Supplement issue

Diagnosis and Differential Diagnosis of Fibromyalgia

Don L. Goldenberg, MD
Department of Rheumatology, Newton-Wellesley Hospital, Newton, Massachusetts, USA.
ABSTRACT
Fibromyalgia is a chronic functional illness that presents with widespread musculoskeletal pain as well as
a constellation of symptoms including fatigue, cognitive dysfunction, sleep difculties, stiffness, anxiety,
and depressed mood. The diagnosis of bromyalgia, similar to other functional disorders, requires that
organic diseases are not causing the symptoms. Systemic and rheumatic diseases can be ruled out by a
patient history, physical examination, and laboratory investigations. Because there are no specic labo-
ratory tests for bromyalgia, the 1990 American College of Rheumatology (ACR) classication criteria
have been used in clinical settings; however, they are not ideal for individual patient diagnosis. Clinicians
should be aware of limitations inherent in using tender points in the diagnosis of bromyalgia. The multiple
symptoms of bromyalgia often overlap with those of related disorders and may further complicate the
diagnosis. One of the most challenging diagnostic dilemmas that clinicians face is distinguishing bro-
myalgia from other central pain disorders (e.g., irritable bowel syndrome, chronic fatigue syndrome,
migraine). Screening questions based on published criteria can be used as a rst approach in diagnosing
functional illnesses. Numerous studies report a higher prevalence of psychiatric disorders in patients with
bromyalgia. Therefore, a careful history and evaluation should be taken for the presence of primary mood
disturbances. To date, there is no gold standard for diagnosing bromyalgia. Until a better clinical case
denition of bromyalgia exists, all diagnostic criteria should be interpreted with caution, considered
rudimentary, and subject to modication.
2009 Elsevier Inc. All rights reserved. The American Journal of Medicine (2009) 122, S14S21
KEYWORDS: Chronic functional illness; Clinical symptoms; Comorbid disorders; Differential diagnosis; Fibromy-
algia; Tender point examination
Some clinicians regard the diagnosis of bromyalgia as
confusing and controversial, while others consider it simple
and straightforward. There is probably some truth to both
perspectives. The confusion and controversy regarding the
diagnosis of bromyalgia center on the absence of any
dened disease pathology. Fibromyalgia is often classied
as a functional illness, implying that there is no organic
disease. There are no specic diagnostic laboratory tests, or
radiographic or imaging ndings that can conrm this dis-
order, and the only physical abnormality that has been
advocated for diagnosis, namely excess tenderness on pal-
pation of soft tissue sites, is highly subjective. Such diag-
nostic shortcomings are present in many chronic illnesses,
including low back pain and other regional pain disorders,
muscular and migraine headaches, irritable bowel syndrome
(IBS), chronic fatigue syndrome (CFS), atypical facial pain,
and temporomandibular pain, as well as a variety of chronic
pelvic and bladder pain syndromes. Like bromyalgia, these
functional illnesses may be part of a spectrum of chronic
pain disorders in which organic diseases are excluded prior
to consideration of diagnosis. In each of these disorders, the
diagnosis is based on symptoms rather than signs; however,
the symptoms of bromyalgia often overlap with those of
related disorders, further complicating diagnosis. In addi-
tion, bromyalgia may be comorbid with a variety of func-
tional illnesses.
1-3
Clinicians are often faced with the chal-
lenge of differentiating among these conditions and
recommending appropriate treatment. Subsequently, clini-
cians must contend with asserting the bromyalgia diagno-
sis and labeling a patient, which may either positively
affect overall health status or precipitate damaging illness
behaviors such as learned pain or learned helplessness.
Regardless, a number of guidelines have been developed
to help identify bromyalgia, the most well known being
Statement of author disclosure: Please see the Author Disclosures
section at the end of this article.
Requests for reprints should be addressed to Don L. Goldenberg, MD,
Department of Rheumatology, Newton-Wellesley Hospital, 2000 Wash-
ington Street, MOBBlue Suite 304, Newton, Massachusetts 02462.
E-mail address: dgoldenb@massmed.org
0002-9343/$ -see front matter 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjmed.2009.09.007
the 1990 American College of Rheumatology (ACR) crite-
ria.
4
Although these criteria have been validated and shown
to be reliable, they are subjective and not without limita-
tions. There is no gold standard for diagnosing bromy-
algia or other functional disorders; rather, a group of experts
reached a consensus on appropriate diagnostic criteria based
on their experience and then eld-tested the potential
criteria.
The purpose of this article is to provide clinicians with a
set of diagnostic tools and approaches that will help them
identify bromyalgia in clinical practice, as well as distin-
guish this disorder from other associated conditions. Fur-
thermore, a critical look into the controversial issues sur-
rounding bromyalgia diagnosis should help contribute to
improved guidelines that support the recognition of bro-
myalgia as a multisymptom disorder.
CLINICAL MANIFESTATIONS AND DIAGNOSIS
Pain and Multidimensional Symptoms
The cardinal symptom of bromyalgia is chronic wide-
spread pain that cannot be attributed to a dened musculo-
skeletal disorder. According to ACR criteria, the diagnosis
of bromyalgia should not be seriously considered until the
pain has been persistent for 3 months (Table 1).
4
The pain of bromyalgia is, by denition, widespread,
involving the body on both sides and above and below the
waist. Common patient descriptions include I feel as if I
hurt all over and It feels as if I always have the u.
5
Patients typically describe pain that is predominantly dis-
persed throughout the muscles, but sometimes they will also
complain of swelling and pain in the joints. However, in
bromyalgia, unless there is concurrent arthritis, such as
rheumatoid arthritis (RA) or osteoarthritis (OA), joint swell-
ing does not occur.
6
Patients with bromyalgia also com-
monly report paresthesias, including numbness, tingling,
burning, creeping, or crawling sensations, especially in the
arms and legs.
4,5
However, unless a concurrent neurologic
disorder, such as carpal tunnel syndrome or a cervical ra-
diculopathy is present, the neurologic evaluation is un-
remarkable.
6,7
Fibromyalgia is more than just pain; the condition com-
prises a constellation of bothersome symptoms (Table 1 and
Figure 1).
4,5,8-10
Along with chronic widespread pain, the
other universal symptom of bromyalgia is fatigue.
4,11
This
is especially notable when arising from sleep, but also is
marked in the mid afternoon. Seemingly minor activities
aggravate the pain and fatigue, although prolonged inactiv-
ity also heightens these symptoms.
12,13
Because widespread
pain and fatigue may be the initial manifestations of self-
limited events such as the u or overexertion, the somewhat
arbitrary 3-month duration of symptoms serves to eliminate
such diagnostic possibilities.
Patients with bromyalgia are often stiff in the morning
and feel unrefreshed, even if they have slept 8 to 10 hours.
They characteristically sleep lightly, wake frequently, and
Table 1 The American College of Rheumatology (ACR) 1990 Criteria and Clinical Features
ACR Criteria Denition
History of widespread pain
(persisting 3 mo)
Pain is considered widespread when it is present in all 4 quadrants of the body (left and
right sides, above and below waist). Axial skeletal pain (cervical spine or anterior chest
or thoracic spine or low back) must be present. Shoulder and buttock pain is considered
as pain for each involved side. Low back pain is considered lower segment pain.
Pain in 11 of 18 tender point sites
on digital palpation
Occiput: bilateral, at the suboccipital muscle insertions
Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5C7
Trapezius: bilateral, at the midpoint of the upper border
Supraspinatus: bilateral, at origins, above the scapula spine near the medial border
Second rib: bilateral, at the second costochondral junctions just lateral to the junctions
on upper surfaces
Lateral epicondyle: bilateral, 2 cm distal to the epicondyles
Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle
Greater trochanter: bilateral, posterior to the trochanteric prominence
Knee: bilateral, at the medial fat pad proximal to the joint line
Clinical symptoms Common descriptions by patient
Fatigue Lack of energy, unmotivated; difculty in moving or exercising
Patient global/quality of life Effect on ability to make plans, accomplish goals, or complete tasks
Multidimensional function Affects normal daily life and household activities
Tenderness Feels tender where touched
Sleep Difculty falling asleep, staying asleep, or getting up in the morning
Dyscognition Problems with attention or concentration; bro-fog
Stiffness Usually stiff upon waking
Depression/anxiety Feeling overwhelmed, disappointed, sad, or resigned
Adapted from Arthritis Rheum with permission of John Wiley & Sons, Inc.
4
S15 Goldenberg Diagnosis of Fibromyalgia
have difculty getting back to sleep. A common patient
quote is No matter how much sleep I get, it feels like a
truck ran me over in the morning.
Cognitive disturbances and mood disorders are also
present in the majority of patients with bromyalgia and
may decrease health-related quality of life. For example, a
phrase commonly used by patients to describe problems
with attention or concentration is bro-fog. Additionally,
many other clinical manifestations reduce patient well-be-
ing and physical functioning, including headaches (mi-
graine and muscular tension)which are present in 50%
of casesdizziness/vertigo, muscle spasms, tinnitus, leg
cramps, restless legs, Sicca symptoms, Raynaud disease,
and pain in the chest, low back, and jaw.
5
Tender Point Examination
In patients with bromyalgia, the only reproducible nding
on physical examination is tenderness in specic anatomic
locations. As mentioned, the 1990 ACR classication cri-
teria for bromyalgia have been used in most clinical and
therapeutic trials.
4
These criteria were based on the opinions
of a group of rheumatologists regarding the optimal histor-
ical and physical ndings that could differentiate patients
with bromyalgia from those with other rheumatic diseases
and other forms of chronic pain. These criteria were not
specically designed for use in a clinical setting. They were
later used in a number of academic rheumatology clinics
and ofce practices. The nal bromyalgia classication
criteria included the symptom of widespread pain, including
above and below the waist as well as the right and left sides
of the body, and the physical ndings of 11 of 18 tender
points (Table 1). These simple criteria provided 85%
specicity and sensitivity in differentiating patients with
bromyalgia from those with other rheumatic diseases.
4
The tender point examination requires that the examiner
knows where to palpate and how much pressure to apply
(Figure 2). The 9 pairs of tender points used for the ACR
criteria are at locations that most primary care physicians
and specialists routinely evaluate in patients with soft tissue
complaints. These locations include the upper mid-trapezius
muscle, the lateral epicondyle (the tennis elbow location),
the second costochondral junction (the site of costochondri-
tis), and the greater trochanter (the site of trochanteric bur-
sitis of the hip). The amount of pressure exerted at each
tender point should equal 4 kg/cm
2
, which is enough to
whiten the nail bed of the examiners nger tip. In research
studies, a pressure gauge called a dolorimeter may provide
more accuracy, but in the clinic, the examiners nger will
sufce. While evaluating the tenderness of the 18 specic
tender points, it is recommended that control locations,
such as over the thumb, the mid forearm, or the forehead, be
palpated in the same fashion. Patients with bromyalgia are
typically not as tender in these control areas compared with
the specied tender points. A specic joint examination
should be carried out, looking for any synovitis and also
palpating for tenderness over the joints themselves.
The tender points represent a heightened pain perception
rather than sites of inammation or tissue pathology. The
presence of 11 of 18 tender points as part of the ACR
classication criteria was based on a statistical evaluation in
large patient populations. The recommended number of
tender points is based on a continuum of pain sensitivity.
The presence or absence of a certain number of tender
points is not a dichotomous variable. Not all patients with
bromyalgia experience tenderness in 11 points.
14,15
The
ACR criteria for bromyalgia were designed for patient
Figure 1 Associated symptoms and conditions of bromy-
algia. The bars represent the average percentage of symptom
occurrence in 4 large clinical studies.
4,8-10
The recognition of
multiple symptoms plays an important role in differential di-
agnosis. (Adapted with permission from Fibromyalgia & Other
Central Pain Syndromes.
5
)
Figure 2 Tender point examination. Tender points are sites
of local tendon and bursa pain, such as the lateral epicondyle or
the greater trochanter. When performing the examination, the
clinician should use enough pressure to whiten the nail bed of
his or her nger and press down gradually over a few seconds.
Pressure should be kept consistent at each point, and the patient
should be asked the same question: Do you feel pain? Fi-
nally, control locations, such as the mid-forehead or thumb,
should be evaluated.
S16 The American Journal of Medicine, Vol 122, No 12A, December 2009
classication, not for individual patient diagnosis. Just as a
patient with RA can be diagnosed in the clinic without
meeting all RA classication criteria, so too can a patient
with bromyalgia be diagnosed, even if 11 of 18 tender
points are not present.
For these reasons, some investigators have advocated not
using the tender point examination as part of the bromyalgia
diagnostic criteria.
14
Katz and colleagues
15
and Wolfe
16
found
that the symptom of widespread pain and a patient-com-
pleted pain diagram performed as well as the ACR classi-
cation criteria. Similar to the Diagnostic and Statistical
Manual of Mental Disorders, 4th Edition (DSM-IV)
17
cri-
teria used for diagnosis of major depressive disorder
(MDD), Hudson and Pope
18
designed a structured interview
that reliably diagnosed bromyalgia using symptom crite-
ria. The symptom criteria included a history of widespread
pain lasting 3 months and 4 of the following 6 symp-
toms: generalized fatigue, headaches, sleep disturbance,
neuropsychiatric complaints, numbness or tingling sensa-
tions, and irritable bowel.
Nevertheless, performing a tender point examination
should be considered an important part of the musculoskel-
etal examination in any patient complaining of generalized
pain. Palpating soft tissue locations as well as specic joints
allows for a direct comparison of tender locations. It reas-
sures the examiner that there is no synovitis or myositis,
because other than the excess tenderness, the musculoskel-
etal examination is unrevealing in bromyalgia.
Clinicians should be aware of shortcomings inherent in
using tender points in the diagnosis of bromyalgia. The
exact number of soft tissue points to palpate and the specic
locations are somewhat arbitrary.
19
Furthermore, some in-
vestigators have criticized the concept of control soft
tissue points to palpate, because 63% of patients with bro-
myalgia report tenderness at these points owing to lower
pressure pain thresholds.
20-22
Until new studies are pub-
lished regarding optimal diagnostic tests for bromyalgia,
the clinician should palpate both joint and soft tissue loca-
tions for tenderness and determine his or her own comfort
level in the exact number and locations of these sites.
DIFFERENTIAL DIAGNOSIS
Systemic and Rheumatic Illnesses
The differential diagnosis of bromyalgia at rst may ap-
pear overwhelming but is really quite straightforward. Co-
occurring systemic and rheumatic diseases can be excluded
during the assessment process on the basis of patient his-
tory, physical examination, and laboratory investigations.
However, a diagnosis of bromyalgia does not exclude
these diseases as potential comorbid conditions. Rheumatic
diseases including polymyalgia rheumatica (PMR), RA,
systemic lupus erythematosus (SLE), and Sjgren syndrome
may present initially with diffuse pain and fatigue, but have
characteristic clinical features that help distinguish them
from bromyalgia (Table 2). PMR may mimic bromyal-
gia, because there may be no obvious physical ndings and
patients with both conditions report morning stiffness and
fatigue. PMR usually begins after age 60 and often is asso-
ciated with fever, weight loss, and other systemic signs. In
contrast to bromyalgia, the erythrocyte sedimentation rate
(ESR) is almost always very elevated in patients with PMR,
and patients respond extremely well to modest doses of
corticosteroids. The small joint swelling in the hands and
feet characteristic of RA are never part of bromyalgia.
None of the dermatologic, renal, cardiac or other systemic
manifestations of SLE or Sjgren syndrome are found in
bromyalgia. Ankylosing spondylitis or other inammatory
back conditions may mimic bromyalgia when patients
present with axial skeleton pain and stiffness, but the char-
acteristic radiologic features of spondylitis will provide the
correct diagnosis. In a report from Fitzcharles and Boulos,
23
bromyalgia was the correct diagnosis in only one third of
patients referred to rheumatologists. One of the more com-
mon misdiagnoses was inammatory back disease. Inam-
matory myositis and metabolic myopathies cause muscle
weakness and muscle fatigue but usually are not associated
with diffuse pain. Furthermore, patients with bromyalgia
do not have signicant muscle weakness other than that
related to pain or disuse, and they have normal muscle
enzyme tests and normal or nonspecic histopathologic
ndings on muscle biopsy.
A shing expedition for a systemic connective tissue
disease is likely to be misleading. Laboratory analyses that
can be useful include an ESR or a C-reactive protein (CRP)
test (Table 2 and Figure 3).
24
Because bromyalgia is not an
inammatory condition, normal acute phase reactants im-
mediately provide condence that an occult inammatory
disorder is unlikely. Serologic tests such as the antinuclear
antibody and rheumatoid factor should only be ordered
when the patients history and physical examination point to
an inammatory systemic disease. These tests are often
positive in otherwise healthy people and have very poor
Table 2 Differential Diagnosis of Fibromyalgia
Condition
Distinguishing Feature from
Fibromyalgia
Rheumatoid arthritis Joint swelling, deformities, elevated
ESR, CRP
Systemic lupus
erythematosus
Rash, multisystemic inammation,
elevated ESR, ANA
Polymagia rheumatica Age 60 yr, severe stiffness when
inactive, elevated ESR
Myositis, myopathies Weakness, elevated muscle enzymes
Ankylosing spondylitis Back, neck immobility, elevated
ESR, abnormal X-rays
Hypothyroidism Abnormal thyroid function tests
Neuropathies Weakness, loss of sensation,
abnormal EMG, NCV
ANA antinuclear antibody; CRP C-reactive protein; EMG
electromyography; ESR erythrocyte sedimentation rate; NCV nerve
conduction velocity.
S17 Goldenberg Diagnosis of Fibromyalgia
predictive value unless there is signicant clinical suspicion
of a systemic rheumatic disease.
Endocrine disorders that cause unexplained fatigue and
muscle aches, most notably hypothyroidism, may also
mimic bromyalgia. It is reasonable to obtain thyroid func-
tion tests routinely in the workup for possible bromyalgia.
Because headaches and paresthesias are often reported by
patients with bromyalgia, peripheral neuropathies, entrap-
ment syndromes (such as carpal tunnel syndrome) and neu-
rologic disorders (such as multiple sclerosis and myasthenia
gravis) are sometimes considered in the differential diagno-
sis. Nonicteric hepatitis may also present with exhaustion
and myalgia. It is reasonable to test thyroid and liver func-
tion as well as creatine phosphokinase (CPK) levels during
the initial evaluation.
Because bromyalgia can complicate rheumatic and sys-
temic diseases, it is more difcult to diagnose bromyalgia
in patients with those conditions. For example, in a patient
whose RA is in remission and who complains of exhaustion,
generalized achiness, muscle soreness, and morning stiff-
ness, the clinician should evaluate for bromyalgia rather
than assume the RA is active. In these situations, early
referral to a rheumatologist is appropriate. It is also impor-
tant to evaluate patients with bromyalgia for peripheral
pain generators such as concurrent OA of 1 knee or a
cervical radiculopathy associated with degenerative disc
disease. In such cases, specialty referral is recommended.
Neuropsychiatric Disorders and Sleep
Disturbances
The large number of associated neuropsychiatric symptoms
in bromyalgia can be daunting to the clinician. Patients
with bromyalgia are frequently misdiagnosed with a neu-
rologic disease because the majority of them describe
numbness, tingling, and burning. These symptoms warrant a
careful neurologic evaluation. However, in bromyalgia,
neurologic evaluation is typically unremarkable; in that sit-
uation, further testing, such as imaging studies, electromyo-
graphy (EMG), or nerve conduction velocity (NCV), is not
recommended (Table 2). On the other hand, if the neuro-
logic examination is abnormal or if such symptoms persist,
referral to a neurologist would be appropriate. Because
bromyalgia is associated with a generalized disturbance in
the processing of sensory stimuli, it is not surprising that
auditory or visual stimuli create enhanced reactions in pa-
tients with this disease. Furthermore, patients often report
excess sensitivity to a variety of stimuli including noises,
bright lights, and odors.
Many patients with bromyalgia also describe cognitive
issues, especially with regard to short-term memory. They
often report a signicant decrease in memory, using state-
ments like I used to be bright and quick but now am out of
it. Neuropsychological tests have revealed that patients
with bromyalgia are typically more susceptible to distrac-
tion when performing memory tasks and, in general, have
lower memory performance.
25
There is no evidence for any
intellectual deterioration resulting from bromyalgia.
26
Therefore, neuropsychological testing should be reserved
for patients with severe cognitive impairment or those who
need reassurance that they are not developing dementia.
A careful history should be taken from all patients with
bromyalgia for the presence of primary sleep disturbances
and primary mood disturbances (Figure 3). Patients should
be screened for sleep apnea and repetitive limb movements,
and, if positive, referred for an overnight polysomnogram.
Every patient with bromyalgia should also be asked about
depression and anxiety, and, depending on the clinicians
comfort level with those diagnoses, may require referral to
a mental health professional for further diagnosis.
Numerous studies report a signicantly higher preva-
lence of psychiatric disorders in patients with bromyalgia
compared with the general population.
27,28
For example, in
patients with bromyalgia the lifetime rate of MDD ranges
from 20% to 86% and the current rate ranges from 6% to
35%.
28,29
The frequency of anxiety disorders ranges from
13% to 64%, compared with rates of psychiatric disorders in
the general population ranging from 7% to 10%.
30
This
variability may be attributed to differences in psychosocial
Figure 3 Recommended diagnostic workup for bromyal-
gia. The evaluation should begin with a complete patient his-
tory and thorough physical examination. The clinician should
conduct a complete joint and neurological examination, as well
as necessary laboratory tests to exclude inammatory, nonin-
ammatory, endocrine, or neurologic disorders. To establish
the bromyalgia diagnosis, a tender point examination should
be performed, and the severity of other bromyalgia symptoms
should be evaluated. The impact of multidimensional symp-
toms over time on function/quality of life should be monitored.
(Adapted with permission from Guideline for the Management
of Fibromyalgia Syndrome Pain in Adults and Children.
24
)
S18 The American Journal of Medicine, Vol 122, No 12A, December 2009
as well as genetic characteristics of patients.
28,31
Disparities
in diagnostic criteria used to identify major mood disorders
(e.g., a single item question versus DSM-IV
17
) may also
affect prevalence rates.
2,4,9
Lastly, mood disturbances and
major psychosocial factors are more prevalent in patients
with bromyalgia who are seen in specialty referral cen-
ters.
32
Regardless, it is obviously critical that such diag-
noses be recognized and treated appropriately. Despite a
high number of patients with bromyalgia presenting with a
co-occurring mood disorder at the time of diagnosis,
2,27
it is
important to recognize bromyalgia as an independent,
treatable entity.
33-35
Central Pain Disorders
The most challenging diagnostic dilemma in bromyalgia
may relate to its overlap with other functional pain disor-
ders. Oral specialists may diagnose bromyalgia symptoms
as temporomandibular disorder (TMD). Dryness in the eyes
and mouth may raise the possibility of Sjgren syndrome.
Patients with bromyalgia frequently complain of bowel
and bladder pain as well as pelvic pain, and may be diag-
nosed as having interstitial cystitis, IBS, female urethral
syndrome, vulvodynia, or vulvar vestibulitis.
If the clinician is a diagnostic splitter, patients with
bromyalgia may end up with a variety of diagnoses ac-
cording to subspecialty referral patterns. On the other hand,
if these functional illnesses are considered to be part of a
spectrum, the exact label may not be so important. For
example, various studies have reported that 30% to 70% of
patients with bromyalgia meet the criteria for CFS and
IBS.
1,36,37
Each functional illness has its own classication criteria.
To facilitate diagnosis, various screening questions have
been published that distinguish bromyalgia from com-
monly co-occurring disorders (Table 3).
38-45
CFS is diag-
nosed in a patient with persistent or relapsing fatigue of 6
months duration and with the presence of 4 of the fol-
lowing symptoms: impaired memory, sore throat, tender
Table 3 Screening Questions to Distinguish Fibromyalgia from Other Central Pain Disorders
Co-Occurring Condition Screening Question Published Clinical Criteria
Chronic fatigue syndrome Unexplained, persistent, or relapsing
fatigue for 6 months?
Fatigue plus 4 of the following symptoms: (1) short-term memory
loss; (2) sore throat; (3) tender lymph nodes in the neck or
armpit; (4) muscle pain; (5) joint pain without swelling or
redness; (6) headaches; (7) unrefreshing sleep; (8) malaise
38
Irritable bowel syndrome Abdominal discomfort or pain
accompanied or affected by
constipation or diarrhea for 3
months in the past year?
Abdominal discomfort or pain that has 2 of 3 features: (1) relief
with defecation; (2) onset associated with a change in
frequency of stool; (3) onset associated with a change in form
of stool
39
Temporomandibular
disorders
Recurrent facial/jaw pain and/or
limitation in jaw opening occuring
in the past 6 months?
Pain or tenderness of the temporomandibular joint and/or
surrounding muscles, joint noises, and limitation or loss of jaw
movement often accompanied by headache or ear pain
40
Multiple chemical
sensitivities
Symptoms in multiple organ systems
reliably occuring on exposure to
multiple unrelated chemicals?
Multiple symptoms (e.g., pain, fatigue, difculty concentrating,
numbness) in multiple organs (e.g., central nervous system,
respiratory, skin) upon low-level exposure to multiple
chemicals (pesticides, alcohol, solvents) that usually resolves
when incitants are removed
41
Tension and migraine
headache
Recurrent headaches (5 for
migraine, 10 for tension-type)
lasting 30 minutes occuring in the
past 6 months?
Migraine has 2 of the following characteristics accompanied by
nausea and/or vomiting or photophobia/phonophobia: (1)
unilateral location; (2) pulsating quality; (3) moderate or
severe intensity; (4) aggravation by routine physical activity.
Tension headache has 2 of the following characteristics: (1)
pressing/tightening quality; (2) mild to moderate intensity; (3)
bilateral location; (4) no aggravation by routine physical
activity
42
Interstitial cystitis Symptoms 9 months of bladder
pain, urinary urgency and
frequency (i.e., voiding 8 times
during the day, 2 times during
the night), and a negative urine
culture?
Glomerulations on cytoscopic examination or classic Hunner ulcer
and pain associated with bladder or urinary urgency; multiple
exclusion criteria
43
Localized and myofascial
pain disorder
Localized muscle pain for 3
months?
Trigger points and/or tender spots in a taut band of skeletal
muscle that produce a local twitch response upon palpation
and may result in a predicted pain referral pattern
44
Adapted with permission from Best Pract Res Clin Rheumatol.
45
S19 Goldenberg Diagnosis of Fibromyalgia
cervical or axillary lymph nodes, muscle pain, multifocal
joint pain, new headaches, unrefreshing sleep, and postex-
ertion malaise.
38
IBS is diagnosed when patients report 12
weeks duration, which need not be consecutive, in the
preceding 12 months, of abdominal discomfort or pain that
has 2 of the following 3 features: (1) relief with defecation,
(2) onset associated with a change in the frequency of stool
(abnormal frequency is 3 times per day or 3 times per
week), and (3) onset associated with a change in form (i.e.,
appearance of the stool, where abnormal stool is lumpy/hard
or loose/watery).
39
For research, it is important to identify subsets of patients
with unexplained chronic pain or chronic fatigue. Subspe-
cialty professionals can then better focus on their area of
interest, such as gastroenterologists evaluating gastric mo-
tility in subjects who meet criteria for IBS or an oral sur-
geon evaluating jaw anatomy in patients with TMD. How-
ever, the general principles regarding the diagnosis of
bromyalgia apply to other functional pain disorders. First,
as in the diagnosis of bromyalgia, the diagnosis of any
chronic functional illness is considered only after a com-
plete evaluation has failed to detect a systemic disease. That
evaluation may vary greatly from one physician to another.
For example, many gastroenterologists would not be com-
fortable entertaining the diagnosis of IBS until a colonos-
copy was found to be unrevealing. Second, the diagnostic
criteria for bromyalgia and other functional illnesses are
operational. They are appropriate temporarily while a
search is made to better understand the pathophysiologic
features that dene each disorder.
FIBROMYALGIA DIAGNOSIS: ENABLING OR
DISABLING?
After the clinician excludes systemic disorders and differ-
entiates among overlapping illnesses, labeling the patient
with bromyalgia is the rst step in asserting a diagnosis.
Much controversy regarding the diagnosis of bromyalgia
relates to concern that a diagnostic label might be harmful to
patients. Indeed, any diagnostic label can be disabling if it is
not applied with appropriate logic. If patients with bromy-
algia are led to believe that the diagnosis implies a causal
association with trauma or environmental exposure, they
may assume a sick role in society. Diagnosis should be
coupled with patient education to ensure that psychosocial
factors do not precipitate learned maladaptive illness behav-
iors. However, if the diagnostic label reassures patients and
their healthcare providers that there is a reasonable expla-
nation for their symptoms, there will be fewer referrals,
costly tests, or multiple invasive therapies. Indeed, a number
of investigations have found that after the diagnoses of
bromyalgia, healthcare expenditure decreases.
46,47
Addi-
tionally, White and associates
48
found that patients had
increased satisfaction with health improvements, and the
number of symptoms declined over time after receiving a
diagnosis of bromyalgia.
SUMMARY
Fibromyalgia can and should be diagnosed based on the
typical symptoms of chronic widespread pain and associ-
ated symptoms after systemic diseases have been appropri-
ately excluded. The 1990 ACR classication criteria are
useful for research and clinical trials, but may not be ideal
for individual patient diagnosis. An improved clinical case
denition for bromyalgia, using diagnostic criteria that can
be applied by both primary care physicians and specialists,
is needed. In this regard, Wolfe and colleagues
49
recently
reported that high levels of widespread pain and somatic
symptoms correlate well with the ACR bromyalgia clas-
sication criteria. The use of these symptom-based diagnos-
tic criteria does not require a tender point examination and
allows for variability in symptom severity over time. In
addition to adopting revised clinical diagnostic criteria, pa-
tient subsets must be better dened. In the future, these may
include clinical variables such as pain sensitivity, psychos-
ocial and mental health evaluation, and genetic factors.
Until that time, all diagnostic criteria should be considered
preliminary and subject to change.
ACKNOWLEDGMENT
Editorial assistance was provided by Prescott Medical Com-
munications Group, Chicago, Illinois.
AUTHOR DISCLOSURES
The author of this article has disclosed the following indus-
try relationships:
Don L. Goldenberg, MD, has served as a consultant for
Cypress Bioscience, Inc., Eli Lilly and Company, Forest
Laboratories, Inc., and Pzer Inc.
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S21 Goldenberg Diagnosis of Fibromyalgia