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Objective: To determine if assigning the label of fibromyalgia (FM) to individuals with chronic widespread pain has a significant effect on long-term health status, function, and health service utilization., Methods: In the London Fibromyalgia Epidemiology Study, 100 individuals with FM were identified by screening 3,395 non-institutionalized adults. Only 28 of the 100 had been previously diagnosed with FM; for 72, the diagnostic label was new. All 28 with prediagnosed FM were female compared with 58 of the 72 newly diagnosed cases. In a prospective, within-group comparison, we compared previously non-labeled FM cases at study entry (prelabeling) and at 18 and 36 months followup (postlabeling) with respect to general health status, fibromyalgia-related symptoms, and all items from the Fibromyalgia Impact Questionnaire (FIQ) (including total FIQ score, and several measures of health service utilization) to see if health status, function, and health services utilization had changed, using paired t-tests. We also compared percentage reporting work disability at baseline and 18 months using Pearson's chi(2)., Results: Fifty-six (78%) of the original 72 newly diagnosed FM cases were available for reassessment at 18 months, and 43 (60%) at 36 months. Although physical functioning decreased slightly over time, there also was a statistically significant improvement in satisfaction with health, and newly diagnosed FM cases reported fewer symptoms and major symptoms over the long term. No other differences in clinical status or health service use occurred over time., Conclusion: The FM label does not have a meaningful adverse affect on clinical outcome over the long term. Further research is necessary to document the short- and long-term effect of labeling in the chronic pain patient.

Objective: To estimate the severity of depression, anxiety, and other symptoms of psychological distress in a representative general population sample of fibromyalgia (FM) cases (FC) compared to pain controls (PC), and to identify strong correlates of depression and anxiety., Methods: We compared the severity of depression, anxiety, and other symptoms of psychological distress between 2 representative community samples: (1) 74 confirmed FC, and (2) 48 adults with chronic widespread pain (PC) who did not meet the 1990 ACR criteria for FM. Psychological distress was measured using the Centre for Epidemiological Studies Depression (CES-D) Scale, the State-Trait Anxiety Inventory (STAI), and other measures of psychological distress from the literature. Using cutoff scores for CES-D and trait anxiety, we compared demographic and clinical characteristics in those above and below each cutoff score. Simple linear regression was performed to identify factors strongly and independently correlated with depression and trait anxiety., Results: Compared to PC, FC were more symptomatic on virtually all measures of psychological distress. Similarly, individuals who scored above cutoff scores for depression and anxiety had more physical symptoms and had poorer function than those below. Depression and trait anxiety were highly correlated (r = 0.86). In a simple regression model, the best predictors for both depression and trait anxiety were the total number of symptoms and a physical disability score., Conclusion: Depression and anxiety are common and frequently severe even among community cases of FM.

Objective: To assess the distribution and predictive ability of fibromyalgia (FM) tender points (TP) in adults with chronic widespread pain., Methods: Using published classification criteria, we confirmed 100 FM cases and 76 controls with widespread pain not meeting the 1990 American College of Rheumatology (ACR) classification criteria for FM (pain controls) in a survey of 3,395 adults screened for widespread musculoskeletal pain in a general population survey., Results: At each of the 18 FM tender points, FM cases were more likely than pain controls to have tenderness, and the likelihood ratio (LR) was statistically greater than 1.0 for 13 of 18 points. However, the LR for individual points ranged from 4.0 to as low as 1.2. Females were more likely to have TP, especially at lower body points; however, lower body points were more discriminatory in males., Conclusion: TP differ in their ability to predict FM among adults in the general population with chronic widespread pain.

Objective: To determine which factors physicians consider important in patients with chronic generalized posttraumatic pain., Methods: Using physician membership directories, random samples of 287 Canadian general practitioners, 160 orthopedists, 160 physiatrists, and 160 rheumatologists were surveyed. Each subject was mailed a case scenario describing a 45-year-old woman who sustained a whiplash injury and subsequently developed chronic, generalized pain, fatigue, sleep difficulties, and diffuse muscle tenderness. Respondents were asked whether they agreed with a diagnosis of fibromyalgia (FM), and what factors they considered to be important in the development of chronic, generalized posttraumatic pain., Results: More-recent medical school graduates were more likely to agree with the FM diagnosis. Orthopedists (28.8%) were least likely to agree, while rheumatologists (83.0%) were most likely to agree. On multivariate analysis, 5 factors predicted agreement or disagreement with the diagnosis of FM: (1) number of FM cases diagnosed by the respondent per week (p < 0.0001); (2) patient's sex (p < 0.0001); (3) force of initial impact (p = 0.003); (4) patient's pre-collision psychiatric history (p = 0.03); and (5) severity of initial injuries (p = 0.03). The force of initial impact and the patient's pre-collision psychiatric history were both negatively correlated with agreement in diagnosis. Patient related factors (personality, emotional stress, pre-collision physical, mental health) were considered more important than trauma related factors in the development of chronic, widespread pain., Conclusion: Future studies of the association between trauma and FM should identify potential cases outside of specialty clinics, and baseline assessments should include some measurement of personality, stress, and pre-collision physical and mental health.

Objective: To determine the proportion of adults with fibromyalgia syndrome (FMS) in the general population who also meet the 1988 Centre for Disease Control (CDC) criteria for chronic fatigue syndrome (CFS)., Methods: Seventy-four FMS cases were compared with 32 non-FMS controls with widespread pain and 23 with localized pain, all recruited in a general population survey., Results: Among females, 58.0% of fibromyalgia cases met the full criteria for CFS, compared to 26.1% and 12.5% of controls with widespread and localized pain, respectively (p=0.0006). Male percentages were 80.0, 22.2, and zero, respectively (p=0.003). Compared to those with FMS alone, those meeting the case definitions for both FMS and CFS reported a worse course, worse overall health, more dissatisfaction with health, more non-CFS symptoms, and greater disease impact. The number of total symptoms and non-CFS symptoms were the best predictors of co-morbid CFS., Conclusions: There is significant clinical overlap between CFS and FMS.

Objective: To estimate the point prevalence of fibromyalgia syndrome (FM) among noninstitutionalized Canadian adults; and to assess the effect of demographic variables on the odds of having FM., Methods: A screening questionnaire was administered via telephone to a random community sample of 3395 noninstitutionalized adults residing in London, Ontario. Individuals screening positive were invited to be examined by a rheumatologist to confirm or exclude FM using the 1990 American College of Rheumatology classification criteria., Results: One hundred confirmed cases of FM were identified, of whom 86 were women. Mean age among FM cases was 49.2 years among women, 39.3 years among men (p < 0.02). FM affects an estimated 4.9% (95% CI 4.7%, 5.1%) of adult women and 1.6% (1.3%, 1.9%) of adult men in London, for a female to male ratio of roughly 3 to one. In women, prevalence rises steadily with age from < 1% in women aged 18-30 to almost 8% in women 55-64. Thereafter, it declines. The peak prevalence in men also appears to be in middle age (2.5%; 1.1%, 5.7%). FM affects 3.3% (3.2%, 3.4%) of noninstitutionalized adults in London. Female sex, middle age, less education, lower household income, being divorced, and being disabled are associated with increased odds of having FM., Conclusion: FM is a common musculoskeletal disorder among Canadian adults, especially among women and persons of lower socioeconomic status.

Objective: To identify demographic and clinical features that distinguish fibromyalgia (FM) from other chronic widespread pain., Methods: We identified 100 confirmed FM cases, 76 widespread pain controls, and 135 general controls in a random community survey of 3395 noninstitutionalized adults living in London, Ontario. FM cases were distinguished from pain controls using the 1990 American College of Rheumatology (ACR) classification criteria for FM., Results: The mean age of FM cases was 47.8 years (range 19 to 86), the same as for pain controls; 86% of FM cases were female versus 67.1% of pain controls (p < 0.01). FM cases were less educated than general controls (p = 0.03). Male and female FM cases were similar, except females were older and reported more major symptoms (both p = 0.02). FM cases reported more severe pain and fatigue, more symptoms, more major symptoms, and worse overall health than pain controls or general controls. The most commonly reported major symptoms among FM cases were musculoskeletal pain (77.3%), fatigue (77.3%), severe fatigue lasting 24 h after minimal activity (77.0%), nonrestorative sleep (65.7%), and insomnia (56.0%). Subjects with 11-14 tender points were more similar to those with 15-18 tender points than to those with 7-10 points in 11 of 14 clinical variables. On multivariate analysis, 4 symptoms distinguished FM cases from pain controls: pain severity (p = 0.004), severe fatigue lasting 24 h after minimal activity (p = 0.006), weakness (p = 0.008), and self-reported swelling of neck glands (p = 0.01)., Conclusion: In the general population, adults who meet the ACR definition of FM appear to have distinct features compared to those with chronic widespread pain who do not meet criteria.

Objective: To estimate direct health care costs associated with fibromyalgia (FM) within a representative community sample., Methods: A random sample of 3395 noninstitutionalized adults was screened for widespread pain. Individuals screening positive were examined for FM. Direct health care costs were compared among those with confirmed FM (FM cases, FC), those with widespread pain not having FM (pain controls, PC), controls without widespread pain (general controls, GC), and a random sample of age, sex and geographically matched controls from the Ontario Health Insurance Plan database (OHIP controls, OC)., Results: One hundred FC (86 women) were compared to 76 PC subjects, 135 GC, and 380 OC. FC used more medications and outpatient health services than PC subjects, and about twice the health services at twice the cost compared to GC and OC. The mean difference in direct costs for health services between FC and OC was $493 Cdn annually (p<0.001)., Conclusion: FM has a major effect on direct health care costs.

Objective: To develop and test an instrument to screen for fibromyalgia syndrome (FM) in general population surveys., Methods: We designed a questionnaire with 4 pain and 2 fatigue items. A positive screen was defined 2 ways: (1) positive responses to all 4 items on pain, and (2) positive responses to all pain and fatigue items. Sensitivity was tested in the clinic on 31 outpatients with FM, specificity on 30 outpatients with rheumatoid arthritis (RA) and 30 healthy controls. Test-retest reliability (TRR) was estimated in a community survey of 672 noninstitutionalized adults. Positive predictive value (PPV) was estimated as part of a community survey of 3395 noninstitutionalized adults, in which 100 cases of FM were confirmed by examination., Results: For pain criteria alone sensitivity was 100% (95% confidence intervals 90.3%, 100%); in patients with RA specificity was 53.3% (35.4%, 71.2%). For the pain plus fatigue criteria, sensitivity was 93.5% (83.8%, 100%), and specificity in patients with RA 80% (65.7%, 94.3%). In nonpatient controls, specificity was 100% (89.3%, 100%) using either definition of a positive screen. For those initially screening negative, TRR was 100% (93.2%, 100%) using either definition. For positive screens, TRR was 95.0% (88.8%, 100%) for the pain criteria alone, and 81.0% (69.1%, 92.8%) for the combined criteria. PPV was 56.8% (53.0%, 60.6%) using the pain criteria alone, and 70.6% (CI 55.3%, 85.9%) using the combined criteria., Conclusion: The instrument appears to be useful in screening for FM in general population surveys of noninstitutionalized adults. Confirmation of FM among those who screen positive requires a personal interview to reestablish pain duration and distribution, and an examination for tender points.

Objective: To compare function and disability in fibromyalgia syndrome (FMS) cases in the community versus controls, and to identify variables predicting poor function and disability., Methods: We identified 100 FMS cases, 76 pain controls, and 135 general controls in a random survey of 3,395 noninstitutionalized adults., Results: FMS cases reported worse function (P < 0.00001), more days in bed (P < 0.001), and more healthy years of life lost (P < 0.0001). More FMS cases were disabled (P < 0.00001) and receiving pensions (P < 0.00001). Risk factors for disability included middle age and previous heavy manual labor. Pain, fatigue, and weakness were most often claimed to affect the ability to work Variables predicting work disability were the Fibromyalgia Impact Questionnaire (FIQ) score, a prior diagnosis of FMS, nonrestorative sleep, and past heavy physical labor. Variables influencing the FIQ score were the number of major symptoms, self-reported health satisfaction, tender point count, and education level., Conclusion: FMS commonly results in loss of function and work disability.

Objective: To determine the perceived proportion of fibromyalgia (FMS) among new consultations in rheumatology practices relative to other rheumatologic disorders., Methods: We conducted a cross sectional random mail survey of 100 Canadian rheumatologists. The sampling frame was the 1991 membership directory of the Canadian Rheumatology Association from which 100 nonpediatric rheumatologists practising in Canada were selected by stratified random sampling., Results: Results from 89 respondents indicate that FMS is perceived to be one of the 3 most common diagnoses among new patient consultations across Canada. Perceived incidence was not affected by urban size or university affiliation of practice. FMS was the only rheumatologic disorder believed by a majority of respondents to have increased in proportion over the past 5 years., Conclusion: In Canada, FMS appears to contribute to a high proportion of outpatient care in rheumatology.