FM :: Fibromyalgia  Signs, Symptoms, Diagnostics

DIAGNOSITIC PROTOCOL

The two compulsory pain criteria [adopted from the American College of Rheumatology 1990 Criteria (1)] are merged with Additional Clinical Symptoms & Signs to expand the classification of FMS into a Clinical Working Case Definition of FMS.

1. Compulsory HISTORY of widespread pain. Pain is considered widespread when all of the following are present for at least three months:
· pain in both sides of the body
· pain above and below the waist [including low back pain]
· axial skeletal pain [cervical spine, anterior chest, thoracic spine or low back]. Shoulder and buttock involvement counts for either side of the body. "Low back" is lower segment.

2. Compulsory PAIN ON PALPATION at 11 or more of the 18 defined tender point sites.[see Figure 1]
· Occiput [1,2]­ at the suboccipital muscle insertions [see Figure 1]
· Low cervical [3,4] ­at the anterior aspects of the intertransverse spaces [the spaces between the transverse processes] at C5-C7
· Trapezius [5,6] ­at the midpoint of the upper border
· Supraspinatus [7,8] ­at origins, above the scapular spine near its medial border
· Second rib [9,10] ­just lateral to the second costochondral junctions, on the upper rib surfaces
· Lateral epicondyle [11,12] ­2 cm distal to the epicondyles [in the brachioradialis muscle]
· Gluteal [13,14] ­in upper outer quadrants of buttocks in the anterior fold of muscle
· Greater trochanter [15,16] ­posterior to the trochanteric prominence
· Knee [17,18] ­at medial fat pad proximal to the joint line (and condyle)

3. Additional clinical symptoms & signs. In addition to the compulsory pain and tenderness required for research classification of FMS, many additional clinical symptoms and signs can contribute importantly to the patients' burden of illness. Two or more of these features are present in most FMS patients by the time they seek medical attention. On the other hand, it is uncommon for any individual FMS patient to have all of the associated symptoms or signs. As a result, the clinical presentation of FMS may vary somewhat, and the patterns of involvement may eventually lead to the recognition of FMS clinical subgroups. These additional clinical symptoms and signs are not required for the research classification of FMS but they are still clinically important. For these reasons, the following clinical symptoms and signs are itemized and described in an attempt to expand the compulsory pain criteria into a proposed Clinical Case Definition of FMS [see Appendix 2, p. 79].

· Neurological manifestations: Neurological difficulties are often present such as hypertonic and hypotonic muscles; musculoskeletal asymmetry and dysfunction involving muscles, ligaments and joints; atypical patterns of numbness and tingling; abnormal muscle twitch response, muscle cramps, muscle weakness, and fasciculations. Headaches, temporomandibular joint disorder, generalized weakness, perceptual disturbances, spatial instability, and sensory overload phenomena often occur.

· Neurocognitive manifestations: Neurocognitive difficulties usually are present. These include impaired concentration and short-term memory consolidation, impaired speed of performance, inability to multi-task, easy distractibility, and/or cognitive overload.

· Fatigue: There is persistent and reactive fatigue accompanied by reduced physical and mental stamina, which often interferes with the patient's ability to exercise.

· Sleep dysfunction: Most FMS patients experience unrefreshing sleep. This is usually accompanied by sleep disturbances including insomnia, frequent nocturnal awakening, nocturnal myoclonus, and/or restless leg syndrome.

· Autonomic and/or neuroendocrine manifestations: These manifestations include cardiac arrhythmias, neurally mediated hypotension, vertigo, vasomotor instability, sicca syndrome, temperature instability, heat/cold intolerance, respiratory disturbances, intestinal and bladder motility disturbances with or without irritable bowel or bladder dysfunction, dysmenorrhea, loss of adaptability and tolerance for stress, emotional flattening, lability, and/or reactive depression.

· Stiffness: Generalized or even regional stiffness that is most severe upon awakening and typically lasts for hours as occurs with active rheumatoid arthritis. It can return during periods of inactivity during the day.

• hypersensitivity to pain
• hyper-responsiveness to noxious stimuli
• perceptual and dimensional distortions
• feeling of burning or swelling
• sensory overload phenomena
• loss of cognitive map
• dyspnea

• difficulties processing information
• slowness in cognitive processing
• concentration problems
• difficulties with word retrieval
• confusion and word mix-ups
• short-term memory difficulties

• muscle weakness and paralysis
• poor balance, ataxia and tandem gait
• clumsiness and tendency to drop things
• difficulty in tandem gait
• atypical numbness or tingling 64 percent

• marked weight change
• heat/cold intolerance 85 percent
• neuropsychological
• mood swings, anxiety 60 percent
• reactive depression