To the Editor:
I read with interest the report by Shleyfer, et al concerning the training of family physicians to manage fibromyalgia syndrome (FM)1. Their retrospective analysis has shown that familiarity with the problem is sufficient to make a correct diagnosis, unlike the results of previous studies2,3.
Patients with FM are estimated to comprise 2% to 5% of those treated by family physicians1. As a rheumatologist and a family physician trainer, I should like to draw attention to the following relevant points.
-
What is needed is working knowledge of clinical anatomy and a well mastered algorithm of studying the musculoskeletal system4. Training obtained by the medical student should be expanded, as family physicians encounter rheumatic diseases very often in their everyday practice. Examination of the articular system should also include evaluation of the periarticular structures such as muscles, tendons, and bursae.
-
Training modules should include such issues as chronic fatigue syndrome, chronic pain, and in particular, FM. Family physicians should assess the intensity of pain (on a visual analog scale) and the point pain by pressing specific trigger points.
-
The well known tests for rheumatoid factor (RF) and antinuclear antibodies (ANA) should be prescribed if respective indications are present5. Even if there is no joint swelling, specific rash, or organ involvement, these tests are useful in the differential diagnosis of secondary FM (in rheumatoid arthritis and systemic lupus erythematosus), neoplasms, and hematological diseases. Some family physicians do not order tests for RF and ANA, leaving this to the rheumatologic specialists.
-
Treatment of FM also requires knowledge of neurophysiology and pharmacology. In view of the duration of the treatment and the choice of approach (monotherapy or combined pharmacotherapy) it is appropriate for these patients to be referred to a neurologist6.
The data reported by Shleyfer, et al are of interest with respect to the methodology of training family physicians in the management of articular muscular diseases, FM in particular — i.e., the place of clinical anatomy, examination of rheumatologic problems, and reasons for misdiagnosis.