Case-based learning is often considered a new innovation in medical teaching, but it is actually as old as clinical medicine. Physicians have always consulted with their peers on difficult cases and utilized the case-based form of discussion as an educational tool, as a means of understanding new diagnoses, and as a method of determining the best treatment for a particular patient. Fibromyalgia syndrome (FM), a common clinical disorder with a world-wide distribution, has been unrecognized and/or ignored for years. FM can be likened to a volcano, with pain at the very top and insomnia and depression as key, but less common, manifestations (Slide 1). However, many physicians are insecure about the diagnosis and treatment of patients with FM, because they simply do not know enough about the disorder.

In 1990, The American College of Rheumatology laid out several sets of criteria for the diagnosis of fibromyalgia syndrome (FM). The first criterion required patients to report at least 3 months of widespread pain. Pain was considered widespread if it was present in four quadrants of the body—the right and left side as well as above and below the waist. Axial skeleton pain is also very commonly present in FM and is often considered a fifth “quadrant.” The second diagnostic criterion was widespread pain in response to a tender point examination. In this assessment the clinician presses on 18 specific areas with enough pressure to blanche his fingertip (∼4 kg). The patient's report of pain and not pressure on such testing in at least 11 of the tender points completes the requirements for the diagnosis of FM (Slide 1). Although these criteria were established to standardize patients for research studies, many physicians follow them for diagnostic purposes as well. However, these criteria must be viewed in the same context as the definition of hypertension (ie, blood pressures ≥140/90). Patients who do not quite attain these criteria should still be considered to have probable hypertension; and the same applies to FM. A patient who has three-quadrant pain and 9 tender points does not meet the criteria for FM, but the therapeutic approach to this patient is the same as it is for the patient with definitive FM.

The presentation of fibromyalgia syndrome (FM) is heterogeneous. Hence, the goal of treatment is to develop an individualized approach that takes into account the severity of the patient's pain, the presence and severity of other symptoms and comorbidities or stressors, and the degree of functional impairment. This includes the identification and treatment of all pain sources that might be present in addition to FM, such as peripheral pain generators (eg, comorbid osteoarthritis or neuropathic pain) or visceral pain disorders (eg, comorbid irritable bowel syndrome). It is also important to address other symptoms or disorders that commonly occur in patients with FM, such as fatigue, sleep disturbances, and comorbid sleep disorders (eg, sleep apnea). Cognitive impairment, stiffness, mood disorders, and anxiety disorders are also commonly reported in patients with FM. Finally, the treatment should strive to improve the patient's function and global health status. In most cases, the management involves both pharmacologic and nonpharmacologic treatments (Slide 1).