History and exam
Key diagnostic factors
common
widespread pain and stiffness
Widespread body pain and stiffness is one of the primary symptoms of fibromyalgia.[93] A diagnosis of fibromyalgia requires the presence of widespread body pain for at least 3 months.[93][94]
Pain is usually diffuse/multifocal, but may begin in a localized area, particularly the neck and shoulders and then spread. Initial presentation of pain is commonly insidious, may be intermittent, becoming progressively persistent, and is frequently migratory. Variability of location and severity of pain is a defining feature of fibromyalgia.
The pain of fibromyalgia is often described using "neuropathic" descriptors such as gnawing, lancinating, or accompanied by numbness or tingling. Patients report that musculoskeletal stiffness is most severe during the morning, improving throughout the day. This may be difficult to differentiate from that of rheumatic diseases such as in rheumatoid arthritis or polymyalgia rheumatica.[93] While patients with inflammatory arthritis, polymyalgia rheumatica, and fibromyalgia can report stiffness in the morning, this tends to be more severe and prolonged in inflammatory arthritis. In addition, while patients with stiffness secondary to inflammatory arthritis and polymyalgia rheumatica improve with activity (gelling phenomena), stiffness secondary to fibromyalgia can worsen after prolonged activity (such as at the end of the day).
sleep disturbance/fatigue
Patients may report feeling exhausted even though they have slept 8 hours or more during the night.[93] Characteristically sleep "lightly," waking frequently during the early morning and have difficulty getting back to sleep. One systematic review of case control studies concludes that people with fibromyalgia experience lower sleep quality and sleep efficiency; longer wake time after sleep onset, short sleep duration, and light sleep when assessed objectively.[95] Prospective longitudinal data infer a dose-dependent association between the risk of fibromyalgia (FM) and disordered sleep in women with FM, suggesting poor sleep could be a precursor to developing FM.[44]
There is a high prevalence of obstructive sleep apnea in patients with FM, particularly when reporting daytime somnolence. Observational studies have suggested a possible relationship between sleep apnea and pain severity and a potential role of continuous positive pressure therapy to improve symptoms beyond hypersomnolence. [96][97][98][99]
cognitive difficulties
Cognitive difficulties, commonly referred to as “fibro fog,” which impairs the ability to focus, pay attention, and concentrate is reported by the majority of patients with fibromyalgia.[100] Evidence from meta-analyses suggests that the self-reported cognitive impact of fibromyalgia is supported by objective neuropsychological measures.[101][102]
Other diagnostic factors
common
allodynia and/or hyperalgesia
On physical exam patients may present with allodynia, a type of neuropathic pain, making them extremely sensitive to touch (activities that are not usually painful, e.g., combing hair, can cause severe pain) and/or hyperalgesia, which causes increased pain from a stimulus that provokes pain.[110][111]
diffuse tenderness on exam
Patients exhibit diffuse tenderness to palpation on physical exam, with no sign of systemic disease (e.g., joint inflammation or muscle weakness) from the physical exam as a cause of pain.There is no evidence for a systemic disease (e.g., joint inflammation or muscle weakness) causing the widespread pain.
sensitivity to sensory stimuli
headaches
Patients with fibromyalgia are frequently seen in tertiary headache clinics suffering from migraine, tension-type headaches.[115] One study found that of 889 patients who attended a tertiary headache clinic for the first time, 174 (20%) had fibromyalgia, with 44% of those patients suffering from chronic tension-type headache.[115]
mood disturbance
Lifetime incidence of depression and/or anxiety in patients with fibromyalgia is much higher than in patients without the disorder (74% and 60%, respectively); 30% of patients meet criteria for major depression at diagnosis.[116] When compared with patients with osteoarthritis, patients with fibromyalgia have significantly lower quality of sleep, and significantly higher levels of anxiety, and depression.[43]
numbness/tingling sensations
May be concomitant with pain and variable in nature and duration.
Risk factors
strong
family history of fibromyalgia (FM)
A potential genetic basis for FM has been identified by family studies which report a strong familial aggregation for FM and related conditions.[12][70][71][72][73] Although the mode of inheritance of FM is unknown, it is thought to be polygenic.[72]
The rate of fibromyalgia in the general adult population is around 2% to 8%.[7][10][11] Epidemiologic studies have found that the rate in relatives of patients with fibromyalgia is much higher, perhaps as high as 41%.[72] However, experts acknowledge that the contribution of environmental factors to the increased prevalence of fibromyalgia in families cannot be ruled out.
Abnormalities in serotonergic, dopaminergic, and catecholaminergic genes are found at higher frequency in patients with fibromyalgia than in normal controls.[73][74][75][76][77] These findings have therapeutic implications for treatment of fibromyalgia.
rheumatologic conditions
Although there is no evidence that fibromyalgia is an autoimmune condition, patients with autoimmune rheumatologic conditions (e.g., rheumatoid arthritis, systemic lupus erythematosus) or chronic pain conditions (e.g., osteoarthritis) have a much higher prevalence of fibromyalgia than the general population.[78]
Approximately 15% to 30% of patients with nearly any autoimmune disorder will also meet criteria for fibromyalgia.[79] Diagnostic criteria are not validated in patients with underlying rheumatologic disease.[78] When this occurs these patients need to be recognized and treated for both peripheral and central causes of pain.[79]
age between 20 and 60 years
female sex
Criteria that do not rely on tender points to make the diagnosis report the ratio of female to male FM prevalence is around 2:1.[8]
stressful events
One meta-analysis assessing the impact of lifetime stressors, including physical trauma through to emotional neglect in adult patients with FM reported a significant association between stressor exposure and adult FM, the strongest association found was for physical abuse.[81]
Patients with FM may experience cortisol dysregulation. Studies suggest that patients with FM have a higher level of cortisol, some of whom have shown an association between the degree of cortisol elevation and pain.[45][46]
sleep problems
Prospective longitudinal data infer a dose-dependent association between the risk of FM and disordered sleep in women.[44] When compared with patients with osteoarthritis, patients with FM have significantly lower quality of sleep, and significantly higher levels of anxiety and depression.[43]
Patients with FM may suffer from a generalized state of hyperarousal.[42] Studies demonstrate that disordered sleep patterns may be antecedent of the development of pain and that abnormal sleep and pain may predict depressive symptoms.[38][39][40][41]
infections
weak
vitamin D deficiency
Initial studies on the relationship of vitamin D deficiency with FM reported a higher prevalence of hypovitaminosis D in patients with FM or chronic widespread pain.[87][88][89][90] However, a subsequent systematic review reported inconclusive results on the prevalence of hypovitaminosis D, and the cause-effect relationship between the vitamin D levels and FM.[91]
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