Don’t Miss Fibromyalgia

Here are some quick review resources on fibromyalgia.

Looking for, diagnosing, and successful treating fibromyalgia can be a key 

Consider centralized pain in patients with rheumatic disease
Publish Date: October 8, 2019

The above article is very helpful. The author states that patients with chronic mechanical pain or chronic inflammatory pain can develop central pain amplification, fibromyalgia. Treating the fibromyalgia may lead to great benefit for the patient.

Here are excerpts from the above article:

A fibromyalgia survey [questionnaire] may provide important information about the degree to which patients with rheumatic disease experience centralized pain. This information may guide treatment decisions, said Daniel J. Clauw, MD, professor of anesthesiology, rheumatology, and psychiatry and director of the Chronic Pain and Fatigue Research Center at the University of Michigan in Ann Arbor.

The questionnaire that Dr. Clauw uses is a patient self-report survey* for the assessment of fibromyalgia based on criteria in the 2011 modification of the American College of Rheumatology preliminary diagnostic criteria for fibromyalgia. In it, he asks patients to report where they experience pain throughout the body and symptoms such as fatigue, sleep problems, and memory problems. The survey predicts outcomes of surgery for osteoarthritis better than x-rays, MRI scans, or psychological factors do, he said.

*The two questionnaires below may be more helpful for clinicians in diagnosing and treating fibromyalgia than tender point exam the author of the above article states.

  1. 2010 Fibromyalgia Diagnostic Criteria – Questionnaire [PDF]
  3. The Stanford Health Assessment Questionnaire [Link is to a PDF download from The Stanford Health Assessment Questionnaire: Dimensions and Practical Applications (Full Text HTML) published in Health Qual Life Outcomes. 2003; 1: 20]. 
  4. Stanford HAQ 20-Item Disability Scale [Link is to the PDF]

Returning to Consider centralized pain in patients with rheumatic disease
Publish Date: October 8, 2019:

Physicians should ask every patient with chronic pain, including patients with OA, rheumatoid arthritis, or lupus, to complete the survey, Dr. Clauw said at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education. “This score will tell you the degree to which their central nervous system is augmenting or amplifying what is going on in their body,” he said. “And the higher their score is, the more you should treat them like you would someone with fibromyalgia, even if their underlying disease might be an autoimmune disease.”

Physicians should not use a cutoff of 13 points on the fibromyalgia measure to define whether a patient has the disease, as has been done in the past, he said. The threshold is arbitrary, he said. “We should not think about fibromyalgia as ‘yes’ or ‘no.’ We should think of the degree of fibromyalgia that people have.”

A poor relationship between pain and imaging

Some patients who have severe knee OA on imaging walk without pain. Other patients have normal x-rays, but severe pain. “There is a terrible relationship between what you see on a knee x-ray or an MRI and whether someone has pain,” Dr. Clauw said. Furthermore, the poor relationship between imaging and pain is common across chronic pain conditions, he said.

This phenomenon may occur because pain manifests in different ways, similar to there being multiple ways to adjust the volume of an electric guitar, he said. How hard the strings are strummed affects the volume. But so does the amplifier setting. “In these centralized pain conditions, the problem is an amplifier problem, not a guitar problem,” he said. “The amplifier, i.e., the central nervous system, is set too high.”

Researchers have found that people who have severe OA of the knee on x-ray but do not experience pain “have a very low amplifier setting,” he said. That is, they are nontender and less sensitive to pain. Most of these patients are men. “On average, men have a much lower amplifier setting than women,” he said. “This is also why … women have 1.5 to 2 times the rate of any type of chronic pain than men, because on average women have a higher amplifier setting. … In OA, at any given age, men and women have the exact same percentage of radiographic OA. But if you look at the clinical condition of OA, it is always two-thirds women, one-third men.”

Opioid responsiveness

Patients with higher levels of fibromyalgia were less responsive to opioids.

Diagnosed cases [of fibromyalgia] are the “tip of the iceberg”

Researchers at Dr. Clauw’s institution have identified dozens of patients undergoing knee surgery who met criteria for fibromyalgia but had not received the diagnosis. “This is at the University of Michigan, which is the epicenter for fibromyalgia research. If we are not seeing fibromyalgia superimposed on OA in our patients, no one is seeing it,” he said.

Patients with diagnosed fibromyalgia are “the tip of the iceberg,” he said. “There are far greater numbers of individuals whose primary diagnosis is OA, RA, lupus, ankylosing spondylitis, cancer pain, or sickle cell disease that have the same fundamental problem as fibromyalgia patients. But you do not see it because you label them as having an autoimmune disease or osteoarthritis. And that is at your peril and at their peril. Because treating that individual as if all of their pain and other symptoms are due to a problem out on the periphery will not make that person better.”

Patients with high levels of centralized pain may be less responsive to peripherally directed therapies such as surgery or injections, Dr. Clauw said. Pharmacologic options for patients with centralized pain include gabapentinoids (e.g., pregabalin and gabapentin), serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine and milnacipran), and tricyclic compounds (e.g., amitriptyline and cyclobenzaprine), he said. “Opioids are going to be quite unlikely to help these individuals,” he said. “In fact, it is likely that opioids will make this kind of pain worse.”


Note to myself: I will be rewriting this section with excerpts from the original editorial and article from Arthritis Care and Research from the original articles

Criteria-based fibromyalgia diagnosis and rheumatologists’ clinical diagnosis often disagree. Publish date: February 13, 2019. By Nicola Garrett from Rheumatology News. 

The above article contains also a summary of an editorial, CLASSIFICATION CRITERIA SHOULD NEVER REPLACE CLINICAL ACUMEN*, as well as a summary of the article, Diagnosis of Fibromyalgia: Disagreement Between Fibromyalgia Criteria and Clinician‐Based Fibromyalgia Diagnosis in a University Clinic** [PubMed Abstract].

*You can find full text of both the editorial, titled  and the article itself [Link is to PDF] in the issue of Arthritis Care and Research.

The editorial points out that there is [will be excerpting this editorial]


Update on Treatment Guideline in Fibromyalgia Syndrome with Focus on Pharmacology [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Biomedicines. 2017 May 8;5(2). pii: E20

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