Diagnosis & Integrative Approach to Treatment
Dr. Stephanie Karozos 10/17/19
Fibromyalgia
❖ Chronic pain syndrome
❖ Widespread muscle aches
❖ Fatigue
❖ Pain and stiffness
❖ Soft tissue tenderness
❖ Sleep disturbances
❖ Unknown etiology
❖ 8:1 female to male ratio*
❖ Symptoms overlap with other conditions
A few points
❖ Not a deteriorating disease
➢ Worsening pain can be a sign that something else is going on
❖ Multi-system disorder that often co-occurs with mood disorders, sleep issues,
irritable bowel, etc.
❖ Co-exists with other rheumatologic diseases often
➢ Flares during disease flares
Diagnosing fibromyalgia
Initial Evaluation
❖ History and physical
➢ Widespread pain
➢ Pain worsens with stress
➢ Often stiffness and paresthesias as well
➢ Somatic symptoms
■ Fatigue
■ memory/concentration difficulties
■ Comorbid syndromes: IBS, interstitial cystitis, headache, TMJ
❖ Labs: TSH, Vitamin D, CBC, BMP, CRP
❖ Consider Rheum labs
❖ Imaging/sleep study if clinically indicated
❖ 2016 Diagnostic Criteria
➢ WPI (widespread pain index) at least 7 and SSS (symptom severity scale) at least 5 OR WPI of 4-6 and
SSS at least 9
➢ Generalized pain in at least 4 of 5 regions
➢ Symptoms at least 3 months
➢ No other diagnoses explain symptoms
An aside…
If a patient has the appropriate history but scores arenʼt quite adding up and has:
● Associated fatigue
● Lack of restorative sleep
● Irritable bowel symptoms
You may still consider clinically diagnosing fibromyalgia, particularly if they have pain in
4 of 5 regions.
Consider the “ABC” indicators:
Algesia
Bilateral, axial-symmetric pain distribution
Chronic distress
Multimodal approach
❖ Pharmacologic therapies
➢ Strongest evidence:
■ SNRIs (duloxetine)
■ Cyclic medications (cyclobenzaprine, amitriptyline)
■ Alpha-2-delta ligands (gabapentin, pregabalin)
➢ Modest evidence:
■ Tramadol
■ SSRIs
■ Dopamine agonists
➢ Least evidence:
■ Opioids
■ Steroids
■ NSAIDs
■ Benzos
❖ Supplements
➢ Adaptogens
■ Rhodiola – more energizing/activating, good for chronic fatigue
■ Ashwagandha – for stress/sleep
➢ Valerian
➢ Lemon Balm
➢ SAMe
➢ B vitamins
➢ Magnesium
■ Topical
■ Oral
Nonpharmacologic therapies:
➢ Exercise
■ Aerobic
■ Strengthening
➢ Education
➢ Sleep hygiene
➢ CBT
➢ Acupuncture
➢ OMT
➢ PT: ultrasound & electrotherapy
➢ Dietary interventions
Resources
AZCIM Integrative Medicine Fellowship Curriculum: Fibromyalgia
Fibromyalgia powerpoint and video lecture: Tieraona Low Dog for AZCIM
American College of Rheumatology “2016 revisions to the 2010/2011 Fibromyalgia
Diagnostic Criteria”
Journal of pain research “Rethinking the criteria for fibromyalgia in 2019: the ABC
indicators” 2019 Jul 10