New Dimensions in Fibromyalgia

Diagnosis and Classification of Fibromyalgia:
Where do we draw the line?

Robert Bennett, MD

According to the 1990 American College of Rheumatology criteria the diagnosis of fibromyalgia is based on the history of widespread pain and the finding of 11 or more out of 18 designated tender point areas. Rheumatologists often encounter other scenarios:

  1. Patients with widespread pain who only have 6 or 7 tender points.
  2. Patients with regional pain associated with sleep disturbance and multiple tender points.
  3. FM patients with widespread pain and a few criteria tender points but multiple tender points in other locations.
  4. FM patients who have pain allover and have the physical finding of allodynia.
  5. FM patients with associated major depression
  6. FM patients who are fully functional and patients who are very dysfunctional.
  7. FM patients with the findings of neurally mediated hypotension.
  8. FM patients with an associated growth hormone deficiency.

Epidemiological studies suggest that fibromyalgia is at one end of a spectrum of chronic pain. This often starts with regional pain syndromes and ends in severe, widespread intractable pain with allodynia. Diagnosing fibromyalgia is analogous to diagnosing hypertension; a critical question is: where do we draw the line? The salient feature of fibromyalgia appears to be an abnormality of central pain processing. A discussion of how this notion could be incorporated into diagnostic criteria seems relevant. Consideration also needs to be given to providing guidelines for the diagnosis of fibromyalgia subsets. For instance most practitioners can readily differentiate between their patients with simple fibromyalgia and those with complex fibromyalgia. The latter group usually have significant psychosocial problems and are more likely to be dysfunctional. Examples of possible subsets include: Major depression, widespread allodynia, primary sleep disorders (e.g. sleep apnea), neurally mediated hypotension, growth hormone deficiency, and a primary pain diagnosis (e.g. RA, SLE, RSD, etc.). Fibromyalgia is more than a pain syndrome. The possibility of developing a Multi-Axial classification, similar to that used in psychiatry should be explored. Before any recommendations could be implemented a multi-center study would have to be initiated to validate the proposed changes.

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