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The Relation Between Tender Points and Fibromyalgia Symptom Variables

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The Relation Between Tender Points and Fibromyalgia Symptom Variables 268 Annals of the Rheumatic Diseases 1997;56:268–271 CONCISE REPORTS Ann Rheum Dis: first published as 10.1136/ard.56.4.268 on 1 April 1997. Downloaded from The relation between tender points and fibromyalgia symptom variables: evidence that fibromyalgia is not a discrete disorder in the clinic Frederick Wolfe Abstract Fibromyalgia represents the intersection of a Objective—To investigate the relation considerably abnormal and reduced pain between measures of pain threshold and threshold with a series of clinical distress vari- symptoms of distress to determine if ables, including pain, fatigue, sleep distur- fibromyalgia is a discrete construct/ bance, anxiety, and depression, among others. disorder in the clinic. In the clinic, it is best diagnosed by counting Methods—627 patients seen at an the number of tender points a patient has. In outpatient rheumatology centre from 1993 the presence of 11 or more tender points and to 1996 underwent tender point and dolor- widespread pain, fibromyalgia is diagnosed (classified) according to American College of imetry examinations. All completed the Rheumatology (ACR) Criteria.1 assessment scales for fatigue, sleep The ability to diagnose fibromyalgia with disturbance, anxiety, depression, global commonly agreed upon criteria has stimulated severity, pain, functional disability, and a research into basic and clinic aspects of the composite measure of distress con- syndrome. In general, research has used structed from scores of sleep disturbance, ‘normals’ or patients with other rheumatic dis- fatigue, anxiety, depression, and global eases as control subjects. This comparison, of severity—the rheumatology distress index fibromyalgia with such control subjects, (RDI). implies that fibromyalgia is a discrete entity. http://ard.bmj.com/ Results—In regression analyses, the RDI However, epidemiological studies suggest, was linearly related to the count of tender instead, that fibromyalgia may be merely the points (r2=0.30). Lesser associations were end of a continuum of distress.23 Epidemio- found between the RDI and dolorimetry logically defined disease may be diVerent from measurements (r2=0.08). The RDI was clinically defined disease, and the issue of more strongly correlated with the two whether fibromyalgia is a relatively discrete measures of pain threshold than any of the clinical entity has not been investigated in the individual fibromyalgia symptom vari- clinic. This is an important question, because if on September 24, 2021 by guest. Protected copyright. ables. In partial correlation analyses, all of fibromyalgia does represent a clinical as well as the information relating to symptom vari- an epidemiological continuum, then we may be ables was contained in the tender point failing to identify many patients in the clinic count, and dolorimetry was not independ- with syndromes similar to fibromyalgia, though ently related to symptoms. with fewer symptoms or tender points. In addi- Conclusion—Tender points are linearly tion, in characterising patients as having or not having fibromyalgia we may be missing, in related to fibromyalgia variables and those with not enough tender points, distress, and there is no discrete enhance- important symptoms of distress. Finally, we ment or perturbation of fibromyalgia or may be concentrating basic and clinical distress variables associated with very research inappropriately into a constricted area high levels of tender points. Although of a pain-distress continuum. fibromyalgia is a recognisable clinical We investigated the question of whether Arthritis Research entity, there seems to be no rationale for Center and University fibromyalgia is a relatively discrete clinical of Kansas School of treating fibromyalgia as a discrete entity in 627 clinic patients by obtaining meas- Medicine, Wichita, disorder, and it would seem appropriate to ures of fibromyalgia symptoms as well as Kansas, USA consider the entire range of tenderness F Wolfe physical measures of tender point counts and and distress in clinic patients as well as in dolorimetry scores. Correspondence to: research studies. The tender point count Professor F Wolfe, Arthritis Research Center, functions as a ‘sedimentation rate’ for dis- Methods 1035 N Emporia, Suite 230, tress, and is a better measure than the SUBJECTS Wichita, KS 67214, USA. dolorimetry score. Subjects in this study were 627 patients seen at Accepted for publication an outpatient rheumatology centre (Wichita 10 January 1997 (Ann Rheum Dis 1997;56:268–271) Arthritis Center) during a period of three and Fibromyalgia and distress symptoms 269 half years from 22 February 1993 to 23 August and patient estimate of health status. In 1996, 1996. Patients consisted of two groups, 374 the helplessness subscale of the rheumatology Ann Rheum Dis: first published as 10.1136/ard.56.4.268 on 1 April 1997. Downloaded from patients seen before 1 August 1993 as part of a attitudes index (RAI) was added to the CLIN- project to examine serial patients returning for HAQ.9 The variables contained in this follow up visits and 253 patients seen after that instrument consider factors that are thought to date in whom the examinations were made for be of major importance in fibromyalgia.10 11 the purpose of clinical diagnosis. The specific fatigue assessment used a 15 cm double anchored VAS labelled on one end, PHYSICAL EXAMINATION DATA ‘Fatigue is no problem’ and on the other end, All patients underwent a count of tender points ‘Fatigue is a major problem.’ The question using the 18 sites specified in the American read ‘How much of a problem has fatigue or College of Rheumatology 1990 Classification tiredness been for you in the past week?’ The criteria for fibromyalgia.1 Tender point data are range of the scale is 0-3. The specific questions reported as a count of positive tender point and anchors for the other 15 cm VAS scales sites. In addition, each patient had a were pain: ‘How much pain have you had dolorimetry examination performed at the tra- because of your illness in the past week?’ (no pezii, knees, lateral epicondyle, and second rib pain, severe pain); global severity: ‘Consider all using the Fischer Dolorimeter (Pain Diagnos- of the ways that your illness aVects you, rate tics and Thermography, Great Neck, NY) with how you are doing by placing a mark on the a one centimetre in diameter rubber tip. A line’ (very well, very severe); sleep problems: dolorimeter is a pressure algometer. To use it, ‘How much problem has sleep (ie, resting at the examiner places the rubber tip on the night) been for you in the past week?’ (sleep is examination site and gradually increases the no problem, sleep is a major problem). Except pressure at a rate of approximately 1 kg/cm2 per for global severity, which is scored 0-100, all second. The patient is asked to report the other VAS scales are scored 0-3. moment when the sensation at the examination The rheumatology distress index (RDI) is site changes from that of pressure to that of computed from questionnaire variables pain. At that point, the force is recorded in kg. described above. It is an approximate linear The reported dolorimetry score is the mean of combination of questionnaire variables that the sites examined. Dolorimetry values are most accurately identify (a) distressed patients thought to be a measure of pain threshold. and (b) those with fibromyalgia in comparison Dolorimetry scores represent a continuum in to a large series of other questionnaire clinical, the population, with median values for women demographic, and psychological variables.11 12 of 4.25 kg/cm2 and 6.0 kg/cm2 for men being It is computed through the following formula: reported using the same Fisher dolorimeter rheumatology distress index = ((anxiety/9.9) + and methodology.4 Among persons with fibro- (depression/9.9) + (global severity/100) + myalgia in a population survey, mean dolorim- (sleep disturbance/3) + (fatigue/3)) × 20. The 2 3 divisors for each scale convert the variable to a etry scores were approximately 2.7 kg/cm . http://ard.bmj.com/ 0-1 range. For example, the AIMS depression QUESTIONNAIRE DATA and anxiety scales have a range of 0-9.9. Divid- The Clinical Health Assessment Questionnaire ing by 9.9 converts the scales to 0-1. The five (CLINHAQ) was used for each patient.5 This variable scores are then added, producing a instrument contains self reports for the Health scale with a range of 0-5. After multiplication Assessment Questionnaire (HAQ) disability by 20 the range of scores is from 0 (no abnor- index,67 arthritis impact measurement scales mality on any subscale) through 100 8 (AIMS) anxiety and depression index, visual (maximum abnormality on all subscales). In on September 24, 2021 by guest. Protected copyright. analogue scale (VAS) pain, VAS global severity, this study, the RDI was approximately VAS gastrointestinal symptoms, VAS sleep normally distributed with a mean of 46.5 and a problems, VAS fatigue, satisfaction with health standard deviation of 20.7. To test the appropriateness of the RDI index, a new variable that represented the first principal component of the RDI variables (anxiety, depression, global severity, sleep disturbance, and fatigue) was created and then compared with the RDI result. The correlation between RDI and tender point count was 0.55, and the correlation between the new principal compo- nent variable and tender point count was 0.55. Therefore the index is an appropriate compos- ite measure of the five variables. STATISTICAL ANALYSES Data were analysed using Intercooled Stata version 5.0 for Windows.12 Pearson correla- tions coeYcients were used. To test the equal- ity of dependent correlations we used the Goldstein implementation of the Fischer z transformation.13 Data were analysed by least Figure 1 Graph of rheumatology distress index versus tender point count scores. Lines are predicted lowess (locally weighted regression) lines and 95% confidence intervals. The r2 squares linear regression and by lowess (locally values from linear regressions are 0.30 and 0.08, respectively.
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