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Diagnosing Fibromyalgia 

 

MEMBERS OF THE ACR MULTICENTER
FIBROMYALGIA CRITERIA COMMITTEE MEETING
Wichita, Kansas, December 2-3, 1988 

Left to Right: Dr. Muhammad Yunus, Dr.Claire Bombardier, Dr.PeterTugwell,
                 Dr. Don Goldenberg, Dr. Hugh Smythe, Dr. Rob Bennett,
Dr. Fred Wolfe
 

The classification of fibromyalgia for research studies is currently based on the Criteria developed by The American College of Rheumatology in 1990.  

These recommendations are based on 2 features:  

1. A history of widespread pain of 3 months or more. Widespread is defined as pain in an axial distribution plus pain of both left and right sides of the body, and pain above and below the waist. Thus, a patient with axial pain, plus pain in 3 body segments would qualify - as seen below.

 2. The palpation of 18  tender locations (so-called “tender points”). To make a diagnosis of fibromyalgia there needs to be pain on digital palpation of 11 or more out of the18 specified tender points. The recommendations specify that the palpation be made at a final force of 4 kg (the amount of pressure required to blanch a thumbnail) starting at 1 kg and incrementing by 1 kg at a rate of 1 kg per second.

 Here are the locations of the 9 paired tender points:

Diagno4

  1. Low Cervical Region: (front neck area) at anterior aspect of the interspaces
    between the transverse processes of C5-C7.
  2. Second Rib: (front chest area) at second costochondral junctions.
  3. Occiput: (back of the neck) at suboccipital muscle insertions.
  4. Trapezius Muscle: (back shoulder area) at midpoint of the upper border.
  5. Supraspinatus Muscle: (shoulder blade area) above the medial border of the scapular spine.
  6. Lateral Epicondyle: (elbow area) 2 cm distal to the lateral epicondyle.
  7. Gluteal: (rear end) at upper outer quadrant of the buttocks.
  8. Greater Trochanter: (rear hip) posterior to the greater trochanteric prominence.
  9. Knee: (knee area) at the medial fat pad proximal to the joint line.  

 

 

A diagnosis of fibromyalgia ismade if: 

1. A patient has widespread body pain

2. The pain has been present for at least 3 months

3. A patient has at least 11 tender points (out of the 18 specified locations)

4. The patient's symptoms are not completely accounted for by another diagnosis





  Classification versus Diagnostic Criteria

Strictly speaking, classification criteria are used in scientific and epidemiologic studies, as they represent a high degree of separation from other disorders (i.e. specificity). It is generally appreciated that classification criteria are not always optimally sensitive; in other words some patients who have fibromyalgia may not meet the classification criteria specifications. Bearing this in mind most clinicians favor a more "relaxed" approach to diagnosis. 

Revised criteria
The 2016 revised criteria use a widespread pain index (WPI) and symptom severity scale (SS) in place of the tender point testing of the 1990 criteria. The WPI (see manikin below) comprises 19 general body areas in which the person has experienced pain in the preceding two weeks. 

 

The SS rates the severity of the person's fatigue, unrefreshed waking, cognitive symptoms, and general somatic symptoms, each on a scale from 0 to 3, for a composite score ranging from 0 to 12. The revised criteria for diagnosis are: 

   WPI ≥ 7 and SS ≥ 5         OR        WPI 3–6 and SS ≥ 9  

In addition: Symptoms must have been present at a similar level for at least 3 months, and no other diagnosable disorder otherwise explains the pain. 

Other common problems
Symptoms such as sleep disturbance, fatigue, stiffness, skin fold tenderness, and cold intolerance, are common in fibromyalgia patients, but their inclusion did not improve diagnostic accuracy. The recommended number of tender points -- i.e., 11 or greater -- was originally derived from a receiver operating curve and relates to the number giving the best sensitivity and specificity. Fibromyalgia pain typically waxes and wanes in intensity; flares are associated with unaccustomed exertion, soft tissue injuries, lack of sleep, cold exposure, and psychological stressors. Although most patients have widespread body pain, there are typically one or two locations that are the major foci. These pain foci often shift to other locations -- often in response to new biomechanical stresses or trauma. Fibromyalgia is more than a muscle pain syndrome, as most patients have an array of other somatic complaints. Nearly all fibromyalgia patients have severe fatigue, poor sleep, and post-exertional pain. Other symptoms include: tension type headaches, cold intolerance, dry mouth, unexplained bruising, poor memory and concentration, fluid retention, chest pain, jaw pain, dyspnea, dizziness, abdominal pain, paresthesiae, and low grade depression and anxiety. Some symptoms relate to specific syndromes whose prevalence appears to be increased; these include: irritable bowel syndrome, irritable bladder syndrome migraine, premenstrual syndrome, Raynaud’s and restless leg syndrome. 

Do you need blood tests and imaging tests to diagnose fibromyalgia? The 1990 ACR recommendations state that "fibromyalgia is not a diagnosis of exclusion". This means that you do not need special tests torule out other conditions. If a patient meets the historic and exam findings of tender points they can be diagnosed as having FM. This is an important concept, as some physicians only consider a diagnosis of FM after they have done exhaustive testing to rule out other conditions. However, it is equally important to understand that FM often accompanies other conditions such as osteoarthritis, lupus (SLE), rheumatoid arthritits and multiple sclerosis. Thus, depending on the history and physical exam, further testing is often quite appropriate. In fact a careful evaluation for all other conditions that may be contributing to pain is an essential part of an informed treatment plan. However, I stress that the finding of another condition does not necessarily rule out a diagnosis of FM. 

Acceptance of Fibromyalgia as a valid Diagnosis
The publication of the 1990 ACR criteria led to widespread interest and research into this disorder. For instance, the US Government provided research funding for fibromyalgia through the NIH, and both the Social Security Administration and the Veterans Administration recognized fibromyalgia as a potential cause for disability. More recently, the American Boards of Internal Medicine have included questions on fibromyalgia in their certifying examinations. Interestingly many soldiers suffering from “Gulf-War Syndrome” have been found to have fibromyalgia. Here are some links to Government and other influential websites that recognize fibromyalgia: 

Social Security Administration  

Veterans Administration  

Centers for Disease Control  

Mayo Clinic 

The Cleveland Clinic  

The National Institutes of Health

 

   

 

   

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