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Diagnosis

Diagnosis and treatment of fibromyalgia (FM) can be delayed for years with many healthcare visits, referrals, diagnostic tests, a variety of diagnoses, and little impact on symptoms. According to the American Pain Foundation (APF), it takes an average of 5 years for a patient to get a correct diagnosis.1

For fibromyalgia, there are no objective physical or laboratory features or well-characterized pathologic findings. A diagnosis of fibromyalgia is made based on symptom scores and/or a tender point count in addition to a complete history and physical examination.

The diagnostic criteria for FM established by the American College of Rheumatology (ACR) in 1990 include a history of widespread pain in all 4 quadrants of the body for more than 3 months, and pain in a minimum of 11 of the 18 designated tender spots when pressure is applied (see illustration below).2



These ACR classification criteria perform well in specialty clinics and are very useful in providing some patient homogeneity for clinical trials.4 However, they have not been widely embraced in primary care. Tender point counts are rarely performed in primary care where most fibromyalgia diagnoses occur, and when performed, are performed incorrectly.5 Because of issues related to tender point counts and other controversies with the existing criteria, a preliminary update to the ACR criteria was published in 2010.4 These criteria suggest using a widespread pain index and symptom severity score for diagnosis.

ACR Preliminary Fibromyalgia Diagnostic Criteria4

Criteria

A patient satisfies diagnostic criteria for fibromyalgia if the following 3 conditions are met:

1) Widespread pain index (WPI) ³ 7 and symptom severity (SS) scale score ³ 5 or WPI 3–6 and SS scale score ³ 9.

2) Symptoms have been present at a similar level for at least 3 months.

3) The patient does not have a disorder that would otherwise explain the pain.

Ascertainment

1)      WPI: note the number areas in which the patient has had pain over the last week. In how many areas has the patient had pain? Score will be between 0 and 19.

Shoulder girdle, left,

Shoulder girdle, right

Upper arm, left

Upper arm, right

Lower arm, left

Lower arm, right

Hip (buttock, trochanter), left

Hip (buttock, trochanter), right Upper leg, left Upper leg, right Lower leg, left Lower leg, right

Jaw, left

Jaw, right

Chest

Abdomen

Upper back

Lower back

Neck

2) SS scale score:

The SS scale score is the sum of the severity of the 3 symptoms (fatigue, waking unrefreshed, cognitive symptoms) plus the extent (severity) of somatic symptoms in general. The final score is between 0 and 12.

For the each of the 3 symptoms (fatigue, waking unrefreshed, and cognitive symptoms) above, indicate the level of severity over the past week using the following scale:

0 = no problem

1 = slight or mild problems, generally mild or intermittent

2 = moderate, considerable problems, often present and/or at a moderate level

3 = severe: pervasive, continuous, life-disturbing problems

Considering somatic symptoms in general, indicate whether the patient has:*

0 =  no symptoms

1 = few symptoms

2 = a moderate number of symptoms

3 = a great deal of symptoms

* Somatic symptoms that might be considered: muscle pain, irritable bowel syndrome, fatigue/tiredness, thinking or remembering problem, muscle weakness, headache, pain/cramps in the abdomen, numbness/tingling, dizziness, insomnia, depression, constipation, pain in the upper abdomen, nausea, nervousness, chest pain, blurred vision, fever, diarrhea, dry mouth, itching, wheezing, Raynaud’s phenomenon, hives/welts, ringing in ears, vomiting, heartburn, oral ulcers, loss of/change in taste, seizures, dry eyes, shortness of breath, loss of appetite, rash, sun sensitivity, hearing difficulties, easy bruising, hair loss, frequent urination, painful urination, and bladder spasms.


These preliminary criteria correctly classify 88.1% of cases classified by the ACR classification criteria, and do not require a physical or tender point examination.4 The Symptom Severity scale enables assessment of fibromyalgia symptom severity in persons with current or previous fibromyalgia. It will be especially useful in the longitudinal evaluation of patients with marked symptom variability and may be used for monitoring treatment.4

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  1. American Pain Foundation. Fibromyalgia Talking Points. Available at www.painfoundation.org/learn/publications/files/fibrotalkingpoints.pdf.
  2. Wolfe F, Smythe HA, Yunus MB, et al, for the Multicenter Criteria Committee. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis Rheum. 1990;33:160-172.
  3. National Institutes of Arthritis and Musculoskeletal and Skin Diseases. Questions and Answers about Fibromyalgia. Available at www.niams.nih.gov/Health_Info/Fibromyalgia/default.asp
  4. Wolfe F, Clauw DJ, Fitzcharles M-A. The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity Arthritis Car Research 2010;62(5):600-10.
  5. Fitzcharles MA, Boulos P. Inaccuracy in the diagnosis of fibromyalgia syndrome: analysis of referrals. Rheumatology (Oxford) 2003;42:263–7.


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