A Comprehensive Review on the Proposed and Modified Diagnostics for Fibromyalgia
by Celeste Cooper, RN
We all agree that there is centralization of pain in fibromyalgia. It is difficult to deny the brains ability to resurrect previous pain experiences or disconnect the emotional center from the physical response. If you doubt this, ask any nursing mother what happens when she hears a baby cry. The Preliminary Proposed Diagnostic Criteria, PPDC, (1) and its modification (2) do not, in my opinion, attenuate the importance of recognizing conditions that frequently co-occur with FM, which is necessary for making a differential diagnoses so appropriate interventions can be implemented.
Another concern of mine is that the widespread pain index (WPI) does not demand a physical exam, which is generally the accepted standard of care. The second part of the PPDC, the symptom severity index (SSI), considers two things; one, the severity of fatigue, unrefreshed sleep and cognitive difficulties (which are primary to FM), and two, consideration of symptoms not primary to fibromyalgia. The later includes, but is not limited to, symptoms of hypothyroidism, SICCA, irritable bowel syndrome, irritable bladder and/or interstitial cystitis, pelvic floor and sexual dysfunction (male and female), migraine, medication side effects, chronic fatigue syndrome, ankylosing spondylitis, Sjögren’s, systemic lupus erythematosus, rheumatoid arthritis, TMJ, Raynaud’s, multiple chemical sensitivities, leaky gut syndrome, small intestinal bacterial overgrowth, bruxism, restless leg syndrome, postural orthostatic hypotension, neurally mediated hypotension, and myofascial pain syndrome, yet consideration that these symptoms could be due to any one of these is not given. The modified PPDC is greatly lacking in investigation of comorbid disorders considering only, headache, pain or cramps in lower abdomen, and depression over the past 6 months. While disordered sleep, insomnia, cognitive deficit, and widespread pain are primary to fibromyalgia, one cannot lump the symptoms of comorbid disorders together and expect a diagnostic tool that will provide the best patient outcome. Few practitioners who are being expected to diagnose FM are required to complete continuing education on rheumatological or neurological diseases; they have their own specialty as general practitioner or family doctor and must meet the standards of their specialty.
While experts understand and report the centralization, there is little said regarding the comorbidity of myofascial pain syndrome as a major contributor, but there should be. (3) Chronic myofascial pain from myofascial trigger points (MTPs) is prevalent in fibromyalgia (4,5) and helps explain muscle pain and dysfunction. Myofascial trigger points are known as the great neurological imitators(6), which can explain many of the neuropathies involved in patient complaints. Myofascial trigger points could have an autonomic (7) and sympathetic (8) affect as well. When coupled with fibromyalgia this peripheral input from MTPs further sensitizes the brain and it becomes a vicious cycle.
We need diagnostic criteria that alert the physician to the complexity of FM so appropriate referrals can be made. We need to see integrative therapies such as myofascial release, active release therapy, and specific myofascial trigger point therapies and massage (9) move into mainstream. Exercise intolerance in fibromyalgia has also been linked to autonomic dysfunction and lack of heart rate variability, (10, 11, 12, 13) in which case, telling the patient to exercise without close monitoring, could exacerbate symptoms and have severe consequences. Demyelenating neuropathy is present in some (14) lending to more symptoms. Pain progresses if peripheral myofascial trigger points are neglected and we know centralization of pain and other symptoms from MTPs also occurs in migraine, interstitial cystitis, RLS/PLM, TMJ/TMD etc. Fibromyalgia was once thought to be a non-progressive disorder, but it appears as more studies are done, this may not be the case if the development of comorbid disorders are considered.
Considerations of fibromyalgia and its relationship to rheumatologic conditions such as rheumatoid arthritis, systemic lupus erythematosus, ankylosing spondylitis, and Sjogrens should be made. What about the effects of untreated hypothyroidism, thyroid resistance, reactive hypoglycemia or insulin resistance? Could the lack of healing slow wave sleep progression in FM be at the core of fibromyalgia progression of symptoms? These are all questions experts and patients wish to see answered. We need to define better assessments for who really has fibromyalgia so participants are correctly diagnosed, resulting in proper treatments. Remember, there is a patient in the room, one of those is me, and she has questions. (15)
While the development and research involved in the PPDC and its modification is extensive and a move in the right direction, as with any new tool, further testing and modifications should be considered as part of the educational process. It is upon us with the 2013 Alternative Diagnostic Criteria. (16)
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(2) Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB: Fibromyalgia Criteria and Severity Scales for Clinical and Epidemiological Studies: A Modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol 38;1113-1122, 2011.
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(16) Bennett R, Friend R, Marcus D, Bernstein C, Han BK, Yachoui R, Deodar A, Kaell A, Bonafede P, Chino A, Jones K. Criteria for the diagnosis of fibromyalgia: Validation of the modified 2010 preliminary ACR criteria and the development of alternative criteria. Arthritis Care Res (Hoboken). 2014 Feb 4. doi: 10.1002/acr.22301. [Epub ahead of print]