Fibromyalgia: The F Word
When I was a student it was interesting to see how other therapists would treat widespread pain.
A clinical instructor of one of my classmates said you can’t really expect anyone with fibromyalgia to get better. Another therapist said that whenever we see someone who says that they have fibromyalgia, then we should suspect malingering. Wha…?
What do you think? Is fibromyalgia real? And can people with chronic widespread pain improve? Buckle up — this Physio Weekly brings the science.
Help! I Need Some Diagnosis
There is no gold standard for diagnosis of fibromyalgia, though in 2016 the American College of Rheumatology updated the criteria for fibromyalgia. A patient satisfies the criteria if they meet these four criteria:
- Widespread pain index (WPI) >= 7 and symptom severity scale (SSS) >= 5 OR WPI of 4-6 and SSS >= 9. (More on this alphabet soup below.)
- Generalized pain, defined as pain in at least 4 of 5 regions, must be present. Jaw, chest, and abdominal pain are not included in generalized pain definition.
- Symptoms have been generally present for at least 3 months.
- A diagnosis of fibromyalgia is valid irrespective of other diagnoses. A diagnosis of fibromyalgia does not exclude the presence of other clinically important illnesses.
To score the WPI in criterion 1, note the number of body areas in which the patient has had pain in the last week. The body areas are organized in the five body regions that are used to define “generalized pain” in criterion 2 above.
- Region 1 is the left jaw, left shoulder, left upper arm, and left lower arm.
- Region 2 is the right jaw, right shoulder, right upper arm, and right lower arm.
- Region 3 is the left hip, left upper leg, and left lower leg.
- Region 4 is the right hip, right upper leg, and right lower leg.
- Region 5 is the neck, upper back, lower back, chest, and abdomen. Count the number of areas across all regions to score the WPI.
Next, scoring the SSS first involves rating the severity of the symptoms of fatigue, waking unrefreshed, and cognitive symptoms from 0 to 3 (0=no problem and 3=severe). Then the SSS includes additional points for the presence of headaches, abdominal cramps/pain, or depression (1 point each). The maximum scores of the SSS is 12. Take your WPI and SSS scores and see if they satisfy criterion 1 above.
At this point, diagnosing fibromyalgia is just about as complex as filing taxes.The brief approximation would be to see widespread pain of over 3 months with additional symptoms of fatigue, poor sleep, headaches, and/or depression within 6 months.
Imaging All the People
Studies using MRI testing have found differences between those diagnoses with fibromyalgia and those without fibromyalgia. Those with fibromyalgia havedecreased gray matter in the anterior and mid-cingulate and mid-insular cortices. Hippocampal volume is also reduced in those with fibromyalgia, which would offer a neurobiological explanation for cognitive deficits and memory problems, like the “fibro fog.”
Researchers study pain modulation via concepts such as temporal summation and conditioned pain modulation. Temporal summation is a phenomenon where repetitive noxious stimuli amplify the pain experience. Conditioned pain modulation (CPM) is an occurrence where the application of conditioning stimulus to one area of the body can allow greater tolerance of pain in another area of the body.
One example of CPM is the application of a blood pressure cuff on one arm as a conditioning stimulus, while a heat stimulus is applied to the hand of the other arm. Someone with “good” pain modulation would show a decrease in pain with this paradigm.
A recent meta-analysis found that endogenous pain modulation functions differently for those with fibromyalgia. They found a 68% relative difference in temporal summation between those with fibromyalgia and those without, with an effect size of 0.53. Similarly, the authors found a 65% relative difference in conditioned pain modulation between those with and without fibromyalgia, with an effect size 0.57.
Tomorrow Never Knows
So what? Fibromyalgia involves the central nervous system. The etiology is still unclear, but it appears that it’s not a purely musculoskeletal condition, and clinicians who get caught in the trap of performing special tests on every painful joint might create more frustrations than solutions.
What do you do when a patient says, “By the way, my shoulders hurt and my neck hurts and my hips hurt too. What can we do about all of those?” Now you have several examinations on your plate, probably with less time than normal because of how persistent pain affects so much of life. In my experience, this is where the “low tech examination” comes in handy: screen for motor neuron dysfunction, test for mechanical changes to pain to ensure a musculoskeletal component, and go easy on special testing if pain is widespread, for the sake of rapport and avoiding flaring up patients.
But what can we do about fibromyalgia? Lots. The next Physio Weekly will focus on treatment of fibromyalgia and chronic widespread pain.
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