypical patterns of numbness and tingling; abnormal muscle twitch response, muscle cramps, muscle weakness, and fasciculations. Headaches, temporomandibular joint disorder, generalized weakness, perceptual disturbances, spatial instability, and sensory overload phenomena often occur.

· Neurocognitive manifestations: Neurocognitive difficulties usually are present. These include impaired concentration and short-term memory consolidation, impaired speed of performance, inability to multi-task, easy distractibility, and/or cognitive overload.

· Fatigue: There is persistent and reactive fatigue accompanied by reduced physical and mental stamina, which often interferes with the patient's ability to exercise.

· Sleep dysfunction: Most FMS patients experience unrefreshing sleep. This is usually accompanied by sleep disturbances including insomnia, frequent nocturnal awakening, nocturnal myoclonus, and/or restless leg syndrome.

· Autonomic and/or neuroendocrine manifestations: These manifestations include cardiac arrhythmias, neurally mediated hypotension, vertigo, vasomotor instability, sicca syndrome, temperature instability, heat/cold intolerance, respiratory disturbances, intestinal and bladder motility disturbances with or without irritable bowel or bladder dysfunction, dysmenorrhea, loss of adaptability and tolerance for stress, emotional flattening, lability, and/or reactive depression.

· Stiffness: Generalized or even regional stiffness that is most severe upon awakening and typically lasts for hours as occurs with active rheumatoid arthritis. It can return during periods of inactivity during the day.


B. Application of the Clinical Working Case Definition [see also Appendix 3-13]

In a clinical setting, the physician must apply the compulsory criteria for the classification of FMS but also appreciate the clinical spectrum of FMS manifestations and the range of distress it can cause. Thus, in addition to identifying FMS, using the two compulsory pain features, the clinician should assess the patient for other symptoms and signs that typically embody FMS, in order to establish the patient's total illness burden and to direct appropriate treatment for all of the manifestations in a timely fashion.


APPENDIX 2. Symptoms and Signs
As the neurological and endocrine systems are widely distributed, symptoms are numerous, multiform and of variable intensities. Many of the following symptoms and signs are not present in everyone or at all times and, therefore, cannot be included as part of the criteria for diagnosis.

Musculoskeletal System
  • generalized stiffness 80 percent
  • muscle cramps­e.g., legs 40 percent
  • chest pressure and pain
  • TMJ (temporomandibular joint)
Nervous System
  • persistent fatigue 87 percent
  • lack of endurance 67 percent
  • migraines or new onset headaches 58 percent
Sensory
  • hypersensitivity to pain
  • hyper-responsiveness to noxious stimuli
  • perceptual and dimensional distortions
  • feeling of burning or swelling
  • sensory overload phenomena
  • loss of cognitive map
  • dyspnea
Cognitive
  • difficulties processing information
  • slowness in cognitive processing
  • concentration problems
  • difficulties with word retrieval
  • confusion and word mix-ups
  • short-term memory difficulties
Motor and Balance
  • muscle weakness and paralysis
  • poor balance, ataxia and tandem gait
  • clumsiness and tendency to drop things
  • difficulty in tandem gait
  • atypical numbness or tingling 64 percent
Neuroendocrine System
  • marked weight change
  • heat/cold intolerance 85 percent
  • neuropsychological
  • mood swings, anxiety 60 percent
  • reactive depression
Visual and Auditory Disturbances
  • visual changes or eye pain
  • double, blurred or wavy vision
  • dry or itchy eyes
  • photophobia
  • tinnitus ­buzzing or ringing in ears
  • hyperacusis and interference from background noise
Sleep Disturbances 82 percent
  • sleep disorders­hyper or insomnia
  • non-refreshing sleep
Circulatory System
  • neurally mediated hypotension
  • fainting or vertigo
  • palpitations and tachycardia
  • fluid retention
  • bruising
Digestive System Urinary System
  • irritable bladder
  • overactive bladder
Reproductive System
  • dysmenorrhea
  • PMS or irregular menstrual cycles
  • loss of sexual libido or impotence
  • anorgasmia

Address correspondence to: Anil K. Jain, BSc, MD, 118, 1025 Grenon Avenue, Ottawa, ON, K2B 8S5, Canada.
[Haworth co-indexing entry note]: "Fibromyalgia Syndrome: Canadian Clinical Working Case Definition, Diagnostic and Treatment Protocols­A Consensus Document." Jain, Anil Kumar et al.
Co-published simultaneously in Journal of Musculoskeletal Pain [The Haworth Medical Press, an imprint of The Haworth Press, Inc.] Vol. 11, No. 4, 2003, pp. 3-107; and: The Fibromyalgia Syndrome: A Clinical Case Definition for Practitioners [ed: I. Jon Russell] The Haworth Medical Press, an imprint of The Haworth Press, Inc., 2003, pp. 3-107. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. [EST]. E-mail address:
docdelivery@haworthpress.com].
http://www.haworthpress.com/web/JMP
2003 by The Haworth Press, Inc. All rights reserved.

Note: Fig 1 has been altered from the original paper.



MAY 12   2009

Fibromyalgia
Awareness Day


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Fibromyalgia is a prevalent disorder. Pain, fatigue and other symptoms of fibromyalgia have major consequences for the wellbeing and functioning of people with fibromyalgia. An extra burden is the invisibility and medically unexplained character of the symptoms. There is no uniformly accepted pharmacological treatment for fibromyalgia. Research should be aimed at the physiological mechanisms that explain and maintain the disorder and at behavioral processes that impact the physiological underpinnings and the consequences of fibromyalgia. Health care professionals should be educated to recognize the disorder and to help patients by learning them to cope with fibromyalgia. Society should acknowledge fibromyalgia as being a disorder with adverse consequences for wellbeing and functioning.

Prof. Dr. Rinie Geenen, psychologist
Utrecht University & University Medical Center Utrecht, The Netherlands

 
 
 

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