Fibromyalgia Diagnosis – Current Criteria

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In 2010 the American College of Rheumatology (ACR) revised its diagnostic criteria for Fibromyalgia. In the years following the establishment of the original 1990 Fibromyalgia diagnostic criteria, a number of problems concerning the tender point count began to surface. In particular, many general practitioners were either not performing the tender point count at all, or were doing so incorrectly. Of particular concern were the tender points in the cervical spine, or neck area, which are very difficult to examine without proper training. As such, the examination of tender points to establish a diagnosis of fibromyalgia proved to be an unreliable method of diagnosis.

The confusion and difficulties related to tender points also lead to a focus on tender points that was not in line with their true importance relative to the overall syndrome. Furthermore, the 1990 criteria did not cover those fibromyalgia patients who were previously diagnosed but who, due to improvements or initial tender point measurement errors, did not currently satisfy the criteria for a diagnosis of fibromyalgia. Finally, and perhaps most importantly, the 1990 criteria failed to take into account any other key symptoms of fibromyalgia to determine a diagnosis.

To address these discrepancies, the American College of Rheumatology (ACR) diagnostic criteria for fibromyalgia were updated in 2010  in an effort to standardize the symptom-based diagnosis of the disease and ensure that physicians were using the same process to make a diagnosis. In addition, the 2010 criteria also addressed several obstacles presented by the 1990 criteria. They replaced the tender point scale with a Widespread Pain Index (WPI) as well as a measurement of symptom severity, known as the Symptom Severity scale (SS). The WPI is determined by counting the number of areas – out of 19 specific sites – on the body where the patient felt pain within the previous week. The SS score is determined by having patients rate the severity of three common symptoms – fatigue, waking unrefreshed, and cognitive symptoms – on a scale of zero to three (with three being the most severe). Additional points can be added for the presence of other symptoms, such as irritable bowel syndrome, insomnia, depression, Reynaud’s phenomenon, etc., with a final score ranging from zero to 12. Under the new criteria, in order to receive a diagnosis of fibromyalgia, a patient would need to meet the following criteria:

  • have seven or more pain areas and a symptom severity score of five or more; or, three to six pain areas and a symptom severity score of nine or greater;
  • have symptoms at a similar level for at least three months; AND
  • not have another disorder or condition that would otherwise explain the pain.

While the 2010 criteria improve substantially upon the original 1990 criteria, they are still limited in their use of physician assessment of symptoms, which is by nature extremely subjective and narrow in scope. Although standardized and validated questionnaires exist to assess the symptoms associated with fibromyalgia,  they are not uniformly used in the clinical setting, therefore they were not included as part of the revised 2010 criteria.

Revised Fibromyalgia Impact Questionnaire (FIQR)

One such questionnaire is the Fibromyalgia Impact Questionnaire, which has often been used to help doctors evaluate fibromyalgia patients. Developed in the late 1980s, the FIQ was first published in 1991 and has now been translated into 14 languages. The questionnaire originally used a visual analog scale that required patients to place a slash on a 100 millimeter-long line to indicate where they perceived the extent of their symptoms to be. However, the questionnaire was difficult to score, and was worded in a way that made unfair assumptions about patients. It also failed to assess symptoms related to cognition, balance, and environmental sensitivity. In 2010, the FIQ was also revised to correct these deficiencies, creating a version known as the “FIQR.” The FIQR consists of 21 questions, all of which are based on an 11-point numeric rating scale from 0 to 10, with 10 being the worst. The FIQR is organized to evaluate functioning, overall impact of fibromyalgia, and symptoms.

Summary

Despite the publication of improved diagnostic criteria in 2010, the diagnosis of fibromyalgia is still an intricate and highly individualized process, and diagnostic criteria are still not implemented consistently by physicians. The 2010 criteria are still preliminary and subject to revision as clinicians begin to implement them and uncover potential limitations in their definition and scope. On a positive note for fibromyalgia patients is the fact that the 2010 criteria open the door for a more comprehensive and symptom-based diagnosis of the disease – a diagnosis that takes more of the patient’s input into consideration – and relies less on the use of highly variable tender point examinations.

 

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References

1.  Wolfe F, Hauser W. Fibromyalgia diagnosis and diagnostic criteria. Ann Med. 2011;43:495-502.

2.  Wilke WS. New developments in the diagnosis of fibromyalgia syndrome: say goodbye to tender points? Cleve Clin J Med. 2009; 76(6):345-352.

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