A Survey of Physicians' Knowledge and Adherence to the Diagnostic Criteria for Fibromyalgia

Knowledge on cause, clinical manifestation and treatment for fibromyalgia among medical doctors: A worldwide survey

OBJECTIVES

Hench introduced the fibromyalgia syndrome almost 50 years ago. In the meantime, the prevalence has increased, the clinical criteria have changed and the way we explain (chronic) pain has altered.

DESIGN

In the current study, we conducted a worldwide survey in which we investigate whether medical doctors are familiar with the American College of Rheumatology (ACR) criteria for fibromyalgia and, if so, whether these medical doctors adhere to the clinical guidelines following evidence-based treatments.

RESULTS

In total, 286 medical doctors from 43 countries spread over 6 continents filled out the survey. In most of the countries, the diagnosis fibromyalgia was used. Only 10% adhere to the ACR criteria, widespread pain (44%), unrefreshed sleep (24%), fatigue (20%) and cognitive problems (8%) were most used diagnostic criteria. Of the respondents, 94 (32%) mentioned that the cause is unknown or idiopathic, but also a wide variety of other causes was mentioned. More than 70 different treatment options were provided, of which 24% of the responses were classified as according to the clinical guidelines. From this study, we conclude that many medical doctors do not follow the ACR criteria; the majority has an inappropriate knowledge of causes for fibromyalgia and that a minority of treatment advice adhere to the guidelines.

Awareness of somatisation disorder among Swedish physicians at emergency departments: a cross-sectional survey

BACKGROUND

Somatisation is a highly prevalent psychiatric syndrome in both women and men, in which psychological distress is manifested in physical symptoms without a medical explanation. Many patients with somatisation disorder are high healthcare utilisers, particularly at emergency departments. Unnecessary investigations and diagnostic operations occur frequently, which cause both patient suffering and a significant burden on the healthcare system. Emergency department physicians' awareness of somatisation and its manifestations has not previously been studied. This study aimed to investigate awareness about somatisation disorder among physicians working at emergency departments in western Sweden, and to explore differences between gender, specialty, and work experience.

METHODS

A web-based, cross-sectional survey consisting of six dichotomous questions about somatisation disorder was conducted, in December 2021 - January 2022, among licensed physicians of various specialties working at emergency departments in western Sweden. Descriptive analyses and comparative analyses were performed to investigate differences between gender, type of specialty, and years of practice. Data were analysed using chi2 tests and Fisher's exact test.

RESULTS

Of the 526 eligible physicians who received the survey, 241 responded; response rate 45.8%. The majority of the respondents (56.4%) were women, and most (35.3%) were specialised in obstetrics/gynaecology. Average years of work experience was 11.1 (SD 8.7) years. Although 71% of respondents were aware of the diagnosis, only 7% knew the diagnostic criteria and only 6% had ever diagnosed a patient with somatisation disorder. Female physicians were more aware of underlying factors than their male colleagues (55.7% vs. 38.2%; p = .010). Type of specialty or years of practice did not affect awareness.

CONCLUSIONS

Awareness of somatisation disorder is low among physicians working at emergency departments in western Sweden. The findings suggest a need to increase awareness and knowledge and provide training in diagnosing the condition, to ensure correct decisions and optimal patient management. Clinical guidelines need to be developed to support diagnosis, investigation, and treatment, in Sweden as well as internationally.

Health personnel perception about central sensitivity syndrome-fibromyalgia patients

BACKGROUND AND OBJECTIVES

Fibromyalgia is characterized by musculoskeletal pain and asthenia of chronic course. Fibromyalgia patients are often a challenge for the health care community as a whole. Existing studies are often limited to the opinion of rheumatologists or family physicians. With this study we seek to know what are the actions, perceptions and knowledge of health professionals as a whole when caring for patients with this disease.

MATERIALS AND METHODS

Descriptive cross-sectional study, by means of a self-administered and anonymous survey. Distributed mainly in hospital wards and primary care centers. Statistical analysis of the variables collected was performed (p < 0.05).

RESULTS

200 surveys were collected, most of them physicians 63.5% (n = 127) or nurses 25.5% (n = 51). 71% of physicians reported using the WHO analgesic scale. 53% (n = 59) use NSAIDs or Paracetamol. Antidepressants are the third drug of choice. Most believe that the referral specialists should be rheumatologists or primary care physicians, a similar percentage, that management should be multidisciplinary. 52% feel discouraged or annoyed when dealing with these patients. Physicians have more negative connotations and believe that the care that the patient receives is mostly influenced by the diagnosis of fibromyalgia, compared to nurses and other professionals.

CONCLUSIONS

Our study shows that the lack of knowledge and therapeutic tools generates, to a large extent, frustration and discomfort in health personnel. It is important to develop new approaches to this entity.

Healthcare experiences of fibromyalgia patients and their associations with satisfaction and pain relief. A patient survey

OBJECTIVES

The etiology of fibromyalgia (FM) is disputed, and there is no established cure. Quantitative data on how this may affect patients' healthcare experiences are scarce. The present study aims to investigate FM patients' pain-related healthcare experiences and explore factors associated with high satisfaction and pain relief.

METHODS

An anonymous, online, and patient-administered survey was developed and distributed to members of the Norwegian Fibromyalgia Association. It addressed their pain-related healthcare experiences from both primary and specialist care. Odds ratios for healthcare satisfaction and pain relief were estimated by binary logistic regression. Directed acyclic graphs guided the multivariable analyses.

RESULTS

The patients (n = 1,626, mean age: 51 years) were primarily women (95%) with a 21.8-year mean pain duration and 12.7 years in pain before diagnosis. One-third did not understand why they had pain, and 56.6% did not know how to get better. More than half had not received satisfactory information on their pain cause from a physician, and guidance on how to improve was reported below medium. Patients regretted a lack of medical specialized competence on muscle pain and reported many unmet needs, including regular follow-up and pain assessment. Physician-mediated pain relief was low, and guideline adherence was deficient. Only 14.8% were satisfied with non-physician health providers evaluating and treating their pain, and 21.5% were satisfied (46.9% dissatisfied) with their global pain-related healthcare. Patients' knowledge of their condition, physicians' pain competence and provision of information and guidance, agreement in explanations and advice, and the absence of unmet needs significantly increased the odds of both healthcare satisfaction and pain relief.

CONCLUSIONS

Our survey describes deficiencies in FM patients' pain-related healthcare and suggests areas for improvement to increase healthcare satisfaction and pain relief. (REC# 2019/845, 09.05.19).

Physician perspectives on chronic pain management: barriers and the use of eHealth in the COVID-19 era

BACKGROUND

Chronic pain is a highly prevalent and disabling condition which is often undertreated and poorly managed in the community. The emergence of COVID-19 has further complicated pain care, with an increased prevalence of chronic pain and mental health comorbidities, and burnout among physicians. While the pandemic has led to a dramatic increase in virtual health care visits, the uptake of a broader range of eHealth technologies remains unclear. The present study sought to better understand physicians' current needs and barriers in providing effective pain care within the context of COVID-19, as well as gauge current use, interest, and ongoing barriers to eHealth implementation.

METHODS

A total of 100 practicing physicians in British Columbia, Canada, completed a brief online survey.

RESULTS

The sample was comprised of physicians practicing in rural and urban areas (rural = 48%, urban = 42%; both = 10%), with the majority (72%) working in family practice. The most prominent perceived barriers to providing chronic pain care were a lack of interdisciplinary treatment and allied health care for patients, challenges related to opioid prescribing and management, and a lack of time to manage the complexities of chronic pain. Moreover, despite expressing considerable interest in eHealth for chronic pain management (82%), low adoption rates were observed for several technologies. Specifically, only a small percentage of the sample reported using eHealth for the collection of intake data (21%), patient-reported outcomes (14%), and remote patient monitoring (26%). The most common perceived barriers to implementation were cost, complexity, and unfamiliarity with available options.

CONCLUSIONS

Findings provide insight into physicians' ongoing needs and barriers in providing effective pain management during the COVID-19 pandemic. Despite the potential for eHealth technologies to help address barriers in pain care, and strong interest from physicians, enhanced useability, education and training, and funding are likely required to achieve successful implementation of a broader range of eHealth technologies in the future.

Fibromyalgia Rapid Screening Tool (FiRST): Arabic Translation and Cross-Cultural Adaptation and Validation

Background: Fibromyalgia (FM), a complex neurological disorder, has multiple consequences for the patient. To diagnose patients, healthcare practitioners use multiple diagnostic questionnaires. However, Arabic translated or validated tools are lacking. This study aimed to translate and validate the Fibromyalgia Rapid Screening Tool (FiRST) into the Arabic language. Methods: Forward and backward translations of the FiRST were conducted by two Arabic translators and two English-certified translators. The survey was piloted (n = 5) and subjected to cognitive interviews and psychometric analysis. Patients were recruited from a university hospital in Riyadh and an FM support group in Saudi Arabia. The internal consistency, factor analysis, and test–retest correlations were evaluated. Results: This study included 46 patients. The stepwise translation process resulted in minor edits related to the use of synonyms to the survey items. The translated survey had a good internal consistency and test–retest correlation, with a Cronbach’s alpha of 0.7 and Pearson’s correlation coefficient of 0.79 (p-value < 0.001), respectively. The survey was factorable into two themes: generalized symptoms and more specific sensations. Conclusions: The Arabic FiRST is a simple, valid, and reliable tool to diagnose patients with FM in different settings.

Knowledge, Attitude, and Practice Regarding Fibromyalgia Among Primary Care Physicians in Tabuk, Saudi Arabia

BACKGROUND

Adequately informed family physicians have the greatest potential to correctly identify the diagnosis of fibromyalgia (FM) and develop an initial treatment plan. Therefore, it is substantial to determine the levels of weakness and inaccuracy among primary care physicians regarding FM diagnostic criteria and management strategies.

AIM

This study aimed to assess the knowledge, attitude, and practices regarding FM among primary care physicians in Tabuk, Saudi Arabia.

METHODS

This cross-sectional study included family physicians who were board-certified or registered in the family medicine training program and working at the government family healthcare centers in Tabuk. A pre-designed, structured questionnaire was distributed either in written form or as an online survey.

RESULTS

This study included 52 primary healthcare physicians. Twenty-two (42.3%) participants incorrectly recorded localized pain as a diagnostic symptom, and 45 (86.5%) incorrectly recorded nonsteroidal anti-inflammatory drugs (NSAIDs), prednisolone, and/or opioids as drugs that are used for treating FM. Only 59.6% were confident in recognizing the symptoms of FM, and 55.8% were confident in differentiating FM from other similar diseases.

CONCLUSIONS

The primary healthcare physicians working in the government's primary healthcare centers in Tabuk City, Saudi Arabia, have low levels of knowledge about diagnostic criteria and treatment strategies for FM. These findings highlight the need for continuous professional development involving family physicians in the primary healthcare setting with suitable continuous medical education (CME) programs concerning FM.

Survey of knowledge and attitude towards fibromyalgia among physicians in Karachi, Pakistan

Objectives

Our study aims to assess knowledge and understanding of FM among doctors employed at a tertiary care hospital in Karachi, Pakistan with a focus on its diagnostic criteria, treatment modalities, and general knowledge of symptoms.

Study Design

Cross-sectional Study.

Methods

Our cross-sectional study recruited participants through convenience sampling. A total of 104 participants responded, which included (a) House Officers, (b) Medical Officers, and (c) Residents. A structured questionnaire was used, and an electronic form was generated which was then emailed to the participants to acquire their responses.

Results

The majority (66.3%) of our respondents were female and the median age was 26 years. A majority (93.3%) accepted FM as a separate and distinct clinical identity, and 79.8% were confident in recognizing its general symptoms. Widespread pain (95.2%) and fatigue (80.8%) were correctly identified as most commonly observed symptoms. Moreover, 68.3% of respondents possessed no knowledge of both ACR 1990 and 2010 diagnostic criteria for FM. Of those aware, majority favored using the most recent ACR 2010 criteria (72.7%). Majority of our respondents (75%) preferred using pharmaceutical and non-pharmaceutical interventions simultaneously in the treatment.

Conclusions

Our study indicates that while physicians have satisfactory knowledge of the symptoms and treatment modalities of FM, a knowledge gap concerning its diagnostic criteria exists. Proper treatment can only be successful when physicians successfully diagnose FM, therefore, future training programs should use this fact as a stepping stone for advances in its healthcare.

UK healthcare services for people with fibromyalgia: results from two web-based national surveys (the PACFiND study)

Background

The UK’s “Getting It Right First Time” programme recommends that management of people with fibromyalgia should centre on primary care. However, it remains unclear as to how best to organise health systems to deliver services to optimise patient outcomes.

Aim

To profile UK healthcare services for people with fibromyalgia: provision of National Health Services (NHS) and use of non-NHS services by people with fibromyalgia.

Methods

Two online open surveys (A and B) incorporating questions about diagnosis, treatment and management of fibromyalgia and gaps in healthcare services were conducted between 11th September 2019 and 3rd February 2020. These were targeted to NHS healthcare professionals consulting with people with fibromyalgia (Survey A) and people ≥16 years diagnosed with fibromyalgia using non-NHS services to manage their condition (Survey B). Descriptive statistics were used to report quantitative data. Thematic analysis was undertaken for qualitative data.

Results

Survey A received 1701 responses from NHS healthcare professionals across the UK. Survey B received 549 responses from people with fibromyalgia. The results show that NHS services for people with fibromyalgia are highly disparate, with few professionals reporting care pathways in their localities. Diagnosing fibromyalgia is variable among NHS healthcare professionals and education and pharmacotherapy are mainstays of NHS treatment and management. The greatest perceived unmet need in healthcare for people with fibromyalgia is a lack of available services. From the pooled qualitative data, three themes were developed: ‘a troublesome label’, ‘a heavy burden’ and ‘a low priority’. Through the concept of candidacy, these themes provide insight into limited access to healthcare for people with fibromyalgia in the UK.

Conclusion

This study highlights problems across the NHS in service provision and access for people with fibromyalgia, including several issues less commonly discussed; potential bias towards people with self-diagnosed fibromyalgia, challenges facing general practitioners seeking involvement of secondary care services for people with fibromyalgia, and a lack of mental health and multidisciplinary holistic services to support those affected. The need for new models of primary and community care that offer timely diagnosis, interventions to support self-management with access to specialist services if needed, is paramount.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08324-4.

Potential role of blood biomarkers in patients with fibromyalgia: a systematic review with meta-analysis

ABSTRACT

Fibromyalgia (FM) is a complex chronic pain condition. Its symptoms are nonspecific, and to date, no objective test exists to confirm FM diagnosis. Potential objective measures include the circulating levels of blood biomarkers. This systematic review and meta-analysis aim to review studies assessing blood biomarkers' levels in patients with FM compared with healthy controls. We systematically searched the PubMed, MEDLINE, EMBASE, and PsycINFO databases. Fifty-four studies reporting the levels of biomarkers in blood in patients with FM were included. Data were extracted, and the methodological quality was assessed independently by 2 authors. The methodological quality of 9 studies (17%) was low. The results of most studies were not directly comparable given differences in methods and investigated target immune mediators. Thus, data from 40 studies only were meta-analyzed using a random-effects model. The meta-analysis showed that patients with FM had significantly lower levels of interleukin-1 β and higher levels of IL-6, IL-8, tumor necrosis factor-alpha, interferon gamma, C-reactive protein, and brain-derived neurotrophic factor compared with healthy controls. Nevertheless, this systematic literature review and meta-analysis could not support the notion that these blood biomarkers are specific biomarkers of FM. Our literature review, however, revealed that these same individual biomarkers may have the potential role of identifying underlying pathologies or other conditions that often coexist with FM. Future research is needed to evaluate the potential clinical value for these biomarkers while controlling for the various confounding variables.

Placebo Responses and Their Clinical Implications in Fibromyalgia: A Meta-Analysis Using SSRI and SNRI Trials

Background: Fibromyalgia (FM) is a chronic primary pain condition, associated with widespread musculoskeletal pain, disturbed sleep, fatigue, cognitive dysfunction, and a range of comorbid conditions such as irritable bowel syndrome, and depression. Despite its high prevalence of 2% in the general population, FM continues to pose scientific and clinical challenges in definition, etiology, and day-to-day management. In terms of treatment, FM can be treated with selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs). Objective: Patients with FM and other chronic primary pain syndromes are known to experience substantial and clinically relevant placebo effects. An update of the placebo responses for various outcomes in the FM population and especially a discussion about clinical implications is therefore needed. Methods: We used data from a large data pool that includes randomized controlled trials (RCTs) examining within-placebo mean change scores of baseline vs. follow-up assessments in FM trials of SSRIs and SNRIs. The primary outcomes were pain, functional disability, and depression and using different scales. We assessed heterogeneity of included trials. Results: A total of 29 RCTs with N = 8,453 patients suffering from FM were included in our analysis. Within-placebo mean change scores of baseline vs. follow-up assessments were large for pain (mean change = 2.31, 95% CI: 0.42-4.21, p = 0.017), functional disability (mean change = 3.31, 95% CI: 2.37-4.26, p < 0.000), and depression (mean change = 1.55, 95% CI: 0.92-2.18, p < 0.000). Heterogeneity was found to be large for all outcomes. Impact: Our results provide preliminary evidence that placebo responses, which also consist of non-specific effects, might play a role in the treatment of FM. Furthermore, we highlight limitations of our analyses and make suggestions for future studies.

Fibromyalgia in social media: content and quality of the information analysis of videos on the YouTube platform

To evaluate the fibromyalgia (FM) content in YouTube videos and verify if American College of Rheumatology (ACR) guidelines are being met. The videos were searched with the keyword "Fibromyalgia." Two independent researchers evaluated and coded specific characteristics of the videos. The popularity of the videos, the presentation properties, and content related to FM according to the ACR criteria were analyzed. Of the 200 videos included, the majority were presented by health professionals, 61.5%. Most videos covered more than one subject, 38.5%. The videos presented by health professionals were the most viewed. Following the ACR guidelines, 38% defined FM, 24% described the etiology, 19.5% described the diagnostic criteria and 52% presented recommended management strategies. The results indicate that users mainly watch videos published by health professionals. Most of the published videos do not follow the information recommended by the ACR guidelines. Therefore, videos should be interpreted with caution, not being the most appropriate resource for health education for patients with FM. Most of the videos published on YouTube about FM do not meet the ACR guidelines for FM.

The Evolution of Fibromyalgia, Its Concepts, and Criteria

Fibromyalgia developed in the 1950s from a substrate of difficult to explain regional and widespread pain mixed with symptoms of psychosocial distress. Controversies regarding psychological issues were common. Multiple criteria arose to define the disorder, but each identified a different set of patients. The identification of widespread pain as a criterion changed the nature of the disorder by effectively eliminating regional pain as a component condition. The easy-to-measure and relatively reliable widespread pain criterion then came to define the disorder. In the primary care community, diagnostic criteria were largely ignored, and a substantial fraction of diagnosed patients with lower pain scores, particularly women and those with high non-pain symptom scores, were diagnosed. Non-pain symptoms were added back to the fibromyalgia definition and criteria in 2010. Recognition grew that fibromyalgia fit the description of a functional somatic disorder. The idea of fibromyalgia as a primary pain disorder with a neurobiological basis contended with fibromyalgia as a broader biopsychosocial disorder. It is increasingly recognized that fibromyalgia represents a dimensional, non-binary condition and that features of fibromyalgia extend to persons who do not satisfy the criteria. Severity assessments are now available but rarely used. The course of fibromyalgia is not well studied, and improvement and remission criteria have not been successfully defined. The future of fibromyalgia as a discrete disorder remains uncertain as features of fibromyalgia are increasingly observed in patients with multiple different medical conditions.

Investigation of thermal changes in the thyroid gland region of individuals with hypothyroidism and fibromyalgia by analyzing the temperature of brown adipose tissue

This exploratory retrospective study aims to investigate the thermal changes in the thyroid gland region of patients with hypothyroidism and fibromyalgia by analyzing the temperature of the brown adipose tissue (BAT). A total of 166 individuals from 1000 thermographic electronic medical records were classified into four groups: Group HP + FM-50 individuals with hypothyroidism and fibromyalgia; Group FM-56 individuals with fibromyalgia only; Group HP-30 individuals with hypothyroidism only, and Group Control-30 healthy individuals. The thermal images from the electronic medical records were acquired by a FLIR T650SC infrared camera (used for thermometry) and the temperature data for each group were statistically analyzed. Group HP + FM showed r = 0, meaning that the average temperatures of the thyroid and BAT are independent of each other. Groups FM, HP and Control showed r = 1, meaning that the average temperatures of the thyroid and BAT were directly related. Our findings showed that the average temperatures of the thyroid and BAT regions are similar. Also, there was no correlation between thyroid gland temperature and the presence of hypothyroidism or fibromyalgia using thermometry.

The Search for Biomarkers in Fibromyalgia

Fibromyalgia is the most common of the central sensitivity syndromes affecting 2–5% of the adult population in the United States. This pain amplification syndrome has enormous societal impact as measured by work absenteeism, decreased work productivity, disability and injury compensation and over-utilization of healthcare resources. Multiple studies have shown that early diagnosis of this condition can improve patient outlook and redirect valuable healthcare resources towards more appropriate targeted therapy. Efforts have been made towards improving diagnostic accuracy through updated criteria. The search for biomarkers for diagnosis and verification of Fibromyalgia is an ongoing process. Inadequacies with current diagnostic criteria for this condition have fueled these efforts for identification of a reproducible marker that can verify this disease in a highly sensitive, specific and reproducible manner. This review focuses on areas of research for biomarkers in fibromyalgia and suggests that future efforts might benefit from approaches that utilize arrays of biomarkers to identify this disorder that presents with a diverse clinical phenotype.

Factors in the Building of Effective Patient-Provider Relationships in the Context of Fibromyalgia

Objective

Fibromyalgia patients face particular challenges in building relationships with health care providers. In this study, we examine, from patients’ perspectives, factors that influence the formation of effective patient–provider relationships.

Design

This research employed a qualitative approach to analyze data collected from a study that employed semistructured interviews.

Methods

Multiple methods were used to recruit 23 fibromyalgia patients for interviews. Semistructured interviews were conducted to explore how participants’ information behaviors, including their communication with and relationships to providers, changed over time. The interview data were analyzed using a qualitative analytic method based on interpretative phenomenological analysis and constructivist grounded theory.

Results

We identified three important factors that influenced the building of effective relationships: patients and providers’ interactions involving information, identifying health care providers that fit patients’ needs, and realizing shared responsibilities. With regard to information, we described three important themes: information gaps, providers as educators/facilitators, and collaborative information behavior.

Conclusions

Understanding of the key elements of relationship development between patients and providers can be utilized in various ways to improve clinical care. First, the knowledge gained in this study can inform the design of patient education materials that assist patients to identify providers that fit their needs, prepare for consultations, and develop realistic expectations for providers. The findings of this study can also inform the design of resources and tools to enable clinicians to communicate and relate better with their patients.

Knowledge, Awareness, and Perceptions of the Diagnosis and Management of Fibromyalgia Among Physical Therapists in Saudi Arabia: A Cross-Sectional Survey

Aim

To explore awareness of the diagnostic criteria and management of fibromyalgia (FM) among physical therapists practicing in Saudi Arabia.

Methods

A cross-sectional survey was distributed electronically among musculoskeletal physical therapists. It was designed based on the research literature relevant to FM and reviewed by two rheumatologists for accuracy and comprehension. The survey included two sections: participants' demographic information and questions related to FM. The data were described using absolute and relative frequencies.

Results

A total of 234 physical therapists accepted the invitation to participate in the study, and 52 were excluded for not satisfying the inclusion criteria or not completing the survey. Responses were received from March to May 2020; only 118 (65%) respondents completed the FM section. The average age of the participants was 31.2 (SD=6.9) years, and 36% were females. Eighty percent reported seeing fewer than five patients with FM in the past year; 51% acquired FM-related knowledge through self-learning; half reported having little to no confidence in their FM assessments and management; and less than 20% were familiar with common diagnostic criteria and management guidelines for FM.

Conclusion

Participating physical therapists showed little awareness of or confidence in the assessment and management of patients with FM; moreover, their awareness was not supported by their adherence to recent FM guidelines. Despite the common practice of referring patients with FM for physical therapy, there are many misconceptions about FM. This study highlights the need for educational programs to provide up-to-date evidence in undergraduate and postgraduate education.

Assessing our approach to diagnosing Fibromyalgia

Introduction: Fibromyalgia represents the most prevalent of the group of conditions that are known as central sensitivity syndromes. Approximately 2-5% of the adult population in the United States is affected by Fibromyalgia. This pain amplification syndrome has an enormous economic impact as measured by work absenteeism, decreased work productivity, disability and injury compensation, and over-utilization of healthcare resources. Multiple studies have shown that early diagnosis of this condition can improve patient outlook, and redirect valuable health care resources toward more appropriate targeted therapy. Efforts have been made toward improving diagnostic accuracy through updated criteria. Areas Covered: Reviewed here are 1) reasons for the need for more accurate diagnosis of Fibromyalgia, (2) a review of the evolution of Fibromyalgia to current times, and (3) the proliferation of currently available diagnostic criteria and problems related to each of them. From initial literature review until October 2020, PubMed, Embase, and Scopus were searched for applicable literature. Expert Opinion: A discussion of ongoing efforts to obtain a biomarker to enhance diagnostic accuracy concludes this review. A need to include rheumatologists as part of the care team of patients with Fibromyalgia is emphasized.

Diagnostic Criteria for Fibromyalgia: Critical Review and Future Perspectives

Fibromyalgia syndrome (FMS) is a chronic illness characterized by widespread pain and other clinical and emotional symptoms. The lack of objective markers of the illness has been a persistent problem in FMS research, clinical management, and social recognition of the disease. A critical historical revision of diagnostic criteria for FMS, especially those formulated by the American College of Rheumatology (ACR), was performed. This narrative review has been structured as follows: Introduction; historical background of FMS, including studies proposing and revising the diagnostic criteria; the process of development of the ACR FMS diagnostic criteria (1990 and 2010 versions); revisions of the 2010 ACR FMS diagnostic criteria; the development of scales based on the 2010 and 2011 criteria, which could help with diagnosis and evaluation of the clinical severity of the disease, such as the Polysymptomatic Distress Scale and the FMS Survey Questionnaire; relationships of prevalence and sex ratio with the different diagnostic criteria; validity and diagnostic accuracy of the ACR FMS criteria; the issues of differential diagnosis and comorbidity; the strength and main limitations of the ACR FMS criteria; new perspectives regarding FMS diagnosis; and the impact of the novel findings in the diagnosis of FMS. It is concluded that despite the official 2010 FMS diagnostic criteria and the diagnostic proposal of 2011 and 2016, complaints from health professionals and patients continue.

A Patient-Narrative Video Approach to Teaching Fibromyalgia

INTRODUCTION

Although fibromyalgia is one of the most common and clinically important rheumatologic entities, physicians frequently report that their training fails to prepare them to manage this disease. Many medical schools devote insufficient time and attention to the subject of fibromyalgia, resulting in training gaps that can manifest as failures of both knowledge and empathy. There is a need for evidence-based, time-efficient methods for teaching this important subject. We have developed a narrative-driven video presentation for clerkship students and sought to evaluate its impact on fibromyalgia-related knowledge and attitudes.

METHODS

Fibromyalgia: A Patient's Perspective (FPP), a 13-minute video, was presented to third-year medical students (N = 54). Surveys of knowledge and attitudes were collected before and after the video. Composite scores, as well as Knowledge and Attitudes subscales, were computed, and paired t tests were used to compare pre/post means for these scales, as well as for individual questions. Mann-Whitney U and Kruskal-Wallis tests were used to identify correlations between survey scores and student sex and specialty of interest.

RESULTS

Between pre-experience and post-experience surveys, there were statistically significant differences for 11 of 15 questions (73%). The composite score increased from 3.8 (SD = 0.44) to 4.2 (SD = 0.47) (P < .0001). Knowledge and Attitude subscale scores also increased, from 4.0 (SD = 0.5) to 4.38 (SD = 0.5) (P < .0001) and 3.6 (SD = 0.5) to 3.93 (SD = 0.5) (P < .0001), respectively. Students reported favorable impressions of the video, with 87% agreeing that the video was helpful to learners and 79% disagreeing that a lecture would be preferable to the video. No differences in scores by sex or intended specialty were observed.

CONCLUSION

The FPP video demonstrates promise as a tool for enhancing both knowledge of and positive, empathic attitudes toward fibromyalgia in medical learners. It may serve as a useful resource for educators looking to further develop their clinical pain management curricula.

Rethinking the criteria for fibromyalgia in 2019: the ABC indicators

PURPOSE

Diagnostic criteria for fibromyalgia have been subject to debate and controversy for many years. The preliminary diagnostic criteria introduced in 2010 and 2011 have been criticized for different reasons, including questionable diagnostic specificity and a lack of an etiopathogenetic foundation. The "ABC indicators" presented in this study reflect a further development of the 2011 criteria and refer to (A) algesia, (B) bilateral, axial-symmetric pain distribution, and (C) chronic distress.

PATIENTS AND METHODS

We compared the diagnostic performance of the ABC indicators with that of the 2011 criteria by analyzing the data of 409 inpatients with chronic functional pain divided into two subgroups of pain patients: Those with whole-body pain and those with pain not involving the whole body. Under the premise that FM phenotypically represents a whole-body pain disorder, sensitivity, specificity, correct classification and diagnostic odds ratios were calculated.

RESULTS

The 2011 criteria demonstrated a specificity of 68.1%, a sensitivity of 75.5%, a correct classification of 71.0% and a diagnostic odds ratio of 6.56 (CI: 4.17-10.31). The ABC indicators achieved a specificity of 88.3%, a sensitivity of 62.3%, a correct classification of 78.6%, and a diagnostic odds ratio of 12.47 (CI: 7.30-21.28).

CONCLUSION

The ABC fibromyalgia indicators demonstrated better specificity, lower sensitivity, and better overall diagnostic effectiveness than the original 2011 criteria.

The Problematic Nature of Fibromyalgia Diagnosis in the Community

Background

Recently, some studies suggested that clinical diagnosis of fibromyalgia is inaccurate and does not reflect current definitions. However, this hypothesis has not been tested. We examined whether fibromyalgia was accurately diagnosed in the community.

Methods

We surveyed 3276 primary care patients to determine current fibromyalgia status by criteria (CritFM). We also determined whether the patients had a physician's diagnosis of fibromyalgia (MDFM) and the level of symptom severity as measured by the polysymptomatic distress scale (PSD).

Results

The prevalence of MDFM and CritFM was 6.1% (95% confidence interval [CI] 5.3%, 6.9%) and 5.5% (95% CI 4.8%, 6.3%), respectively. However, only 32.2% with MDFM met 2016 criteria (CritFM), and only 35.4% with CritFM also had MDFM. The kappa statistic for diagnostic agreement was 0.296 (minimal agreement). The mean PSD score was 12.4 and 18.4 in MDFM and CritFM, respectively. The odds ratio for being a woman compared with being a man was 3.2 for MDFM versus 1.9 for CritFM, P = 0.023. Of the patients with MDFM, 68.3% received specific fibromyalgia pharmacotherapy.

Conclusions

There is little agreement between MDFM and CritFM. Only one‐third of MDFM satisfy fibromyalgia criteria, and only one‐third of patients who meet the criteria have a clinical diagnosis of fibromyalgia. Physician diagnosis is biased and more likely in women. Fibromyalgia treatment is common in MDFM (70.7%). Overall, MDFM appears subjective and unrelated to fibromyalgia criteria. There appears to be no common definition of fibromyalgia in the community.

Diagnosis of Fibromyalgia: Disagreement Between Fibromyalgia Criteria and Clinician-Based Fibromyalgia Diagnosis in a University Clinic

OBJECTIVE

Recent studies have suggested that fibromyalgia is inaccurately diagnosed in the community, and that ~75% of persons reporting a physician diagnosis of fibromyalgia would not satisfy published criteria. To investigate possible diagnostic misclassification, we compared expert physician diagnosis with published criteria.

METHODS

In a university rheumatology clinic, 497 patients completed the Multidimensional Health Assessment Questionnaire (MD-HAQ) and the 2010 American College of Rheumatology preliminary diagnostic criteria modified for self-administration during their ordinary medical visits. Patients were evaluated and diagnosed by university rheumatology staff.

RESULTS

Of the 497 patients, 121 (24.3%) satisfied the fibromyalgia criteria, while 104 (20.9%) received a clinician International Classification of Diseases (ICD) diagnosis of fibromyalgia. The agreement between clinicians and criteria was 79.2%. However, agreement beyond chance was only fair (κ = 0.41). Physicians failed to identify 60 criteria-positive patients (49.6%) and incorrectly identified 43 criteria-negative patients (11.4%). In a subset of 88 patients with rheumatoid arthritis (RA), the kappa value was 0.32, indicating slight to fair agreement. Universally, higher polysymptomatic distress scores and criteria-based diagnosis were associated with more abnormal MD-HAQ clinical scores. Women and patients with more symptoms but fewer pain areas were more likely to receive a clinician's diagnosis than to satisfy fibromyalgia criteria.

CONCLUSION

There is considerable disagreement between ICD clinical diagnosis and criteria-based diagnosis of fibromyalgia, calling into question ICD-based studies. Fibromyalgia criteria were easy to use, but problems regarding clinician bias, meaning of a fibromyalgia diagnosis, and the validity of physician diagnosis were substantial.

Fatigue in systemic lupus: the role of disease activity and its correlates

OBJECTIVES

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that leads to a variety of negative health outcomes resulting from inflammation in various organ systems. Although treatment continues to advance, fatigue remains one of the most salient, poorly understood and addressed patient complaints. Understanding the mechanisms of fatigue can help guide the development of interventions to improve health outcomes. The aim of this research was to evaluate the contribution of six variables (disease activity, insomnia, depression, stress, pain and physical health) to fatigue in SLE without concomitant fibromyalgia (FM).

METHODS

A total of 116 ethnically diverse, primarily female participants (91%) with SLE, receiving care at university medical centers, completed assessments of disease activity and quality of life outcomes (FACIT-FT, Insomnia Severity Index, Perceived Stress Scale (PSS-4), Pain Inventory, Depression-PHQ-9, and LupusPRO-physical function). All patients met the American College of Rheumatology classification criteria for SLE and did not have a known diagnosis of FM. Multivariate linear and stepwise regression analyses were conducted with fatigue (FACIT-FT) as the dependent variable, and the above six variables as independent variables.

RESULTS

Mean (SD) age was 39.80 (13.87) years; 50% were African American, 21% Caucasian, 13% Hispanic, 9% Asian and 8% other. Mean (SD) FACIT-FT was 20.09 (12.76). Collectively, these six variables explained 57% of the variance in fatigue. In the multivariate model, depression, stress and pain were significantly and independently associated with fatigue, but not disease activity, sleep or physical health. Stress had the largest effect on fatigue (β 0.77, 95% CI 0.17-1.38, p = 0.01), followed by depression (β 0.66, 95% CI 0.21-1.10, p = 0.005). On stepwise regression analysis, only stress, depression and pain were retained in the model, and collectively explained 56% of the variance in fatigue. All three remained independent correlates of fatigue, with the largest contribution being stress (β 0.84, 95% CI 0.27-1.42, p = 0.005), followed by depression (β 0.79, 95% CI 0.44-1.14, p < 0.001) with fatigue.

CONCLUSION

Stress, depression and pain are the largest independent contributors to fatigue among patients with SLE, without concurrent FM. Disease activity, sleep and physical health were not associated with fatigue. The evaluation of stress, depression and pain needs to be incorporated during assessments and clinical trials of individuals with SLE, especially within fatigue. This stress-depression-fatigue model requires further validation in longitudinal studies and clinical trials. Significance and innovation: • Disease activity, sleep, pain, stress, depression, and physical health have been reported individually to be associated with fatigue in lupus. This analysis evaluated the role of each and all of these six variables collectively in fatigue among patients with SLE without a known diagnosis of FM. • Disease activity, sleep and physical health were not significantly related to fatigue, but depression, stress and pain were. • The results emphasize the need to evaluate and treat fatigue in individuals with SLE utilizing a biopsychosocial approach, particularly in the realm of clinical trials. Behavioral medicine interventions are shown to be most effective for the treatment of depression, stress and pain.

Fibromyalgia diagnosis and biased assessment: Sex, prevalence and bias

Purpose

Multiple clinical and epidemiological studies have provided estimates of fibromyalgia prevalence and sex ratio, but different criteria sets and methodology, as well as bias, have led to widely varying (0.4%->11%) estimates of prevalence and female predominance (>90% to <61%). In general, studies have failed to distinguish Criteria based fibromyalgia (CritFM) from Clinical fibromyalgia (ClinFM). In the current study we compare CritFM with ClinFM to investigate gender and other biases in the diagnosis of fibromyalgia.

Methods

We used a rheumatic disease databank and 2016 fibromyalgia criteria to study prevalence and sex ratios in a selection biased sample of 1761 referred and diagnosed fibromyalgia patients and in an unbiased sample of 4342 patients with no diagnosis with respect to fibromyalgia. We compared diagnostic and clinical variables according to gender, and we reanalyzed a German population study (GPS) (n = 2435) using revised 2016 criteria for fibromyalgia.

Results

In the selection-biased sample of referred patients with fibromyalgia, more than 90% were women. However, when an unselected sample of rheumatoid arthritis (RA) patients was studied for the presence of fibromyalgia, women represented 58.7% of fibromyalgia cases. Women had slightly more symptoms than men, including generalized pain (36.8% vs. 32.4%), count of 37 symptoms (4.7 vs. 3.7) and mean polysymptomatic distress scores (10.2 vs. 8.2). We also found a linear relation between the probability of being females and fibromyalgia and fibromyalgia severity. Women in the GPS represented 59.2% of cases.

Discussion

The perception of fibromyalgia as almost exclusively (≥90%) a women’s disorder is not supported by data in unbiased studies. Using validated self-report criteria and unbiased selection, the female proportion of fibromyalgia cases was ≤60% in the unbiased studies, and the observed CritFM prevalence of fibromyalgia in the GPS was ~2%. ClinFM is the public face of fibromyalgia, but is severely affected by selection and confirmation bias in the clinic and publications, underestimating men with fibromyalgia and overestimating women. We recommend the use of 2016 fibromyalgia criteria for clinical diagnosis and epidemiology because of its updated scoring and generalized pain requirement. Fibromyalgia and generalized pain positivity, widespread pain (WPI), symptom severity scale (SSS) and polysymptomatic distress (PSD) scale should always be reported.