[BLANK_AUDIO] Hello. Welcome to the MOOC presentation on Fibromyalgia. I'm Doctor Russell. I'm speaking to you from the video studio in the University of Texas Health Science Center, where I was a faculty member for 32 years, but then retired in 2010 and am now Medical Director of a research organization called Fibromyalgia Research and Consulting here in San Antonio. This slide shows the big picture of the presentations on fibromyalgia. You can see that they're divided into three main segments or three main chapters. What is it? What is wrong with people with people with fibromyalgia? And what can be done for them. And so, for this segment, we're going to be talking about the diagnosis of fibromyalgia. Diagnosis means, to identify the medical condition by name and by a standard name that, physicians and medical dictionaries and medical information on the Internet will recognize. Again, we would point to the state-of-the-art descriptions and the state-of-the-art description that is important to our presentation today is, a common, fibromyalgia is a common chronically painful soft tissue pain condition which is characterized by persistent, widespread pain, tenderness, and multisystem comorbidities. In an earlier lecture on the presentation of fibromyalgia we talked about comorbidities and what they were. But we will be talking more about that. So, in this presentation, we'll ask where does fibromyalgia fit in medicine? How is fibromyalgia diagnosed? Is making the diagnosis of fibromyalgia a good thing or bad thing? And, the final question is, who cares? The who cares sounds like a flippant statement, like, maybe, no one would, or implying that maybe no one did, but it's a play on words. Who cares is who provides the care. We refer to medical care by the word care. And so, this is a play on words regarding who the physician should be that one with fibromyalgia should turn to. So in this slide, we see two columns. On the left hand side are symptoms that can be experienced by people with fibromyalgia. And on the right side, the kinds of medical conditions that that symptom might suggest. And so, you can see that this is a diagnostic challenge for physicians, because patients can, with fibromyalgia can present with symptoms that are, in many ways, like the symptoms of other medical conditions. And as a result, there may be confusion about the diagnosis for a period of time. For example, symptom number one, pain all over. That could present in a person with metastatic cancer, meaning cancer that is spread all over the body. It could recu, result from a spinal cord injury. Neck and shoulder pain could be due to a pinched nerve in the neck, or due to widespread osteoarthritis. Chest wall pain could mimic angina, which is heart pain because of lack of oxygen or blood flow to the heart. It could represent esophageal spasm, spasm of the tube that we use to swallow our food. It could result it could be confused with gall bladder disease in which there is a gall stone or inflammation of the gall bladder. Hip and area, hip area pain could be confused with arthritis or piriformis syndrome or iliopsoas muscle pain. Low back pain could be confused with sciatica or spinal stenosis. Severe headache could be confused with migraine or tumor or pseudo tumor cerebri. Somatic fatigue could be confused, chronic fatigue syndrome, hypothyroidism and depression and so forth. Dizzy and syncope or fainting could be confused with acoustic neuroma or heart rhythm disturbance or something of that nature. So, this is, does represent a diagnostic challenge, and one must take all the information and put it together, and try to figure out what the patient is presenting. One of the early findings in the understanding of fibromyalgia was a finding that, if you give patients a pain diagram, a body diagram to mark the locations of their pain, they mark pain all over. Notice that, in this case, there's an area in which the patient didn't mark any pain on the right back area. But on the front, the, the same area, on the right front is affected in this patient. Notice that it can be in the hands and it can be in the feet a little bit. It can be over the whole body. And some patients marked the areas in which they experienced pain, very darkly and very intensely. Others marked it more lightly. And that's a style, but what they're all telling us, these four patients, are telling us is that their pain is widespread. In this slide we see, an attempt to try to classify fibromyalgia syndrome. Notice that we're using the example of arthritis to see where fibromyalgia fits into the classification of medicine. Arthritis can be characterized as having a single joint involved. In that case, it's referred to as monoarticular arthritis. And is exhibited by or exemplified by gout or by infection in a joint. Oligoarticular arthritis means that there are a few joints involved and that is the characteristic in ankylosing spondylitis. Polyarticular means that there are many joints involved and it implies that they're symmetrically placed. That is, both shoulders would hurt and be swollen, both elbows, both hands and the same fingers, both knees, and so forth. A symmetric, poly, multiple joint arthritis, and that is exemplified by rheumatoid arthritis. Now, if we take the same pattern and talk about soft tissue pain, we could see that there could be localized soft tissue pain which would be presented by a diagnosis of tendonitis with inflammation of tendons or inflammation of bursa, bursitis. On the other hand, the problem could be sort of regional, involving an area of the body but not the whole body and that is exemplified by myofascial pain syndrome, complex regional pain syndrome, referred pain disorders, and so forth. And finally, there is the generalized soft tissue pain conditions and fibromyalgia is the mast head for that category, but also chronic fatigue syndrome, when it's painful, is often involves multiple areas of the body, and a disorder called hypermobility syndrome can be painful and exhibit double-jointedness. So, here we see that a classification of that is used in medicine is entirely compatible with a place for fibromyalgia in this classification. Now, when we talk about clinical diagnosis, how do we go about that? And this was the question that many physicians had early in the time when fibromyalgia was being studied and being evaluated. And many approaches were proposed to come about with a diagnosis for fibromyalgia patients. But it turns out that the most appropriate and valuable approach is one that will be accepted by many. And that is referred to as an expert consensus, that is, people who know the disorder quite well would get together and use some means to come to consensus about what should be included in the diagnostic criteria. And in the case of fibromyalgia, that was done on two different occasions using very extensive research study to try to determine what the characteristics, what characteristics of fibromyalgia should be included in diagnostic criteria. There are two me, methods that have now achieved widespread use. The first one to achieve widespread use was the 1990 American College of Rheumatology research classification criteria. You'll notice, down below here, the abbreviations for those words, are spelled out so that there is no confusion about what the abbreviations mean. But it's easier to use an abbreviation because it fits in the mouth better and it's easier to say. Then, later in 2010, almost exactly 20 years later, there were new criteria developed called the American College of Rheumatology Fibromyalgia Diagnostic Criteria. And so, we'll learn more about these two different criteria in just a moment. The first one involved doing research at 20 different centers in the United States and Canada. Studies done by experts in the field and all of them coordinated to try to find out what the criteria should be. Eventually, after many collections of data at many centers the and, and statistical analysis, it was decided that widespread pain for three months would be one of those important criteria. And the second criteria, only two criteria, very easy to think about and learn and remember was that there were tender places around the body that were unusually tender in people with fibromyalgia. And that 18 of them were very characteristic and contributed nicely to the validity of the diagnosis, and if 11 or more of those 18 criteria were present in a given patient then the diagnosis would be made. There was quite a bit of interest in these tender locations. And so it was, important to think about developing an illustration which could show the location of these places. They were described anatomically in the research papers, but it was nice to be able to see them on a body diagram. And see that in fact, if, if many or all of them were present, this clearly would be widespread tenderness. So, what was shown here in this slide was the original illustration that was associated with fibromyalgia. It comes from the three graces. Who were said to represent mythologic daughters of Zeus. And you see at the bottom of this slide there, the names of each of these beauties and what they were suppose to represent. But, on the bodies of these, women, are the locations of the tender points or areas of unusual tenderness or low pain threshold that can be experienced in people with fibromyalgia, and were helpful in making the diagnosis. And then, a educational program referred to as ADAM, which exists mainly on the Internet to my knowledge, used a different kind of diagram and it only required the front and back of one individual to show the location of the tender points. And then I got involved in the, pursuit of illustrating this and painted a painting of a woman, and showed on the body the tender points location and were able to do it from a single person showing a single view. And I even included in the illustration the hand of god bursting through the back of the painting and showing, pointing to the tender point at the lateral upper condyle. And, in essence, saying that the good lord intended us as physicians to know how to do this tender point examination. But there were certainly very important values in developing these criteria and having satisfactory criteria. This graph shows on the, vertical axis, the number of publications referenced in med line in a given year. And this was showing five showing the graph of the number of publications if we just take every five years to illustrate the data. And you can see that when we come to 1990, when the 1990, American College of Rheumatology Fibromyalgia, the research classification criteria were, were published. There was a dramatic increase from about 10 to 15 articles per year up to, over a 100, very quickly. And then, on to very progressive and dramatic increase in the number of publications. So, this is a soft tissue pain condition which exhibited growth in research, very dramatically impacted by the, agreement of the experts in the field that they now could share diagnostic criteria and knew that each of the patients in their research studies would meet the criteria that other physicians were using. And, I might show that this did not occur in non-specifically. That is, the brown line, down at, toward the bottom, all the way across the graph, is showing the number of publications in another medical condition, myofascial pain syndrome, a regional pain disorder. And the number of articles in that category did not increase dramatically in 1990 as the publications about fibromyalgia did. One other interesting thing here is that some people are trying to avoid the, the affiliation with the name fibromyalgia syndrome and would rather call this disorder chronic widespread pain. And so, I also graphed the frequency of publications about chronic widespread pain which seemed to increase around 2005 and 2010. And then, I also added those to the graph of fibromyalgia because I think they are essentially fibromyalgia being described as chronic widespread pain, and so you can see the pattern here which fits very nicely the pattern already established for fibromyalgia. So then the 1990 American College of Rheumatology Research Classification Criteria came under attack. It had already been maybe 15 years and someone said that the tender point examination was just too hard to learn. There was another problem and that was that epidemiology studies looking for the frequency of fibromyalgia in the community, once a person was identified, perhaps by phone call or by a questionnaire, it was necessary to examine that person for tenderness to determine whether they really met criteria for fibromyalgia. And so that was inconvenient, and then there is a subgroup of psychiatrists who have decided that their profession would be better served by not making physical contact with patients. And so, they prefer not to touch a patient. And so psychiatrists, in this, in this pursuit would not be able to make a diagnosis of fibromyalgia for lack of being able to touch the patient and, and determine the tenderness at the anatomic tender points. Another problem was that the original 1990 criteria were never validated for use in community care, and so, some said we should not be using these criteria in diagnosing fibromyalgia in the doctor's office. It's really only set up to be used in defining people for, with fibromyalgia for research study. And it was true. Another criticism that these criteria addressed only the pain and tenderness of fibromyalgia, so-called allodynia very well. But they did not include any of the other comorbidities. And there was a move to pay more attention to the other comorbidities in fibromyalgia, so we needed an, a diagnostic criteria that addressed comorbidities. And then, the question was, if we're going to include comorbidities, we may not be able to include them all. How do we choose which comorbidities should be included? And so, after a long, process of discussion and consideration, the slide that you see here lists, is, is a list of comorbidities in fibromyalgia. And you'll notice the, blue colored, words were the ones that were chosen to be included in a new set of criteria that were established, again, by research study and they were tiredness, cognitive dysfunction and persistent somatic fatigue. So tiredness, memory trouble, short term memory trouble and persistent fatigue, fatigue where the comorbidities included in the 2010 American College of Rheumatology fibromyalgia diagnostic criteria. And then, these criteria where subjected, not only to large number of patients being evaluated and interviewed by clinicians, but also they were subjected to evaluations so that they would be validated for clinical use in the doctor's office. And so, all of that was done and the information about the research studies was published and this criteria where again, quite simple. That is, the patient would have assessed their widespread pain index or established the widespread index. And that index can range from 0 to 19. And there would also be an assessment of the symptom severity scale that could range from 0 to 12. The widespread pain index would have to do with parts of the body that the patient had experienced pain within, the last short period of time. And the Symptom Severity Scale would include the comorbidities that were associated with it. And then it was discovered that if, rather than having the fit, physician interview the patient, that the same information could be obtained by providing the patient a self-report questionnaire. And so, now that can be done. And I show you here the questionnaire for the 2010 American College of Rheumatology criteria that we use in our research studies. You can see that a person might say, yes, check right here, I've had pain during the last two weeks in the right jaw. Or the right upper arm, or the right lower arm, or the right shoulder, and here would be the balance for that in the left jaw, or the left upper arm, or the left lower arm, and the left shoulder, and so forth, as we go down. And for every check in the Yes column, there would be a a, a single digit added to the widespread pain index. So, if a person filled out yes on ten of these areas here, the the widespread index would be ten. And then, in addition to that, the symptom severity scale is included here and ranging from zero to three. So none would be zero, slight, mild would be one, moderate would be two and severe would be three. And so, for tiredness or fatigue or discognition, forgetfulness, trouble concentrating over the past two weeks, the person would mark which of these categories and then a number would be associated with that. And finally, somatic symptoms within the past week could be any of these. The patient would just check them and the clinician would look at the number of items that were checked, and the value here would be zero to three as well. And then the sum of each of these would make the somatic, the symptom severity score. And then the total score for the 2010 criteria would be the sum of the widespread pain index and the symptom severity score, and that would be recorded here. So, is there value in making the diagnosis of fibromyalgia? Many had argued, many critics had argued, that making the diagnosis of fibromyalgia only hurt or harmed patients by giving them something to focus on, and to foment about, and to cry about and to worry about. But others felt that it was likely that patients were reassured by having a diagnosis. And they felt better about themselves because they now knew what their, what their risk prognosis was on a long term basis and they also could start working to make themselves better by following good instruction about treatment. And so, here we see a study that was done in England by Hughes and other authors, and we see on the vertical axis the rate per 100 person years. So, you would say, for, for every 100 years of patient follow up, these values would show how often there were visits to the doctor, treatments of some sort taken by the patient, or given by the doctor. Tri-cyclic anti-depressant drugs were administered, or non steroidal inflammatory analgesic drugs were administered, so all three of these fit this pattern. And you can see that fibromyalgia patients got more and more visits, more and more treatments, more and more until finally the diagnosis was made and finally the patients could take a deep breath. And the number of visits decreased substantially, significantly. The number of treatments taken by the patient decreased and so forth. And that did not happen for a controlled group with another diagnosis which was made at this point in time. So, this data shows that there is value to not only the patient, but also to society in reduction of medical care costs associated with fibromyalgia when the diagnosis is properly made. Now, something else that I need to share with you that is important to understand is that fibromyalgia while, moving from one patient to the next, the pattern is very, very similar. There are, in fact, are subgroups of people with fibromyalgia, and so we need to understand a little bit about how that comes about. First of all, it's somewhat complex. It does need understanding. It's a convoluted topic. It's perhaps something like taking your cranberry juice, which you, which is so sour you just can't quite get it down, and adding strawberry juice, or grape juice to it, which maybe is a little sweeter and softens it a little bit, so it changes the flavor. So, we talked about various comorbidities in fibromyalgia, and a person with fibromyalgia could have developed or inherited five of those criteria, but another person who lives next door with fibromyalgia might have inherited some of the same and a few different. And so, the actual character of the fibromyalgia will depend a little bit on which of the comorbidities are present. There were several papers with subgroups of fibromyalgia in the title. Subgroups of primary fibromyalgia exist with different proportions of the key comorbidities such as pain, sleep, mood, etc. And, there are sub groups in which fibromyalgia overlaps with other conditions, such as inflammatory or auto immune disorders like rheumatoid arthritis, systemic lupus and chronic infections. There is also subgrouping that has been accomplished by response to medications. And it turns out that some patients respond to one medication, whereas others respond better to other medications. And so that also has been, the subject of discussion about subgroups of fibromyalgia. So, finally we get to our, somewhat flippant statement, who cares? It's, it seems flippant because it implies that no one cares. But, in fact, care is the term that is used by medical care physicians, to say we're providing care for this patient. So who cares for the patient? What kind of physician should be sought? What kind of healthcare provider would be helpful? And the first thing is that primary care physicians that we abbreviate as PCP should always be the captain of the team. That should be the person that the physician that the patient with fibromyalgia, or other medical conditions, should turn to. Primary care physicians typically are family practice doctors, pediatricians or specialists in internal medicine. It's my particular bias that fibromyalgia patients who are adults should seek the care of a specialist in internal medicine for their general medical care or to be their primary care physician. And I have done so myself. Another person that might in care for people with fibromyalgia would be rheumatologists. Rheumatologists actually led in the search to understand fibromyalgia, and patients came to them because they had pain and were sent to them, becau, by their physicians because this pain and other symptoms of aching and stiffness resembled the inflammatory disorders that rheumatologists care for. On the other hand, it is now, fibromyalgia is now known to be a disorder of the central nervous system, with pain amplification due to substance P, a chemical in the spinal fluid. So, that is one of the reigning theories about how, fibromyalgia works and we'll be talking more about that in a future session. Rehabilitation physicians are skilled at helping people, who have lost the ability to be physically active, to regain that ability. And they often worked through physic, physical therapists or massage therapists. Sleep physiologists are very important to the care of fibromyalgia because they have the technology to evaluate sleep. When we sleep we're not just unconscious for a period of hours. There are many things going on during that time. And sleep physiologists are trained to understand those activities of the sleep period. Finally, psychiatrists, psychologists and counselors can be very helpful in helping patience to find new guidance in their life. And to deal with emotional, troubles, that can find themselves in the manifestations of depression, anxiety, panic, and otherwise. I, we would say that orthopedic or general surgeons would be involved in the care of a person with fibromyalgia only for surgery. And so, hopefully those specialists, those surgical specialists, will recognize fibromyalgia when it shows up on their doorstep, but they would refer patients to one of the, physicians who has the skills to evaluate and care for those patients. And so, in conclusion, we would say that the clinical diagnosis of fibromyalgia is now possible by two different methodologies. The 1990 ACR Research Classification Criteria, and the 2010 American College of Rheumatology Fibromyalgia Diagnostic Criteria. The first is seen as facilitating research study, and the more the newer criteria as being validated for community healthcare but in my evaluation of patients I use both criteria, and I'm very pleased when I see that they essentially always identify the same individuals with fibromyalgia. Making a diagnosis has value in a number of respects, not only to the person with fibromyalgia, but to society. There are subgroups, fibromyalgia can be classified as a chronic, widespread pain syndrome. And we believe that primary care physicians are the decision makers and should be the instructors of patients with fibromyalgia. So finally, we would say, we all should care and again, we get back to our happy dog painting in which our dog friend is saying, I'm happy because now fibromyalgia can be diagnosed with confidence. And the patient can be relieved of the anxiety and worry about what is happening to them. Thank you. [BLANK_AUDIO]
