1. Assessment and diagnosis

2. Overview

3. Clinical Features of Central Sensitization/Dysfunctional Pain
Pain all over body
Muscles stiff/achy
Headaches
Pain in jaw
Pelvic pain
Bladder/urination pain
Anxiety/depression
Sad or depressed
Anxiety
Stress makes symptoms worse
Tension in neck and shoulder
Grind/clench teeth
Fatigue
Do not sleep well
Unrefreshed in morning
Easily tired with physical activity
Other symptoms
Difficulty concentrating
Need help with daily activities
Sensitive to bright lights
Skin problems
Diarrhea/constipation
Speaker’s Notes
A growing body of evidence is demonstrating that central sensitization/dysfunctional pain represents a common pathophysiological mechanism for the overlapping clinical features of central sensitivity syndrome such as fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome and temporomandibular disorder. Within this emerging model, one can view symptoms of central sensitization/dysfunctional pain not as individual disorders, but as different manifestations of a common etiology.
This slide shows how clinical features of central sensitization/dysfunctional pain can be categorized as “pain,” “anxiety/depression,” “fatigue,” and “other symptoms.”
Reference
Mayer TG et al. The development and psychometric validation of the central sensitization inventory. Pain Pract 2012; 12(4):
Mayer TG et al. Pain Pract 2012; 12(4):

4. Central Sensitization Inventory (CSI)
A self-report measure designed to assess key somatic and emotional symptoms often associated with central sensitivity syndromes, including fibromyalgia
Clinical goal: help better assess symptoms to aid physicians in syndrome categorization, sensitivity, severity, identification, and treatment planning and to help minimize or avoid unnecessary diagnostics and treatment procedures
Fibromyalgia patients report high CSI scores
Test demonstrates psychometric strength, clinical utility and validity
Speaker’s Notes
Mayer et al developed the Central Sensitization Inventory (CSI), to assess key somatic and emotional complaints often associated with central sensitivity syndrome. This self-report measure was created from a literature search of comorbid symptoms and conditions of fibromyalgia and other central sensitivity syndromes.
The clinical goal the CSI is to help better assess symptoms thought to be associated with central sensitization to help physicians and other clinicians in syndrome categorization, sensitivity, severity identification, and treatment planning, to help minimize, or possibly avoid, unnecessary diagnostics and treatment procedures.
When the CSI was administered to four groups (fibromyalgia, chronic widespread pain without fibromyalgia, work-related regional chronic low back pain, normative control group), analyses revealed that the fibromyalgia patients reported the highest CSI scores, and the normative population the lowest (p <0.05).
The psychometric strength, clinical utility, and the initial construct validity of the CSI in evaluating central sensitization-related clinical symptoms in chronic pain populations has been demonstrated.
Reference
Mayer TG et al. The development and psychometric validation of the central sensitization inventory. Pain Pract 2012; 12(4):
Mayer TG et al. Pain Pract 2012; 12(4):

5. Central Sensitization Inventory (CSI)
Part A
Part B
Speaker’s Notes
The Central Sensitization Inventory (CSI) consists of two sections, parts A and B.
Part A contains 25 items with a range for the total score from 0–100. The item pool is intended to provide an overview of presenting symptoms that are common to central sensitivity syndromes, with higher scores associated with a higher degree of symptomology.
Part B identifies if one has been diagnosed by a physician with specific disorders within the central sensitivity syndrome family, as well as related disorders, including anxiety and depression. Because co-occurrence of these disorders in patients diagnosed with central sensitivity syndrome has been relatively well established, clinicians should consider the presence of a central sensitivity syndrome in patients who endorse one or more disorders on this section (particularly when accompanied by a high CSI score from part A).
Reference
Mayer TG et al. The development and psychometric validation of the central sensitization inventory. Pain Pract 2012; 12(4):
Mayer TG et al. Pain Pract 2012; 12(4):

6. Diagnosing Fibromyalgia
On average it takes patients >2 years to be diagnosed with fibromyalgia
A estimated 75% of people with fibromyalgia remain undiagnosed
Overview of Diagnosis
History of fibromyalgia or related conditions
Personal and family history
Physical examination
Most important to identify any other possible conditions
Differential diagnosis
Clinical/laboratory evaluation to identify other possible conditions
Consequences of Non-diagnosis
Failure to diagnose fibromyalgia is associated with increased costs and increased use of medical resources
Speaker’s Notes
The diagnosis of fibromyalgia is not straight forward. In fact, on average, patients are not diagnosed for more than two years after the onset of symptoms and an estimated 75% of patients with fibromyalgia go undiagnosed.
A diagnosis of fibromyalgia is made following a clinical evaluation, which includes a history of current complaints, attention to past health status and a physical examination, without any confirmatory diagnostic test. Physical examination is very important to identify any other possible conditions. The physician should consider the established diagnostic criteria for fibromyalgia, rule out other reasons for diffuse body pain, and perform a tender point exam. A differential diagnosis can be made by excluding other conditions such as osteoarthritis, rheumatoid arthritis, polymyalgia rheumatica, hypothyroidism, lupus and Sjögren’s syndrome. This can be achieved through clinical and laboratory evaluations.
Note: extensive lab evaluation is usually not necessary to rule out fibromyalgia. In some cases, a thyroid-stimulating hormone test may be called for. Polymyalgia rheumatica seldom occurs under the age of 60, whereas the onset of fibromyalgia after 65 years is rare.
References
Annemans L et al. Health economic consequences related to the diagnosis of fibromyalgia syndrome. Arthritis Rheum 58(3):
Choy E et al. A patient survey of the impact of fibromyalgia and the journey to diagnosis. BMC Health Serv Res 2010; 10:102.
Clauw DJ et al. The science of fibromyalgia. Mayo Clin Proc 2011; 86(9):
Mease P. Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment. J Rheumatol 2005; 32(Suppl 75):6-21.
Wolfe F et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: Report of the Multicenter Criteria Committee. Arthritis Rheum 1990; 33(2):
Annemans L et al. Arthritis Rheum 58(3): ; Choy E et al. BMC Health Serv Res 2010; 10:102; Clauw DJ et al. Mayo Clin Proc. 2011; 86(9):907-11; Mease P. J Rheumatol 2005; 32(Suppl 75):6-21; Wolfe F et al. Arthritis Rheum 1990; 33(2):

7. FiRST: Fibromyalgia Rapid Screening Tool
Self-administered 6-item questionnaire
Score of ≥5 is indicative of fibromyalgia
Sensitivity: 90.5%
Specificity: 85.7%
Items
I have pain all over my body.
My pain is accompanied by continuous and very unpleasant general fatigue.
My pain feels like burns, electric shocks or cramps.
My pain is accompanied by other unusual sensations throughout my body, such as pins and needles, tingling or numbness.
My pain is accompanied by other health problems such as digestive problems, urinary problems, headaches or restless legs.
My pain has a significant impact on my life, particularly on my sleep and my ability to concentrate, making me feel slower generally.
Speaker’s Notes
The Fibromyalgia Rapid Screening Tool (FiRST) was developed to detect fibromyalgia in patients with diffuse chronic pain. It is important to note that this tool is useful for screening for fibromyalgia but not for diagnosis.
Items requiring "yes/no" responses and relating to the most relevant clinical characteristics of fibromyalgia were compiled by a group of rheumatologists and pain experts. The provisional questionnaire was tested in a prospective multicenter study of 162 patients with chronic pain due to fibromyalgia (according to American College of Rheumatology [ACR] criteria) (n = 92) compared with a group of patients with chronic diffuse pain due to other rheumatic conditions, including rheumatoid arthritis (n = 32), ankylosing spondylitis (n = 25) and osteoarthritis (n = 13). Identification of the most discriminant combinations of items for fibromyalgia and the calculation of their sensitivity and specificity were based on both univariate and multivariate (stepwise logistic regression) analyses. The assessment of the psychometric properties of the questionnaire also dealt with face validity, content validity, test-retest reliability and convergent/divergent validity. Based on univariate and multivariate analyses, six items were retained in the final version of FiRST. These items were used to calculate the sensitivity, specificity and predictive accuracy of the questionnaire. A score of 5 or more is indicative of fibromyalgia with a sensitivity of 90.5% and a specificity of 85.7%.
Reference
Perrot S et al. Development and validation of the Fibromyalgia Rapid Screening Tool (FiRST). Pain 2010; 150(2):250-6.
Perrot S et al. Pain 2010; 150(2):250-6.

8. History

9. How to Recognize Fibromyalgia: Pain Is the Common Piece of the Puzzle
Leg cramps
Restless legs
Numbness/tingling
Fatigue
Pain
Insomnia
Speaker’s Notes
While there are a variety of symptoms associated with fibromyalgia, as shown n this slide, pain is the central component. In 293 patients with fibromyalgia, Wolfe et al found that widespread pain (axial plus upper and lower segment plus left- and right-sided pain) was present in almost all (97.6%) patients with fibromyalgia compared with 69.1% of all control patients (n = 265).
Reference
Wolfe F et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990; 33(2):
Nervousness
Impaired memory/concentration
Depression
Wolfe F et al Arthritis Rheum 1990; 33(2):

10. Patients with Fibromyalgia Present with a Global Pain Disorder
4/16/2017
Patients with Fibromyalgia Present with a Global Pain Disorder
This is a pain drawing
Patient colors all areas of the body in which he or she feels pain1
The diagram shows that the pain of fibromyalgia is widespread2
Speaker’s Notes
The pain of fibromyalgia is widespread.1 Typically, fibromyalgia patients present with complaints of diffuse body pain. Pain drawings can be used to characterize the location and size of painful areas. When fibromyalgia patients are asked to color in areas that are painful, they typically shade in areas all over the body to indicate their widespread pain.2
References
Silverman SL, Martin SA. In: Wallace DJ, Clauw DJ (eds). Fibromyalgia & Other Central Pain Syndromes. Lippincott, Williams & Wilkins; Philadelphia, PA: 2005.
Wolfe F et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990; 33(2):
Back
Front
Adapted from pain drawing provided courtesy of L Bateman.
1. Silverman SL, Martin SA. In: Wallace DJ, Clauws DJ (eds.). Fibromyalgia & Other Central Pain Syndromes. Lippincott, Williams & Wilkins; Philadelphia, PA: 2005; 2. Wolfe F et al. Arthritis Rheum 1990; 33(2):

11. Symptoms of Fibromyalgia
Pain, fatigue and sleep disturbance are present in at least 86% of patients*
100%
96%
100
86% 80
72%
60%
56% 60
52%
46%
42%
41% 40
Speaker’s Notes
Chronic, widespread pain is the defining feature of fibromyalgia. In 293 patients with fibromyalgia, Wolfe et al found that widespread pain (axial plus upper and lower segment plus left- and right-sided pain) was present in almost all (97.6%) patients with fibromyalgia compared with 69.1% of all control patients (n = 265).
In addition to pain, fatigue and sleep disturbances are the most common symptoms, occurring in ≥86% of patients with fibromyalgia. Other common physical symptoms associated with fibromyalgia include joint pain, headache, restless legs, numbness and tingling, and leg cramps.
Psychological symptoms are not uncommon in patients with fibromyalgia. As is seen in other chronic pain conditions, such as low back pain, osteoarthritis or rheumatoid arthritis, mood disorders such as depression or anxiety are sometimes present in fibromyalgia. As depicted on this slide, as many as 20% of patients with fibromyalgia may present with major depression. Other psychological symptoms can include impaired concentration and nervousness.
Reference
Wolfe F et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990; 33(2):
32%
20% 20
Fatigue
Insomnia
Muscular pain
Joint pains
Headaches
Restless legs
Impaired memory
Leg cramps
Nervousness
Major depression
Impaired concentration
*United States data
Wolfe F et al Arthritis Rheum 1990; 33(2):

12. Core Clinical Features of Fibromyalgia
Widespread pain
Neurocognitive impairment
(“fibro fog”)
Chronic, widespread pain is the defining feature of fibromyalgia
Patient descriptors of pain include:
Aching
Exhausting
Nagging
Hurting
Widespread Pain
Chronic, widespread pain is the defining feature of fibromyalgia
Patient descriptors of pain include: aching, exhausting, nagging, and hurting
Presence of tender points
Sleep disturbance/fatigue
Mood disorders
Speaker’s Notes
Although the defining feature of fibromyalgia is chronic, widespread pain, neurocognitive impairment (“fibro fog”), sleep disturbances, fatigue, mood disorders, tenderness and morning stiffness may also be present. Patients often describe their pain as aching, exhausting, nagging or hurting. Cognitive dysfunction, which includes poor working memory, spatial memory alterations, free recall and verbal fluency, associates with pain in fibromyalgia as well as other pain patients and is different from healthy controls. “Fibro fog” is characterized by confusion, slowed processing of information and reaction time, difficulty in word retrieval or speaking, concentration, attention, short- term memory consolidation, and disorientation.
Fibromyalgia-associated sleep disturbances are typically characterized by non-restorative sleep and increased awakenings. Abnormal components of sleep include sleep latency, sleep disturbance, and fragmented sleep leading to impaired daytime function. Poor sleep negatively impacts fatigue, affect and pain, with improvement in these parameters when sleep specifically is addressed. Other sleep disorders such as restless leg syndrome or sleep apnea may also occur in patients with fibromyalgia.
Fatigue, reported to be present in over 90% of fibromyalgia patients, is the most common associated complaint. Fatigue may be more disabling than pain for some, and contributes to subjective report of functional impairment. Patients with fibromyalgia often describe their fatigue as physically or emotionally draining.
Mood disorder, including depression and/or anxiety, is present in up to 75% of persons with fibromyalgia , but mood disorders and fibromyalgia are likely distinct. Anxiety commonly coexists with depression, but is also independently increased in fibromyalgia patients.
Morning stiffness is also a common characteristic of fibromyalgia.
References
Carruthers BM et al. Myalgic encephalomyelitis/chronic fatigue syndrome: clinical working case definition, diagnostic and treatment guidelines, a consensus document. J Chron Fat Synd 2003; 11(1):7-115.
Harding SM. Sleep in fibromyalgia patients: subjective and objective findings. Am J Med Sci 1998; 315(6):
Henriksson KG. Fibromyalgia – from syndrome to disease: overview of pathogenetic mechanisms. J Rehabil Med 2003; 41(41 Suppl):89-94.
Leavitt F et al. Comparison of pain properties in fibromyalgia patients and rheumatoid arthritis patients. Arthritis Rheum 1986; 29(6):
Roizenblatt S et al. Alpha sleep characteristics in fibromyalgia. Arthritis Rheum 2001; 44(1):
Wolfe F et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990; 33(2):
Wolfe F et al. Arthritis Rheum The prevalence and characteristics of fibromyalgia in the general population. 1995; 38(1):19-28.
Morning stiffness
Carruthers BM et al. J Chron Fat Synd 2003; 11(1):7-115; Harding SM. Am J Med Sci 1998; 315(6):367-37; Henriksson. J Rehabil Med 2003; 41(41 Suppl):89-94; Leavitt et al. Arthritis Rheum 1986; 29(6):775-81; Roizenblatt S et al. Arthritis Rheum 2001; 44(1):222-30; Wolfe F et al Arthritis Rheum 1990; 33(2):160-72; Wolfe F et al. Arthritis Rheum 1995; 38(1):19-28.

13. Stressors
Some triggering event may trigger fibromyalgia but is not a prerequisite
Onset of fibromyalgia is often gradual, with no identifiable trigger
Stressors that may trigger fibromyalgia:
Peripheral pain syndromes
Physical trauma,
Infections (e.g., parvovirus, Epstein-Barr virus, Lyme disease, Q fever)
Psychological stress/distress, including sleep disturbances
Speaker’s Notes
Stressful events may contribute to the development of fibromyalgia. These stressors — including traumatic events such as motor vehicle collision or infectious illness, and situations such as military deployment — may contribute to the development of persistent somatic symptoms, such as chronic pain and fatigue, and/or psychological disturbances.
Recent findings from the study of risk factors for the development of chronic somatic symptoms after a traumatic, infectious or situational stressor suggest that similar pre-event, event-related and post-event risk factors influence the development of chronic symptoms. Females, and those with pre-event distress or psychological factors, may be at higher risk of developing chronic symptoms after such events.1
However, it is important to note that, in many cases, the onset of fibromyalgia is gradual, with no identifiable cause or trigger.
In a Canadian study,2 29 of 127 (23%) patients reported having trauma, surgery or a medical illness before the onset of fibromyalgia, and were classified as having reactive fibromyalgia. Patients in this group were more disabled than those with primary fibromyalgia, resulting in loss of employment in 70%, disability compensation in 34%, and reduced physical activity in 45%. So, the development of fibromyalgia after a precipitating event may represent the onset of a prolonged and disabling pain syndrome with considerable social and economic implications.
References
McLean SA, Clauw DJ. Predicting chronic symptoms after an acute "stressor"— lessons learned from 3 medical conditions. Med Hypotheses 2004; 63(4):653-8.
Greenfield S et al. Reactive fibromyalgia syndrome. Arthritis Rheum 1992; 35(6):
Development of fibromyalgia after a precipitating event may represent the onset of a prolonged and disabling pain syndrome with considerable social and economic implications.
Greenfield S et al. Arthritis Rheum 1992; 35(6):678-81; McLean SA, Clauw DJ. Med Hypotheses 2004; 63(4):653-8.

14. Fibromyalgia as a Consequence of Trauma
Factors Triggering Fibromyalgia or Associated with its Onset (n = 136)
Factor
Trigger factors
Associated factors*
Cold 15
Stress 9 35
Emotions 5
Overwork 22
Trauma 24
Surgery 4 13
Death in the family
Family problems 2 25
Fatigue 23
No cause/association 55
Speaker’s Notes
Findings from a study by Wolfe et al showed that in the majority of cases there is no identifiable cause of fibromyalgia.
Reference
Wolfe F. The clinical syndrome of fibrositis. Am J Med 1986; 81(3A):7-14.
In most cases of fibromyalgia, there is no predisposing trigger.
*More than one factor possible for the same patient
Adapted from: Wolfe F. Am J Med 1986; 81(3A):7-14.

15. Modulating Factors of Fibromyalgia Syndrome Pain
Exacerbating factors
Mean %
Relieving factors
Weather (cold, humidity) 65
Local heat 58
Poor sleep 70
Rest 54
Anxiety, stress 61
Moderate activities 46
Physical inactivity 49
Stretching exercises 43
Noise 22
Massage 40
Speaker’s Notes
This table shows the mean percentage of patients with fibromyalgia whose symptoms are exacerbated or improved by the activities listed.
Pain and stiffness associated with fibromyalgia are often aggravated by cold or humid weather, anxiety, stress, overuse (including occupational use), inactivity and poor sleep. Up to 70% of patients with fibromyalgia complain of poor sleep. Many patients with fibromyalgia are also sensitive to smell and noise, and psychological distress is associated with the severity of pain and other symptoms.
Many patients report moderate physical activity, local heat, massage, rest and relaxation, and stretching exercises to be beneficial.
Reference
Yunus MB. In: Wallace DJ, Clauw DJ (eds). Fibromyalgia & Other Central Pain Syndromes. Lippincott, Williams & Wilkins; Philadelphia, PA: 2005.
Yunus MB In: Wallace DJ, Clauw DJ (eds). Fibromyalgia & Other Central Pain Syndromes. Lippincott, Williams & Wilkins; Philadelphia, PA: 2005.

16. Symptom Intensity Scale (SIS)
Easy, rapid way to assess regional pain and fatigue in a patient
Can uncover comorbid depression
Is a simple way to measure overall health
Can detect fibromyalgia in patients who have other diseases
When fatigue is the dominant system, questionnaire includes consideration of obstructive sleep apnea
SIS score is derived from 2 distinct measures:
Speaker’s Notes
The SIS is an easy, rapid way to assess regional pain and fatigue in a patient. The questionnaire serves as a surrogate measure of depression, anxiety, other serious personality disorders, previous or ongoing abuse. When fatigue is the dominant system, the questionnaire includes consideration of obstructive sleep apnea.
The SIS score is derived from two distinct measures:
The Regional Pain Scale score, which is the number of anatomic areas – out of a possible 19 – in which the patient feels pain
A fatigue visual analog scale score, in which the patient makes a mark somewhere along a 10-cm line to indicate how tired he or she feels. Subsequently, the clinician measures the position of the mark from the left end of the line with a ruler.
Reference
Wilke WS. New developments in the diagnosis of fibromyalgia syndrome: say goodbye to tender points? Cleve Clin J Med 2009; 76(6):
Regional Pain Score +
Fatigue Visual Analog Score
Number of anatomic areas (out of 19) in which the patient feels pain
Patient makes a mark somewhere along a 10-cm line to indicate how tired he or she feels
Wilke WS. Cleve Clin J Med 2009; 76(6):

17. Symptom Intensity Scale (SIS)
Speaker’s Notes
The SIS is an easy, rapid way to assess regional pain and fatigue in a patient. The questionnaire serves as a surrogate measure of depression, anxiety, other serious personality disorders, previous or ongoing abuse. When fatigue is the dominant system, the questionnaire includes consideration of obstructive sleep apnea.
The SIS score is derived from two distinct measures:
The Regional Pain Scale score, which is the number of anatomic areas – out of a possible 19 – in which the patient feels pain
A fatigue visual analogue scale score, in which the patient makes a mark somewhere along a 10-cm line to indicate how tired he or she feels. Subsequently, the clinician measures the position of the mark from the left end of the line with a ruler.
Reference
Wilke WS. New developments in the diagnosis of fibromyalgia syndrome: say goodbye to tender points? Cleve Clin J Med 2009; 76(6):
Wilke WS. Cleve Clin J Med 2009; 76(6):

18. Fibromyalgia Impact Questionnaire (FIQ)
Developed to capture the total spectrum of problems related to fibromyalgia and responses to therapy
Has been shown to have a credible construct validity, reliable re- test characteristics, and a good sensitivity in demonstrating therapeutic change
Commonly used as an outcome measure in therapeutic trials
Self-administered; requires 3–5 minutes to complete
Simple directions and scoring
Has been translated into 8 languages
Most recent version is available at
Speaker’s Notes
The Fibromyalgia Impact Questionnaire (FIQ) was developed to capture the total spectrum of problems related to fibromyalgia and the responses to therapy. Overall, it has been shown to have a credible construct validity, reliable re-test characteristics, and a good sensitivity in demonstrating therapeutic change.
The test is self-administered and patients can normally complete it in 3–5 minutes. The directions for the test are simple and the scoring is self-explanatory.
Overall, the FIQ appears to be a sensitive index of change in fibromyalgia related symptomatology, which correlates with degree of disability, and discriminates between fibromyalgia and some other chronic pain problems. The FIQ has been most commonly used as an outcome measure in therapeutic trials. In general, it has shown a good response to appropriate clinical change.
 The FIQ has been translated into eight languages: German, French, Korean, Spanish, Turkish, Italian, Hebrew and Swedish. Each of these translations, with the exception of one, tested the construct validity with the Health Assessment Questionnaire (HAQ) or Arthritis Impact Measurement Scale (AIMS). All translations provided data on test-retest reliability. All but two assessed internal consistency with a Cronbach's alpha statistic. Overall, the translations performed with a validity, consistency and test-retest reliability similar to the original English version.
Reference
Bennett R. The Fibromyalgia Impact Questionnaire (FIQ): a review of its development, current version, operating characteristics and uses. Clin Exp Rheumatol 2005; 23(5 Suppl 39):S
Bennett R. Clin Exp Rheumatol 2005; 23(5 Suppl 39):S

19. Fibromyalgia Impact Questionnaire (FIQ)
Speaker’s Notes
The Fibromyalgia Impact Questionnaire (FIQ) is composed of 10 questions. The first question contains 11 items related to the ability to perform large muscle tasks; each question is rated on a four-point Likert type scale. Items 2 and 3 ask the patient to mark the number of days they felt well and the number of days they were unable to work (including housework) because of fibromyalgia symptoms. Items 4 through 10 are horizontal linear scales marked in 10 increments on which the patient rates work difficulty, pain, fatigue, morning tiredness, stiffness, anxiety and depression.
The FIQ is a self-administered instrument that takes approximately 3–5 minutes to complete. The directions are simple and the scoring is self-explanatory. Extensive use of the questionnaire indicates that most subjects can follow the written instructions accurately without any additional verbal instruction.
Reference
Bennett R. The Fibromyalgia Impact Questionnaire (FIQ): a review of its development, current version, operating characteristics and uses. Clin Exp Rheumatol 2005; 23(5 Suppl 39):S
Bennett R. Clin Exp Rheumatol 2005; 23(5 Suppl 39):S

20. Fibromyalgia Impact Questionnaire (FIQ)
“For the remaining items, mark the point on the line that beat indicates how you felt overall for the past week.”
Speaker’s Notes
The Fibromyalgia Impact Questionnaire (FIQ) is composed of 10 questions. The first question contains 11 items related to the ability to perform large muscle tasks; each question is rated on a four-point Likert type scale. Items 2 and 3 ask the patient to mark the number of days they felt well and the number of days they were unable to work (including housework) because of fibromyalgia symptoms. Items 4 through 10 are horizontal linear scales marked in 10 increments on which the patient rates work difficulty, pain, fatigue, morning tiredness, stiffness, anxiety and depression.
The FIQ is a self-administered instrument that takes approximately 3–5 minutes to complete. The directions are simple and the scoring is self-explanatory. Extensive use of the questionnaire indicates that most subjects can follow the written instructions accurately without any additional verbal instruction.
Reference
Bennett R. The Fibromyalgia Impact Questionnaire (FIQ): a review of its development, current version, operating characteristics and uses. Clin Exp Rheumatol 2005; 23(5 Suppl 39):S
Bennett R. Clin Exp Rheumatol 2005; 23(5 Suppl 39):S

21. Physical Examination

22. Physical Exam: Manual Tender Point Survey
Based on 1990 ACR tender point protocol for fibromyalgia
Can be performed in 5–10 minutes
18 survey and 3 control sites examined in a specific numerical order
Control sites reveal baseline of patient's pain perception
Speaker’s Notes
The Manual Tender Point Survey, based on the 1990 ACR tender point protocol for fibromyalgia, takes about 5–10 minutes to perform. The standard procedure for applying pressure uses the thumb pad of the examiner's dominant hand. This method has been shown to be as reliable as the use of a dolorimeter (strain gauge) and allows the examiner to make use of important tactile cues
Reference
National Fibromyalgia Association. The Manual Tender Point Survey. Available at: Accessed: August 13, 2013.
ACR = American College of Rheumatology
National Fibromyalgia Association. The Manual Tender Point Survey. Available at: Accessed: August 13, 2013

23. Performing a Manual Tender Point Survey
Digital palpation with an approximate force of 4 kg
Estimated pressure needed to turn the examiner’s thumbnail white upon depressing
For a “positive” tender point, subject must state palpation was painful
Accuracy for fibromyalgia:
Sensitivity: 88.4%
Specificity: 81.1%
Controversies regarding tender point evaluation:
Subjective
May not be necessary for diagnostic studies
What about fewer than 11 of 18 tender points?
Speaker’s Notes
The Manual Tender Point Survey, based on the 1990 American College of Rheumatology tender point protocol for fibromyalgia, takes about 5–10 minutes to perform. The standard procedure for applying pressure uses the thumb pad of the examiner's dominant hand. This method has been shown to be as reliable as the use of a dolorimeter (strain gauge) and allows the examiner to make use of important tactile cues.
Survey sites are first located visually, and then with light palpation. Thumb pressure is then applied perpendicular to each survey site. Each site is pressed for 4 seconds only once to avoid sensitization that may occur with repeated palpation. The force is increased by 1 kg/second until 4 kg of pressure is achieved. Whitening of the examiner's nail bed usually occurs when applying the 4 kg of pressure.
A number of factors may influence the sensitivity of tender points during an examination: (1) amount of force applied at the survey site, (2) number of times (single vs. repeated) and method (finger pad, dolorimeter) by which the force is applied, and (3) patient's position, which affects muscle tone and survey site localization. The sequence of site examination may influence the patient's response based on the anchoring effect of sensations experienced at prior survey sites. A standardized procedure enhances the reliability of the test. According to Wolfe et al, these criteria are sensitive (88.4%) and specific (81.1%) for fibromyalgia. However, the method remains controversial due to its subjective nature and the fact that it does not account for patients who have fewer than 11 tender points but who may still have fibromyalgia.
References
National Fibromyalgia Association. The Manual Tender Point Survey. Available at: Accessed: August 13, 2013.
Wilke WS. New developments in the diagnosis of fibromyalgia syndrome: say goodbye to tender points? Cleve Clin J Med 2009; 76(6):
Wolfe F et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990; 33(2):
National Fibromyalgia Association. The Manual Tender Point Survey. Available at Accessed August 13, 2013; Wilke WS. Cleve Clin J Med 2009; 76(6):345-52; Wolfe F et al. Arthritis Rheum 1990; 33(2):

24. Manual Tender Point Survey: Illustration of 18 Tender Points
Lateral epicondyle (2) – 2 cm distal to epicondyles
Occiput (2) – at suboccipital muscle insertions
Low cervical (2) – at anterior aspects of the intertransverse spaces at C5-C7
Trapezius (2) – at midpoint of upper border
Supraspinatus (2) – at origins, above scapula spine near medial border
Second rib (2) – upper lateral to second costochondral junction
Gluteal (2) – in upper outer quadrants of buttocks in anterior fold of muscle
Greater trochanter (2) – posterior to trochanteric prominence
Knee (2) – at medial fat pad proximal to joint line
Speaker’s Notes
This slide illustrates the location of the tender points. Emphasize that the examiner should perform the examination with sufficient pressure to turn the thumbnail white.
Reference
Wolfe F et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990; 33(2):
Wolfe F et al. Arthritis Rheum 1990; 33(2):

25. Imaging and Other Tests

26. Imaging and Laboratory Tests: Fibromyalgia
No specific tests are necessary to diagnosis fibromyalgia, but may be useful to exclude other diagnoses
Speaker’s Notes
While there are no specific tests available to diagnose fibromyalgia, laboratory tests or X-rays may be used to rule out other health problems.
Reference
American College of Rheumatology. Fibromyalgia. Available at: romyalgia/. Accessed: September 9, 2013.
American College of Rheumatology. Fibromyalgia. Available at: Accessed: September 9, 2013.

27. Differential Diagnosis of Fibromyalgia
Hypothyroidism
Vitamin D deficiency
Inflammatory rheumatic disease
Cancer
Inflammatory muscle diseases
Speaker’s Notes
Many cases of fibromyalgia do not precisely align with a standardized set of diagnostic criteria. However, it is not believed to be a diagnosis of exclusion, although some health care providers have labeled it as such. Because there is an absence of absolute, definitive diagnostic criteria with universal applicability, providers often settle upon this diagnosis following negative testing for other differentials. Rather than assuming a diagnosis of fibromyalgia, carefully considering a multitude of potential diagnoses, as shown in this slide, will decrease the likelihood of a misdiagnosis. Some of the common differentials to consider in patients exhibiting symptoms of fibromyalgia are hypothyroidism, vitamin D deficiency, cancer, inflammatory muscle disease and inflammatory rheumatic diseases.
Rahman A et al. Fibromyalgia. BMJ 2014; 348:g1224.
Rahman A et al. BMJ 2014; 348:g1224.

28. Differential diagnoses Diagnostic testing options
Differential Diagnoses for Fibromyalgia and Corresponding Testing Options
Differential diagnoses
Diagnostic testing options
Adrenal dysfunction
Morning serum cortisol, urinary catecholamine metabolites
Anemia
CBC with differential, RBC indices (MCV, MCH, MCHC)
Bone marrow disease
WBC differential, ESR, CRP, CMP
Chronic fatigue syndrome
Clinical history
Functional disorders (e.g., intestinal dysbiosis, subtle endocrine imbalances, and postviral immune suppression)
Standard laboratory testing yields unclear results
Hypothyroidism
Thyroid function tests (T3, T4, TSH)
Lyme disease
Lyme titer, CMP
Psychiatric conditions (e.g., post-traumatic stress disorder, anxiety, and depression)
Refer to DSM
Speaker’s Notes
Many cases of fibromyalgia do not precisely align with a standardized set of diagnostic criteria. However, it is not believed to be a diagnosis of exclusion, although some health care providers have labeled it as such. Because there is an absence of absolute, definitive diagnostic criteria with universal applicability, providers often settle upon this diagnosis following negative testing for other differentials. Rather than assuming a diagnosis of fibromyalgia, carefully considering a multitude of potential diagnoses, as shown in this slide, will decrease the likelihood of a misdiagnosis. Five of the common differentials to consider in patients exhibiting symptoms of fibromyalgia are mental health disorders, hypothyroidism, rheumatoid arthritis, adrenal dysfunction, and multiple myeloma.
Reference
Bellato E et al. Fibromyalgia syndrome: etiology, pathogenesis, diagnosis, and treatment. Pain Res Treat 2012; 2012:
CBC = complete blood count; CMP = common myeloid progenitor; CRP = C-reactive protein; DSM = Diagnostic and Statistical Manual of Mental Disorders; ESR = erythrocyte sedimentation rate; MCH = mean corpuscular hemoglobin; MCHC = mean corpuscular hemoglobin concentration; MCV = mean corpuscular volume; RBC = red blood cell; TSH = thyroid-stimulating hormone; WBC = white blood cell
Bellato E et al. Pain Res Treat 2012; 2012:

29. Differential Diagnoses Diagnostic Testing Options
Differential Diagnoses for Fibromyalgia and Corresponding Testing Options (cont’d)
Differential Diagnoses
Diagnostic Testing Options
Multiple sclerosis
MRI scan, lumbar puncture, evoked potential testing
Phenomenological referred myofascial pain
Muscular tender points on physical examination
Rheumatoid autoimmune disorders (e.g., rheumatoid arthritis, ankylosing spondylitis, scleroderma)
Rheumatic profile (rheumatoid factor, ESR/CRP), ANA
Sleep disorders
EEG sleep studies
Spinal facet pain or sacroiliac joint pain
Radiologic studies (MRI scan, CT scan), bone scans (minimal diagnostic assistance)
Spinal disc herniation
MRI scan
Systemic inflammation or infection
Vitamin and/or mineral deficiency
Speaker’s Notes
Many cases of fibromyalgia do not precisely align with a standardized set of diagnostic criteria. However, it is not believed to be a diagnosis of exclusion, although some health care providers have labeled it as such. Because there is an absence of absolute, definitive diagnostic criteria with universal applicability, providers often settle upon this diagnosis following negative testing for other differentials. Rather than assuming a diagnosis of fibromyalgia, carefully considering a multitude of potential diagnoses, as shown in this slide, will decrease the likelihood of a misdiagnosis. Five of the common differentials to consider in patients exhibiting symptoms of fibromyalgia are mental health disorders, hypothyroidism, rheumatoid arthritis, adrenal dysfunction, and multiple myeloma.
Reference
Bellato E et al. Fibromyalgia syndrome: etiology, pathogenesis, diagnosis, and treatment. Pain Res Treat 2012; 2012:
ANA = antinuclear antibody; CRP = C-reactive protein; CT = computed tomography; EEG = electroencephalography ESR = erythrocyte sedimentation rate; MRI = magnetic resonance imaging
Bellato E et al. Pain Res Treat 2012; 2012:

30. Diagnosis

31. Is it fibromyalgia or chronic fatigue syndrome?
Primary symptom is generalized muscle pain
Primary sign is pain at more than 11 of 18 tender points
20–70% meet criteria for chronic fatigue syndrome1
Primary symptom is post-exertional malaise, fatigue
No current diagnostic test but mitochondrial dysfunction is suspected
Score of <50 on SF-36 physical function scale can help differentiate from major depression
75% also meet criteria for fibromyalgia2 
Speaker’s Notes
Patients with chronic fatigue syndrome and fibromyalgia share many clinical illness features such as myalgia, fatigue, sleep disturbances, and impairment in ability to perform activities of daily living as a consequence of these symptoms. However, fibromyalgia and chronic fatigue syndrome can be differentiated on the basis of symptom balance: pain is the major feature of fibromyalgia whereas post-exertional malaise and fatigue are the major symptoms of chronic fatigue syndrome.
Many patients with chronic fatigue syndrome are also diagnosed with fibromyalgia and vice versa.
References
Aaron LA et al. Overlapping conditions among patients with chronic fatigue syndrome, fibromyalgia and temporomadibular disorder. Arch Intern Med 2000; 160(2):221-7.
Goldenberg DL et al. High frequency of fibromyalgia in patients with chronic fatigue seen in a primary care practice. Arthritis Rheum 1990; 33(3):381-7.
1. Aaron LA et al. Arch Intern Med 2000; 160(2):221-7; 2. Goldenberg DL et al. Arthritis Rheum 1990; 33(3):381-7.

32. ACR Classification Criteria for Fibromyalgia (1990)
ACR criteria:
History of chronic widespread pain ≥3 months
Patients must exhibit ≥11 of 18 tender points
ACR criteria are both sensitive (88.4%) and specific (81.1%)
Speaker’s Notes
The 1990 ACR criteria for the classification for fibromyalgia require that patients have a history of chronic pain for ≥3 months and pain in ≥11 of 18 tender point sites on digital palpation. To determine the criteria for the classification of fibromyalgia, Wolfe et al studied 558 patients; widespread pain, defined as axial plus upper and lower segment plus left- and right-sided pain, was demonstrated in 97.6% of fibromyalgia patients (n = 293) and 69.1% of control patients (n = 265). Controls were age- and sex-matched patients with neck pain syndromes, low back pain syndromes, trauma-related pain syndromes, and possible systemic lupus erythematosus or rheumatoid arthritis. Sleep disturbances, fatigue and morning stiffness were present in >75% of fibromyalgia patients.
Although the ACR criteria can be used to differentiate fibromyalgia from other rheumatologic conditions, the criteria were originally intended as a research tool. Therefore, it is important to note that the ACR criteria are useful for classification of fibromyalgia but not for diagnosis. “Expert opinion” remains the gold standard in making a diagnosis of fibromyalgia. There are no objective findings for fibromyalgia on physical exam or from laboratory tests. Although Wolfe et al found tender points were the most powerful discriminator between fibromyalgia patients and controls, tenderness is subjective and depends upon the examiner’s strength of palpation.
It should be noted that Wolfe et al reported the ACR criteria are sensitive (88.4%) and specific (81.1%) for fibromyalgia; this was not demonstrated outside a rheumatology clinic.
Reference
Wolfe F et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990; 33(2):
ACR = American College of Rheumatology
Wolfe F et al. Arthritis Rheum 1990; 33(2):

33. ACR Proposed Diagnostic Criteria for Fibromyalgia (2010)
Fibromyalgia can be diagnosed if:
Patient experiences widespread pain and associated symptoms
Symptoms have been present at same level for ≥3 months
No other condition otherwise explains the pain
Associated symptoms include:
Unrefreshed sleep
Cognitive symptoms
Fatigue
Other somatic symptoms
Speaker’s Notes
Over time, a series of objections to the 1990 ACR classification criteria for fibromyalgia developed. First, it became increasingly clear that the tender point count was rarely performed in primary care where most fibromyalgia diagnoses occurred, and when performed, was performed incorrectly. Many physicians did not know how to examine for tender points and some simply refused to do so. Consequently, fibromyalgia diagnosis in practice has often been a symptom-based diagnosis. Second, the importance of certain symptoms, such as fatigue, cognitive symptoms and the extent of somatic symptoms, were not considered when the 1990 guidelines were developed. Additionally, many fibromyalgia experts believed tender points obscured important considerations and erroneously linked the disorder to peripheral muscle abnormality. Finally, some physicians considered that fibromyalgia was a spectrum disorder and was not well served by dichotomous criteria.
Another important problem was that patients who improved or whose symptoms and tender points decreased could fail to satisfy the ACR 1990 classification definition. It was not clear how to categorize or assess these patients. In addition, the ACR classification criteria set such a high bar for diagnosis that there was little variation in symptoms among fibromyalgia patients. These two considerations suggested the need for a broad-based severity scale that could differentiate among patients according to the level of fibromyalgia symptoms.
As a result, in 2010, the ACR proposed that a patient satisfies diagnostic criteria for fibromyalgia if the following three conditions are met:
Widespread Pain Index (WPI) score of 7 and symptom severity (SS) scale score of 5 or WPI of 3–6 and SS scale score of 9
Symptoms have been present at a similar level for ≥3 months
The patient does not have a disorder that would otherwise explain the pain
Reference
Wolfe F et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken) 2010; 62(5):
ACR = American College of Rheumatology
Wolfe F et al. Arthritis Care Res (Hoboken) 2010; 62(5):

34. ACR Diagnostic Criteria for Fibromyalgia – 2010
The 2010 ACR criteria require assessment of 3 key elements:
Presentation of widespread pain and symptoms for ≥3 months
Widespread Pain Index (WPI)*
Assesses number of painful body areas
Symptom Severity Scale (SSS)*
Assesses severity of fatigue, waking unrefreshed, cognitive symptoms, and extent of other somatic symptoms
Speaker’s Notes
In 2010, the ACR proposed that a patient satisfies diagnostic criteria for fibromyalgia if all of the following three conditions are met:
Widespread pain index (WPI) score of 7 and symptom severity (SS) scale score of 5 or WPI of 3 to 6 and SS scale score of 9
Symptoms have been present at a similar level for ≥3 months
The patient does not have a disorder that would otherwise explain the pain
Reference
Wolfe F et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken) 2010; 62(5):
*Health care practitioner-administered questionnaire
ACR = American College of Rheumatology
Wolfe F et al. Arthritis Care Res (Hoboken) 2010; 62(5):

35. Widespread Pain Index (WPI)
Speaker’s Notes
The patient’s Widespread Pain Index (WPI) should be calculated by using the list of 19 body areas and identifying the areas where the patient felt pain over the past week. As a visual aid, front/back body diagrams are included. Each area identified on the list counts as one. The number of painful body areas is totaled to given the WPI score, which can range from 0–19.
Reference
Wolfe F et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken) 2010; 62(5):
Wolfe F et al. Arthritis Care Res (Hoboken) 2010; 62(5):

36. Symptom Severity Scale (SSS) (Part A)
Speaker’s Notes
The patient’s level of symptom severity can be measured by indicate the patient’s level of symptom severity over the past week on a scale of 0–3 in each of the three symptom categories. Only one level of severity should be chosen for each category. The score is the sum of the numbers that correspond to the severity levels identified in all three categories
Reference
Wolfe F et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken) 2010; 62(5):
Wolfe F et al. Arthritis Care Res (Hoboken) 2010; 62(5):

37. Symptom Severity Scale – Other Somatic Symptoms (Part B)
Speaker’s Notes
The extent of the patient’s other somatic symptoms may be determined by counting the number of somatic symptoms based on the symptoms listed.
Reference
Wolfe F et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken) 2010; 62(5):
Wolfe F et al. Arthritis Care Res (Hoboken) 2010; 62(5):

38. What the Patient’s Scores Mean
Speaker’s Notes
In 2010, the American College of Rheumatology (ACR) proposed that a patient satisfies diagnostic criteria for fibromyalgia if all of the following three conditions are met:
Widespread pain index (WPI) score of 7 and symptom severity (SS) scale score of 5 or WPI of 3–6 and SS scale score of 9
Symptoms have been present at a similar level for ≥3 months
The patient does not have a disorder that would otherwise explain the pain
Reference
Wolfe F et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken) 2010; 62(5):
WPI = widespread Pain Index; SS = Symptom Severity
Wolfe F et al. Arthritis Care Res (Hoboken) 2010; 62(5):

39. Example of Patient Self-report Survey for the Assessment of Fibromyalgia
Speaker’s Notes
The self-completed fibromyalgia assessment shown on this slide was developed to allow for the use of the ACR diagnostic criteria in epidemiological and clinical studies without requiring an examiner. However, busy clinical practitioners may also find such self-completed screening tools to be useful.
Reference
Wolfe F et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR preliminary diagnostic criteria for fibromyalgia. J Rheumatol 2011; 38(6):
The possible score ranges from 0 to 31 points; a score ≥13 points is consistent with a diagnosis of fibromyalgia.
Wolfe F et al. J Rheumatol 2011; 38(6):

40. Tips on Providing the Diagnosis of Fibromyalgia
Be specific about the diagnosis
Be positive about the diagnosis
Promote and encourage patient self-efficacy around the disease but...
Set realistic expectations
Emphasize there is no cure but improved control of symptoms is usually possible
Speaker’s Notes
This slide lists several tips for providing a patient with a diagnosis of fibromyalgia.
It is important to be both specific and positive about the diagnosis. It is important to promote and encourage patient self-efficacy around fibromyalgia, but it is equally important to ensure patients have realistic expectations for therapies and to emphasize that while improved control of symptoms is usually possible, there is no cure for fibromyalgia.
Reference
Arnold LM et al. A framework for fibromyalgia management for primary care providers. Mayo Clin Proc 2012; 87(5):
Arnold LM et al. Mayo Clin Proc 2012; 87(5):

41. Diagnosis of Fibromyalgia Can Improve Patient Satisfaction
IMPROVEMENT
Speaker’s Notes
For a variety of reasons, the labeling of certain chronic pain patients as having fibromyalgia sparked much debate. One of the arguments was that the label of fibromyalgia , in itself, might precipitate or exacerbate behavior that has been variably termed “illness behavior,” “learned pain” and “learned helplessness”. This might result in heightened symptoms, worsened function, increased disability claims and increased health care- seeking behavior.
To determine if assigning the label of fibromyalgia to individuals with chronic widespread pain has a significant effect on long-term health status, function, and health service utilization, White et al conducted the London Fibromyalgia Epidemiology Study in which 100 individuals with fibromyalgia were identified by screening non-institutionalized adults. Only 28 of the 100 had been previously diagnosed with fibromyalgia; for 72, the diagnostic label was new. All 28 with pre-diagnosed fibromyalgia were female compared with 58 of the 72 newly diagnosed cases. The researchers compared previously non-labeled fibromyalgia cases at study entry (pre-labeling) and at 18 and 36 months follow-up (post-labeling) with respect to general health status, fibromyalgia -related symptoms, and all items from the Fibromyalgia Impact Questionnaire (FIQ) (including total FIQ score, and several measures of health service utilization) to determine if health status, function and health services utilization had changed.
Fifty-six (78%) of the original 72 newly diagnosed fibromyalgia cases were available for reassessment at 18 months, and 43 (60%) at 36 months. Although physical functioning decreased slightly over time, by 36 months, the newly diagnosed fibromyalgia cases reported a clinically and statistically significant decrease in dissatisfaction with health (2.2 vs. 3.0 on a five-point Likert scale; 95% confidence interval 1.2–0.4). No other differences in clinical status or health service use occurred over time. Therefore, it appears that the fibromyalgia label does not have a meaningful adverse effect on clinical outcome over the long term.
Note that investigators did not control for treatment patients may have received post-diagnosis; therefore, this improvement may have been the result of having received treatment earlier.
Reference
White KP et al. Does the label “fibromyalgia” alter health status, function, and health service utilization? A prospective, within-group comparison in a community cohort of adults with chronic widespread pain. Arthritis Rheum 2002; 47(3):260-5.
*Statistically significant vs. baseline (confidence interval -1.2 to -0.4)
White KP et al. Arthritis Rheum 2002; 47(3):260-5.

42. Summary

43. Assessment and Diagnosis: Summary
Key clinical features of central sensitization/dysfunctional pain syndromes are pain, anxiety/depression and fatigue
The cardinal symptoms of fibromyalgia are widespread pain, fatigue, sleep disturbance, and cognitive slowing
Diagnosis of fibromyalgia is based on widespread pain and associated symptom cluster, with a physical exam (and possible laboratory investigations) to exclude other conditions
A number of questionnaires are available for use in assessing patients
A diagnosis of fibromyalgia can improve health outcomes and reduce costs
Speaker’s Notes
This slide can be used to summarize the key messages of this section.