Fibromyalgia diagnosis: Exclude other diseases

You can find the video after the text

This is the first of three short videos where we look at the examination and diagnosis of fibromyalgia. The first step is to exclude other underlying diseases and in-depth history.

My name is Andreas Persson and I am a physiotherapist and specialist in pain and pain rehabilitation. What I say in the film can be found in text form together with references to the scientific literature that the things I say are based on. The link is in the description.

The most common reason for investigating a person for fibromyalgia is that the person has developed chronic pain. There are slightly different definitions of long-term pain, but this usually means that you have been in pain for more than three months.(3) If there is a clear connection between the pain and an injury or inflammation, such as a broken bone or osteoarthritis in the knee, which causes the joint to swell, you often do not need to do any further investigation.

But if it hurts in places where there is no damage or inflammation or if it continues to hurt in an area where you had an injury or inflammation that should have healed, you can start to suspect other reasons why it hurts, which motivates further investigation. Another thing that makes healthcare professionals often begin to suspect fibromyalgia is that the sufferer has pain in many different areas of the body.

The first step in a fibromyalgia examination is to rule out other underlying diseases. I want to point out how important this step is because there are many diseases and health conditions that can cause long-term pain and similar symptoms as in fibromyalgia. These conditions are often treatable, which can make the sufferer asymptomatic. Exclusion of underlying diseases should always be done by a doctor. Usually, it is the doctor at your health center who does this.

The doctor usually does a physical examination where she examines, among other things, whether the victim has swollen joints or other signs of illness. A neurological examination is often included where the doctor tests whether there is anything that indicates a neurological disease or tumor in the brain or spinal cord.

Blood samples and sometimes also urine samples are collected where, among other things, they are tested for signs of inflammation in the body, abnormal levels of hormones, immune-related molecules, minerals and vitamins, and more.

Sometimes, but not always the examination includes imaging investigations such as example Magnetic camera examination of the painful area or an area that is thought to be causing the pain.

Sometimes it is also necessary to refer to another specialist doctor, such as a neurologist or rheumatologist. This is often done if there are signs of another underlying disease but where the referring doctor is not sure.

When the first step is finished and signs of other underlying diseases have been ruled out, the examination proceeds with an in-depth anamnesis to get more information about the sufferer and the symptoms.

Anamnesis is the same as an interview and it is often done by a doctor, but can also be performed by other healthcare professionals such as a nurse, physiotherapist, or occupational therapist. The therapist often starts with general questions such as what you work with if you have a family and what you do in your free time.

Health habits such as alcohol, tobacco, and physical activity, as well as if you feel stressed and how you sleep, are usually also included in the anamnesis. You may be wondering what this has to do with the pain. Sometimes there are factors in these areas that can affect the risk of developing long-term pain and the ability to manage life when living with a long-term pain condition.

The anamnesis also contains more specific questions about the pain. You often make a pain drawing that shows where it hurts. You tell how long you have been in pain. What aggravates the pain and what relieves it. If there is a pattern over time, for example, if the pain has gotten worse since it started and if there is a recurring pattern of pain intensity over the day.

The health care professional also asks about other symptoms such as numbness, muscle weakness, swelling, sensitivity to other sensory input such as sound, light, and smells. For more information on common symptoms of fibromyalgia, feel free to check out my video on the nine most common symptoms of fibromyalgia.

An essential part of the investigation is the tests according to the diagnostic criteria. This is a little more complicated than it sounds because there are different criteria. The most widely used and accepted diagnostic criteria came in 1990 and were developed by the American College of Rheumatology.(2) These are often referred to as the ACR 1990 criteria. The ACR-1990 criteria include testing for tender points, which is not included in the newer criteria.

The American College of Rheumatology has released new diagnostic criteria in 2010(3) which have since been revised in 2016.(4) The new criteria do not include physical tests. Instead, they focus on the location of the pain and how many and how severe the other related symptoms are.

The recent diagnostic criteria have not been accepted by some who work in health care, mainly because there are no physical tests. That is why many still use the criteria from 1990. My recommendation is to use both the criteria from 1990 and those from 2016. Then you get both the physical test of the tender points from the 1990 criteria and you get a more comprehensive picture of the other related symptoms through the criteria from 2016.

In the next video, we will take a closer look at the criteria from 2016 and in the third and final film, we will go through the ACR-1990 criteria.

References

1. Mills SEE, Nicolson KP, Smith BH. Chronic pain: a review of its epidemiology and associated factors in population-based studies. Br J Anaesth. 2019;123(2):e273-83.

2. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990;33(2):160-72. 

3. Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RS, et al. J Rheumatol. 2011;38(6);1113-22.

4. Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RL, et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum. 2016;46(3):319-29

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