Article

The Concept of Incomplete Fibromyalgia Syndrome Comparison of Incomplete Fibromyalgia Syndrome With Fibromyalgia Syndrome by 1990 ACR Classification Criteria and Its Implications for Newer Criteria and Clinical Practice

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Abstract

The 1990 American College of Rheumatology (ACR) classification criteria for fibromyalgia/fibromyalgia syndrome (FMS) has 2 components: (a) widespread pain (WSP) and (b) presence of 11 or more tender points (TP) among possible 18 sites. Some clinic patients fulfill 1 component but not the other. We have considered these patients to have incomplete FMS (IFMS). The purpose of this study was to examine the clinical and psychological differences between IFMS and FMS (by 1990 ACR criteria) because such comparison may be helpful to diagnose patients in the clinic. Six hundred consecutive patients referred to our rheumatology clinic with a diagnosis of FMS were examined by a standard protocol to determine whether they fulfilled the 1990 criteria for FMS. Both IFMS and FMS groups were compared in demographic, clinical, and psychological variables using appropriate statistical methods. One hundred twelve (18.7%) patients did not satisfy the 1990 ACR criteria and were classified as IFMS. Symptoms in IFMS and FMS were similar, generally with less frequent and less severe symptoms in the IFMS group. In IFMS, no significant difference was found among the WSP and TP component subgroups. Both TP and WSP were correlated with important features of FMS. Fulfillment of the ACR 1990 criteria is not necessary for a diagnosis of FMS in the clinic. For diagnosis and management of FMS in the clinical setting, IFMS patients, along with consideration of the total clinical picture, may be considered to have FMS, albeit generally mild.

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... Although Wolfe pointed out the unreliability of digital palpation and TPCs (4), physicians probably still use it while referring to the older ACR classification criteria. However, it is only fair to note that, though approximate, evaluating tender points is the only practical and reliable means of testing the pain threshold, which is the manifestation of the central sensitisation that is the essence of FM (15,16). Furthermore, FM is often associated with rheumatic diseases such as osteoarthritis, rheumatoid arthritis or spondyloarthritis, or connective tissue diseases such as Sjögren's syndrome (17)(18)(19), and the simple count of painful points for the widespread pain index of the 2016 ACR 2016 criteria may be insufficient, unsatisfactory, or even dangerous in the absence of a careful evaluation of the features and sites of pain. ...
... Furthermore, FM is often associated with rheumatic diseases such as osteoarthritis, rheumatoid arthritis or spondyloarthritis, or connective tissue diseases such as Sjögren's syndrome (17)(18)(19), and the simple count of painful points for the widespread pain index of the 2016 ACR 2016 criteria may be insufficient, unsatisfactory, or even dangerous in the absence of a careful evaluation of the features and sites of pain. The difficult of ensuring that all patients satisfy the ACR diagnostic criteria could be overcome by adopting the old and new concept of "incom- plete FM" to describe the patients who do not meet the positive FM criterion at a first evaluation, but have its main features in a milder form with fewer symptoms (15,20,21). It must also be remembered that CWP itself can be a diagnosis, especially in the absence or minimal presence of the typical non-painful symptoms of FM (21)(22)(23)(24)(25). Finally, it is frequent to come across patients who have been given an often questionable, inconclusive diagnostic hypothesis of FM that leads them on a continuous pilgrimage in the search for diagnostic confirmation. ...
... In the case of clinical correspondence, the definition of incomplete FM (IFM) was used for the patients with a previous diagnosis/hypothesis of FM (as proposed by Yunus) (15), but in the presence of borderline ACR scores. Borderline scores not fulfilling the ACR criteria were defined as follows: a GP score of 4-5 and a PSD score of 9-11, a GP score of 4-5 and a PSD 12-14 (not corresponding to case A or B), or a GP score of 3 and a PSD score of ≥9. ...
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Objective Fibromyalgia (FM) is a complex syndrome whose hallmark features are chronic widespread pain, sleep disturbances, fatigue and cognitive dysfunctions. However, it is still difficult to apply validated diagnostic criteria. The aim of this study is to examine the accuracy of a previous diagnosis/diagnostic hypothesis of FM according to the 2016 ACR diagnostic criteria. Methods All of the patients newly referred to a private rheumatological clinic with the specific request for a consultation because if FM over an 18-month period were evaluated by means of a standardised protocol in order to determine whether they fulfilled the 2016 ACR diagnostic criteria for FM. They were initially divided into three groups: those with a previous diagnosis of FM (group 1), those with a physician's diagnostic hypothesis of FM (group 2) and those who personally hypothesised FM (group 3). They were subsequently classified as having FM, IFM (borderline scores) or not having FM (non-FM) on the basis of the 2016 ACR diagnostic criteria. Results The study involved 216 patients (25 males and 191 females): 112 in group 1, 49 in group 2, and 55 in group 3. Only 89 patients (41.2%) fulfilled the ACR criteria; 42 (19.44%) met the study protocol-defined scores for IFM; and 85 (39.35%) were diagnosed as not having FM. Only 50% of the patients with a previous diagnosis of FM fulfilled the ACR criteria, and just under 25% did not have FM. Almost 50% of the patients with a physician's diagnostic hypotheses of FM did not have FM, whereas 20% of the patients who personally hypothesised FM fulfilled the ACR criteria. GP scores and TPCs were significantly different (FM > IFM, FM > non-FM, and IFM > non-FM) as were WPI, SSS and PSD scores for FM > IFM group. Rheumatologists made the previous diagnosis in 92.85% of patients, 53.84% of whom met the ACR criteria and about 20% did not have FM; and as many as 37.5% of the patients with a previous diagnosis made by a non-rheumatologist did not have FM. The non-FM patients were given 84 alternative diagnoses, 78.5% of which referred to rheumatic diseases. One hundred and thirty-one patients had 86 closely pain-related co-morbidities, 94.1% of which were rheumatic diseases. Conclusion Our findings confirm the inaccuracy of FM diagnoses and highlights the possibility that in everyday clinical practice, they are not always made with reference to very specific criteria and that there is a high risk of classifying non-FM patients as having FM. They also underline the importance of an accurate differential diagnosis. Separately classifying as IFM those patients who do not meet the ACR criteria, but have clinical findings indicating FM, may help to prevent their exclusion from specific treatment(s).
... Although Wolfe pointed out the unreliability of digital palpation and TPCs (4), physicians probably still use it while referring to the older ACR classification criteria. However, it is only fair to note that, though approximate, evaluating tender points is the only practical and reliable means of testing the pain threshold, which is the manifestation of the central sensitisation that is the essence of FM (15,16). Furthermore, FM is often associated with rheumatic diseases such as osteoarthritis, rheumatoid arthritis or spondyloarthritis, or connective tissue diseases such as Sjögren's syndrome (17)(18)(19), and the simple count of painful points for the widespread pain index of the 2016 ACR 2016 criteria may be insufficient, unsatisfactory, or even dangerous in the absence of a careful evaluation of the features and sites of pain. ...
... Furthermore, FM is often associated with rheumatic diseases such as osteoarthritis, rheumatoid arthritis or spondyloarthritis, or connective tissue diseases such as Sjögren's syndrome (17)(18)(19), and the simple count of painful points for the widespread pain index of the 2016 ACR 2016 criteria may be insufficient, unsatisfactory, or even dangerous in the absence of a careful evaluation of the features and sites of pain. The difficult of ensuring that all patients satisfy the ACR diagnostic criteria could be overcome by adopting the old and new concept of "incom- plete FM" to describe the patients who do not meet the positive FM criterion at a first evaluation, but have its main features in a milder form with fewer symptoms (15,20,21). It must also be remembered that CWP itself can be a diagnosis, especially in the absence or minimal presence of the typical non-painful symptoms of FM (21)(22)(23)(24)(25). Finally, it is frequent to come across patients who have been given an often questionable, inconclusive diagnostic hypothesis of FM that leads them on a continuous pilgrimage in the search for diagnostic confirmation. ...
... The patients with a GP score of 4-5, a WPI of ≥7 and a SSS score of ≥5 (case A) or a WPI of 4-6 and a SSS score of 9 (case B) were di-agnosed as having FM according to the 2016 ACR criteria. In the case of clinical correspondence, the definition of incomplete FM (IFM) was used for the patients with a previous diagnosis/hypothesis of FM (as proposed by Yunus) (15), but in the presence of borderline ACR scores. Borderline scores not fulfilling the ACR criteria were defined as follows: a GP score of 4-5 and a PSD score of 9-11, a GP score of 4-5 and a PSD 12-14 (not corresponding to case A or B), or a GP score of 3 and a PSD score of ≥9. ...
Article
Objectives: Fibromyalgia (FM) is a complex syndrome whose hallmark features are chronic widespread pain, sleep disturbances, fatigue and cognitive dysfunctions. However, it is still difficult to apply validated diagnostic criteria. The aim of this study is to examine the accuracy of a previous diagnosis/diagnostic hypothesis of FM according to the 2016 ACR diagnostic criteria. Methods: All of the patients newly referred to a private rheumatological clinic with the specific request for a consultation because if FM over an 18-month period were evaluated by means of a standardised protocol in order to determine whether they fulfilled the 2016 ACR diagnostic criteria for FM. They were initially divided into three groups: those with a previous diagnosis of FM (group 1), those with a physician's diagnostic hypothesis of FM (group 2) and those who personally hypothesised FM (group 3). They were subsequently classified as having FM, IFM (borderline scores) or not having FM (non-FM) on the basis of the 2016 ACR diagnostic criteria. Results: The study involved 216 patients (25 males and 191 females): 112 in group 1, 49 in group 2, and 55 in group 3. Only 89 patients (41.2%) fulfilled the ACR criteria; 42 (19.44%) met the study protocol-defined scores for IFM; and 85 (39.35%) were diagnosed as not having FM. Only 50% of the patients with a previous diagnosis of FM fulfilled the ACR criteria, and just under 25% did not have FM. Almost 50% of the patients with a physician's diagnostic hypotheses of FM did not have FM, whereas 20% of the patients who personally hypothesised FM fulfilled the ACR criteria. GP scores and TPCs were significantly different (FM > IFM, FM > non-FM, and IFM > non-FM) as were WPI, SSS and PSD scores for FM > IFM group. Rheumatologists made the previous diagnosis in 92.85% of patients, 53.84% of whom met the ACR criteria and about 20% did not have FM; and as many as 37.5% of the patients with a previous diagnosis made by a non-rheumatologist did not have FM. The non-FM patients were given 84 alternative diagnoses, 78.5% of which referred to rheumatic diseases. One hundred and thirty-one patients had 86 closely pain-related co-morbidities, 94.1% of which were rheumatic diseases. Conclusions: Our findings confirm the inaccuracy of FM diagnoses and highlights the possibility that in everyday clinical practice, they are not always made with reference to very specific criteria and that there is a high risk of classifying non-FM patients as having FM. They also underline the importance of an accurate differential diagnosis. Separately classifying as IFM those patients who do not meet the ACR criteria, but have clinical findings indicating FM, may help to prevent their exclusion from specific treatment(s).
... The prevalence of widespread chronic pain is about 10% worldwide. The correct diagnosis is the most challenge for the physician, since many painful diseases and/or syndromes like inflammatory arthritis, spondyloarthropathies, autoimmune connective tissue disease, myositis, myopathy, primary generalized osteoarthritis, rheumatic polymyalgia, and some malignancies may present symptoms similar to those of fibromyalgia, Yunus and Aldag (2012), Adams and Turk (2015), Cohen (2017). Fibromyalgia syndrome (FMS) is a condition characterized by chronic and generalized skeletal muscle pain, which can be assessed clinically by a marked sensitivity to specific tender points, fatigue, exhaustion, irritability, sleep disorders, cognitive impairment, diarrhea and/or constipation, dry mouth and anxiety according to Martinez, Panossian and Gavioli (2006), Santos et al. (2006), Cohen (2017). ...
... This group of patients reported pain intensity ranging from mild to severe, and rarely absent. The perception of the painful sensation relies on nociceptive stimulation, central pain mechanisms, cortical circuits, emotional, psychological and behavioral response, which varies from each individual, Smith, Harris, and Clauw (2011), Yunus and Aldag (2012), Clauw (2014). Table 1 shows that almost half of the patients (42.85%) presented analgetic state ranging from 6 to 10 years, but there is no consensus regarding their etiology or a specific factor or agent related to the onset of FMS. ...
... Table 1 shows that almost half of the patients (42.85%) presented analgetic state ranging from 6 to 10 years, but there is no consensus regarding their etiology or a specific factor or agent related to the onset of FMS. FMS symptoms are insidious, especially in adult life, and are preceded by skeletal muscle pain episodes, infection diseases,surgical procedures, physical or emotional trauma, Yunus and Aldag (2012), Goulart, Pessoa, and Lombardi Junior, (2016), Freitas et al. (2017). Acta Scientiarum. ...
Article
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This study aimed to obtain personal and clinical characteristics of patients with fibromyalgia, and to identify the factors responsible for the initiation, recurrence or intensification of painful state in each patient. The information was collected using General Characterization Form of Fibromyalgia Patients, consisting of 32 questions about personal data, location, and type of pain, identification of factors or circumstances related to the algetic state, physical activity, and pharmacological treatment. Among 14 patients included in this study, 85.71% were female. The pain intensity and time spam varied among patients, and 42.85% of them presented pain (algetic state) lasting between 6 to 10 years. Emotional trauma was the factor or circumstance related to the onset of symptoms of 71.43% of the patients. All patients reported that stressful situations resulting from conflicts in the family, social or work environment are factors responsible for reactivating and intensifying the symptoms of fibromyalgia. Factors and circumstances related to the onset, recurrence, and intensity of fibromyalgia symptoms reveal that it is necessary to inform patients that it is a benign disease, despite the painful condition,since the way they respond to daily events is a determining factor in the course of the disease.Improving physical conditioning and conducting cognitive-behavioral therapy, along with pharmacological treatments, can be successful in treating or minimizing the symptoms of fibromyalgia.
... Over the years, the homogeneity of fibromyalgia patients has been questioned (11)(12)(13), even prior to the development of the 1990c (14). With the new understanding of fibromyalgia as a polysymptomatic distress condition (9,15), it is even more convincing the existence of fibromyalgia subgroups according to their complex clinical profile. ...
... However, subgrouping of fibromyalgia patients is not a simple task. Different clusters according to measurements of tender points (11,16), fibromyalgia patients' psychological distress and/or psychosocial characteristics (17)(18)(19) have been proposed. Wilson et al. (13) tried to create fibromyalgia subgroups according to psychological and physical symptoms (13). ...
... It might be suggested that there is a subgroup of fibromyalgia patients who mainly suffer from tenderness and present a better clinical picture. Yunnus et al. (11) previously proposed the term of 'incomplete fibromyalgia' referring to those patients who fulfil one component of the 1990c but not the other (11 or more positive tender points or widespread pain for at least 3 months). These patients with 'incomplete fibromyalgia' presented less frequent and severe symptoms than those with 'complete fibromyalgia' (11). ...
Article
OBJECTIVES: We aimed to investigate the symptom profiles in subsets of fibromyalgia patients according to the subgroups created from the satisfaction of the 1990 American College of Rheumatology (ACR) diagnostic criteria (1990c) and/or the modified 2010 ACR preliminary diagnostic criteria (m-2010c). METHODS: A total of 913 (84 men) participants took part in this cross-sectional study. Participants were grouped as follows: i) 285 who did not fulfil any ACR diagnostic criteria (non-fibromyalgia); ii) 73 who fulfilled the 1990c only; iii) 96 who fulfilled the m-2010c only; iv) 459 who fulfilled both ACR diagnostic criteria. Experimental and clinical pain, chronic pain self-efficacy, pain catastrophising, fibromyalgia severity, fatigue, health-related quality of life, depression, state anxiety and physical fitness were assessed by means of several questionnaires and tests. RESULTS: Overall, the differences were consistent across all study outcomes (all, overall p<0.001), showing that the subgroup fulfilling both diagnostic criteria had the worst profile of all the subgroups, whereas those fulfilling any diagnostic criteria (non-fibromyalgia participants) had the most favourable results. Furthermore, the subgroup fulfilling the m-2010c only had a worse profile than the subgroup fulfilling the 1990c only, and presented similar but slightly better results than those fulfilling both diagnostic criteria. CONCLUSIONS: Our results reinforce the understanding of fibromyalgia as a heterogeneous condition. Subgrouping of fibromyalgia patients is highly recommendable, since these subgroups show diverse clinical pictures and therefore treatment options should be individually tailored to their specific profile. The combination of 1990c and the m-2010c is potentially useful to identify subgroups of fibromyalgia patients.
... It is as yet unclear whether the ACR 2010 criteria are sufficiently accurate to allow for a distinction between FM and other functional or neuropsychiatric pain syndromes (8), or between FM and disorders so far subsumed under the term 'incomplete fibromyalgia syndrome' (9). ...
... In addition, functional pain syndromes with hemibody distribution (in our FM 2010 cohort a further 10.4%) were classified as FM, although they can otherwise be characterized in a clearly more specific way (18)(19)(20). In sum, the ACR 2010 criteria do not help to differentiate 'incomplete forms of FM' from other forms of chronic widespread pain but instead result in a mixing up of terms (9). For this reason, this aspect of the ACR 2010 criteria was criticized for being 'inconsistent' and causing a 'dilution' of the former concept of FM 1990 (6). ...
... Contrary to the Budapest criteria for complex regional pain syndromes (21), the ACR 2010 criteria 'diagnose' FM solely on the basis of symptoms mentioned in the patient history; that is they do not take into account criteria that can be clinically examined. This methodological approach was subject to criticism from the very beginning (6,8,9). Regarding the 'modified' ACR 2010 criteria, the ACR author team went even a step further in that patients could self-declare and score their own symptoms (this even eliminated the need for diagnostic medical interviews). ...
Article
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In 2010, the American College of Rheumatology (ACR) proposed new criteria for the diagnosis of fibromyalgia (FM) in the context of objections to components of the criteria of 1990. The new criteria consider the Widespread Pain Index (WPI) and the Symptom Severity Score (SSS). This study evaluated the implications of the new diagnostic criteria for FM across other functional pain syndromes. A cohort of 300 consecutive in-patients with functional pain syndromes underwent a diagnostic screen according to the ACR 2010 criteria. Additionally, systematic pain assessment including algometric and psychometric data was carried out. Twenty-five patients (8.3%) had been diagnosed with FM according to the ACR 1990 criteria. Twenty-one of them (84%) also met the new ACR 2010 criteria. In total, 130 patients (43%) fulfilled the new ACR 2010 criteria. A comparison of new vs. old cases showed a high degree of conformity in most of the pain characteristics. The new FM cases, however, revealed a pronounced heterogeneity in the anatomical pain locations, including several types of localized pain syndromes. Furthermore, patients fulfilling the ACR 2010 FM criteria differed from those with other functional pain syndromes; they had increased pain sensitivity scores and increased psychometric values for depression, anxiety, and psychological distress (p < 0.01). FM according to the ACR 2010 criteria describes the 'severe half' of the spectrum of functional pain syndromes. By dropping the requirement of 'generalized pain', these criteria result in a blurring of the distinction between FM and more localized functional pain syndromes.
... Fatigue is commonly defined as a feeling of tiredness, lack of energy, emotional stability and motivation, or difficulty in concentration and memory [1,2]. The clinical course is frequently aggravated by a variety of attending symptoms such as headache or muscle pain. ...
... The clinical course is frequently aggravated by a variety of attending symptoms such as headache or muscle pain. Applicable duration categories are: recent fatigue: < 1 month; prolonged fatigue: 1-6 months; chronic fatigue: > 6 months [2,3]. ...
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Background: Rhodiola rosea roots and rhizomes are a herbal medicine for temporary relief of stress symptoms such as fatigue and sensed weakness. A daily dosage of 400 mg is recommended. Methods: A dry ethanolic extract of R. rosea (WS® 1375) was studied in 100 subjects with prolonged or chronic fatigue symptoms. In an uncontrolled, open-label multicenter clinical trial, the subjects were administered 2 × 200 mg WS® 1375 over 8 weeks. Outcome measures were scales and tests related to fatigue. They were evaluated in an exploratory data analysis to generate hypotheses regarding efficacy. The pilot character of the trial is marked by its broad focus on subjects suffering from fatigue in general and by its comparatively long duration. Results: The greatest change was observed after 1 week of treatment. The fatigue symptoms continued to decline further, with statistically significant improvement at week 8. The safety assessments of WS® 1375 during the trial proved to be favorable, with most adverse events being of mild intensity and not related to the study drug. Conclusions: The results indicate that 2 × 200 mg WS® 1375 may be an effective treatment in subjects suffering from prolonged or chronic fatigue. The safety and tolerability of WS® 1375 also presented a favorable profile.
... Thus, the ACR 1990 criteria are more of a severity assessment tool than a diagnostic tool [11,12]. For these reasons, it is not currently recommended to use the ACR 1990 criteria for a diagnosis of FM [13]. However, the combination of the ACR 1990 and 2010 criteria has allowed the identification of subgroups in patients with FM, but its clinical utility remains unclear, and further research is needed [14]. ...
... 10,53,54 One inclusion can arguably be made regarding early stages of FM, ie incomplete FM Syndromes, which may do not (yet) exhibit a "whole-body" distribution of pain. 55 However, we surmise that even incomplete FM syndromes would correspond to our indicators of hyperalgesia (indicator A), bilateral axial-symmetric pain distribution (indicator B), and chronic stress symptoms (indicator C). ...
Article
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Purpose Diagnostic criteria for fibromyalgia have been subject to debate and controversy for many years. The preliminary diagnostic criteria introduced in 2010 and 2011 have been criticized for different reasons, including questionable diagnostic specificity and a lack of an etiopathogenetic foundation. The “ABC indicators” presented in this study reflect a further development of the 2011 criteria and refer to (A) algesia, (B) bilateral, axial-symmetric pain distribution, and (C) chronic distress. Patients and methods We compared the diagnostic performance of the ABC indicators with that of the 2011 criteria by analyzing the data of 409 inpatients with chronic functional pain divided into two subgroups of pain patients: Those with whole-body pain and those with pain not involving the whole body. Under the premise that FM phenotypically represents a whole-body pain disorder, sensitivity, specificity, correct classification and diagnostic odds ratios were calculated. Results The 2011 criteria demonstrated a specificity of 68.1%, a sensitivity of 75.5%, a correct classification of 71.0% and a diagnostic odds ratio of 6.56 (CI: 4.17–10.31). The ABC indicators achieved a specificity of 88.3%, a sensitivity of 62.3%, a correct classification of 78.6%, and a diagnostic odds ratio of 12.47 (CI: 7.30–21.28). Conclusion The ABC fibromyalgia indicators demonstrated better specificity, lower sensitivity, and better overall diagnostic effectiveness than the original 2011 criteria.
... The adjusted covariates varied across studies and comprised gender, sunlight exposure, social status, cigarette smoking, alcohol consumption, physical activities, and dietary supplement. The mean values of serum C hronic widespread pain (CWP), including fibromyalgia, is a global musculoskeletal disorder leading to disability and a reduced quality of life, and has a prevalence ranging from 10% to 18% in the general population (1,2). Concomitant somatic symptoms may present as complaints of circulatory, respiratory, and neurological system problems and impose a tremendous burden on psychosocial and medical care resources (3). ...
Article
Background: Chronic widespread pain (CWP) is a global musculoskeletal disorder leading to disability and a reduced quality of life. Low levels of serum vitamin D has long been proposed to be associated with CWP, but previous research remains inconclusive. Objectives: To determine whether hypovitaminosis D was independently associated with CWP. Study Design: Meta-analysis of observational study. Methods: Electronic databases were searched for studies published up to November 2014 comparing the prevalence of hypovitaminosis D and serum vitamin D levels between participants with and without CWP. The crude and adjusted odds ratios (ORs) of hypovitaminosis D with CWP were calculated. Subgroup analysis according to gender, threshold of hypovitaminosis, and definition of patients was performed, as well as meta-regression to test the linear relationship between crude ORs and the latitude of study locations. Results: Twelve studies were included, comprising 1,854 patients with CWP. The patient group showed a significantly higher risk of hypovitaminosis D than the control group (crude OR, 1.63; 95% CI, 1.20 - 2.23). The association was slightly attenuated after adjusting confounders, with a pooled adjusted OR of 1.41 (95% CI, 1.00 - 2.00). There was an increase in ORs of hypovitaminosis D using a lower diagnostic value of serum vitamin D (8 and 10 ng/mL). The subgroup analysis according to gender and definition of CWP did not reveal significant between-group differences. The meta-regression showed no linear relationship between latitude and the crude ORs. Conclusions: There was a positive crude association between hypovitaminosis D and CWP, and the association was likely to remain after adjusting confounding factors. Use of a cut-off value of hypovitaminosis D (8 - 10 ng/mL) could better define the population with and without CWP. Further prospective follow-up studies are warranted to clarify the causal relationship between hypovitaminosis D and CWP.
... Although it is important for clinical research studies to make distinction between FMS and CWP, the findings of this study deserve special attention because of their relevance for clinical practice. Our findings strongly support the recent suggestions that there seems to be no rationale for diagnosing FMS as a discrete disorder in patients presenting with CWP [34,35]. To characterize patients with CWP as having or not having FMS by using rigid diagnostic criteria, we may miss many patients with CWP who need treatment. ...
Article
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The applicability of the American College of Rheumatology (ACR) 1990 and 2010 criteria for the diagnosis of fibromyalgia syndrome (FMS) was determined in 284 patients with chronic widespread pain (CWP) including those with regional and systemic painful disorders. On the basis of initial evaluation, patients were classified into three groups. Group 1, those without any comorbid disease (N = 105), group 2, those having regional non-inflammatory painful disorders (N = 104), and group 3, those with a diagnosis of an inflammatory rheumatic disease (N = 75). Overall, 65 % of the patients fulfilled the 1990 criteria, while 94 % of them fulfilled the 2010 criteria. Almost all of the patients (97 %) with CWP did meet at least one of the criteria set, regardless of whether they have accompanying painful disorders. Widespread pain index (WPI), symptom severity scale (SS), and fibromyalgia impact questionnaire (FIQ) scores were found to be significantly higher in the patients who satisfied the 1990 criteria than those who did not (P < 0.001). Tender point counts were found to be significantly correlated with WPI, SS, FIQ, and Beck depression inventory (BDI) scores (P < 0.001). The findings of the study support the suggestion that FMS is just a continuum of CWP, rather than a distinct diagnostic entity. As treatment of FMS is usually identical with that of CWP, strict diagnosis of FMS will provide little or no significance from the viewpoint of clinical practice. We suggest that future research should be directed toward classification of CWP to provide guidance to clinicians in selecting effective therapies.
... This combination of criteria had not previously been reported, but it seems that when the combination of the two criteria is available, satisfying one of two criteria shows the best overall characteristics to meet the diagnosis of FM. As recently shown, FM patients might not necessarily fulfil the tender points criteria to be diagnosed [30], which agrees with our findings. Furthermore, this criteria combination might help to identify more homogeneous subgroups of patients (e.g. ...
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The aim of this study was to validate the modified 2010 ACR preliminary criteria for FM in a Spanish population. Five hundred and seventy-nine (550 women) FM and 294 (240 women) control participants were enrolled in the study. FM patients were previously diagnosed by a rheumatologist. All participants underwent both the 1990 ACR criteria (1990c) and the modified 2010 ACR criteria (m-2010c). The tender points count showed correlations of 0.69, 0.65 and 0.71 with the widespread pain index (WPI), symptoms severity (SS) and polysymptomatic distress (PSD) scales, respectively (all P < 0.001). The WPI, SS and PSD showed greater correlations with impact of FM health-related quality of life, general fatigue and depression than the tender points count. The 1990c showed sensitivity and specificity values of 84.1 and 97.6, respectively, whereas the m-2010c showed values of 88.3 and 91.8, respectively. Both criteria showed the same overall accuracy, with a value of 0.89. When the 1990c and m-2010c were combined and patients had to satisfy one of two criteria to be diagnosed with FM, the sensitivity, specificity and accuracy of questionnaires were 96.7, 89.8 and 0.94, respectively. The original cut-off points (WPI ≥ 7, SS ≥ 5 and PSD ≥ 12) showed the best test characteristics in the present study. The m-2010c, with the same cut-off points as the original version, are a valid tool for the diagnosis of FM in our population. Whenever possible, the combination of the 1990c and m-2010c is recommended (patients have to meet one of the two criteria to be diagnosed), since this approach showed the best diagnostic characteristics.
... The WPI denotes the number of areas in which a patient feels pain, and the SSS refers to the severity of fatigue, waking unrefreshed, and cognitive symptoms plus the extent of additional somatic symptoms [21]. In the realm of central hypersensitivity syndromes, to which fibromyalgia belongs [22], subjective pain and other somatic symptoms without objective clinical findings are deemed clinical manifestations of central sensitization [23]. In fibromyalgia, increased pressure pain sensitivity due to augmented central pain processing has been demonstrated [24]. ...
Article
Low vitamin D is implicated in various chronic pain conditions with, however, inconclusive findings. Vitamin D might play an important role in mechanisms being involved in central processing of evoked pain stimuli but less so for spontaneous clinical pain. This study aims to examine the relation between low serum levels of 25-hydroxyvitamin D3 (25-OH D) and mechanical pain sensitivity. We studied 174 patients (mean age 48 years, 53% women) with chronic pain. A standardized pain provocation test was applied, and pain intensity was rated on a numerical analogue scale (0-10). The widespread pain index and symptom severity score (including fatigue, waking unrefreshed, and cognitive symptoms) following the 2010 American College of Rheumatology preliminary diagnostic criteria for fibromyalgia were also assessed. Serum 25-OH D levels were measured with a chemiluminescent immunoassay. Vitamin deficiency (25-OH D < 50 nmol/L) was present in 71% of chronic pain patients; another 21% had insufficient vitamin D (25-OH D < 75 nmol/L). After adjustment for demographic and clinical variables, there was a mean ± standard error of the mean increase in pain intensity of 0.61 ± 0.25 for each 25 nmol/L decrease in 25-OH D (P = 0.011). Lower 25-OH D levels were also related to greater symptom severity (r = -0.21, P = 0.008) but not to the widespread pain index (P = 0.83) and fibromyalgia (P = 0.51). The findings suggest a role of low vitamin D levels for heightened central sensitivity, particularly augmented pain processing upon mechanical stimulation in chronic pain patients. Vitamin D seems comparably less important for self-reports of spontaneous chronic pain.
... It seems as though in the field of functional musculoskeletal pain syndromes, pertinent "labels" are still lacking. If, however, the new preliminary fibromyalgia criteria 2010 of the ACR that subsumes more localized musculoskeletal pain syndromes under fibromyalgia prevails, this gap will be closed soon [20,21]. ...
... The 2010 criteria uses only a questionnaire, whereas the 1990 criteria consider fibromyalgia to be present only when diffuse pain has been present for more than 3 months and when there is pain in 11 or more of the 18 points tested [12,13]. The 2010 ACR criteria [12] have been considered to be inferior to the 1990 criteria, principally because they eliminate the evaluation of the tender points and increase the possibility of diagnostic confusion with other types of dysfunction [19][20][21][22][23][24]. ...
Article
Abstract The objectives of the study were to assessed if there is any difference in the prevalence of fibromyalgia and in quality of life (QoL) between women with and without endometriosis. A cross-sectional study was conducted in 2011-2013, involving 257 women with surgically and histopathologically confirmed endometriosis and 253 women with no history of endometriosis and no endometriosis-related symptoms. Women were recruited both at the family planning and endometriosis clinic, Department of Obstetrics and Gynecology, University of Campinas, Brazil. The Short Form 36 questionnaire (SF-36) was used to assess QoL, while the 1990 and 2010 American College of Rheumatology (ACR) criteria were used to evaluate fibromyalgia. According to the 1990 ACR criteria, there were no cases of fibromyalgia in either group. Nevertheless, according to the 2010 ACR criteria, four women, two with endometriosis and two without the disease, were diagnosed with fibromyalgia. Scores were significantly lower in all the domains of the QoL questionnaire for the women with endometriosis compared to those without the disease. This study reports no difference in the prevalence of fibromyalgia between women with and without endometriosis; however QoL was poorer among women with endometriosis when compared to women without the disease.
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To provide objective diagnostic markers for fibromyalgia symptoms (FMS) diagnosis, we have created interpretable extreme gradient boosting (XGBoost) models using radiomics to aid in the diagnosis of chronic pain (CP) and to develop nomogram models for diagnosing subgroups of FMS. A group of 54 patients with CP and 71 healthy controls was randomly separated into training and validation groups, using a 7:3 ratio. Radiomics features were extracted from grey-matter and white-matter in the filtered mwp0* image. The Mann-Whitney U test, Spearman’s rank correlation test, and least absolute shrinkage and selection operator (LASSO) were utilized to select features. An XGBoost model was created based on these features, and Shapley Additive exPlanations (SHAP) was used for personalization and visual interpretation. A nomogram was developed for the diagnosis of FMS subgroups, utilizing radiomics scores and clinical predictors. The efficacy of the nomogram was evaluated using the area under the receiver operating characteristic curve, while decision curve analysis was employed to evaluate its clinical efficacy. The XGBoost model displays stability in the training validation group, indicating lower overfitting of CP model. The nomogram model combined with the rad-score has a greater ability to distinguish between typical and sub-clinical than the clinical factor model alone. We developed and validated a CP diagnosis model by XGBoost and realized model visualization through SHAP. The rad-score obtained by machine learning was used to build a nomogram model that combines clinical scales to distinguish patients with typical and sub-clinical fibromyalgia.
Chapter
The classification of fibromyalgia is controversial, and as it lacks a defined etiology or a consensual pathophysiology, debates are held over whether it should be defined as a disease, and by which medical field it should be treated. Therefore, some might prefer to describe it as a “functional somatic syndrome,” pointing to the complexity of physical manifestations it has.
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Fatigue is a common symptom in elderly persons, but it is often ignored as many patients and healthcare providers assume it is a natural progression of aging or may mistake it for somnolence, dyspnea, or muscle weakness. Since its importance is often underestimated, patients with fatigue may not receive an intervention, potentially resulting in significant functional decline. This article discusses the importance of identifying the underlying etiology or etiologies of a patient's fatigue so that it can be eliminated, if possible, or managed appropriately. History-taking, including consideration of the patient's symptom severity, is the most important part of evaluating fatigue. The authors present an algorithm that can be used to help identify the cause of a patient's fatigue.
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To investigate in primary Sjögren's syndrome, the differences between patients with and without widespread pain (WSP) with respect to the cumulative prevalence of extra-glandular manifestations (EGMs) and systemic auto-antibodies. All outpatients diagnosed with primary Sjögren's syndrome (2) were included in a prospective follow-up, with at least one check up each year, from June 1991 until November 2011. Patients who also fulfilled criteria for concomitant connective tissue disorders were excluded. Widespread pain was defined as the presence of long-lasting (>one year) diffuse pain in all four body quadrants. Data were collected with respect to the cumulative prevalence of systemic auto-antibodies (anti-nuclear antibodies [ANA], anti-Sjögren syndrome A antigen [anti-SSA], anti-Sjögren syndrome B antigen [anti-SSB] and immunoglobulin M-Rheumatoid factor [IgM-RF]) and EGMs related to primary Sjögren's syndrome. Eighty-three patients were included in the final analysis. Thirty-nine (34.9%) patients had widespread pain. Anti-SSB was found less frequently (p<0.05) in patients with WSP than in patients without WSP. The WSP-positive patients were more frequently negative for all four tested autoantibodies (p<0.05). The patients with WSP had fewer EGMs than the patients without WSP (p<0.01); more specifically, polyneuropathy occurred less frequently (p<0.05) in the patients with WSP. Cytopenia, uveitis, pericarditis, pleuritis, interstitial lung disease, vasculitis, monoclonal gammapathy of unknown significance and non-Hodgkin lymphoma only occurred in the patients without WSP. Primary Sjögren's patients with WSP form a benign subgroup, with a lower prevalence of anti-SSB and EGMs (in particular polyneuropathy). We suggest a shorter period of follow-up for this subset than for the WSP-negative patients.
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Fibromyalgia is a common chronic syndrome defined by core symptoms of widespread pain, fatigue, and sleep disturbance. Other common symptoms include cognitive difficulty, headache, paresthesia, and morning stiffness. Fibromyalgia is increasingly understood as 1 of several disorders that are referred to as central sensitivity syndromes; these disorders share underlying causes and clinical features. Tender points are often detected in patients with fibromyalgia and were formerly required for diagnosis. Newly proposed criteria, however, rely on patients' reports of widespread pain and other somatic symptoms to establish the diagnosis of fibromyalgia. The management of fibromyalgia requires a multidimensional approach including patient education, cognitive behavioral therapy, exercise, and pharmacologic therapy. The present review provides an update on these various aspects of treating a patient with fibromyalgia.
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To validate a self-report fibromyalgia screener in a chronic pain population. Adults with chronic pain were evaluated with a six-item, self-report fibromyalgia screening tool based on revised American College of Rheumatology (ACR) fibromyalgia diagnostic criteria, with fibromyalgia diagnosed when patients experienced chronic pain and scored ≥13 on the ACR fibromyalgia symptom severity scale. Patients were independently assigned clinical diagnoses by treating clinicians. University-based, tertiary care pain clinic. Three hundred thirty-seven mixed chronic pain patients. Agreement between the clinical diagnosis and screener diagnosis was good (P < 0.001), with 76% sensitivity and 82% specificity. A self-administered, brief fibromyalgia screening questionnaire can effectively identify chronic pain patients who will likely have clinical fibromyalgia.
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Objectives: To present diagnostic criteria for the clinical diagnosis of fibromyalgia syndrome (FMS) and to offer a scheme for diagnostic work-up in clinical practice. Methods: Narrative review of the literature, consensus documents by the American College of Rheumatology (ACR), evidence-based interdisciplinary German guidelines on the diagnosis and management of FMS. Results: The ACR 1990 classification criteria emphasized tender points and widespread pain as the key features of FMS. In 2010, the ACR proposed preliminary diagnostic criteria for fibromyalgia that abandoned the tender point count and placed increased emphasis of patient symptoms. A later modification of the ACR 2010 criteria for use in surveys employed a self-report questionnaire (Fibromyalgia Survey Questionnaire FSQ) to assess patient symptoms. The FSQ can be used to assist physician's diagnosis of FMS. We recommend a stepwise diagnostic work-up of patients with chronic widespread pain (CWP) in primary care: Complete medical history including medication, complete medical examination, basic laboratory tests to screen for inflammatory or endocrinology diseases, referral to specialists only in case of suspected somatic diseases, assessment of limitations of daily functioning, screening for other functional somatic symptoms and mental disorders, and referring to mental health specialists in case of mental disorder. Conclusions: The diagnosis of FMS is easy in most patients with CWP and does not ordinarily require a rheumatologist. A rheumatologist's expertise might be needed to exclude difficult to diagnose or concomitant inflammatory rheumatic diseases. In the presence of mental illness referral to a mental health specialist for evaluation is recommended.
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To describe the diagnosis status and outcome of patients diagnosed with fibromyalgia (FM) by US rheumatologists. We assessed 1555 patients with FM with detailed outcome questionnaires during 11,006 semiannual observations for up to 11 years. At entry, all patients satisfied American College of Rheumatology preliminary 2010 FM criteria modified for survey research. We determined diagnosis status, rates of improvement, responder subgroups, and standardized mean differences (effect sizes) between start and study completion scores of global well-being, pain, sleep problems, and health related quality of life. (QOL) RESULTS: The 5-year improvement rates were pain 0.4 (95% CI 0.2, 0.5), fatigue 0.4 (95% CI 0.2, 0.05), and global 0.0 (95% CI -0.1, 0.1). The standardized mean differences were patient global 0.03 (95% CI -0.02, 0.08), pain 0.22 (95% CI 0.16, 0.28), sleep problems 0.20 (95% CI 0.14, 0.25), physical component summary of the Short-form 36 (SF-36) 0.11 (95% CI -0.14, -0.07), and SF-36 mental component summary 0.03 (95% CI -0.07, 0.02). Patients switched between criteria-positive and criteria-negative states, with 716 patients (44.0%) failing to meet criteria at least once during 4228.5 patient-years (7448 observations). About 10% of patients had substantial improvement and about 15% had moderate improvement of pain. Overall, FM severity worsened in 35.9% and pain in 38.6%. Although we found no average clinically meaningful improvement in symptom severity overall, 25% had at least moderate improvement of pain over time. The result that emerged from this longitudinal study was one of generally continuing high levels of self-reported symptoms and distress for most patients, but a slight trend toward improvement.
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To develop criteria for the classification of fibromyalgia, we studied 558 consecutive patients: 293 patients with fibromyalgia and 265 control patients. Interviews and examinations were performed by trained, blinded assessors. Control patients for the group with primary fibromyalgia were matched for age and sex, and limited to patients with disorders that could be confused with primary fibromyalgia. Control patients for the group with secondary-concomitant fibromyalgia were matched for age, sex, and concomitant rheumatic disorders. Widespread pain (axial plus upper and lower segment plus left- and right-sided pain) was found in 97.6% of all patients with fibromyalgia and in 69.1% of all control patients. The combination of widespread pain and mild or greater tenderness in greater than or equal to 11 of 18 tender point sites yielded a sensitivity of 88.4% and a specificity of 81.1%. Primary fibromyalgia patients and secondary-concomitant fibromyalgia patients did not differ statistically in any major study variable, and the criteria performed equally well in patients with and those without concomitant rheumatic conditions. The newly proposed criteria for the classification of fibromyalgia are 1) widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. No exclusions are made for the presence of concomitant radiographic or laboratory abnormalities. At the diagnostic or classification level, the distinction between primary fibromyalgia and secondary-concomitant fibromyalgia (as defined in the text) is abandoned.
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To investigate relationships between sex, pain threshold and fibromyalgia (FM) symptoms in the general population. Data were obtained from a randomized populations survey of 3,006 persons in Wichita, KS and a subsample of 391 who completed a detailed interview and had an examination. Tender point counts, dolorimetry scores, clinical and psychological variables were measured. Dolorimetry scores were 2.04 kg/cm (1.42-2.66) lower in women than men, and women were almost 10 times more likely to have 11 tender points [OR 9.6 (2.00-46.3)] than men. Women are also more likely to have FM symptoms than men: "Pain all over," [OR 3.94 (1.34-11.38)], sleep disturbance [OR 3.06 (1.45-6.46)], fatigue [OR 4.52 (2.03-10.09)], and irritable bowel syndrome [OR 5.23 (1.83-14.96)]. Tender point counts are more correlated with FM symptoms than dolorimetry scores. Symptoms of FM are correlated with pain threshold in the general population, but tender point counts correlate better than dolorimetry. These 2 measures of pain threshold assay different but overlapping factors. Pain threshold is lower in women; and women have more FM symptoms. Decreased pain threshold correlates with all of the symptoms of FM, even in those who do not meet criteria for the syndrome. This suggests that decreased pain threshold, as measured by the tender point counts, is an intrinsically important aspect of patient distress, regardless of the extent and kind of concomitant disease; and that much can be learned about patients by employing this examination.
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To assess the efficacy and safety of gabapentin in patients with fibromyalgia. A 12-week, randomized, double-blind study was designed to compare gabapentin (1,200-2,400 mg/day) (n=75 patients) with placebo (n=75 patients) for efficacy and safety in treating pain associated with fibromyalgia. The primary outcome measure was the Brief Pain Inventory (BPI) average pain severity score (range 0-10, where 0=no pain and 10=pain as bad as you can imagine). Response to treatment was defined as a reduction of >or=30% in this score. The primary analysis of efficacy for continuous variables was a longitudinal analysis of the intent-to-treat sample, with treatment-by-time interaction as the measure of effect. Gabapentin-treated patients displayed a significantly greater improvement in the BPI average pain severity score (P=0.015; estimated difference between groups at week 12=-0.92 [95% confidence interval -1.75, -0.71]). A significantly greater proportion of gabapentin-treated patients compared with placebo-treated patients achieved response at end point (51% versus 31%; P=0.014). Gabapentin compared with placebo also significantly improved the BPI average pain interference score, the Fibromyalgia Impact Questionnaire total score, the Clinical Global Impression of Severity, the Patient Global Impression of Improvement, the Medical Outcomes Study (MOS) Sleep Problems Index, and the MOS Short Form 36 vitality score, but not the mean tender point pain threshold or the Montgomery Asberg Depression Rating Scale. Gabapentin was generally well tolerated. Gabapentin (1,200-2,400 mg/day) is safe and efficacious for the treatment of pain and other symptoms associated with fibromyalgia.
Article
• Thirty-eight patients with incomplete lupus erythematosus (ILE) (defined as the presence of fewer than four of the criteria of the American College of Rheumatology for systemic lupus erythematosus [SLE]) were identified and compared with 42 patients with SLE. Both groups were comparable with respect to age, sex, and race. Patients with ILE had symptoms for an average of 38 months before seeking rheumatologic care and were followed up for a mean of 19 months; patients with SLE averaged 9 months with symptoms before their diagnosis was made and were followed for a mean of 30 months. Characteristic clinical features of patients with ILE included positive antinuclear antibody titers (83%), polyarticular nonerosive arthritis (47%), and cutaneous findings (61%). These were comparable with findings in the the SLE group. However, patients with ILE had significantly fewer systemic manifestations than did those with SLE. Patients with ILE were treated with nonsteroidal anti-inflammatory drugs more frequently (47%) than were patients with SLE, while the latter group received more topical and oral corticosteorids and immunosuppressives. Only two of the patients with ILE went on to have typical SLE. Thus, ILE may be frequent, mild, and relatively stable or benign, apparently evolving slowly if at all into SLE or other rheumatic disease. (Arch Intern Med. 1989;149:2473-2476)
Article
To develop criteria for the classification of fibromyalgia, we studied 558 consecutive patients: 293 patients with fibromyalgia and 265 control patients. Interviews and examinations were performed by trained, blinded assessors. Control patients for the group with primary fibromyalgia were matched for age and sex, and limited to patients with disorders that could be confused with primary fibromyalgia. Control patients for the group with secondary-concomitant fibromyalgia were matched for age, sex, and concomitant rheumatic disorders. Widespread pain (axial plus upper and lower segment plus left- and right-sided pain) was found in 97.6% of all patients with fibromyalgia and in 69.1% of all control patients. The combination of widespread pain and mild or greater tenderness in ⩾ 11 of 18 tender point sites yielded a sensitivity of 88.4% and a specificity of 81.1%. Primary fibromyalgia patients and secondary-concomitant fibromyalgia patients did not differ statistically in any major study variable, and the criteria performed equally well in patients with and those without concomitant rheumatic conditions. The newly proposed criteria for the classification of fibromyalgia are 1) widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. No exclusions are made for the presence of concomitant radiographic or laboratory abnormalities. At the diagnostic or classification level, the distinction between primary fibromyalgia and secondary-concomitant fibromyalgia (as defined in the text) is abandoned.
Article
In this issue of The Journal Dr. Wolfe and colleagues introduce 2 new and different protocols (there have been many prior versions) to identify what they call “fibromyalgianess”1,2. In what ways are the new proposals unhelpful? Dilution (the inclusion of milder cases changes prognosis); inconsistency (multiple diagnostic strategies identify different patients); loss of specificity [later criteria sets lose information and fail to discriminate symptoms of rheumatoid arthritis (RA), fibromyalgia (FM), systemic lupus erythematosus (SLE), and osteoarthritis (OA)]; and loss of the ability to recognize FM concurrent with other diseases. Statistical approaches are used that do not make most efficient use of the information available. More fundamental is the continuing distraction from the obligation to accurately identify the origins of pain and choose appropriate treatments3. The odyssey was not without purpose or logic. FM has been described as a spectrum disorder. But there are 2 quite separate spectra. One is a continuous spectrum expressing severity, with FM separated from lesser chronic pain by arbitrary cutpoints. The other is better described as a palette of characteristic symptoms, found to be associated with FM however defined. Many of these statistically significant associations were found in the 1990 Classification Criteria study4. Sleep disturbance, fatigue, morning stiffness > 15 minutes, paresthesias, anxiety, headache, prior depression, irritable bowel syndrome, sicca symptoms, urinary urgency, dysmenorrhea history, and Raynaud’s phenomenon are all listed in Table 6 of the 1990 paper. Because symptoms other than widespread pain were not embedded in the Criteria, the statistical strength of the association of these and other symptoms associated with FM could be tested independent of the 1990 Criteria. Other links were added later, including cognitive problems (“Fibrofog”)5, “dizziness,” jaw pain6,7, and low abdominal pain. If this symptom profile … Address correspondence to Dr. H.A. Smythe, 2 Heathbridge Park, Toronto, Ontario M4G 2Y6, Canada. E-mail: hasmythe{at}rogers.com
Article
To develop simple, practical criteria for clinical diagnosis of fibromyalgia that are suitable for use in primary and specialty care and that do not require a tender point examination, and to provide a severity scale for characteristic fibromyalgia symptoms. We performed a multicenter study of 829 previously diagnosed fibromyalgia patients and controls using physician physical and interview examinations, including a widespread pain index (WPI), a measure of the number of painful body regions. Random forest and recursive partitioning analyses were used to guide the development of a case definition of fibromyalgia, to develop criteria, and to construct a symptom severity (SS) scale. Approximately 25% of fibromyalgia patients did not satisfy the American College of Rheumatology (ACR) 1990 classification criteria at the time of the study. The most important diagnostic variables were WPI and categorical scales for cognitive symptoms, unrefreshed sleep, fatigue, and number of somatic symptoms. The categorical scales were summed to create an SS scale. We combined the SS scale and the WPI to recommend a new case definition of fibromyalgia: (WPI > or =7 AND SS > or =5) OR (WPI 3-6 AND SS > or =9). This simple clinical case definition of fibromyalgia correctly classifies 88.1% of cases classified by the ACR classification criteria, and does not require a physical or tender point examination. The SS scale enables assessment of fibromyalgia symptom severity in persons with current or previous fibromyalgia, and in those to whom the criteria have not been applied. It will be especially useful in the longitudinal evaluation of patients with marked symptom variability.
Article
American College of Rheumatology (ACR) 1990 criteria, initially introduced to classify fibromyalgia (FM) syndrome, has gained popularity in research and clinical grounds for diagnostic purposes. The objectives of this study were designed to assess the consistency of ACR criteria against the time in classifying FM. This was a prospective cohort study performed in a multidisciplinary pain clinic from October 2002 to June 2005. Patients who were clinically suspected of having FM and had a normal screening laboratory evaluation were scheduled for dolorimetry. Those found to have 6 or more tender points were considered eligible and labeled as either classic or atypical FM if they did or did not, respectively, fulfil ACR criteria. The 2 groups were assessed using the Fibromyalgia Impact Questionnaire (FIQ) and compared using baseline characteristics. We reassessed dolorimetric exam and FIQ 6 months later. Of 91 patients who participated in this study,70 completed the follow-up. Of them, 34 (49%) patients were identified as atypical, and 36 (51%) were labeled as classic FM. At first visit, the classic FM group had higher scores on sleep quality, stiffness, anxiety, depression, and total FIQ score (p\0.05) but not for other variables. At 6 months, there was no significant difference between the 2 groups in all measured variables. Labeling shift from classic to atypical FM and vice versa occurred at a rate of 36.1 and 32.4%, respectively. This study showed the ACR 1990 criteria was not able to consistently classify affected patients with FM syndrome within a group of patients having nonspecific body pain and multiple tender points over 6 months of follow-up.
Article
As in other diseases of undetermined etiology, the diagnosis of ankylosing spondylitis (AS) and related spondyloarthropathies (SpA) is based on clinical and roentgenographic features. The current criteria for diagnosis of some of these diseases are too restricted, and do not recognize the existence of a much wider disease spectrum. For example, radiographically detected sacroiliitis is extremely frequent in AS, but may not be an obligate manifestation, especially in early or atypical forms of the disease. Arthritis involving the axial skeleton, including the sacroiliac joints, can be present in some patients without evidence of erosive disease roentgenographically. The disease spectrum of Reiter's syndrome has also been broadened considerably, and "incomplete" forms of Reiter's syndrome are observed much more commonly than the classical triad of arthritis, conjunctivitis, and urethritis. The term "B27-associated reactive arthritis" has been used in recent years to refer to SpA following enteric or urogenital infections, and the disease spectrum includes the clinical picture of typical Reiter's syndrome. The clinical spectrum of psoriatic SpA has been better clarified. Some of the less well defined B27-associated clinical syndromes include seronegative oligoarthritis, polyarthritis, or dactylitis ("sausagelike" toes) of the lower extremities, and heel pain caused by calcaneal (and tarsal) periostitis. These and other undifferentiated SpA have been ignored in previous epidemiological studies because of the inadequacy of the existing classification criteria. The European Spondylarthropathy Study Group (ESSG) has completed a study aimed at developing preliminary classification criteria for the whole group of SpA patients, with the specific intention of encompassing patients with undifferentiated SpA.
Article
Thirty-eight patients with incomplete lupus erythematosus (ILE) (defined as the presence of fewer than four of the criteria of the American College of Rheumatology for systemic lupus erythematosus [SLE]) were identified and compared with 42 patients with SLE. Both groups were comparable with respect to age, sex, and race. Patients with ILE had symptoms for an average of 38 months before seeking rheumatologic care and were followed up for a mean of 19 months; patients with SLE averaged 9 months with symptoms before their diagnosis was made and were followed for a mean of 30 months. Characteristic clinical features of patients with ILE included positive antinuclear antibody titers (83%), polyarticular nonerosive arthritis (47%), and cutaneous findings (61%). These were comparable with findings in the the SLE group. However, patients with ILE had significantly fewer systemic manifestations than did those with SLE. Patients with ILE were treated with nonsteroidal anti-inflammatory drugs more frequently (47%) than were patients with SLE, while the latter group received more topical and oral corticosteroids and immunosuppressives. Only two of the patients with ILE went on to have typical SLE. Thus, ILE may be frequent, mild, and relatively stable or benign, apparently evolving slowly if at all into SLE or other rheumatic disease.
Article
Eighty patients with Reiter's syndrome (RS) were studied retrospectively. A comparison was made between patients with the complete syndrome and patients with the incomplete syndrome. A comparison was also made between patients with and without HLA-B27. There were no major differences in severity and duration of the arthritic symptoms or in mucocutaneous involvement between the complete and incomplete groups, which indicates that they, in fact, represent the same disease. Most of the patients with sacroiliac joint involvement belonged to the HLA-B27 positive group; otherwise there was no difference in arthritic symptoms between the HLA-B27 positive and the HLA-B27 negative group.
Article
Detailed clinical study of 50 patients with primary fibromyalgia and 50 normal matched controls has shown a characteristic syndrome. Primary fibromyalgia patients are usually females, aged 25-40 yr, who complain of diffuse musculoskeletal aches, pains or stiffness associated with tiredness, anxiety, poor sleep, headaches, irritable bowel syndrome, subjective swelling in the articular and periarticular areas and numbness. Physical examination is characterized by presence of multiple tender points at specific sites and absence of joint swelling. Symptoms are influenced by weather and activities, as well as by time of day(worse in the morning and the evening). In contrast, symptoms of psychogenic rheumatism patients have little fluctuation, if any, and are modulated by emotional rather than physical factors. In psychogenic rheumatism, there is diffuse tenderness rather than tender points at specific sites. Laboratory tests and roentgenologic findings in primary fibromyalgia are normal or negative. Primary fibromyalgia should be suspected by the presence of its own characteristic features, and not diagnosed just by the absence of other recognizable conditions. This study has also shown that primary fibromyalgia is a poorly recognized condition. Patients were usually seen by many physicians who failed to provide a definite diagnosis despite frequent unnecessary investigations. A guideline for diagnosis of primary fibromyalgia, based upon our observations, is suggested. Management is usually gratifying in these frustrated patients. The most important aspects are a definite diagnosis, explanation of the various possible mechanisms responsible for the symptoms, and reassurance regarding the benign nature of this condition. A combination of reassurance, nonsteroidal antiinflammatory drugs, good sleep, local tender point injections, and various modes of physical therapy is successful in most cases.
Article
The standard life events methodology for the prediction of psychological symptoms was compared with one focusing on relatively minor events, namely, the hassles and uplifts of everyday life. Hassles and Uplifts Scales were constructed and administered once a month for 10 consecutive months to a community sample of middle-aged adults. It was found that the Hassles Scale was a better predictor of concurrent and subsequent psychological symptoms than were the life events scores, and that the scale shared most of the variance in symptoms accounted for by life events. When the effects of life events scores were removed, hassles and symptoms remained significantly correlated. Uplifts were positively related to symptoms for women but not for men. Hassles and uplifts were also shown to be related, although only modestly so, to positive and negative affect, thus providing discriminate validation for hassles and uplifts in comparison to measures of emotion. It was concluded that the assessment of daily hassles and uplifts may be a better approach to the prediction of adaptational outcomes than the usual life events approach.
Article
To determine the relation between tender points, complaints of pain, and symptoms of depression, fatigue, and sleep quality in the general population. Two stage cross sectional study with an initial questionnaire about pain to classify those eligible for an examination of tender points. Two general practices in north west England. Stratified random sample of adults from age-sex registers. Of the responders, 250 were selected for examination of tender points on the basis of their reported pain complaints; 177 subsequently participated. Tender point count (0 to 18) grouped into four categories with the highest (> or = 11) corresponding to the criteria of the American College of Rheumatology for fibromyalgia. Assessment of pain (chronic widespread, regional, none). Measures of depression, fatigue, and difficulty with sleeping. Women had a higher median tender point count (six) than did men (three). Counts were higher in those with pain than in those who had no pain and in those with widespread compared with regional pain. Most subjects with chronic widespread pain, however, had fewer than 11 tender points (27/45; 60%). Two people with counts of 11 or more were in the group reporting no pain. Mean symptom scores for depression, fatigue, and sleep problems increased as the tender point count rose (P value for trend < 0.001). These trends were independent of pain complaints. Tender points are a measure of general distress. They are related to pain complaints but are separately associated with fatigue and depression. Sleep problems are associated with tender points, although prospective studies are needed to determine whether they cause tenderness to develop. Fibromyalgia does not seem to be a distinct disease entity.
Article
To identify demographic and clinical features that distinguish fibromyalgia (FM) from other chronic widespread pain. We identified 100 confirmed FM cases, 76 widespread pain controls, and 135 general controls in a random community survey of 3395 noninstitutionalized adults living in London, Ontario. FM cases were distinguished from pain controls using the 1990 American College of Rheumatology (ACR) classification criteria for FM. The mean age of FM cases was 47.8 years (range 19 to 86), the same as for pain controls; 86% of FM cases were female versus 67.1% of pain controls (p < 0.01). FM cases were less educated than general controls (p = 0.03). Male and female FM cases were similar, except females were older and reported more major symptoms (both p = 0.02). FM cases reported more severe pain and fatigue, more symptoms, more major symptoms, and worse overall health than pain controls or general controls. The most commonly reported major symptoms among FM cases were musculoskeletal pain (77.3%), fatigue (77.3%), severe fatigue lasting 24 h after minimal activity (77.0%), nonrestorative sleep (65.7%), and insomnia (56.0%). Subjects with 11-14 tender points were more similar to those with 15-18 tender points than to those with 7-10 points in 11 of 14 clinical variables. On multivariate analysis, 4 symptoms distinguished FM cases from pain controls: pain severity (p = 0.004), severe fatigue lasting 24 h after minimal activity (p = 0.006), weakness (p = 0.008), and self-reported swelling of neck glands (p = 0.01). In the general population, adults who meet the ACR definition of FM appear to have distinct features compared to those with chronic widespread pain who do not meet criteria.
Article
To describe possible differences between male and female patients with fibromyalgia syndrome (FM) in their clinical manifestations. Five hundred thirty-six consecutive patients with FM (469 women, 67 men) seen in a university rheumatology clinic and 36 healthy men without significant pain seen in the same clinic were included in the study. Data on demographic and clinical features were gathered by a standard protocol. Tender point examination was performed by the same physician. Level of significance was set at p < or = 0.01. Several features were significantly (p < or = 0.01) milder or less common among men than women, including number of tender points (TP), TP score, "hurt all over," fatigue, morning fatigue, and irritable bowel syndrome (IBS). The total number of symptoms was also fewer among men and approached significance (p = 0.02) by parametric test, but reached significance (p = 0.001) by nonparametric analysis. All clinical and psychological symptoms as well as TP were significantly (p < 0.01) more common or greater in male patients with FM than healthy male controls, with the exception of IBS (p = 0.03). Patient assessed global severity of illness, Health Assessment Questionnaire disability score, and pain severity were similar in both sexes. Male patients with FM had fever symptoms and fewer TP, and less common "hurt all over," fatigue, morning fatigue, and IBS, compared with female patients. Stepwise logistic regression showed significant differences between men and women in number of TP (p < 0.001).
Article
Patients characterized with antinuclear antibodies (ANA) and disease symptoms related to one organ system can be described as having incomplete systemic lupus erythematosus (SLE). The aim of this multicentre study was to describe the outcome of these so-called incomplete SLE patients. Two aspects of the outcome were studied: (i) the disease course, defined by the presence or absence of clinical symptoms; and (ii) the number of patients that eventually developed full SLE. Outcome parameters were the ACR criteria, the SLE disease Activity Index (SLEDAI), the European Consensus Lupus Activity Measure (ECLAM) and the requirement for treatment. In 10 European rheumatology centres, patients who had been evaluated in the last 3 months of 1994 and had been diagnosed as having incomplete SLE on clinical grounds for at least 1 yr were included in the study. All 122 patients who were included in the study were evaluated annually during 3 yr of follow-up. Our results are confined to a patient cohort defined by disease duration of at least 1 yr, being under clinical care at the different centres in Europe. These patients showed disease activity that was related mostly to symptoms of the skin and the musculoskeletal system, and leucocytopenia. During the follow-up, low doses of prednisolone were still being prescribed in 43% of the patients. On recruitment to the study, 22 of the 122 incomplete SLE patients already fulfilled the ACR criteria for the diagnosis of SLE. In the 3 yr of follow-up only three patients developed SLE. A high proportion of patients in our cohort defined on clinical grounds as having incomplete SLE eventually showed disease activity defined by the SLEDAI as well as ECLAM. However, only three cases developed to SLE during the follow-up. This suggests that incomplete SLE forms a subgroup of SLE that has a good prognosis.
Article
The object of this study was to determine the association between tender point pain ratings, tender point counts and distress in people with fibromyalgia and to review the pharmacotherapy of fibromyalgia. Demographic, psychosocial, and health status information was collected from 316 health maintenance organization members with fibromyalgia. A manual tender point exam was conducted. Tender point counts predicted 3.0%, and tender point severity ratings predicted 8.3%, of the variance in distress. Little difference was found between the variance predicted for physical versus psychologic distress. A principal components analysis of all measures produced four distinct factors: global-physical functioning, tender points, psychologic, and physical. Tender point pain ratings and counts predicted a small but significant amount of variance in distress. In addition, FMS involves at least four rather distinct factors, one of which is related to tender points. Pharmacotherapeutic management is provided on a patient-specific basis including pharmacokinetics, pharmacodynamic, pathophysiologic, and psychosocial needs designed and modulated for each individual patient.
Article
The fact that there is a need for assessing depression, whether as an affect, a symptom, or a disorder is obvious by the numerous scales and inventories available and in use today.
Article
The objective was to identify cases of incomplete systemic lupus erythematosus (SLE) within a defined population in southern Sweden, risk factors for development of complete SLE (> or = 4 classification criteria) and study outcome of the patients. During prospective retrieval of SLE cases within a defined population in southern Sweden, 28 patients (26 women, two men) with incomplete SLE (< 4 ACR criteria) were identified between 1981 and 1992. All patient records were reviewed and clinical and laboratory data were extracted from standardized formats. Organ damage was defined according to the SLICC/ACR damage index. During follow-ups, 16 of 28 patients developed complete SLE (median 13 years; range 10-20 years). The time to develop complete SLE varied between one and ten years with a median time of 5.3 years. Three patients were anti-DNA positive at inclusion; only one of them developed complete SLE. False positive Wasserman reaction and anti-cardiolipin antibodies (aCl) were only found in patients who developed complete SLE (P < 0.04; Fisher exact test). Six patients had malar rash from the start and they all had complete SLE at follow-up (P < 0.04; Fisher exact test). Of eight patients with arthritis, three developed complete SLE. Thrombocytopenia was only found in two patients, both developing complete disease. At follow-up, patients that developed complete SLE had high SLICC damage scores (mean 1.5) compared with patients that remained as incomplete SLE (mean 0.16). In conclusion, in this follow-up study of patients with incomplete SLE 57% developed complete disease after a median time of 5.3 years. Malar rash and aCl were predictors of complete SLE. Individuals that developed complete SLE were more prone to organ damage.
Article
The American College of Rheumatology (ACR) criteria for fibromyalgia are the de facto criteria used for research. However, ACR criteria are not generally utilized by nonrheumatologists, and rheumatologists may diagnose fibromyalgia in patients who do not satisfy the ACR criteria. We undertook this study to determine concordance between ACR criteria and clinician diagnosis and between proposed survey criteria and clinician diagnosis. Consecutive patients in a clinical practice setting were evaluated by tender point examination, survey criteria for fibromyalgia (Regional Pain Scale score > or =8 and fatigue score > or =6), and clinical diagnosis. Among the 206 patients, the clinician diagnosed fibromyalgia in 49.0%, while 29.1% satisfied ACR criteria and 40.3% satisfied survey criteria. Clinical and survey criteria were concordant in 74.8% of cases (kappa = 0.49 [95% confidence interval 0.36, 0.60]). Clinical criteria and ACR criteria were concordant in 75.2% of cases (kappa = 0.50 [95% confidence interval 0.35, 0.59]), and survey criteria and ACR criteria were concordant in 72.3% (kappa = 0.40 [95% confidence interval 0.25, 0.51]). The ACR tender point criterion (> or =11) was not a factor in clinical and survey criteria. However, the tender point count was useful in clinical diagnosis. Clinical diagnosis and ACR and survey criteria are moderately concordant (72-75%) and address a common pool of symptoms and physical findings. Because there is no gold standard for fibromyalgia diagnosis and because fibromyalgia is often viewed as a trait diagnosis, all methods of diagnosis have utility. The survey method has the advantage that it does not require physical examination.
Article
This study aims to compare fibromyalgia (FM) and chronic widespread pain (CWP) patients who do not fulfill the criteria for tender points (TP). We included 150 patients diagnosed with FM according to ACR 1990 criteria and 42 patients with CWP who did not fulfill TP criteria for FM into the study. The clinical features of the patients were recorded, and the TP count was determined. By means of a visual analog scale (VAS), all patients were questioned about the severity of pain and FM-related symptoms. In addition, the patients were administered the Duke Anxiety Depression (Duke-AD) scale and somatization symptom questionnaire. Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale was used to determine the neuropathic pain score. According to VAS, the severity of pain, sleep disturbance, the number of somatization symptoms, LANSS, and Duke-AD scores were significantly higher in FM patients than in patients with CWP (all P values <0.05). The number of TP correlated with severity of pain (r = 0.32, P < 0.001), the number of somatization symptoms (r = 0.26, P = 0.01), sleep disturbance (r = 0.18, P = 0.01), and LANSS score (r = 0.4, P < 0.001). Multiple logistic regression analysis revealed that independent factors that affected the presence of > or =11 TP were the severity of pain on VAS (OR: 1.03, 95% CI: 1.01-1.06, P = 0.045) and LANSS score (OR: 1.36, 95% CI: 1.12-1.62, P = 0.001). CWP patients have symptoms similar to FM patients, though less severe. The most important factor that affects the criteria for fulfilling the number TP in CWP patients is the neuropathic pain score, which suggests that FM is primarily a neuropathic pain syndrome.
Article
To discuss fibromyalgia syndrome (FMS) and overlapping conditions, eg, irritable bowel syndrome, headaches, and chronic fatigue syndrome, within the concept of central sensitivity syndromes (CSS). A critical overview of the literature and incorporation of the author's own views. The concept of CSS seems viable. It is based on mutual associations among the CSS conditions as well as the evidence for central sensitization (CS) among several CSS members. However, such evidence is weak or not available in other members at this time, requiring further studies. The biology of CSS is based on neuroendocrine aberrations, including CS, that interact with psychosocial factors to cause a number of symptoms. CSS is an important new concept that embraces the biopsychosocial model of disease. Further critical studies are warranted to fully test this concept. However, it seems to have important significance for new directions for research and patient care involving physician and patient education. Each patient, irrespective of diagnosis, should be treated as an individual considering both the biological and psychosocial contributions to his or her symptoms and suffering.
Article
Fibromyalgia is currently classified as chronic widespread pain with widespread allodynia to pressure pain. There are few data describing pain characteristics, quality of life, consequences for daily living, and psychosocial status in patients who meet the classification criteria for fibromyalgia proposed by the American College of Rheumatology compared with patients with chronic widespread pain but not widespread allodynia. This study used a randomly selected sample from the general population. A postal questionnaire and a pain mannequin were sent to 9952 people. The response rate was 76.7%. The pain drawings showed that 345 people had widespread pain; that is, they noted pain in all four extremities and axially. Clinical examination, which included a manual tender point examination, was performed in 125 subjects. These people answered commonly used questionnaires on pain, quality of life, coping strategies, depression, and anxiety. Compared with chronic widespread pain without widespread allodynia, fibromyalgia was associated with more severe symptoms/consequences for daily life and higher pain severity. Similar coping strategies were found. Chronic widespread pain without widespread allodynia to pressure pain was found in 4.5% in the population and fibromyalgia in 2.5%.