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Clinical manifestations and diagnosis
of fibromyalgia in adults

Author

Don L Goldenberg, MD

Section Editor

Peter H Schur, MD

Deputy Editor

Paul L Romain, MD

Last literature review for
version 16.3: October 1,
2008  |  This topic last
updated: June 1, 2008

INTRODUCTION — Fibromyalgia is a common cause of chronic musculoskeletal
pain. It is one of a group of soft tissue pain disorders that affect muscles
and soft tissues such as tendons and ligaments. None of these conditions is
associated with tissue inflammation and the etiology of the pain is not known.

Despite the fact that each of these
conditions is very common, they are also controversial. Patients look well,
there are no obvious abnormalities on physical examination, and laboratory and radiologic studies are normal. Thus, the role of organic
illness has been questioned and such disorders have often been considered to be
psychogenic or psychosomatic in nature.

Fibromyalgia, initially termed fibrositis,
was described in France and England in the
mid-nineteenth century. By the end of the twentieth century, many
rheumatologists recognized fibromyalgia as a discrete
syndrome. Diagnostic classification criteria were proposed, evaluated, and then
validated. Using such criteria, fibromyalgia is now
considered to be the most common cause of generalized, musculoskeletal pain in
women between ages of 20 and 55 years; in the United States, the prevalence is
approximately two percent and increases with age [1-4].

The clinical manifestations and diagnosis
of fibromyalgia will be reviewed here. The possible pathogenic mechanisms. differential
diagnosis of widespread pain, and treatment of fibromyalgia
are discussed separately. (See "Pathogenesis of fibromyalgia"
and see "Differential diagnosis of fibromyalgia"
and see "Treatment of fibromyalgia
in adults").

The clinical manifestations, diagnosis,
and treatment of fibromyalgia in children and
adolescents are also presented separately. (See "Fibromyalgia in children
and adolescents").

CLINICAL
MANIFESTATIONS — Fibromyalgia is 6 times more common in females. The
prevalence of this disorder in the community increases with age from two
percent at age 20 to eight percent at age 70; most patients present between the
ages of 30 and 55 [1-4].
In approximately one-half of cases, the symptoms appeared to begin after a
specific event, most often some form of physical or emotional trauma or a
flu-like illness.

The cardinal manifestation of fibromyalgia is diffuse musculoskeletal pain (show
figure 1). Although the pain may initially be localized, often in the neck
and shoulders, it eventually involves many muscle groups. Patients typically
complain of axial pain in the neck, middle, and lower back, and pain in the
chest wall, arms, and legs. The pain is chronic and persistent, although it
usually varies in intensity. Patients often have difficulty distinguishing
joint and muscle pain and also may report a sensation of swelling; however, the
joints do not appear swollen or inflamed on examination. Pain is often
aggravated by exertion, stress, lack of sleep and weather changes. Sensations
of numbness, tingling, burning, or a crawling sensation are often described.

Patients also may have a variety of poorly
understood pain symptoms, including abdominal and chest wall pain and symptoms
suggestive of irritable bowel syndrome, pelvic pain and bladder symptoms of
frequency and urgency suggestive of the interstitial cystitis/painful bladder
syndrome (formerly female urethral syndrome) [3-8].
(See "Clinical manifestations and diagnosis of irritable
bowel syndrome", and see "Clinical features and diagnosis of painful bladder
syndrome/interstitial cystitis").

Fatigue is present in more than 90 percent
of cases and is occasionally the chief complaint. Most patients report light
sleep and feeling unrefreshed in the morning, while
others report symptoms suggestive of pathologic sleep disturbances such as
sleep apnea or nocturnal myoclonus. Light-headedness,
dizziness, and feeling faint are common symptoms. Mood
disturbances (especially depression, anxiety, and heightened somatic concern),
cognitive dysfunction (such as short term memory loss). Headaches
(either muscular or migraine-type) are present in a majority of patients [5,6].

Additional symptoms and clinical
manifestations may include complaints of ocular dryness, multiple chemical
sensitivity and "allergic" symptoms, palpitations, dyspnea, vulvodynia, dysmenorrhea, sexual dysfunction, weight fluctuations,
night sweats, dysphagia, dysgeusia,
and orthostatic intolerance [5,7,8].

The only helpful finding on physical
examination is excessive tenderness to palpation of soft tissues. This is best
determined by palpation of predefined muscle and tendon insertions, termed
tender points (show
figure 2). These tender points are usually bilateral and symmetrically
tender. However, patients with fibromyalgia are more tender than healthy controls at any musculoskeletal
site.

Aside from tenderness, the musculoskeletal
examination is unremarkable and there is no evidence to indicate a systemic
connective tissue or neurologic disease, unless the
patient has an associated illness. As an example, fibromyalgia
may occur concurrently with any rheumatic disorder, including rheumatoid
arthritis, osteoarthritis, and systemic lupus erythematosus.

CLASSIFICATION
CRITERIA — A number of classification criteria for the diagnosis of fibromyalgia have been proposed. In 1990, the largest
diagnostic criteria study, under the auspices of the American College
of Rheumatology, enrolled 293 fibromyalgia patients
and 265 patients with chronic rheumatic disorders such as low back pain, neck
and arm pain, osteoarthritis, and rheumatoid arthritis [9].
These controls were selected, since they would be most difficult to distinguish
from patients with fibromyalgia. Over 300 variables,
including symptoms, physical findings, and laboratory and radiologic
studies, were analyzed. The recommended diagnostic criteria were quite simple:

·
Widespread musculoskeletal pain

·
Excess tenderness in at least 11 of 18 predefined anatomic
sites (show
figure 2).

Requiring both criteria
to be present results in 80 percent sensitivity and specificity in
differentiating patients with fibromyalgia from
controls with other chronic painful disorders. No exclusionary criteria were proposed.

Satisfying both criteria is particularly
important in clinical studies to assure homogeneity of patients. These criteria
have been validated in broad-based population studies and are highly reliable.
However, in practice, a patient may be diagnosed with fibromyalgia
without having the recommended number of tender points. Furthermore, this criteria may be considered subjective, since both are
based on patient report. Unfortunately, there is no gold standard, such as a histologic tissue change or a laboratory measure of disease
activity.

DIAGNOSIS — The
clinical diagnosis of fibromyalgia is based largely
upon the patient's history of chronic, generalized pain and associated
features, including fatigue, sleep disturbances, headache, cognitive
difficulty, and mood disturbances.

Physical
examination — A thorough general physical examination is valuable to
assess for concomitant disorders. A general musculoskeletal examination and neurologic examination should be routinely performed to
help exclude any obvious arthritis, connective tissue disorder, or neurologic condition.

Tender point
examination — To establish the diagnosis, the tender point examination
noted above should always be done in the same fashion, applying pressure
equivalent to about 4 kg/cm to selected anatomic locations (show
figure 2). This can be accurately measured with a dolorimeter
or estimated by palpation with a finger. Applying enough pressure to whiten the
examiner's fingernail bed generates approximately 4 kg/cm of pressure [10].
The pressure should be applied gradually over a few seconds and to both right
and left sides of the body. Control locations, such as over the thumbnail or
the mid-forearm, should also be examined and should not be as tender as the
predefined tender points.

The optimal threshold for the number of
tender points for use in clinical diagnosis is uncertain. A number less than 11
(which is used in the ACR criteria for fibromyalgia)
may be appropriate. In one study of 200 subjects, of whom one-half had a
clinical diagnosis of fibromyalgia, the presence of
≥6 tender points had a sensitivity and specificity of 80 and 87 percent,
respectively [11].
In this population the sensitivity and specificity of a threshold of ≥11
tender points were approximately 50 and 95 percent, respectively. Furthermore,
using pain diagrams, rather than a tender point examination, provided similar
diagnostic utility. However, until further studies are reported, we suggest the
ACR criteria of ≥11 of 18 tender points be used for clinical trials and
diagnostic classification.

Laboratory
testing — Many
patients have previously undergone multiple laboratory and radiologic
studies, which are unrevealing. If a patient has not been previously evaluated,
initial laboratory testing should include a complete blood count, erythrocyte
sedimentation rate, thyroid function tests, and muscle enzymes.

More extensive laboratory testing is
unnecessary and will often provide confusing results. For example, the
prevalence of elevated antinuclear antibody levels in otherwise healthy persons
is substantial. Thus the predictive value of a positive antinuclear antibody
test in a patient without characteristic symptoms and signs of systemic lupus erythematosus (SLE) is low. Too often, patients with fibromyalgia are told that they may have SLE or another
connective tissue disease based upon inappropriate use of such laboratory
tests. (See "Measurement and clinical significance of antinuclear
antibodies", section on False positives).

Neuropsychologic testing — Psychiatric and cognitive disturbances may be
assessed using standardized brief questionnaires or referral to appropriate
specialists for formal evaluation [12,13]. Neuropsychologic
testing includes assessment of memory and instruments that screen for
depression. (See "Mild cognitive impairment", section on Screening cognitive examinations).

Autonomic nervous system function can be
evaluated by testing for orthostatic hypotension [14].
However, this generally requires specialized centers and procedures such as
tilt table testing. The description of such (See "Upright tilt table testing in the evaluation of
syncope", section on Test procedure).

DIFFERENTIAL
DIAGNOSIS — The multiple nonspecific symptoms of fibromyalgia
can mimic many other conditions. As examples, pain localized to the chest wall
may suggest cardiac disease, whereas pain in the abdominal or pelvic muscles
can mimic gastrointestinal or genitourinary disease. Similar confusion can
occur with paresthesias and the Raynaud
phenomenon. Myalgias and the perception of muscle
weakness may suggest an inflammatory muscle disease or a metabolic myopathy. The broad differential diagnosis of fibromyalgia is presented separately. (See "Differential diagnosis of fibromyalgia").

COEXISTING
DISORDERS — Coexisting
connective tissue diseases, psychiatric illnesses, sleep disorders, and chronic
infections complicate the assessment of patients with pain and tenderness that
meets criteria for classification as fibromyalgia.
Overlap between symptoms of fibromyalgia and other
diseases of unknown etiology, such as chronic fatigue syndrome, further
complicating efforts at classification and diagnosis.

Connective
tissue disease — Since fibromyalgia may develop in
patients with rheumatic or systemic illness, it may be difficult to determine
whether a patient's symptoms are related to that associated illness or to fibromyalgia. The history is often helpful in this regard.
Suppose that a patient with chronic but inactive rheumatoid arthritis complains
of diffuse pain and fatigue but has no active synovitis
and a normal ESR. In this setting, it is worthwhile to consider fibromyalgia as a cause of those symptoms, rather than
escalating or reinstituting therapy for rheumatoid arthritis.

Psychiatric
illness — Approximately
30 percent of patients with fibromyalgia have major
depression at the time of diagnosis; the lifetime prevalence of depression is
74 percent and that of an anxiety disorder is 60 percent [15,16]. Indeed, in some patients mood and
cognitive problems are much more prominent than tenderness [15].
However, the majority of patients with fibromyalgia
do not have any current psychopathology and patients rarely meet diagnostic
criteria for somatization disorders. Nevertheless, a
careful psychiatric evaluation is often useful. (See "Depression: Clinical manifestations and
diagnosis" and see "Somatization",
section on Definitions).

Sleep
disorders — The constellation of a sleep disorder, fatigue, and diffuse
pain may also be observed in some patients with sleep apnea and the restless
leg syndrome. The ability to distinguish among these sleep disorders is
important, since their therapy is quite different from that of the sleep
disorder associated with fibromyalgia. (See "Overview of obstructive sleep apnea-hypopnea in adults" and see "Restless legs syndrome").

Infectious
diseases — Chronic pain and tenderness typical of fibromyalgia
are also present in some patients with chronic viral or bacterial infections.

Hepatitis C — Some data support an association
between hepatitis and an increased prevalence of fibromyalgia
although this has not been confirmed in other studies [17,18].

Lyme disease — Fibromyalgia can be triggered by Lyme
disease. Furthermore, persistent symptoms of pain and fatigue may reflect fibromyalgia rather than persistent infection. This issue
is discussed elsewhere. (See "Diagnosis of Lyme
disease", section on Distinction from fibromyalgia).

Other
disorders of uncertain etiology — Fibromyalgia also overlaps with other poorly understood
syndromes, especially chronic fatigue syndrome (CFS), myofascial
pain, and temporomandibular joint syndrome (show
table 1) [3-5,19].

Chronic
fatigue syndrome — Operational
diagnostic criteria for the classification of CFS are similar to those for fibromyalgia and studies have demonstrated that the
majority of patients with CFS meet tender point criteria for fibromyalgia [20];
similarly, approximately 70 percent of patients with fibromyalgia
meet the criteria for CFS [21].
(See "Clinical features and diagnosis of chronic fatigue
syndrome").

Myofascial pain — Myofascial pain is considered by many to be a localized
form of fibromyalgia [22].
Patients with this disorder complain of pain in one anatomic region, such as
the right side of the neck and shoulder, and tenderness is confined to that
area. (See "Overview of soft tissue rheumatic disorders",
section on Regional myofascial pain).

INFORMATION FOR PATIENTS — Educational materials on this
topic are available for patients. (See "Patient information: Fibromyalgia"). We
encourage you to print or e-mail this topic, or to refer patients to our public
web site www.uptodate.com/patients,
which includes this and other topics.

SUMMARY AND
RECOMMENDATIONS — In summary, fibromyalgia can and
should be diagnosed in patients who present with chronic myalgias
and arthralgias but who have no evidence of joint or
muscle inflammation on physical examination or laboratory testing. The physical
examination should reveal multiple tender points at specific soft tissue
locations (show
figure 2). Since there are no diagnostic laboratory tests, testing should
be kept to a minimum.

There is no highly effective therapy and
therefore treatment cannot be used to help confirm the diagnosis. Since fibromyalgia is a chronic disorder, the diagnosis is best
made after observation of the patient's symptoms and signs over time.

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REFERENCES

1.Goldenberg,
DL. Fibromyalgia syndrome. An emerging but
controversial condition. JAMA 1987; 257:2782.

2.Goldenberg,
DL. Fibromyalgia syndrome a decade later. Arch Intern
Med 1999; 159:777.

3.Weir,
PT, Harlan, GA, Nkoy, FL, et al. The incidence of fibromyalgia and its associated comorbidities:
a population-based retrospective cohort study based on International
Classification of Diseases, 9th Revision codes. J Clin
Rheumatol 2006; 12:124.

4.Mease, P, Arnold, LM, Bennett, R, et al. Fibromyalgia syndrome. J Rheumatol
2007; 34:1415.

5.Yunus, MB. Fibromyalgia and
overlapping disorders: The unifying concept of central sensitivity syndromes. Semin Arthritis Rheum 2007; 36:339.

6.Marcus,
DA, Bernstein, C, Rudy, TE. Fibromyalgia and
headache: an epidemiological study supporting migraine as part of the fibromyalgia syndrome. Clin Rheumatol 2005; 24:595.

7.Rhodus, NL, Fricton, J, Carlson,
P, Messner, R. Oral symptoms associated with fibromyalgia syndrome. J Rheumatol
2003; 30:1841.

8.Aydin, G, Basar, MM, Keles, I, et al. Relationship between sexual dysfunction
and psychiatric status in premenopausal women with fibromyalgia. Urology 2006; 67:156.

9.Wolfe,
F, Smythe, HA, Yunus, MB,
et al. The American College of Rheumatology 1990 criteria for the
classification of fibromyalgia: Report of the Multicenter Criteria Committee. Arthritis Rheum 1990;
33:160.

10.  Okifuji, A, Turk, DC, Sinclair, JD, et al. A standardized
manual tender point survey. I. Development and determination of a threshold
point for the identification of positive tender points in fibromyalgia
syndrome. J Rheumatol 1997; 24:377.

11.  Katz,
RS, Wolfe, F, Michaud, K. Fibromyalgia diagnosis: a
comparison of clinical, survey, and American College of Rheumatology criteria.
Arthritis Rheum 2006; 54:169.

12.  Glass,
JM, Park, DC, Minear, M, Crofford,
LJ. Memory beliefs and function in fibromyalgia
patients. J Psychosom Res
2005; 58:263.

13.  Bergman,
S. Psychosocial aspects of chronic widespread pain and fibromyalgia.
Disabil Rehabil 2005;
27:675.

14.  Martinez-Lavin,
M, Hermosillo,
AG. Autonomic nervous system dysfunction may explain the multisystem
features of fibromyalgia. Semin
Arthritis Rheum 2000; 29:197.

15.  Giesecke, T, Williams, DA, Harris, RE, et al. Subgrouping of fibromyalgia
patients on the basis of pressure-pain thresholds and psychological factors.
Arthritis Rheum 2003; 48:2916.

16.  Arnold,
LM, Hudson, JI, Hess, EV, et al. Family study of fibromyalgia.
Arthritis Rheum 2004; 50:944.

17.  Adak, B, Tekeoglu, I, Ediz, L, et al. Fibromyalgia
frequency in hepatitis B carriers. J Clin Rheumatol 2005; 11:157.

18.  Narvaez, J, Nolla, JM, Valverde-Garcia, J. Lack of association of fibromyalgia with hepatitis C virus infection. J Rheumatol 2005; 32:1118.

19.  Aaron,
LA, Burke, MM, Buchwald, D. Overlapping conditions among patients with chronic
fatigue syndrome, fibromyalgia, and temporomandibular disorder. Arch Intern Med 2000; 160:221.

20.  Goldenberg,
DL, Simms, RW, Geiger, A, Komaroff,
AL. High frequency of fibromyalgia in patients with
chronic fatigue seen in a primary care practice. Arthritis Rheum 1990; 33:381.

21.  White,
KP, Speechley, M, Harth, M,
Ostbye, T. Co-existence of chronic fatigue syndrome
with fibromyalgia syndrome in the general population.
A controlled study. Scand J Rheumatol 2000; 29:44.

22.  Tunks, E, Crook, J. Regional soft tissue pains: alias myofascial pain?. Baillieres Best Pract Res Clin Rheumatol
1999; 13:345.

GRAPHICS

Manifestations of fibromyalgia

History

Female,
usually age 20 to 65

Chronic,
generalized pain

Fatigue

Sleep
and mood disturbances

Headaches

Irritable
bowel syndrome

Physical
examination

Multiple
tender areas of muscle and tendons

No
inflammatory muscle or joint disease

Laboratory
tests

Unremarkable

Tender points in fibromyalgia

The 18
"tender points" important for the diagnosis of fibromyalgia. Note the bilateral symmetry of the
labeled regions. Tenderness on palpation of at least 11 of these sites in a
patient with at least a three month history of diffuse musculoskeletal pain is
recommended as a diagnostic standard for fibromyalgia.
Adapted
from Goldenberg, DL, Hosp Pract (Off Ed) 1989; 24:39.

Symptoms that distinguish between
chronic fatigue syndrome, fibromyalgia, and temporomandibular joint disorder

Symptoms
common to all three conditions

Muscle
pain, aching, or discomfort

Problems
falling or staying asleep, or sleeping too much

Wake up
feeling tired, unrefreshed after a full night's
rest

Difficulty
concentrating or thinking, forgetfulness

Abdominal
pain relieved by a bowel movement

Hard,
loose, or watery stools

Symptoms
that distinguish CFS and FM from TMD

Fatigue
greater than six months

Fatigue
resulting in a 50 percent reduction of normal activity

Unexplained
muscle weakness

Migratory
arthralgias without redness or swelling

Burning,
shooting, or throbbing muscle pain

Symptoms
that distinguish CFS from FM and TMD

Mild
fever (37.5°C to 38.6°C) or chills

Sore
throat

Symptoms
that distinguish FM from CFS and TMD

Pain
made better by heat or massage

Pain
made worse by sitting or standing

Symptoms
that distinguish TMD from CFS and FM

Pain in
jaw muscles, temporomandibular joint, or inside the
ear

CFS: chronic
fatigue syndrome; FM: fibromyalgia; TMD: temporomandibular joint disorder.

Data
from Aaron, LA, Burke, MM, Buchwald, D, Arch Intern Med
2000; 160:221.

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