What is the plan to rule out fibromyalgia?

Plan to Rule Out Fibromyalgia

The diagnosis of fibromyalgia requires a comprehensive assessment of pain, function, and psychosocial context, as it is a complex condition characterized by abnormal pain processing and various secondary features. 1

Diagnostic Approach

• Utilize the American College of Rheumatology (ACR) 1990 classification criteria, which requires a history of widespread pain for at least 3 months and pain at 11 or more of the 18 specific tender point sites 1, 2
• Consider using the Fibromyalgia Rapid Screening Tool as an initial screening method for patients presenting with diffuse chronic pain 3
• Alternatively, apply the 2010 ACR criteria or the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks-American Pain Society Pain Taxonomy diagnostic criteria, which don't require tender point examination 3, 4

Key Assessment Components

• Document pain distribution: Verify if pain is present in all four quadrants of the body (right/left side, above/below waist) for at least 3 months 2, 5
• Assess for associated symptoms that commonly accompany fibromyalgia:
  • Fatigue and non-restorative sleep 3, 5
  • Cognitive dysfunction ("fibro fog") 3, 6
  • Mood disturbances including depression and anxiety 3, 5
  • Other common symptoms: headache, irritable bowel symptoms, urinary frequency 2, 5

Exclusionary Testing

• Limited laboratory tests should be performed to rule out other conditions that may mimic fibromyalgia 3, 5:

  • Complete blood count
  • Comprehensive metabolic panel
  • Thyroid function tests
  • Erythrocyte sedimentation rate or C-reactive protein
  • Creatine kinase (to rule out myopathies)
  • Vitamin D levels

• Avoid extensive imaging studies as they are not required for fibromyalgia diagnosis and may lead to unnecessary healthcare utilization 3, 5

Evaluating Comorbidities

• Screen for common comorbid conditions that frequently coexist with fibromyalgia 3, 4:
  • Rheumatologic conditions (e.g., rheumatoid arthritis, systemic lupus erythematosus)
  • Psychiatric disorders (depression, anxiety)
  • Other functional somatic syndromes (irritable bowel syndrome, chronic fatigue syndrome)

Diagnostic Pitfalls to Avoid

• Relying solely on tender points for diagnosis, as the newer criteria incorporate other symptoms beyond pain 3, 4
• Assuming that fibromyalgia is a diagnosis of exclusion—it is a specific clinical entity with defined criteria 2, 5
• Continuing to search for other explanations after fibromyalgia diagnosis is established, which can lead to excessive testing and patient anxiety 3, 5

Next Steps After Diagnosis

• Provide patient education about the nature of fibromyalgia as a centralized pain syndrome 1, 7
• Develop a multidisciplinary treatment approach combining non-pharmacological and pharmacological modalities 1, 7
• Consider evidence-based treatments such as exercise therapy, cognitive behavioral therapy, and medications like amitriptyline, duloxetine, milnacipran, or pregabalin 1, 7, 8

Remember that establishing a positive diagnosis of fibromyalgia can actually reduce healthcare utilization and improve patient outcomes by providing a framework for appropriate management 1, 3.