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jep.12836

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Received: 26 March 2017
Revised: 29 August 2017
Accepted: 6 September 2017
DOI: 10.1111/jep.12836
ORIGINAL ARTICLE
A simple screening test to recognize fibromyalgia in primary
care patients with chronic pain
Kim D. Jones PhD, FNP, FAAN, Professor1,2
|
Jonathan H. Aebischer DNP, FNP, Instructor3
Amanda W. St. John DNP, FNP, Instructor2 | Ronald Friend PhD, Professor Emeritus1,4
Robert M. Bennett MD, FRCP (Lond), FACP, FACR, Professor1
|
|
1
School of Nursing, Oregon Health and
Science University, Portland, USA
2
School of Medicine (Anesthesiology and
Perioperative Medicine), Oregon Health and
Science University, Portland, USA
3
School of Medicine (Family Medicine),
Oregon Health and Science University,
Portland, USA
4
Department of Psychology, College of Arts
and Sciences, Stony Brook University, Stony
Brook, New York, USA
Correspondence
Kim D. Jones, School of Nursing, Oregon
Health and Science University, Mail Code SN‐
ORD, 3455 SW US Veterans Hospital Rd, OR
97239, Portland, USA.
Email: joneskim@ohsu.edu
Funding information
Harry W. and Genevieve M. Pierong School of
Nursing Memorial fund; Fibromyalgia Information Foundation
Abstract
Rationale, aims, and objectives:
Primary care providers are increasingly expected to recog-
nize and treat fibromyalgia (FM) without significant interaction with rheumatologists. The
purpose of this study was to evaluate the potential usefulness of 3 simple measures (tenderness
to digital pressure, BP cuff‐evoked pain, and a single patient question) as a screening test for
possible FM in a patient with chronic pain.
Methods:
A total of 352 patients (mean age 50 ± 16.3 years, 70% female) scheduled for
routine examination in 2 primary care practices were studied. They were comprised of 52
patients (14.8%) who carried a chart diagnosis of FM, 108 (30.7%) with chronic pain but not
FM, and 192 who had neither pain nor FM (54.5%). Subjects were assessed for tenderness to digital pressure at 10 locations, BP cuff‐evoked pain, and a single question, “I have a persistent deep
aching over most of my body” (0–10).
Results:
FM patients endorsed the single deep ache question substantially more than those
with chronic pain but without FM (7.4 ± 2.9 vs 3.2 ± 3.4; P < .0001) and exhibited greater bilateral
digital evoked tenderness (6.1 ± 3.1 vs 2.4 ± 2.4, P < 0.0001), and BP‐evoked pressure pain
(132.6 mmHg ±45.5 vs 169.2 mmHg ±48.0, P < 0.0001). However, on multivariate logistic regressions, the BP cuff‐evoked pain became non‐significant. On further analyses, a useful screening test
was provided by: (1) pain on pinching the Achilles tendon at 4 kg/pressure over 4 seconds, and (2)
and positive endorsement of the question “I have a persistent deep aching over most of my body”.
Conclusion:
These results suggest that 2 tests, taking less than 1 minute, can indicate a
probable diagnosis of FM in a chronic pain patient. In the case of a positive screen, a follow‐up
examination is required for confirmation or refutation.
KEY W ORDS
ache, chronic pain, diagnosis, fibromyalgia, primary health care, screening test, tenderness
1
|
I N T RO D U CT I O N
interstitial cystitis/painful bladder syndrome, chronic pelvic pain,
temporomandibular pain disorder, restless leg syndrome, and
Fibromyalgia (FM) is a chronic widespread pain syndrome that
systemic exertion intolerance disease.4,5
conservatively affects 3.4% of women and 0.5% of men in the
Data from the US, Europe, and Asia report that approximately
United States.1,2 In primary care, up to 1 in 20 patients have symp-
half of providers admit uncertainty in confidently making a diagnosis
toms consistent with a diagnosis of FM.3 Besides pain, FM is
of FM6-8 and often refer these patients to specialty clinics. Labora-
commonly associated with many comorbidities: sleep disturbances,
tory, x‐ray, and other biomarkers to aid in diagnosing FM remain
fatigue, psychological distress, headache, irritable bowel syndrome,
elusive. A diagnosis of FM is further complicated by its common
J Eval Clin Pract. 2017;1–7.
wileyonlinelibrary.com/journal/jep
© 2017 John Wiley & Sons, Ltd.
1
2
JONES
ET AL.
comorbidities, and its management often incurs high health care costs
enrolled, subject age, subject gender, and a list of common chronic pain
for what turns out to be treatment for these comorbidities. A diagno-
disorders. A chart diagnosis of FM by providers was guided by the
sis of FM may take 2 to 3 years, with many patients seeing 3 to 4
1990 ACR criteria and/or the proposed American College of
medical
providers
before
receiving
the
correct
diagnosis.9,10
Rheumatology preliminary diagnostic criteria of 2010.2,15
Diagnosing FM more promptly should reduce unnecessary tests,
specialty referrals, health care costs, and patient anxiety.9,11
2.2.2
|
Pressure‐evoked pain assessments
Complicating matters, unified diagnostic guidelines for FM are
Pressure evoked allodynia or tender points have been reported
lacking.12 For nearly 3 decades, the 1990 American College of
previously.16 In order to simplify and shorten the screening protocol,
Rheumatology (ACR) criterion has been used to reduce heterogeneity
we avoided use of the 1990 ACR defined tender points and instead
of subjects enrolled in research. It relies on widespread pain ≥3 months
assessed 5 paired pain locations, based on our clinical experience.
and the presence of pain upon palpation of 11 of 18 tender points.2
These bilateral locations were upper trapezii, brachio‐radialis, anterior
However, accurately evaluating 18 tender points is problematic,
thighs, Achilles tendon pinch, and 2 joints (91st and 2nd proximal
particularly in primary care where the scope of practice is broader than
interphalangeal joints). Pain was evoked by the investigator applying
in specialty settings.13 Two more recently proposed patient self‐rated
4 kg/pressure over 4 seconds with the presence or absence of pain,
questionnaires for diagnosing FM take into account not only pain,
being determined by the subject's verbal response recorded in a
but common symptoms.14,15 Outside of rheumatology, providers
yes/no classification. Additionally, we sought to extend novel findings
have yet to embrace Wolfe's diagnostic criterion or Bennett's 2013
by 2 earlier investigators which have demonstrated lower pain
alterative diagnostic criteria. Based on our clinical experience, we
thresholds in FM the patients using BP cuff‐evoked pain.17,18
surmise that clinicians need a simple screening test that can be
Participants were evaluated seated and using appropriately fitting BP
performed as part of the routine evaluation in all patients with
cuffs on the arm selected by the patient. Investigators manually
persistent pain complaints. In reality, these patients will usually be
inflated the cuff on the upper arm of the subject a single time at a rate
seen as part of an encounter for another diagnosis (eg, hypertension,
of ~10 mmHg per second to a maximum of 220 mmHg. Patients were
diabetes, asthma). If the brief screen is positive, the clinician would
asked to state the point at which the cuff pressure caused pain. The
schedule a follow‐up visit or referral to confirm or refute a diagnosis
level of mmHg was then recorded at which pain was induced. If no pain
of FM.
was induced, an upper level of 220 mmHg was recorded.
Herein, we describe a study that evaluates the utility of 3 clinical
measures that provide a simple screening test for the potential presence
of FM. Specifically, we assessed BP cuff‐evoked pain, digital palpation
evoked pain, and a single question about “persistent deep aching”.
2.2.3
|
Patient questionnaire
Following tenderness testing, subjects were given a tablet with a self‐
report questionnaire. The first question was: “do you have any pain?”
If subjects answered “no,” the survey was ended; if subjects
2
METHODS
|
answered “yes,” they were then asked if their pain had been present
for greater than 3 months. The remainder of the survey assessed pain
2.1
Study design and participants
|
This study was approved by the university's institutional review board
and FM‐associated symptoms. In a previous study, we found that a
single question “I have a persistent deep aching over most of my body”
was commonly endorsed by FM patients.19 This question was scored
(# 00015219). Neither investigators nor patients were compensated
on a 0 to 10 VAS with anchors of “none to severe”. All patients
for their participation. All subjects were at least 21 years of age, were
complaining of pain also completed the Revised Symptom Impact
able to read and speak English fluently, and demonstrated capacity for
Questionnaire
providing written informed consent. Subjects were recruited at the time
diagnosis.14,20
(SIQR),
as
an
independent
validation
of
FM
of being seen for a routine follow‐up evaluation. Evaluations were done
in a federally qualified health center/family practice clinic and a separate
internal medicine clinic, both affiliated with an academic health care
3
|
STATISTICAL METHODS
institution. The overarching principle of enrolling subjects was to obtain
a sample that was representative of the diversity of patients routinely
Descriptive statistics were used to characterize the sample. Skewness
encountered in primary care settings. A total of 352 patients were
was evaluated by the Shapiro‐Wilk W statistic.21 F‐tests (ANOVAs),
studied of which 160 were determined to have chronic pain (52 FM
t tests, and chi‐squares were used to assess group differences in means
and 108 Pain/NoFM) and 192 were determined to have NoPain/NoFM.
and proportions. Mean and percent column plots with 99% confidence
A subject was determined to have a diagnosis of FM if the clinics' senior
intervals were generated to illustrate differences in the 3 primary
clinician had documented that diagnosis in the patient's records.
measures of the study between the FM and Pain/NoFM groups: for
BP‐cuff evoked pain, the “deep aching” question and pain on digital
2.2
2.2.1
Demographic and clinical measures
|
|
Electronic medical record
palpation (Figure 1). A series of logistic regressions were conducted
to assess the relative merits of the 3 predictors (pain on digital palpation, BP cuff pressure‐evoked pain, and the “deep ache” question) as
Individual data collection included recording of basic subject data from
single (univariate) or combined (multivariate) predictors of FM and
the electronic medical record, the clinic at which the subject was
Pain/NoFM. The area under the receiver operating curve (ROC), odds
JONES
3
ET AL.
Persistent deep aching
Achilles tenderness
100%
90%
220
210
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
50
9
1
8
80%
7
70%
6
60%
2
5
50%
4
40%
3
30%
2
20%
10%
1
0%
0
BP cuff pressure
3
FM
Y axis graph #1: Percentage of patients that were tender at right Achilles
Pain but no FM
Y axis graph #2: Persistent deep aching score (range 0–10)
CI 0.99
Y axis graph #3: Systolic BP reading at which patient experienced pain
FIGURE 1 Analysis of the 3 primary measurements.
Right Achilles: 71% vs 27%; χ2 = 28.4; P < .0001.
Deep ache: 7.4 vs 3.2; F = 57.2; P < .0001.
BP‐cuff evoked pain: 132.6 vs 169.2; F = 21.1; P = < .0001.
Interpretation: With 99% confidence interval (CI), all 3 tests showed substantial differentiation between fibromyalgia (FM) and Pain but No FM
groups, with no overlap
ratio, sensitivity, specificity, and Somers' D were reported for each
5
PAIN ON DIGITAL PALPATION
|
variable separately and in combination. In logistic regression, Somers'
D is a measure of the rank correlation of the predictor variables with
Pain on digital palpation for the 3 clinical groups, (FM, Pain/NoFM, and
a binary outcome (eg, FM vs Pain/NoFM).
NoPain/NoFM) at the 5 paired sites is seen in Table 1. When assessing
These analyses employed Statistica software (version 13.2). All
sites, the mean percent of pain locations for all 10 sites was 61% ± 5.6
statistical tests were 2 tailed. A conservative Type 1 error rate of 1%
(range, 52–71), for the Pain/NoFM group 24% ± 5.0 (range 16–34),
and 99% confidence intervals (CI) were applied. To describe the study's
and for the NoPain/NoFM group 8% ± 2.9 (range 5–14%). Analysis
sample response to pain on palpation (FM patients; Pain/NoFM
of all 3 groups (F = 281.6; P < .0001; with all paired comparisons,
patients; and NoPain/NoFM patients), tables for the 3 groups are
P < .0001) provided strong evidence for the validity of the digital
provided. For purposes of recognizing suspicion of FM among pain
palpation assessment, with responses for the 10 sites being roughly
patients, 2‐group analyses are conducted in pain patients with and
equivalent within each group. When analysing patient scores, the
without FM (FM and Pain/NoFM).
mean pain on digital palpation (0–10 sites) was significantly different
among the 3 groups (X = 6.1 ± 3.1; 2.4 ± 2.4; 0.8 ± 1.7; F = 129.9;
P < .0001). The means for the 2 pain groups, with and without FM, are
4
|
RESULTS
illustrated in Figure 1, and show substantially non‐overlapping 99%
confidence intervals (CI). In FM patients, tenderness on digital palpation
As noted, participants were enrolled at either a family practice or
at 1 or more sites was reported by 48 of 52 subjects. The Achilles tendon
internal medicine clinic. Slightly over half (55.3%) of all patients were
pinch was the most commonly endorsed pain site on exam (71%), while
enrolled from the family practice. There were no significant differ-
the left anterior thigh pain was the least commonly endorsed pain site
ences between the 2 locations on age or percentage of patients with
(52%), but there were no significant differences among sites for FM
a history of FM (14% vs 15%) or between examiners in the assess-
patients (P > .26). A total digital pain score measure (0–10 sites) with a
ment of BP‐cuff pressure evoked pain. There were no differences
cutoff of 4 or more tender areas of pain generated an OR = 10.6 with a
between the 2 examiners in the assessment of right Achilles tendon
sensitivity/specificity of 77/76. The Achilles had the highest correlation
pinch for FM patients (80% vs. 70%; P < 0.62) or for Pain but No
with the total digital pain score (item‐total correlation) of the 10 sites.
FM patients (31% vs 25%; P < 0.55). Some 14.8% of patients had
FM, and an additional 30.7% had chronic pain but NoFM. The SIQR
5.1
score in the FM group was 60.1 ± 21.7 compared with 36.1 ± 22.6
Patients with FM reported lower BP cuff pressures when they experi-
for the Pain/NoFM group (t = 6.3; P < .001); this helps to affirm the
enced pain, compared with those with Pain/NoFM (132.6 ± 45.5 mmHg
providers' diagnosis of FM.14
vs 169.2 ± 48.0 mmHg; t = 4.6; P < .0001).
|
BP cuff‐evoked pain
4
JONES
TABLE 1
ET AL.
Percent in each group endorsing tenderness at each site
Group
Tender Site
FM
(n = 52)
No FM
(n = 300)
Pain but No
FM (n = 108)
No FM No
Pain (n = 192)
Skin roll over upper radius—Left
62
14
21
9
Skin roll over upper radius—Right
67
15
31
6
Tenderness of 1st or 2nd IP joints—Left
56
12
19
7
Tenderness of 1st or 2nd IP joints—Right
56
12
20
8
Skin roll upper trapezius—Left
60
15
28
8
Skin roll upper trapezius—Right
63
19
34
10
Skin roll upper anterior thigh—Left
52
10
19
5
Skin roll upper anterior thigh—Right
58
9
16
5
Achilles tendon pinch—Left
63
19
28
14
Achilles tendon pinch—Right
71
17
27
12
Average % per 10 sites
60.8
14.2
24.3
8.4
Mean skin roll (0–10) per patient
6.1 (3.1)a
1.4 (2.0)b
2.4 (2.2)c
0.8 (1.7)d
ab
t = 14.1; P < .00001; 2 mean comparison (FM, No FM).
acd
F = 129.9, P < .00001; 3 mean comparison (FM, Pain but No FM, No FM No Pain).
Legend: The percentage of FM and No FM patients responding with pain differed substantially (60.8% vs 14.2%). Among patients without FM (i.e., Pain but
No FM and No FM No Pain) patients with pain differed from pain‐free patients (24.3% vs 8.4%). Among patients responding with pain (i.e., FM vs Pain but
No FM), FM patients differed substantially from Pain but No FM patients (60.8% vs 24.3%). (All comparisons P=.0001). By contrast, percent differences
among the ten individual sites within each patient group were minimal (see columns), and nonsignificant (P > .26).
5.2
|
Persistent deep aching question
Pain/NoFM) increases in magnitude as one proceeds from the single
In response to the question, “I have a persistent deep aching over most
of my body,” (0–10) the Pain/NoFM group scored 3.2 ± 3.4
compared with 7.4 ± 2.9 for patients with FM (P < 0.001), a 4‐point
difference. This difference compares with only a 1‐point difference
on a standard SIQR VAS pain score (5.1 ± 2.6 vs 6.5 +/− 2.0;
predictor to the 3 predictor multivariate model (D = .44 to .69).
Additionally, blood pressure evoked pain, while significant at the univariate level (P < .01), became nonsignificant in the 3 predictor model
(P = .24) and therefore became superfluous in predicting FM. When
comparing the 2 and 3 multivariate models, pain on digital palpation,
P < .01) (see Figure 2). The comparison between these 2 questions
Comparison of Deep Aching score to SIQR Pain score
provides discriminant validation for the deep aching question by
10
showing the FM, and Pain/NoFM patients differ substantially on
the deep ache assessment but similarly on VAS pain assessment.
9
Notably, the responses by the FM and the Pain/NoFM groups to
the FM group having a median of 9 and the pain/no FM group having a median of 3. As the distribution for the Pain/NoFM is
extremely positively skewed from normality (W = 0.83; P < .0000)
and
the
FM
extremely
negatively
skewed
from
normality
(W = 0.79; P < .0000), a simple Yes/No response is a sufficient sub-
8
Intensity score (0-10)
the deep ache question have a bimodal distribution (Figure 3) with
SIQR Pain VAS
Deep Ache VAS
7
6
5
4
stitute for the VAS assessment. Thus, we recommend that the clini-
3
cian asks the “deep aching question” as a dichotomous “yes/no”
2
question.
1
5.3
|
Predictive value of the 3 clinical features
Univariate prediction (Table 2): Using logistic regression, we assessed
the value of BP cuff‐evoked pain, pain on pinching the Achilles tendon,
and the question “I have a persistent deep aching over most of my body”,
singly or together, in predicting chart diagnosis of FM. Univariate
analyses showed that each of the 3 assessments predicted FM classification significantly: BP (OR = 3.0; P < .01), Achilles (OR = 6.7; P < .01),
and deep ache (OR = 5.3; P < .01).
Multivariate prediction (Table 2): As seen by the Somers' D column,
the rank correlation of the predictors with the response variable (FM;
FIGURE 2
Pain/No FM
FM
Comparison of a standard Pain VAS with the question
“I have a persistent deep aching over most of my body” in chronic pain
patients with and without FM. Connecting lines refer to column means
that can be compared by their respective CI.
Interpretation: The VAS Pain of FM subjects seems to consist of deep
ache over most of body whereas for No FM subjects the VAS Pain
does not consist of deep aching over most of body. There is large
clinical difference between Pain Groups in the new “deep ache”
questions compared with a small difference in standard Pain VAS
question. Among FM patients, deep ache is greater than VAS Pain; in
Pain No FM patients, VAS Pain is greater than deep ache. All means are
significant from each other (P < .01)
JONES
5
ET AL.
% patients with aching at each score
35
Persistent deep aching: comparing FM
a specificity of .59. A “deep aching” cutoff of 3 or greater coupled
patients with pain patients without FM
with Achilles tenderness raises specificity to .80. As noted previously,
we recommend that a potentially useful benchmark for suspecting a
diagnosis of FM is suggested by (1) a “yes” in response to the “deep
30
aching” question (which provides high sensitivity) and (2) a “yes” in
FM
25
response to Achilles tendon pinch (which provides increased
Pain/No FM
20
specificity).
15
6
|
DISCUSSION
10
Recognizing FM can be a difficult task for a busy clinician faced
5
with a chronic pain patient with multiple other complaints. Herein,
we have found that 2 simple tests, added to the routine
0
0
1
2
3
4
5
6
7
8
9
10
Persistent deep aching score (range 0 – 10)
evaluation of any chronic pain patient, could alert the clinician
to a diagnosis of FM.
FIGURE 3
Persistent deep aching. Comparison FM patients with Pain
patients without FM. Bimodal distribution of FM and Pain but No FM
to the question “I have a persistent deep aching over most of my body”
(0–10).
Interpretation: 70% of FM patients scored 7 to 10 contrasted with
63% of Pain but No FM who scored 0 to 3. A cut‐off of 3 produced
sensitivity/specificity of 92/59 and a cut‐off of 4 is 86/64
In order to replicate a normal patient experience, all subjects
were seen as part of their routine follow‐up examination without
knowing that they would be invited to take part in the study; in
other words, they were not preselected for having FM. A diagnosis
of FM was made in 14.8% of patients. Additionally, 30.7% had
chronic pain but did not have FM; thus, a total of 45.5% of the
sample had chronic pain. These findings are almost identical to that
TABLE 2
Prediction of FM chart diagnosis in pain patients using univariate and multivariate logistic regression
ROC
OR
Se/Sp
Somers' D
One predictor (univariate) models
.72
2.96
29/88
.44
ATa (binary)
‐‐‐
6.72
71/73
.44
DAa (continuous)
.82
5.27
56/81
.64
BPa + ATa
.78
7.84
58/85
.56
BPb + DAa
.83
5.87
54/83
.65
ATa + DAa
.85
11.02
64/86
.69
.85
13.03
66/87
.69
Two predictor (multivariate) models
Rasu et al (2013) reported that approximately 45% of chronic pain
patient visits were with primary care providers.22 This suggests that
primary care.
There is a general agreement that an important diagnostic feature
of FM is the presence of widespread pain, but there is no general
agreement as to how this should be defined. There is also general
Three predictor (multivariate) model
agreement that FM patients have widespread tenderness; this was
the rationality for palpation of the 18 tender points recommended in
the 1990 ACR criteria. Some recent diagnostic criteria have eliminated
the tenderness examination completely, on the rationale that they
a
P = .01.
b
sample was over 690 million non‐cancer chronic pain patient visits.
the present sample is representative of chronic pain patients seen in
BPa (continuous)
BPc + ATa + DAa
reported by the National Ambulatory Medical Care Survey whose
were often not performed in routine practice. It is our belief that
widespread pain and tenderness should still be key diagnostic features
P = .06.
of FM. To achieve this end, we recommend a response (“yes/no”) to a
c
P = .24.
single question. “I have a persistent deep aching over most of my body” as
AT, right Achilles tenderness; BP, BP‐cuff evoked pain; DA, deep aching
question; OR, odds ratio; ROC, area under the receiver operating curve;
Se/Sp, sensitivity, specificity.
a surrogate for widespread pain.
Legend: Overall, the addition of BP‐cuff evoked pain to both skin roll
tenderness and/or the deep aching question did not significantly improve
the prediction of FM. Among univariate analyses while all 3 measures were
significant, the deep aching question provided the best predicted value
overall (ROC=.82 and Somers' =.64). In the 2 variable multi‐item analysis,
the combination of Achilles tenderness and deep aching question provided
the best prediction with an impressive ROC of .85 and odds ratio of 11.02.
These did not differ from the ROC of .85 and odds ratio of 13.03 in the 3
variable model. The best sensitivity of .92 was provided by the deep aching
question with the cutoff of 3 or greater.
In order to define widespread tenderness, we assessed the
patient's pain response (yes/no) to palpation (4 kg/pressure over 4 seconds) at 10 locations (Table 1). All 10 locations were significantly more
tender in FM patients than chronic pain patients without FM, and
there was no significant difference between the individual locations.
The Achilles tendon pinch was the most commonly endorsed pain site
and was predictive of overall tenderness as measured in response to
palpation at all 10 sites.
Literature, prior to and including the 1990 ACR diagnostic criteria,
endorsed the concept of pain on digital palpation, and pressure‐
induced allodynia.23 In this current study, we found that BP‐cuff pain
and deep ache do as well as the 3 predictor model (OR = 11.0 vs
taken alone was significantly different between groups, replicating 2
13.0; ROC = .80 vs. .82; Somers' D = .69 vs .69) (Table 2). However,
previous studies17,18 but did not improve diagnostic accuracy when
a score of 3 on “deep aching” provides a level of sensitivity of .92 but
analysed together with the other 2 variables (deep ache question and
6
JONES
Achilles tendon tenderness), suggesting that digital palpation is a more
ET AL.
D E C L A R A T I O N OF I N T E R E S T
valid indicator of FM presence than BP pressure evoked pain.
Thus, just 2 positive responses to a question about a persistent
The authors declare no conflict of interest.
aching over most of the body and pain on pinching the Achilles tendon
suggest that a patient with chronic pain has a diagnosis of FM.
ACKNOWLEDGEMENTS
However, we are not advocating the use of these 2 tests for making
We acknowledge Madeleine Sanford MSN, FNP and Kaitlin Haws
a definitive diagnosis of FM, but rather we envisage their potential
DNP, ANP, WHCNP, and their respective Oregon Health and Science
for alerting a clinician to the possibility that a chronic pain patient
University departments, Family Medicine, and Internal Medicine, for
may have a diagnosis of FM; a definitive diagnosis of FM will require
their contributions and permission to carry out this study. We thank
a more focused evaluation. As the 2 recommended tests take less than
the Fibromyalgia Information Foundation and Harry W. and Genevieve
1 minute to perform, their use in all chronic pain patients should not
M. Pierong School of Nursing Memorial fund for financial support. We
add a significant time burden.
thank our subjects for their participation in this study.
A major strength of this study is that it was conducted in 2 separate primary care practices in 2 locations by 2 different clinicians of
opposite genders (AS and JA). Subjects were recruited at the time of
A U T H O R S ' CONT RI BUT I ONS
being seen for a routine follow‐up evaluation; thus, the subjects were
representative of pain patients seen in primary care. The study design
RB, KJ, AS, and JA conceived of the study, analysed the data, and
also combined data generated from diverse sources that included the
drafted the manuscript. AS and JA collected the data. RF conducted
electronic medical record, clinician examination, and patient self‐report
statistical analysis and provided feedback on the manuscript. All
forms. These were used to assess and evaluate 3 different outcome
authors read and approved the final manuscript.
measures that produced converging results (ie, convergent validity).
There are a few issues in the interpretation of these results. There
ORCID
were only 6 males with a history of FM in our cohort making subgroup
Kim D. Jones
http://orcid.org/0000-0001-6384-8613
analyses by gender impossible. Another potential problem was the use
of the chart diagnosis of FM (based on the senior clinician's opinion).
However, those patients with a chart diagnosis of FM also had a SIQR
score typical of FM patients. This study was relatively small, but the
statistical analysis showed a convincing robustness. As always, these
findings need independent confirmation.
7
|
C O N CL U S I O N
Despite increasing acceptance of FM as a significant pain disorder,
there is evidence that it remains underdiagnosed.24 Past studies have
incorporated the concepts of widespread pain, tenderness, and patient
rated severity of symptoms in algorithms for FM diagnosis .13,25,26 This
current study follows a similar algorithm but offers a shorter but more
practical screen for identifying those at risk for having FM. Thus, we
are recommending 2 simple assessments to be added to the routine
evaluation of any chronic pain patient. The first assessment is the
yes/no response to a single question. “I have a persistent deep aching
over most of my body”. The second assessment is pain elicited by
pinching the Achilles tendon with approximately 4 kg/pressure over
4 seconds. We envisage these assessments be used as a screening
instrument not a diagnostic test, with a definitive diagnosis of FM
being reserved for later. By raising a providers' index of suspicion,
patients may be spared a lengthy cycling through the medical system
before receiving a diagnosis of FM and beginning treatment.
DECLARATION
The study was approved by the Oregon Health and Science
University's institutional review board (# 00015219).
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