JAMA Revisited May 22/29, 1987
Fibromyalgia Syndrome An Emerging but Controversial Condition Don L. Goldenberg, MD The syndrome termed fibromyalgia or fibrositis has recently attracted the interest of investigators and become a subject of general medical interest. Although some authors believe that fibromyalgia is not a discrete condition, rheumatologists now report that fibromyalgia is one of the most common diagnoses in ambulatory practice. Recent estimates of the prevalence of fibromyalgia in the United States have ranged from 3 to 6 million.…
Evolution of the Concept of Fibromyalgia One of the major difficulties in the evolution of the concept of fibromyalgia has been the use of the terms tender points and fibrositis nodules. Tender points were reported to be associated with rheumatism by Balfour in 1824, although Valleix’s description in his treatise on neuralgia, published in 1841, was particularly insightful: “If, in the intervals of the shooting pains, one asks what is the seat of his pain, he replies then by designating limited points.… It is only with the aid of pressure … that one discovers exactly the extent of the painful points.… It is not very rare to encounter points painful to pressure, without spontaneous pain, and reciprocally.…” Currently, tender points are considered to be anatomic sites of excessive tenderness on palpation and are found at characteristic locations. Many of these locations are at sites commonly tender in regional pain syndromes such as cervical and lumbar strain, lateral and medial epicondylitis, anserine bursitis, and shoulder tendinitis. Valleix and many subsequent authors noted that pressure on the tender points produced radiating pain and that careful palpation was required to find such tender points. In contrast, trigger points or trigger zones are soft-tissue regions that, either spontaneously or following direct pressure,
Editor’s Note: JAMA Revisited is transcribed verbatim from articles published previously, unless otherwise noted. 1570
cause radiating pain, paresthesias, and autonomic symptoms. The zone of radiating pain and paresthesias were reproduced by the injection of saline into muscle groups. Travell and Rinzler popularized the term myofascial pain syndromes to account for these trigger zones and postulated a circular positive feedback movement of neural impulses: “The pathways . . . must include the central nervous system, and probably also the sympathetic nervous system.”… During the past decade, a number of authors have suggested that fibromyalgia is a specific syndrome with uniform signs and symptoms. Suggested diagnostic criteria emphasize chronic, diffuse aches and pains, disturbed sleep, morning fatigue and stiffness, and the presence of multiple characteristic tender points. The initial preliminary criteria for the diagnosis of primary fibromyalgia were proposed by Yunus et al. We and others have used such criteria with slight modification.... Yunus et al reported that a combination of historical symptoms and tender points on examination could differentiate patients with fibromyalgia from normal controls. Campbell et al used similar historical items in a questionnaire to screen general medical outpatients for fibromyalgia. The gold standard for diagnosis in these reports has been the presence of a minimum number offender points. The minimum number has varied from four of 40 to 12 of 14 possible tender points. Multiple tender points are uncommonly found in healthy patients. In patients with rheumatoid arthritis or other chronic rheumatic conditions, multiple tender points are uncommon; the average number is two. The evaluation of tender points requires some experience in regard to the characteristic locations and the amount of pressure to exert to elicit tenderness. Most studies have used direct palpation over commonly involved anatomic regions…. Tenderness is often quantitated as slight, moderate, or severe but also has been more objectively measured with a dolorimeter. Tender points are clustered in regions, especially at the shoulder and knee.… JAMA. 1987;257(20):2782-2787.
Section Editor: Jennifer Reiling, Assistant Editor.
JAMA April 16, 2014 Volume 311, Number 15
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a SUNY Binghamton User on 05/14/2015
jama.com
Fibromyalgia Syndrome An Emerging but Controversial Condition Don L. Goldenberg, MD The syndrome termed fibromyalgia or fibrositis has recently attracted the interest of investigators and become a subject of general medical interest. Although some authors believe that fibromyalgia is not a discrete condition, rheumatologists now report that fibromyalgia is one of the most common diagnoses in ambulatory practice. Recent estimates of the prevalence of fibromyalgia in the United States have ranged from 3 to 6 million.…
Evolution of the Concept of Fibromyalgia One of the major difficulties in the evolution of the concept of fibromyalgia has been the use of the terms tender points and fibrositis nodules. Tender points were reported to be associated with rheumatism by Balfour in 1824, although Valleix’s description in his treatise on neuralgia, published in 1841, was particularly insightful: “If, in the intervals of the shooting pains, one asks what is the seat of his pain, he replies then by designating limited points.… It is only with the aid of pressure … that one discovers exactly the extent of the painful points.… It is not very rare to encounter points painful to pressure, without spontaneous pain, and reciprocally.…” Currently, tender points are considered to be anatomic sites of excessive tenderness on palpation and are found at characteristic locations. Many of these locations are at sites commonly tender in regional pain syndromes such as cervical and lumbar strain, lateral and medial epicondylitis, anserine bursitis, and shoulder tendinitis. Valleix and many subsequent authors noted that pressure on the tender points produced radiating pain and that careful palpation was required to find such tender points. In contrast, trigger points or trigger zones are soft-tissue regions that, either spontaneously or following direct pressure,
Editor’s Note: JAMA Revisited is transcribed verbatim from articles published previously, unless otherwise noted. 1570
cause radiating pain, paresthesias, and autonomic symptoms. The zone of radiating pain and paresthesias were reproduced by the injection of saline into muscle groups. Travell and Rinzler popularized the term myofascial pain syndromes to account for these trigger zones and postulated a circular positive feedback movement of neural impulses: “The pathways . . . must include the central nervous system, and probably also the sympathetic nervous system.”… During the past decade, a number of authors have suggested that fibromyalgia is a specific syndrome with uniform signs and symptoms. Suggested diagnostic criteria emphasize chronic, diffuse aches and pains, disturbed sleep, morning fatigue and stiffness, and the presence of multiple characteristic tender points. The initial preliminary criteria for the diagnosis of primary fibromyalgia were proposed by Yunus et al. We and others have used such criteria with slight modification.... Yunus et al reported that a combination of historical symptoms and tender points on examination could differentiate patients with fibromyalgia from normal controls. Campbell et al used similar historical items in a questionnaire to screen general medical outpatients for fibromyalgia. The gold standard for diagnosis in these reports has been the presence of a minimum number offender points. The minimum number has varied from four of 40 to 12 of 14 possible tender points. Multiple tender points are uncommonly found in healthy patients. In patients with rheumatoid arthritis or other chronic rheumatic conditions, multiple tender points are uncommon; the average number is two. The evaluation of tender points requires some experience in regard to the characteristic locations and the amount of pressure to exert to elicit tenderness. Most studies have used direct palpation over commonly involved anatomic regions…. Tenderness is often quantitated as slight, moderate, or severe but also has been more objectively measured with a dolorimeter. Tender points are clustered in regions, especially at the shoulder and knee.… JAMA. 1987;257(20):2782-2787.
Section Editor: Jennifer Reiling, Assistant Editor.
JAMA April 16, 2014 Volume 311, Number 15
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a SUNY Binghamton User on 05/14/2015
jama.com
