SAN FRANCISCO – A two-page questionnaire is more helpful than a tender-point exam for diagnosing fibromyalgia in clinical practice, according to Dr. Andrew Gross.
Tender point exams – pressing on the 18 tender points of the body as advised in the American College of Rheumatology’s fibromyalgia classification criteria – can make even healthy people flinch in pain. The exam may be useful when enrolling patients in studies, but "for the most part, I find this a complete waste of time," he said at a conference on women’s health sponsored by the University of California, San Francisco.
Dr. Andrew Gross
*Instead, Dr. Gross hands patients with suspected fibromyalgia a brief questionnaire based on the ACR’s modified Diagnostic Criteria for Fibromyalgia (J. Rheumatol. 2001;38:1113-22) and steps out of the room while the patient completes the form."I use this in clinical practice all the time," said Dr. Gross, director of the Rheumatology Clinic at the university.
Patients fill out the questionnaire by checking off areas of the body in which they’ve experienced pain in the past week (the Widespread Pain Index). Dr. Gross also asks patients to provide information about the severity of their symptoms using a scale of 0-3 (none to severe) to quantify their degree of fatigue, extent of waking from sleep feeling unrefreshed, and cognitive symptoms, giving a symptom severity score. He then reviews the questionnaire with patients to understand the extent and severity of symptoms, and often diagnoses fibromyalgia when he determines there is a widespread pain score of 7 or more areas of the body plus a symptom severity score of at least 5.
Dr. Gross gives the questionnaire to patients who have the three hallmarks of fibromyalgia – widespread pain present for longer than 3 months, fatigue, and poor sleep. "If someone has pain in multiple areas, right away I’m thinking about fibromyalgia," he said.
Other tip-offs to fibromyalgia include cognitive problems, pain unrelieved by changing the body’s position, or the complaint that a specific activity had consequences. For example, "I helped my sister move the other day and I was in bed for a week." Odd complaints are another tip-off. One patient recently told him, "My body feels like it has tinnitus."
Before diagnosing fibromyalgia, Dr. Gross evaluates the patient for other medical conditions that can cause pain and/or fatigue. In addition to a comprehensive patient interview and physical examination, he orders a limited panel of blood tests to evaluate for other conditions. These include tests for erythrocyte sedimentation rate and C-reactive protein tests, a CBC, a comprehensive metabolic panel, a fasting glucose test, thyroid hormone tests, hepatitis B and C tests, and in some populations an HIV test. He checks vitamin D levels because vitamin D deficiency can aggravate pain, though it doesn’t cause it. If the patient is having weakness, he’ll check the creatinine phosphokinase level. In rare cases he’ll test for antinuclear antibodies. He’ll sometimes order x-rays of affected areas to look for joint damage, and he biopsies skin lesions that are concerning, particularly rashes. If there are many persistent neurologic symptoms, he may order an electromyogram.
Multiple studies have shown that the number of medical tests and costs increase over time for patients with undiagnosed fibromyalgia but level off or decrease once the diagnosis is made. "People stop looking for Lyme disease or multiple sclerosis or whatever," he said.
Dr. Gross reported having no relevant financial disclosures.
*CLARIFICATION: This story was revised on 1/15/2014 to include new information provided by Dr. Gross after publication.
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