Clinical manifestations and diagnosis of fibromyalgia in adults
- Don L Goldenberg, MD
Don L Goldenberg, MD
- Section Editor — Pain Disorders in Rheumatology
- Emeritus Professor of Medicine, Tufts University School of Medicine
- Affiliate Assistant, Rheumatology Division, Oregon Health Science University
- Affiliate Instructor, School of Nursing Oregon Health Sciences University
Fibromyalgia (FM) is a common cause of chronic widespread musculoskeletal pain, often accompanied by fatigue, cognitive disturbance, psychiatric symptoms, and multiple somatic symptoms. The etiology of the syndrome is unknown, and the pathophysiology is uncertain [1,2]. Despite symptoms of soft tissue pain affecting the muscles, ligaments, and tendons there is no evidence of tissue inflammation.
FM, like other functional somatic syndromes, has been a controversial condition [1,2]. Patients look well, there are no obvious abnormalities on physical examination other than tenderness, and laboratory and radiologic studies are normal. Thus, the role of organic illness had been questioned, and FM was often been considered to be psychogenic or psychosomatic. However, ongoing research suggests that FM is a disorder of pain regulation, often classified as a form of central sensitization . (See "Pathogenesis of fibromyalgia".)
FM is often associated with other conditions that may cause musculoskeletal pain, disruption of sleep, or psychiatric symptoms; features of these conditions may also mimic FM, and the presence of such disorders should be considered in the diagnostic evaluation. (See "Differential diagnosis of fibromyalgia".)
The clinical manifestations and diagnosis of FM will be reviewed here. The differential diagnosis of FM is discussed in detail separately, as are the possible pathogenic mechanisms and treatment of FM in adults, and the clinical manifestations, diagnosis, and treatment of FM in children and adolescents. (See "Differential diagnosis of fibromyalgia" and "Pathogenesis of fibromyalgia" and "Initial treatment of fibromyalgia in adults" and "Treatment of fibromyalgia in adults not responsive to initial therapies" and "Fibromyalgia in children and adolescents: Clinical manifestations and diagnosis" and "Fibromyalgia in children and adolescents: Treatment and prognosis".)
Fibromyalgia (FM) is a common cause of chronic pain and the most common cause of generalized, musculoskeletal pain in women between ages of 20 and 55 years; in the United States and in other countries, the prevalence is approximately 2 to 3 percent and increases with age [4-7]. FM is more common in women than men and occurs in both children and adults [4-8]. It is six times more common in women in reports from specialty clinics, although the female predominance is not as striking in the community and when using survey criteria that do not require a tender point examination . The diagnosis may be underrecognized in clinical practice; prevalence estimates in one US county using surveys with standardized criteria were higher than estimates based upon medical record documentation of the diagnosis (6.4 versus 1.1 percent) . Prevalence studies in adolescents have been very similar to those in adults .
- Goldenberg DL. Fibromyalgia syndrome. An emerging but controversial condition. JAMA 1987; 257:2782.
- Clauw DJ. Fibromyalgia: a clinical review. JAMA 2014; 311:1547.
- Schmidt-Wilcke T, Kairys A, Ichesco E, et al. Changes in clinical pain in fibromyalgia patients correlate with changes in brain activation in the cingulate cortex in a response inhibition task. Pain Med 2014; 15:1346.
- Vincent A, Lahr BD, Wolfe F, et al. Prevalence of fibromyalgia: a population-based study in Olmsted County, Minnesota, utilizing the Rochester Epidemiology Project. Arthritis Care Res (Hoboken) 2013; 65:786.
- Wolfe F, Ross K, Anderson J, et al. The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum 1995; 38:19.
- Jones GT, Atzeni F, Beasley M, et al. The prevalence of fibromyalgia in the general population: a comparison of the American College of Rheumatology 1990, 2010, and modified 2010 classification criteria. Arthritis Rheumatol 2015; 67:568.
- Walitt B, Nahin RL, Katz RS, et al. The Prevalence and Characteristics of Fibromyalgia in the 2012 National Health Interview Survey. PLoS One 2015; 10:e0138024.
- Ting TV, Barnett K, Lynch-Jordan A, et al. 2010 American College of Rheumatology Adult Fibromyalgia Criteria for Use in an Adolescent Female Population with Juvenile Fibromyalgia. J Pediatr 2016; 169:181.
- Perrot S, Vicaut E, Servant D, Ravaud P. Prevalence of fibromyalgia in France: a multi-step study research combining national screening and clinical confirmation: The DEFI study (Determination of Epidemiology of FIbromyalgia). BMC Musculoskelet Disord 2011; 12:224.
- Senna ER, De Barros AL, Silva EO, et al. Prevalence of rheumatic diseases in Brazil: a study using the COPCORD approach. J Rheumatol 2004; 31:594.
- Haq SA, Darmawan J, Islam MN, et al. Prevalence of rheumatic diseases and associated outcomes in rural and urban communities in Bangladesh: a COPCORD study. J Rheumatol 2005; 32:348.
- Brill S, Ablin JN, Goor-Aryeh I, et al. Prevalence of fibromyalgia syndrome in patients referred to a tertiary pain clinic. J Investig Med 2012; 60:685.
- Bennett RM. Clinical manifestations and diagnosis of fibromyalgia. Rheum Dis Clin North Am 2009; 35:215.
- Björkegren K, Wallander MA, Johansson S, Svärdsudd K. General symptom reporting in female fibromyalgia patients and referents: a population-based case-referent study. BMC Public Health 2009; 9:402.
- Aggarwal VR, McBeth J, Zakrzewska JM, et al. The epidemiology of chronic syndromes that are frequently unexplained: do they have common associated factors? Int J Epidemiol 2006; 35:468.
- Glass JM. Cognitive dysfunction in fibromyalgia and chronic fatigue syndrome: new trends and future directions. Curr Rheumatol Rep 2006; 8:425.
- Fuller-Thomson E, Nimigon-Young J, Brennenstuhl S. Individuals with fibromyalgia and depression: findings from a nationally representative Canadian survey. Rheumatol Int 2012; 32:853.
- Arnold LM, Hudson JI, Keck PE, et al. Comorbidity of fibromyalgia and psychiatric disorders. J Clin Psychiatry 2006; 67:1219.
- Aguglia A, Salvi V, Maina G, et al. Fibromyalgia syndrome and depressive symptoms: comorbidity and clinical correlates. J Affect Disord 2011; 128:262.
- Toussaint LL, Vincent A, McAllister SJ, et al. A Comparison of Fibromyalgia Symptoms in Patients with Healthy versus Depressive, Low and Reactive Affect Balance Styles. Scand J Pain 2014; 5:161.
- Chang MH, Hsu JW, Huang KL, et al. Bidirectional Association Between Depression and Fibromyalgia Syndrome: A Nationwide Longitudinal Study. J Pain 2015; 16:895.
- Soriano-Maldonado A, Amris K, Ortega FB, et al. Association of different levels of depressive symptoms with symptomatology, overall disease severity, and quality of life in women with fibromyalgia. Qual Life Res 2015; 24:2951.
- de Tommaso M, Federici A, Serpino C, et al. Clinical features of headache patients with fibromyalgia comorbidity. J Headache Pain 2011; 12:629.
- Küçükşen S, Genç E, Yılmaz H, et al. The prevalence of fibromyalgia and its relation with headache characteristics in episodic migraine. Clin Rheumatol 2013; 32:983.
- Vehof J, Sillevis Smitt-Kamminga N, Kozareva D, et al. Clinical Characteristics of Dry Eye Patients With Chronic Pain Syndromes. Am J Ophthalmol 2016; 162:59.
- Sawada F, Nomura Y, Goto F, et al. Relationship of physical distress to dizziness in patients with fibromyalgia. Acta Otolaryngol 2016; 136:56.
- Bossema ER, van Middendorp H, Jacobs JW, et al. Influence of weather on daily symptoms of pain and fatigue in female patients with fibromyalgia: a multilevel regression analysis. Arthritis Care Res (Hoboken) 2013; 65:1019.
- Watson NF, Buchwald D, Goldberg J, et al. Neurologic signs and symptoms in fibromyalgia. Arthritis Rheum 2009; 60:2839.
- Hughes G, Martinez C, Myon E, et al. The impact of a diagnosis of fibromyalgia on health care resource use by primary care patients in the UK: an observational study based on clinical practice. Arthritis Rheum 2006; 54:177.
- Viola-Saltzman M, Watson NF, Bogart A, et al. High prevalence of restless legs syndrome among patients with fibromyalgia: a controlled cross-sectional study. J Clin Sleep Med 2010; 6:423.
- Prados G, Miró E, Martínez MP, et al. Fibromyalgia: gender differences and sleep-disordered breathing. Clin Exp Rheumatol 2013; 31:S102.
- Staud R. Autonomic dysfunction in fibromyalgia syndrome: postural orthostatic tachycardia. Curr Rheumatol Rep 2008; 10:463.
- 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.
- Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken) 2010; 62:600.
- Arnold LM, Stanford SB, Welge JA, Crofford LJ. Development and testing of the fibromyalgia diagnostic screen for primary care. J Womens Health (Larchmt) 2012; 21:231.
- Wolfe F, Clauw DJ, Fitzcharles MA, et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol 2011; 38:1113.
- Ferrari R, Russell AS. A questionnaire using the modified 2010 American College of Rheumatology criteria for fibromyalgia: specificity and sensitivity in clinical practice. J Rheumatol 2013; 40:1590.
- Almansa C, Rey E, Sánchez RG, et al. Prevalence of functional gastrointestinal disorders in patients with fibromyalgia and the role of psychologic distress. Clin Gastroenterol Hepatol 2009; 7:438.
- Fraga BP, Santos EB, Farias Neto JP, et al. Signs and symptoms of temporomandibular dysfunction in fibromyalgic patients. J Craniofac Surg 2012; 23:615.
- Kato K, Sullivan PF, Evengård B, Pedersen NL. Chronic widespread pain and its comorbidities: a population-based study. Arch Intern Med 2006; 166:1649.
- Lai HH, Gardner V, Ness TJ, Gereau RW 4th. Segmental hyperalgesia to mechanical stimulus in interstitial cystitis/bladder pain syndrome: evidence of central sensitization. J Urol 2014; 191:1294.
- Buchwald D, Goldenberg DL, Sullivan JL, Komaroff AL. The "chronic, active Epstein-Barr virus infection" syndrome and primary fibromyalgia. Arthritis Rheum 1987; 30:1132.
- McBeth J, Tomenson B, Chew-Graham CA, et al. Common and unique associated factors for medically unexplained chronic widespread pain and chronic fatigue. J Psychosom Res 2015; 79:484.
- Aaron LA, Buchwald D. A review of the evidence for overlap among unexplained clinical conditions. Ann Intern Med 2001; 134:868.
- Aaron LA, Bradley LA, Alarcón GS, et al. Psychiatric diagnoses in patients with fibromyalgia are related to health care-seeking behavior rather than to illness. Arthritis Rheum 1996; 39:436.
- Diaz-Piedra C, Catena A, Sánchez AI, et al. Sleep disturbances in fibromyalgia syndrome: the role of clinical and polysomnographic variables explaining poor sleep quality in patients. Sleep Med 2015; 16:917.
- Liedberg GM, Björk M, Börsbo B. Self-reported nonrestorative sleep in fibromyalgia - relationship to impairments of body functions, personal function factors, and quality of life. J Pain Res 2015; 8:499.
- Wolfe F, Häuser W, Hassett AL, et al. The development of fibromyalgia--I: examination of rates and predictors in patients with rheumatoid arthritis (RA). Pain 2011; 152:291.
- Andersson ML, Svensson B, Bergman S. Chronic widespread pain in patients with rheumatoid arthritis and the relation between pain and disease activity measures over the first 5 years. J Rheumatol 2013; 40:1977.
- Lee YC, Lu B, Boire G, et al. Incidence and predictors of secondary fibromyalgia in an early arthritis cohort. Ann Rheum Dis 2013; 72:949.
- Coury F, Rossat A, Tebib A, et al. Rheumatoid arthritis and fibromyalgia: a frequent unrelated association complicating disease management. J Rheumatol 2009; 36:58.
- Magrey MN, Antonelli M, James N, Khan MA. High frequency of fibromyalgia in patients with psoriatic arthritis: a pilot study. Arthritis 2013; 2013:762921.
- Bello N, Etcheto A, Béal C, et al. Evaluation of the impact of fibromyalgia in disease activity and treatment effect in spondyloarthritis. Arthritis Res Ther 2016; 18:42.
- Wolfe F, Petri M, Alarcón GS, et al. Fibromyalgia, systemic lupus erythematosus (SLE), and evaluation of SLE activity. J Rheumatol 2009; 36:82.
- Torrente-Segarra V, Salman-Monte TC, Rúa-Figueroa Í, et al. Fibromyalgia prevalence and related factors in a large registry of patients with systemic lupus erythematosus. Clin Exp Rheumatol 2016; 34:S40.
- Segal BM, Pogatchnik B, Henn L, et al. Pain severity and neuropathic pain symptoms in primary Sjögren's syndrome: a comparison study of seropositive and seronegative Sjögren's syndrome patients. Arthritis Care Res (Hoboken) 2013; 65:1291.
- Lee YC, Lu B, Bathon JM, et al. Pain sensitivity and pain reactivity in osteoarthritis. Arthritis Care Res (Hoboken) 2011; 63:320.
- Haliloglu S, Carlioglu A, Akdeniz D, et al. Fibromyalgia in patients with other rheumatic diseases: prevalence and relationship with disease activity. Rheumatol Int 2014; 34:1275.
- Nordeman L, Gunnarsson R, Mannerkorpi K. Prevalence and characteristics of widespread pain in female primary health care patients with chronic low back pain. Clin J Pain 2012; 28:65.
- Genc H, Nacir B, Duyur Cakit B, et al. The effects of coexisting fibromyalgia syndrome on pain intensity, disability, and treatment outcome in patients with chronic lateral epicondylitis. Pain Med 2012; 13:270.
- Choy E, Perrot S, Leon T, et al. A patient survey of the impact of fibromyalgia and the journey to diagnosis. BMC Health Serv Res 2010; 10:102.
- Annemans L, Wessely S, Spaepen E, et al. Health economic consequences related to the diagnosis of fibromyalgia syndrome. Arthritis Rheum 2008; 58:895.
- Kim SK, Kim SH, Lee CK, et al. Effect of fibromyalgia syndrome on the health-related quality of life and economic burden in Korea. Rheumatology (Oxford) 2013; 52:311.
- Baron R, Perrot S, Guillemin I, et al. Improving the primary care physicians' decision making for fibromyalgia in clinical practice: development and validation of the Fibromyalgia Detection (FibroDetect®) screening tool. Health Qual Life Outcomes 2014; 12:128.
- Masters ET, Mardekian J, Emir B, et al. Electronic medical record data to identify variables associated with a fibromyalgia diagnosis: importance of health care resource utilization. J Pain Res 2015; 8:131.
- CLINICAL MANIFESTATIONS
- Physical findings
- Laboratory testing and other studies
- Clinical diagnosis
- Diagnostic evaluation
- Additional evaluation
- Classification criteria and proposed diagnostic criteria
- - 1990 ACR classification criteria
- - 2010 ACR preliminary diagnostic criteria
- DIFFERENTIAL DIAGNOSIS
- COEXISTING DISORDERS
- FIBROMYALGIA AND PRIMARY CARE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS