Managing fibromyalgia: An update on diagnosis and treatment

Fibromyalgia syndrome (FMS) is characterized by widespread chronic pain and tenderness. Persons with FMS are a diverse population, with widely variable symptom presentation and severity, as well as secondary symptoms. Because the symptoms are so diverse, diagnosis and management become challenging. Mounting evidence supports altered CNS processing of nociceptive stimuli as a mechanism. American College of Rheumatology criteria have become accepted as the standard classification system for clinical research, but their use is controversial in the clinical setting. Diagnosis is based on a combination of the patient history, reports of clinical and evoked pain, and laboratory testing. Treatment currently focuses on controlling pain, improving sleep, reducing affective distress, and increasing physical function with a combination of pharmacological and nonpharmacological therapies. Fibromyalgia syndrome (FMS) is characterized by widespread chronic pain and tenderness at specific points across the body. The syndrome affects about 2% to 3% of the general US population and 4% of the female population.1 The ratio of female to male treatment-seekers ranges from 7 to 9 to 1.2 FMS has been observed in children, but its prevalence tends to peak in the fourth to sixth decade of life. The classic patient who has FMS presents with pain at multiple locations throughout her body, reports severe fatigue and stiffness, and describes difficulty in obtaining adequate sleep. However, persons with FMS are a diverse population, with widely variable symptom presentation and severity. Presentation of secondary symptoms, including cognitive dysfunction, abdominal pain, and headaches, is common. Because the symptoms reported are so diverse, diagnosis and management become challenging. In the medical literature, the set of symptoms associated with FMS has appeared in various forms and with different names (eg, fibrositis, tension myalgia, psychogenic rheumatism) since the early 1900s. In addition to the problem of multiple labels, diverse criteria (eg, pain reported on palpation of 11, 22, or 43 locations) and symptoms (eg, sleep disorders, diarrhea, headaches, fatigue) have been presented as core features of FMS. Given the inconsistencies in the literature, some authors have suggested that FMS is merely a vague set of associated symptoms that does not warrant a specific label and, furthermore, any label such as FMS is detrimental to the patient because it supports the person's belief that he or she is ill. The complexity of symptom presentation in FMS contributed to a 3-fold increase in total health care costs in patients with the condition compared with a control group of patients randomly selected from an insurance database.3 Given the prevalence and increased health care utilization, primary care physicians encounter patients with FMS on a routine basis and have a special need for current information with regard to diagnosis and treatment recommendations. In this article, we highlight recent developments about the diagnosis of FMS and evidence-based clinical practice guidelines for treatment. We outline current knowledge of the mechanisms that may underlie FMS, review current recommendations for disease classification, provide a diagnostic algorithm that may be used in clinical assessment, present both pharmacological and nonpharmacological treatment options, and describe American Pain Society (APS) treatment recommendations. CAUSES AND PATHOPHYSIOLOGY The causes and pathophysiology of FMS remain unclear; however, growth in understanding of the mechanisms has been seen over the past decade. It was thought originally that there was a peripheral mechanism involving the musculoskeletal system that manifested with reports of pain