When treating chronic back pain, over-reliance on imaging studies frequently suggest arthritis, disc herniations, spinal stenosis, degenerative disc disease, and spondylolisthesis as the underlying diagnoses. Unsuccessful treatment often results if muscles, tendons, and fascia are not considered in the differential diagnosis.
Widespread pain is often diagnosed as Fibromyalgia Syndrome (FMS). In 1990 the American College of Rheumatology (ACR) presented classification criteria for the diagnosis of FMS [http://bit.ly/1bCzlC4.] 11 of 18 specified tender points as well as widespread pain defined as pain experienced on the left and right side, in the upper and lower body, and axially. Most patients are diagnosed with FMS by their primary care physician. However, most primary care physicians do not perform a physical examination of tender points. Because of this the ACR in 2010 proposed an additional set of diagnostic criteria for FMS that did not rely on a physical examination (http://bit.ly/1bCzlC4).
Three conditions must be met to satisfy the criteria:
- Threshold scores on two new indices created by the ACR- the widespread pain index and the symptom severity scale score based on the presence of fatigue, waking un-refreshed and cognitive symptoms.
- Patients must have similar symptoms at approximately the same intensity for at least three months.
- No other disorder would reasonably explain the pain.
Although there is reasonable correlation between patients diagnosed with the 1990 criteria and the 2010 criteria, the absence of the physical examination may lead to overlooking patients whose diffuse pain can be successfully treated by addressing peripheral pain generators. Painful tissue peripherally (for example muscle or joint) can sensitize muscles diffusely [Woolf CJ, Central Sensitization: Implications for the diagnosis and treatment of pain. Pain 152 (2011) S2-S 15].
I welcome your comments on the complexities of diagnosing and treating FMS; more on central sensitization in my next post.
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