FIBROMYALGIA IS A SYNDROME WITH an unknown etiology that is characterized by widespread, bilateral pain, abnormal pain processing, sleep disturbance, fatigue and psychological distress.(1) Fibromyalgia affects 10 million people in the United States and is more likely to occur in women, with a ratio of about 8 to 2, women over men.(2)
Patients are usually diagnosed during middle age, and the prevalence of the disorder increases with age. Fibromyalgia has been associated with lower levels of health-related quality of life and a loss of work productivity, according to a 2011 study in the Journal of Occupational and Environmental Medicine.(1)
Doctors of chiropractic (DCs) can diagnose fibromyalgia or discover another cause of the symptoms, and create an effective treatment plan or make appropriate referrals.
Fibromyalgia is a tricky disorder to diagnose accurately. Past research has found that the diagnosis of fibromyalgia could be confirmed only in 34 percent of cases at follow-up – a 66 percent diagnostic error rate.(3)
It is often characterized by widespread pain and abnormal pain processing, but there are a slew of other symptoms that may also be associated with fibromyalgia, such as sleep disturbances, fatigue, morning stiffness, headaches, irritable bowel syndrome, cognitive cloudiness and more.1
DCs should not be quick to choose a diagnosis of fibromyalgia until a patient’s condition meets all of the criteria set by the American College of Rheumatology.(4) These include:
Widespread pain index (WPI) Th7 and symptom severity (SS) scale score Th5 or WPI 3-6 and SS scale score Th9;
Symptoms lasting at least three months at a similar level; and
- No other health problem that would explain the pain and other symptoms.
The widespread pain index score (WPI) is determined from the number of body regions that the patient indicates have been painful in the past week. The symptom severity (SS) scale score is derived from the answers to four questions about fatigue, unrefreshing sleep, cognitive deficit and a number of somatic symptoms experienced in the preceding six months.
To determine a patient’s WPI and SS scale score, clinicians should first give their patients a questionnaire (http://neuro.memorialhermann.org/uploadedfiles/ThlibraryThfiles/mnii/newfibrocriteriasurvey.pdf) that allows them to check the areas on their body where they’ve had pain in the past week and to record the severity of co-occurring symptoms common with fibromyalgia.
Second, even though a physical examination is not required for diagnosing fibromyalgia, DCs should simply press on the patient’s muscles to determine the level of tenderness to palpation. “A true fibromyalgia patient won’t be able to stand much pressure anywhere on their body,” says Michael Schneider, DC, PhD, an associate professor of the Department of Physical Therapy, School of Health and Rehabilitation Sciences and of the Clinical and Translational Science Institute at the University of Pittsburgh.
He notes that a quickness to diagnose patients with fibromyalgia may potentially lead to the omission of serious medical conditions, such as Lyme disease or cancer. In patients presenting with widespread pain and fatigue, the clinician should rule out medical conditions that may also be associated with these symptoms, such as hypothyroidism, anemia, rheumatoid arthritis, Lyme disease, ankylosing spondylitis, multiple sclerosis or occult malignancy.(5)
However, keep in mind that fibromyalgia often occurs with other rheumatic conditions such as rheumatoid arthritis and ankylosing spondylitis, up to 65 percent of the time.(1)
In further diagnosing this very complex syndrome, DCs can use a diagnostic algorithm created by three chiropractic physicians and presented in a commentary article published in the Journal of Manipulative and Physiological Therapeutics (JMPT) (see sidebar). This quick reference “allows a clinician to sort through all of the possibilities when confronting the diagnostic challenge of a patient with multiple physical complaints and widespread pain.”(5)
Using the diagnostic algorithm, the DC should be able to determine if the pain is more localized, suggestive of a musculoskeletal or joint disorder, or more widespread, which suggests a diagnosis of fibromyalgia.
If the latter is the case, the DC should either assess the patient in the form of testing in a standard clinical laboratory or refer the patient to a specialty doctor, to determine a patient’s complete red blood count (RBC) with white cell differential, thyroid function tests (T3, T4, TSH), SMA 254 (or other similar metabolic screening panel), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), Lyme test and rheumatic profile.5 [See “Six Reasons to Employ Blood Panels,” ACA News, March 2012, Page 30 at http://mydigimag.rrd.com/publication/?i=101171.]
A diagnosis of fibromyalgia may not be made until all lab tests come back negative and fail to detect a specific reason for the symptoms. The diagnosis of fibromyalgia should be made only for patients with chronic widespread pain and fatigue for which no other medical disease, musculoskeletal condition or metabolic dysfunction can be found. (5)
“The best treatment for true fibromyalgia patients is a multidisciplinary approach at a specialty fibromyalgia clinic,” says Dr. Schneider.
This would include patient management among clinicians, chiropractors and physical therapists to ensure that patients receive the appropriate diagnosis and therapy, without resorting to a default diagnosis of fibromyalgia in all cases of widespread pain.(5)
In a 2011 study published in the Journal of Rehabilitation Medicine, researchers found that a long-term combination of aerobic exercise, strengthening and flexibility improves psychological health status and health-related quality of life in patients withfibromyalgia.(6)
According to the American Pain Society’s guidelines on fibromyalgia and discussed in the aforementioned study, patients are recommended to perform moderately intense aerobic exercise, especially as they are sensitive to movement and touch.6 Dr. Schneider reminds DCs that when a patient has true fibromyalgia, the body is tender all over. “They respond better to light-intensity exercise and a light touch,” he says, as opposed to only chiropractic spinal manipulation, for which there is inconclusive evidence for the treatment of fibromyalgia.(7)
Mind-body therapies (i.e., guided imagery, meditation and biofeedback) and balneotherapy (i.e., waterbased treatments) have also shown evidence of effectiveness in treating fibromyalgia pain, as discussed in a systematic review published in JMPT.(8)
DCs should know how to properly and accurately diagnose fibromyalgia. If a patient’s pain is not widespread and does not meet the ACR’s guidelines and criteria, it could be a musculoskeletal disease, a metabolic disorder or another underlying medical issue. It is important that the chiropractic physician know when to refer a patient to another clinician for treatment, especially when a musculoskeletal disease is ruled out.
3) Fitzcharles MA, Boulos P. Inaccuracy in the diagnosis of fibromyalgia syndrome: analysis of referrals. Rheumatology (Oxford). 2003;42:263-7.
5) Schneider MJ, Brady DM, Perle SM. Commentary: differential diagnosis of fibromyalgia syndrome: proposal of a model and algorithm for patients presenting with the primary symptom of chronic widespread pain. JMPT. 2006 Jul;29(6):493–501.
6) Sanudo B, Galiano D, Carrasco L, de Hoyo M, McVeigh JG. Effects of a Prolonged Exercise Programme on Key Health Outcomes in Women with Fibromyalgia: A Randomized Controlled Trial. J Rehab Med. 2011;43(521-526).
7) Clar C, Tsertvadze A, Court R, Lewando Hundt G, Clarke A, Sutcliffe P. Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence reportChiropr Man Therap. 2014; 22: 12.
8) Terhost L, Schneider MJ, Kim KH, Goozdic LM, Stilley CS. Complementary and Alternative Medicine in the Treatment of Pain in Fibromyalgia: A Systematic Review of Randomized Controlled Trials. JMPT 2011 Sept;34(7):483-496.
Fibromyalgia Syndrome Clinical Algorithm
CLINICAL ALGORITHMS essentially provide a map to guide the practitioner in case management, especially for complex and multifactorial conditions. Using evidence-based clinical algorithms supports effective standardized care. Drs. Schneider, Brady and Perle published a diagnostic algorithm for fibromyalgia syndrome in the Journal of Manipulative and Physiological Therapeutics in Appendix A at www.jmptonline.org/article/S0161-4754(06)00154-0/pdf.
Fibromyalgia Diagnosis Guidelines
THE AMERICAN COLLEGE OF RHEUMATOLOGY’S 2010 GUIDELINES for diagnosing fibromyalgia eliminate the need of examining a certain amount of tender points on a patient’s body. Previously, the patient was required to have 11 out of 18 tender points to be diagnosed with fibromyalgia. Now, a WPI score and SS scale score take the place of the earlier diagnostic criteria.
ICD-10 and Fibromyalgia
ON OCT. 1, 2015, FIBROMYALGIA WAS RECOGNIZED as an official diagnosis in the ICD-10 list of codes. Under ICD-9, doctors were required to use the code “Myalgia and myositis, unspecified (729.1)," which constituted any disorder with muscle pain or inflammation as symptoms. Muscle pain is one of the many symptoms of fibromyalgia, along with unrefreshing sleep, cognitive cloudiness and fatigue. To better reflect this, fibromyalgia now gets its own code, under ICD-10: “Fibromyalgia (M79.7).”