A 47-year-old female presents to the Physical Medicine and Rehabilitation (PM&R) clinic with increasing fatigue and pain in both of her shoulders, hips, back, and arms for 8 months. Patient reports that the pain started precipitously. Reports that “everything hurts” and that she feels “tired all the time.” States that the pain seems to be in her muscles and does not necessarily feel pain in her joints. Pain is a constant, dull, throbbing, 7/10 pain that does not really improve with nonsteroidal antiinflammatory drugs (NSAIDs), ice, acetaminophen. Notes that sometimes a heating pad seems to help the pain but that it only helps for small amounts of time. Pain interferes with her sleep and is worse in the mornings and before bed. Denies any changes in her mood and states that she normally is happy but over the last several months the constant pain is making her less upbeat. States she is too busy to exercise and that she is usually sedentary during the workday. Denies any nausea, vomiting, diarrhea, shortness of breath, swelling of her joints, joint stiffness, weight loss, difficulty breathing, fevers, chills, or recent cough.
Past medical history: Obesity, hypertension.
Past surgical history: Cholecystectomy.
Allergies: Shellfish.
Medications: Ibuprofen as needed, acetaminophen as needed, lisinopril 20 mg daily.
Social history: Lives with her three children and husband in a third-floor walk-up building. Works as a receptionist. Drinks about 1 to 2 glasses of wine weekly. Denies any current or past cigarette or illicit drug use.
BP: 145/85 mmHg, PR: 88 per min, RR: 16/min, pulse oxygenation: 98% on room air, Temp: 98.8° F, BMI: 35 kg/m 2 .
General: Mild distress, appears tired and uncomfortable. Slightly withdrawn.
Head, eyes, ears, nose, throat: Normocephalic. Pupils equal, reactive to light. Extraocular muscles intact. Sclera nonicteric. Moist oral mucosa.
Neck: Supple. Thyroid nonenlarged, no goiter appreciated.
Lungs: Breathing comfortably on room air. Clear to auscultation bilaterally, no wheezing, rales, rhonchi.
Cardiovascular: Regular rate and rhythm with no murmurs, rubs, gallops.
Abdomen: Obese, soft, nontender. Bowel sounds present in all four quadrants.
Extremities: Trace bilateral, nonpitting pedal edema.
Musculoskeletal: Passive and active range of motion mostly within normal limits in all four extremities, with some voluntary resistance secondary to reported pain on terminal bilateral shoulder flexion and initial shoulder abduction. Active range of motion decreased on forward flexion at the waist.
Tenderness noted on palpation over bilateral deltoids, biceps, quadriceps, gastrocnemii. Tenderness noted over bilateral sternocleidomastoid, splenius capitus, and trapezius.
Neurologic:
Manual muscle testing 4/5 bilaterally on shoulder abduction, shoulder flexion, hip flexion. 5/5 bilaterally on elbow flexion, elbow extension, finger flexion, finger extension, knee flexion, knee extension, dorsiflexion, plantar flexion, great toe flexion, and great toe extension.
Sensation grossly intact to light touch.
Labs: Complete blood count (CBC): white blood cell (WBC): 7.8 x 10 9 /L, Hgb: 13.2g/dL, HCT 40%, platelets 230 x 10 9 /L.
Erythrocyte sedimentation rate (ESR): 13 mm/h.
Imaging: No prior imaging available.
Discussion
Fibromyalgia (FM) is a chronic functional illness that presents with widespread musculoskeletal pain, as well as a constellation of symptoms, including fatigue, cognitive dysfunction, sleep difficulties, stiffness, anxiety, and depressed mood. It is the most common cause of chronic widespread musculoskeletal pain. Fibromyalgia’s prevalence in the United States is between 2% and 8% of the general population with women being diagnosed with the illness 2:1 as compared with men. , The average age of onset is between the ages of 30 and 50 years. Risk factors include female gender, lower educational status, lower household income, history of disability, and middle age.
Because of the nature of disease, where patients experience invalidation by medical services, their families and societies regarding the recognition and management of disease, direct, indirect, and immeasurable costs are considerable. FM patients make 10 to 18 primary care appointments per year and are hospitalized on average once every 3 years. Patients also reported missing 0.4 to 3.0 days from work and being unable to complete 3.6 to 35.4 hours of unpaid informal work because of FM, including child care, housework, yard work, or other daily activities. ,
The mean annual cost per patient ranged from US $2274 to $9573 or even more in various studies depending on the severity of symptoms and rout of cost calculation. , , , Overall, it seems the clinical and economic burden of the disease on societies is so high that FM is on the same level as other chronic diseases, such as diabetes or hypertension; however, the latter usually receives much more attention from the healthcare and nonhealthcare systems. , ,
Symptoms
Pain is the most common reported symptom of FM. The pain reported can be described as chronic, deep, widespread, aching, radiating, shooting, or tender. However, in addition to pain other symptoms are also present. The National Fibromyalgia Association conducted a survey in which people with FM reported their symptoms as shown in Fig. 9.1 .
Differential Diagnosis
Because of the various presentations of FM and the multiple associated comorbidities, diagnosis can often be a challenge. Several disorders can also mimic FM, such as hypothyroidism and inflammatory rheumatic diseases. In addition, some medications may contribute to pain, such as statins, aromatase inhibitors, bisphosphonates, and opioids (i.e., opioid-induced hyperalgesia). However, these conditions and many others (e.g., rheumatoid arthritis, osteoarthritis, systemic lupus erythematosus [SLE], spinal stenosis, neuropathies, Ehlers Danlos syndrome, sleep disorders [e.g., sleep apnea], and mood and anxiety disorders) also cooccur in patients with FM.
Table 9.1 summarizes some of the key medical disorders considered in the differential diagnosis of FM that require additional assessment, tests, and specific treatment.
| Differentiating Key Disorders From Fibromyalgia | |
|---|---|
| Medical Disorder | Differentiating Signs and Symptoms |
| Rheumatologic | |
| Rheumatoid arthritis | Predominant joint pain, symmetric joint swelling, joint line tenderness, morning stiffness >1 hour |
| Systemic lupus erythematosus | Multisystem involvement, joint/muscle pain, rash, photosensitivity, fever |
| Polyarticular osteoarthritis | Joint stiffness, crepitus, multiple painful joints |
| Polymyalgia rheumatica | Proximal shoulder and hip girdle pain, weakness, stiffness, more common in the elderly |
| Polymyositis or other myopathies | Symmetric, proximal muscle weakness, and pain |
| Spondyloarthropathy | Localization of spinal pain to specific sites in the neck, midthoracic, anterior chest wall, or lumbar regions, objective limitation of spinal mobility because of pain and stiffness |
| Osteomalacia | Diffuse bone pain, fractures, proximal myopathy with muscle weakness |
| Neurologic | |
| Neuropathy | Shooting or burning pain, tingling, numbness, weakness |
| Multiple sclerosis | Visual changes (unilateral partial or complete loss, double vision), ascending numbness in a leg or bandlike truncal numbness, slurred speech (dysarthria) |
| Infectious | |
| Lyme disease | Rash, arthritis or arthralgia, occurs in areas of endemic disease |
| Hepatitis | Right upper quadrant pain, nausea, decreased appetite |
| Endocrine | |
| Hyperparathyroidism | Increased thirst and urination, kidney stones, nausea/vomiting, decreased appetite, thinning bones, constipation |
| Cushing syndrome | Hypertension, diabetes, hirsutism, moon facies, weight gain |
| Addison disease | Postural hypotension, nausea, vomiting, skin pigmentation, weight loss |
| Hypothyroidism | Cold intolerance, mental slowing, constipation, weight gain, hair loss |
Diagnostic Criteria
Because of the sometimes vague presentation of FM, it can frequently be difficult to diagnose. A 2018 study showed that the mean total time to diagnose fibromyalgia after initial presentation was 6.42 years. Patients who presented with other comorbidities, at a younger age, or to an older physician were associated with an even longer time to diagnosis.
The definition of FM continues to evolve reflecting the changes in understanding and shifts in diagnostic criteria. The American College of Rheumatology (ACR) 1990 diagnostic criteria required the presence of pain on both sides of the body and above and below the waist present for at least 3 months, with the presence of at least 11 out of a possible 18 tender points and not better explained by any other disorder. The newer 2010 ACR diagnostic criteria define FM as a chronic widespread pain condition associated with fatigue, sleep and cognitive disturbance, and a variety of somatic symptoms. ,
The 2010 ACR diagnostic criteria focus on measurement of symptom severity and no longer rely on tender point examination. Instead, many other symptoms were promoted as key features of FM. , , These include fatigue, cognitive symptoms, and somatic symptoms. The 2010 criteria rely on a series of questions based on the Widespread Pain Index (WPI) and Symptom Severity (SS) scale. According to this new ACR “Proposed Criteria,” FM is defined as:
WPI score of 7 or higher and SS score of 5 or higher or WPI of 3–6 or higher and SS score of 9 or higher
Symptoms remaining at approximately that level for 3 months
The patient having no disorder that would otherwise explain the pain
The areas of pain include:
Shoulder girdle (left), shoulder girdle (right), upper arm (left), upper arm (right), lower arm (left), lower arm (right), hip (buttock, trochanter, [left]), hip (buttock, trochanter, [right]), upper leg (left), upper leg (right), lower leg (left), lower leg (right), jaw (left), jaw (right), chest, abdomen, upper back, lower back, and neck.
Diagnostic Evaluation
History
A thorough history should always be taken. Questions emphasizing the nature, duration, and location of the pain should be asked. Associated signs and symptoms should also be addressed, including questions regarding sleep, fatigue, and mental and physical energy. Cognitive disturbances, mood disorders and other psychiatric conditions, and other conditions that overlap with FM and may be considered to be part of the diagnostic spectrum. These include symptoms of chronic migraine or other headache disorders, irritable bowel syndrome, chronic pelvic and/or bladder pain, and chronic temporomandibular pain.
Physical Examination
A thorough physical examination should be performed, with particular attention to a careful joint and neurologic examination to identify generalized widespread soft tissue tenderness and to exclude other illness presenting with similar symptoms. The examination should include palpating multiple soft tissue and joint sites, and a joint examination should always be done, looking for any synovitis and also palpating for tenderness over the joints themselves. In general, many soft tissue sites are very tender with modest palpation and are more tender than the joints. There should be no soft tissue or joint swelling or redness.
Laboratory Testing
There is no diagnostic laboratory test or radiographic or pathologic finding for FM. Thus testing should be kept to a minimum.
As such, laboratory testing is generally unremarkable but necessary to rule out other diseases. Basic laboratory tests, such as CBC and ESR or C-reactive protein (CRP) should be collected.
CBC and ESR or CRP for initial laboratory evaluation is helpful. Because FM is not an inflammatory condition, normal acute phase reactants immediately provide confidence that an occult inflammatory disorder is unlikely.
Serologic tests, such as antinuclear antibody and rheumatoid factor, should be obtained only if the history and physical examination suggest an inflammatory, systemic rheumatic disease. These tests are often positive in otherwise healthy people and have very poor predictive value unless there is significant clinical suspicion of a systemic rheumatic disease.
Imaging
Like laboratory testing, imaging is done primarily to exclude an associated disease or another illness that may mimic FM, because FM itself does not cause any abnormalities in routine imaging.
Treatment
Although there is no cure for FM, treatment can still be very beneficial. Treatment should be multidisciplinary and focus on improving functional activities and quality of life and on decreasing pain and other associated symptoms. Because of the heterogeneity of symptoms and the poorly known pathogenesis, the therapy of FM remains a challenge.
Fig. 9.2 shows treatment approaches available for patients with FM.
