Tuesday, July 28, 2009
The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the multicenter criteria committee
Arthritis Rheum. 1990 Feb;33(2):160-72.
Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, Tugwell P, Campbell SM, Abeles M, Clark P, et al.
To develop criteria for the classification of fibromyalgia, we studied 558 consecutive patients: 293 patients with fibromyalgia and 265 control patients. Interviews and examinations were performed by trained, blinded assessors. Control patients for the group with primary fibromyalgia were matched for age and sex, and limited to patients with disorders that could be confused with primary fibromyalgia. Control patients for the group with secondary-concomitant fibromyalgia were matched for age, sex, and concomitant rheumatic disorders. Widespread pain (axial plus upper and lower segment plus left- and right-sided pain) was found in 97.6% of all patients with fibromyalgia and in 69.1% of all control patients. The combination of widespread pain and mild or greater tenderness in greater than or equal to 11 of 18 tender point sites yielded a sensitivity of 88.4% and a specificity of 81.1%. Primary fibromyalgia patients and secondary-concomitant fibromyalgia patients did not differ statistically in any major study variable, and the criteria performed equally well in patients with and those without concomitant rheumatic conditions. The newly proposed criteria for the classification of fibromyalgia are 1) widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. No exclusions are made for the presence of concomitant radiographic or laboratory abnormalities. At the diagnostic or classification level, the distinction between primary fibromyalgia and secondary-concomitant fibromyalgia (as defined in the text) is abandoned.
Fibromyalgia syndrome: Canadian clinical working case definition, diagnostic and treatment protocols- A consensus document
J Musculoskeletal Pain, 2004; 11(4): 3-107
Jain AK, Carruthers BM, van de Sande MI, Barron SR, Donaldson CCS, Dunne JV, Gingrich E, Heffez DS, Leung FYK, Malone DG, Romano TJ, Russell IJ, Saul D, Seibel DG.
Background: There has been a growing recognition of the need for information about objective abnormalities in people with the fibromyalgia syndrome [FMS] and for an integrated approach to its diagnosis and management by primary care physicians.
Objectives: To establish an expert consensus toward a working case definition of FMS and a working guide to its management for physicians in Canada.
Methods: An Expert Subcommittee of Health Canada established the Terms of Reference and selected an Expert Medical Consensus Panel representing treating physicians, teaching faculty, and researchers. The editors prepared a draft document which was reviewed by the Panel members in preparation for the Consensus Workshop, which was held on March 30 to April 1, 2001. Subsequent writing assignments produced subdocuments on key topics relevant to the objectives. The subdocuments were then integrated into a submission document which was approved by each of the panel members.
Results: The completed document is provided. It contains sections on a new approach to case definition, on proposed research to validate the new case definition, on a practical approach to assessment of severity, on empathetic management; and on what is known about pathogenesis.
Conclusions: A consensus document was developed to assist clinicians in distinguishing FMS from other syndromes/illnesses that may present with body pain. It is intended that this document serve as a guide: to a better understanding of FMS; to a more reasoned approach to its management; and to further research on the clinical care of people with FMS.
Fibromyalgia: more than just a musculoskeletal disease
Am Fam Physician. 1995 Sep 1;52(3):843-51, 853-4.
Fibromyalgia is a common condition characterized by diffuse musculoskeletal pain and fatigue. The syndrome is defined by the presence of musculoskeletal tender points on physical examination. Additionally, persons with this syndrome have a high incidence of headaches, ocular and vestibular complaints, paresthesias, esophageal dysmotility, "allergic" symptoms, irritable bowl syndrome, genitourinary symptoms and affective disorders. Recent research has revealed a number of objective biochemical, hormonal and neurotransmitter abnormalities associated with fibromyalgia, making it a clearly identifiable condition. These abnormalities may clarify our understanding of the pathogenesis and treatment of fibromyalgia.
J. Rheumatol. 2005 Nov;32(11):2270-7.
Mease PJ, Clauw DJ, Arnold LM, Goldenberg DL, Witter J, Williams DA, Simon LS, Strand CV, Bramson C, Martin S, Wright TM, Littman B, Wernicke JF, Gendreau RM, Crofford LJ.
The objectives of the first OMERACT Fibromyalgia Syndrome (FM) Workshop were to identify and prioritize symptom domains that should be consistently evaluated in FM clinical trials, and to identify aspects of domains and outcome measures that should be part of a concerted research agenda of FM researchers. Such an effort will help standardize and improve the quality of outcomes research in FM. A principal assumption in this workshop has been that there exists a clinical syndrome, generally known as FM, characterized by chronic widespread pain typically associated with fatigue, sleep disturbance, mood disturbance, and other symptoms and signs, and considered to be related to central neuromodulatory dysregulation. FM can be diagnosed using 1990 American College of Rheumatology criteria. In preparation for the workshop a Delphi exercise involving 23 FM researchers was conducted to establish a preliminary prioritization of domains of inquiry. At the OMERACT meeting, the workshop included presentation of the Delphi results; a review of placebo-controlled trials of FM treatment, with a focus on the outcome measures used and their performance; a panel discussion of the key issues in FM trials, from both an investigator and regulatory agency perspective; and a voting process by the workshop attendees. The results of the workshop were presented in the plenary session on the final day of the meeting. A prioritized list of domains of FM to be investigated was thus developed, key issues and controversies in the field were debated, and consensus on a research agenda on outcome measure development was reached.
Fibromyalgia subgroups: profiling distinct subgroups using the Fibromyalgia Impact Questionnaire. A preliminary study
Rheumatol Int. 2008 Sep 27.
de Souza JB, Goffaux P, Julien N, Potvin S, Charest J, Marchand S.
The main goal of this project was to identify the presence of fibromyalgia (FM) subgroups using a simple and frequently used clinical tool, the Fibromyalgia Impact Questionnaire (FIQ). A total of 61 women diagnosed with FM participated in this study. FM subgroups were created by applying a hierarchical cluster analysis on selected items of the FIQ (pain, fatigue, morning tiredness, stiffness, anxiety and depressive symptoms). We also tested for group differences on experimental pain, psychosocial functioning and demographic characteristics. Two cluster profiles best fit our data. FM-Type I was characterized by the lowest levels of anxiety, depressive and morning tiredness symptoms, while FM-Type II was characterized by elevated levels of pain, fatigue, morning tiredness, stiffness, anxiety and depressive symptoms. Both FM subgroups showed hyperalgesic responses to experimental pain. These results suggest that pain and stiffness are universal symptoms of the disorder but that psychological distress is a feature present only in some patients.
Chronic widespread pain and fibromyalgia: what we know, and what we need to know
Best Pract Res Clin Rheumatol. 2003 Aug;17(4):685-701.
Clauw DJ, Crofford LJ.
Fibromyalgia (FM) is currently defined as the presence of both chronic widespread pain (CWP) and the finding of 11/18 tender points on examination. Only about 20% of individuals in the population with CWP also have 11/18 tender points; these individuals are considerably more likely to be female, and have higher levels of psychological distress. There is no clear clinical diagnosis for the other 80% of individuals with less than 11/18 tender points, but it is likely that these persons, like FM patients, also have pain that is 'central' (i.e. not due to inflammation or damage of structures) rather than peripheral in nature. Research into FM has taught us a great deal about the confluence of neurobiological, psychological and behavioural factors that can cause chronic central pain. These conditions respond best to a combination of symptom-based pharmacological therapies, and non-pharmacological therapies such as exercise and cognitive behavioural therapy. In contrast to drugs that work for peripheral pain due to damage or inflammation (e.g. NSAIDs, corticosteroids), neuroactive compounds [especially those that raise central levels of noradrenaline (norepinephrine) or serotonin] are most effective for treating central pain.
Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment
J Rheumatol Suppl. 2005 Aug;75:6-21.
Fibromyalgia syndrome (FM) is a common chronic pain condition that affects at least 2% of the adult population in the USA and other regions in the world where FM is studied. Prevalence rates in some regions have not been ascertained and may be influenced by differences in cultural norms regarding the definition and attribution of chronic pain states. Chronic, widespread pain is the defining feature of FM, but patients may also exhibit a range of other symptoms, including sleep disturbance, fatigue, irritable bowel syndrome, headache, and mood disorders. Although the etiology of FM is not completely understood, the syndrome is thought to arise from influencing factors such as stress, medical illness, and a variety of pain conditions in some, but not all patients, in conjunction with a variety of neurotransmitter and neuroendocrine disturbances. These include reduced levels of biogenic amines, increased concentrations of excitatory neurotransmitters, including substance P, and dysregulation of the hypothalamic-pituitary-adrenal axis. A unifying hypothesis is that FM results from sensitization of the central nervous system. Establishing diagnosis and evaluating effects of therapy in patients with FM may be difficult because of the multifaceted nature of the syndrome and overlap with other chronically painful conditions. Diagnostic criteria, originally developed for research purposes, have aided our understanding of this patient population in both research and clinical settings, but need further refinement as our knowledge about chronic widespread pain evolves. Outcome measures, borrowed from clinical research in pain, rheumatology, neurology, and psychiatry, are able to distinguish treatment response in specific symptom domains. Further work is necessary to validate these measures in FM. In addition, work is under way to develop composite response criteria, intended to address the multidimensional nature of this syndrome. A range of medical treatments, including antidepressants, opioids, nonsteroidal antiinflammatory drugs, sedatives, muscle relaxants, and antiepileptics, have been used to treat FM. Nonpharmaceutical treatment modalities, including exercise, physical therapy, massage, acupuncture, and cognitive behavioral therapy, can be helpful. Few of these approaches have been demonstrated to have clear-cut benefits in randomized controlled trials. However, there is now increased interest as more effective treatments are developed and our ability to accurately measure effect of treatment has improved. The multifaceted nature of FM suggests that multimodal individualized treatment programs may be necessary to achieve optimal outcomes in patients with this syndrome.
Posted by Dr. Shaw at 12:23 AM