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From the Townsend Letter
November 2016

Fibromyalgia: Proper Diagnosis is Half the Cure
by David M. Brady, ND, DC, CCN, DACBN
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Here's a checklist of symptoms found most commonly in patients with classic FM:

  • Unrefreshing sleep
  • Extreme sensitivity to touch
  • Difficulty with concentration           
  • Widespread pain/tenderness
  • Extreme fatigue/low energy
  • Migraine headaches
  • Inability to tolerate exercise
  • Grinding/clenching teeth
  • Irritable bowel syndrome
  • Multiple chemical/food sensitivity
  • History of depression/anxiety
  • Irritable bladder syndrome

If your patient has experienced widespread pain for more than 3 months and has at least 4 of the above symptoms, they may very well be suffering from classic FM and may be a candidate for the standard medical approach. Certain medications, or nonmedication neurotransmitter precursors such as 5-hydroxytryptophan (5-HTP), can be helpful to reduce the level of pain, unrefreshing sleep, and emotional stress.11 However, other approaches can be helpful to "retrain" the nervous system and the body's responses to pain. These include activities such as mild aerobic exercise, yoga, tai chi, meditation, and self-relaxation techniques.12 Sometimes psychological counseling that uses a cognitive behavioral therapy approach is also quite beneficial to classic FM patients.
If your patient does
not have at least 4 of the symptoms noted above, then you should look for some other cause of their FM symptoms. It is likely that instead of having classic FM, they are suffering from some other medical problem that may mimic FM. The first thing is to make sure that their symptoms of widespread pain and fatigue are not caused by some undiagnosed medical problem, which we will discuss in the next section.
Common Medical Problems That May Be Confused with Classic FM
In patients who complain about generalized pain and fatigue, it is imperative that the doctor rule out the presence of any medical condition or disease known to cause many of the symptoms associated with classic FM. Hypothyroidism, anemia, rheumatoid arthritis, Lyme disease, rheumatic auto-immune disorders such as ankylosing spondylitis (AS) or scleroderma, multiple sclerosis, and cancer are some possible causes for symptoms of vague and diffuse musculoskeletal pain associated with pronounced fatigue.5 Most of the medical assessments appropriate in this type of situation come in the form of laboratory testing, to include any or all of the following screening tests:

  • Complete red and white blood cell count with white cell differential
  • Thyroid function tests (total and free T3 & T4, TSH, and thyroid antibodies)
  • Standard blood chemistry
  • C-reactive protein and/or erythrocyte sedimentation rate (ESR)
  • Lyme test, rheumatic/autoimmune profiles (as necessary)

As simple as these screening tests may be to perform, it is not uncommon for doctors to fail to have any laboratory tests performed on their patient and still render a diagnosis of FM despite the fact that according to American College of Rheumatology (ACR) guidelines and criteria, a diagnosis of FM should not be rendered until all lab tests come back negative and fail to detect any obvious medical reason for the symptoms.2
The doctor should employ a simple, rational approach to laboratory assessment, which includes an initial complete blood count (CBC) as a screen for common forms of anemia (unhealthy or low levels of critical oxygen-carrying red blood cells), and an assessment of white cells to rule out infection or marrow disease.13 More specifically, obvious reasons for excessive fatigue, such as anemia, can be ruled out on the CBC by screening for low RBC count, altered hemoglobin and abnormal RBC indices such as MVC, MCH, and MCHC tests. An erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) test can help to confirm the presence or absence of inflammation or infection. Although the ESR and CRP tests are nonspecific, extremely high values found on these tests may indicate the need for further laboratory testing for underlying autoimmune rheumatic diseases or possible undiagnosed serious illnesses, including malignancy (cancer).
Thyroid blood tests should be routinely performed in patients who present with the complaints of widespread pain and fatigue in order to rule out obvious hypothyroidism as the cause of these symptoms. While the classic signs and symptoms of low thyroid function, including fatigue, weakness, cold intolerance, low temperatures, weight changes (usually weight gain), and depression are routinely considered by doctors, common musculoskeletal signs and symptoms of hypothyroidism including muscle pain, stiffness, muscle cramping, muscle weakness, numbness and tingling, and joint pain are often not considered. The incidence of muscle and joint symptoms with hypothyroidism has been reported to be as high as 30% to 80%.14 These facts are extremely important since it is precisely these vague muscle or joint symptoms that may drive the patient to you initially. Many patients suffering from these symptoms will likely be unaware that they have a thyroid condition, and if missed by the physician, their symptoms may inadvertently be misdiagnosed as FM. More information will be provided on thyroid conditions in the later section on functional metabolic disorders often misdiagnosed as FM.
The doctor should also order a standard blood chemistry panel, as it is very useful to evaluate the general health of a patient experiencing widespread pain and fatigue. This panel should be done after an 8- to 10-hour fast and generally includes serum blood sugar, liver enzymes (liver function tests), cholesterol, blood lipids (fats), and kidney function tests. Of course these laboratory tests should be correlated with physical examination findings and other diagnostic tests. If the physical exam findings suggest that the patient may be suffering from joint pain and/or obvious soft tissue inflammation, not simply increased pain perception in the soft tissues, additional laboratory studies such as a rheumatoid panel and Lyme disease and coinfection screening tests may be warranted.
It is highly important to note that if laboratory studies are positive for any of the above noted medical conditions or diseases, a diagnosis of FM may very well be inappropriate. In the author's clinical experiences, patients who have diseases that go undetected due to a shoddy examination and investigation are often misdiagnosed as having FM in an attempt to explain or justify their constellation of symptoms. As a general rule, no patient should ever be given a diagnosis of FM without a complete physical examination and basic screening laboratory testing to rule out the underlying medical conditions.
Muscle and Joint Conditions That May Be Confused with Classic FM
One of the most common reasons for a mistaken diagnosis of classic FM is pain that is actually arising from several muscles and joints of the body. Widespread pain is often caused by a few different painful conditions that all put together feel like just one big painful condition. For example, a patient might have injured the lower back in a work-related accident 2 years ago, had a whiplash to the neck from a car accident, and also twisted the knee while walking down the stairs. When this patient makes an appointment, the doctor asks, "Where do you hurt?" The response might be, "My lower back, neck, and knee … geez, Doc, I just seem to hurt everywhere." The busy doctor may quickly make the diagnosis of classic FM and not take enough time to sort out the fact that this patient actually has three separate problems: a low back problem, a neck problem, and a knee problem. Sure, the patient may be thought to have "widespread pain," but it is actually caused by three distinct muscle and joint problems and not classic FM.
This happens quite frequently with older patients, who often have some degree of arthritis in several joints and come to their doctor with a complaint of widespread pain. Most primary care doctors simply don't have the time or training to perform a comprehensive physical examination of the muscles and joints, and may be quick to label a patient with classic FM. Many older patients have an overlap of general widespread pain from arthritis, but also have one or two localized muscle or joint problems that could respond well to treatment by a physical therapist, chiropractor, or massage therapist.
It might seem simple, but there is a basic principle of diagnosis that can quickly determine if the pain is coming from a muscle or joint. Movement should reproduce the pain if the pain is coming from a musculoskeletal structure. For example, if the patient has pain between the shoulder blades coming from the neck or shoulders, movements of the neck or shoulders should cause it to get worse. If there is absolutely no movement or position that makes the pain worse, it may not be coming from a muscle or joint, and other sources should be considered.
A certain type of muscle pain is often mistaken for classic FM. To talk about this, we first need to clear up a very common mistake that is made in medical clinics. This is the mistaken belief that the
tender points found in FM are the same as the trigger points found in another condition known as myofascial pain.15 Most doctors know about trigger points; they are the "knots," "lumps," or "taut bands" found in painful muscles after too much exercise or remaining in a poor posture for too long.
It is really important not to confuse trigger points and tender points. These are
not the same condition. Tender point is used with the classic type of FM wherein the patient reports widespread pain and multiple areas that are extremely painful to even the lightest touch. In classic FM, these tender points are painful but generally not lumpy, hard, or nodular; they are simply "tender." However, the trigger points found in myofascial pain have a very distinctive texture; they feel hard and lumpy. Some people describe the way trigger points feel as "cords" or "guitar strings." All of these words are simply attempts to describe the observation by patients and doctors that trigger points have a distinctive texture to them, whereas tender points have no such distinctive texture.
As a patient, you can figure out for yourself whether your painful areas are tender or trigger points. Gently rub the muscles over the areas of your pain. Close your eyes and let your fingers tell you what you feel. Does the area of painful muscle feel different from the same area on the opposite side of the body? If you roll across these painful "knots," does it reproduce your pain and cause a "twitch" in the muscle? If so, you may very well be suffering from trigger points and myofascial pain, not tender points and FM.
Of course, trigger points can be successfully treated with deep massage, ischemic compression techniques, and stretching methods that are commonly used by chiropractors, physical therapists, physiatrists, and massage therapists. Acupuncture can also be used to treat trigger points. But remember that the tender points found with classic FM are generally not going to respond to manual massage or therapies, because the tender points are centrally mediated alterations in pain perception and not really areas of true muscle problems. They are just painful areas due to abnormal processing of pain signals by the brain and nervous system. That's why deep pressure massage techniques don't seem to work as well with classic FM patients.
It is also possible that your patient's pain is coming from joints that lie deep to the muscles. In this case, you will not feel any lumps, knots, or taut bands in the muscles because the painful joint is much deeper. However, you should still be able to provoke the pain with certain movements and positions. For example, if the patient has pain in the neck area that is coming from the joints of the cervical spine, the pain should get worse when rotating the neck fully to the right and left, looking up toward the ceiling and down toward the floor. If there is pain in the shoulder that is coming from the shoulder joint, the pain should worsen with full elevation of the arm toward the ceiling or reaching back behind the back.
Functional Problems with Metabolism That May Confused with Classic FM
More subtle
functional disorders may represent various types of subclinical disease states and disorders involving dysfunction of internal organs and individual metabolism, rather than true pathology. These functional disorders are often not on the busy traditionally trained clinician's radar screen and range the gamut from simple vitamin and mineral insufficiencies, to more hidden functional disorders such as energy metabolism disorders (mitochondrial dysfunction), subtle endocrine imbalances (subclinical thyroid disorders, abnormalities in stress physiology, etc.), opportunistic intestinal infections (dysbiosis), blood sugar abnormalities (reactive dysglycemia), postviral immune suppression, and other conditions that are not readily apparent on standard laboratory screening tests.

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