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ACR Explains Proposed New Fibromyalgia Diagnostic Criteria

  [ 42 votes ]   [ 3 Comments ] • May 25, 2010

"This is a big deal for patients who suffer symptoms but have had no diagnosis."

The American College of Rheumatology (ACR) is proposing a new set of diagnostic criteria for fibromyalgia that includes common symptoms such as fatigue, sleep disturbances, and cognitive problems, as well as pain. The new criteria, developed by a "Who's Who" of fibromyalgia & pain researchers, were published May 13 in the ACR journal Arthritis Care & Research.(1)

“These new criteria recognize that fibromyalgia is more than just body pain,” said Robert S. Katz,  one of the authors of the new criteria and a rheumatologist at Rush University Medical Center. “This is a big deal for patients who suffer symptoms but have had no diagnosis.  A definite diagnosis can lead to more focused and successful treatment and reduce the stress of the unknown.”

Routine lab tests can not detect fibromyalgia, a condition that is characterized by unexplained pain from head to toe and exhaustion. Instead, the diagnosis has been made by a tender point test, a physical exam that focuses on 18 points throughout the body. When light pressure is applied to these points, clustered around the neck, shoulder, chest, hip, knee, and elbow regions, patients with fibromyalgia feel tenderness or pain.

Limitations of Previous Criteria

To meet the previous diagnostic criteria, which were established in 1990, patients must have widespread pain in all four quadrants of their body for a minimum duration of three months and experience moderate pain and tenderness at a minimum of 11 of the 18 specified tender points.

According to Katz:

• “There are numerous shortcomings with the previous criteria, which didn’t take into account the importance of common symptoms including:
- Significant fatigue,
- A lack of mental clarity and forgetfulness,
- Sleep problems,
- And an impaired ability to function doing normal activities.”

• Also, Katz notes, fibromyalgia pain may fluctuate, which can affect the number of tender points,

• The tender point test did not adequately measure symptom severity or the effectiveness of new treatments,

• And “The tender point test also has a gender bias because men may report widespread pain, but they generally aren’t as tender as women,” said Katz.

Overall, “Fibromyalgia may be under-diagnosed in both men and women because of the reliance on 11 tender points, and also due to failing to account for the other central features of the illness,” he says.

Most PC Docs Can’t or Don’t Do Tender Point Tests

Additionally, due to the confusion regarding the tender point test, the authors note that most primary care doctors don’t bother to check tender points or they aren’t checking them correctly. Consequently, fibromyalgia diagnosis in practice has often been a symptom-based diagnosis. The new criteria will standardize a symptom-based diagnosis so that all doctors are using the same process.

The tender point test is being replaced with a widespread pain index and a symptom severity scale.

• The widespread pain index score is determined by counting the number of areas on the body where the patient has felt pain in the last week. The checklist includes 19 specified areas.

• The symptom severity score is determined by rating on a scale of zero to three, three being the most pervasive, the severity of three common symptoms: fatigue, waking unrefreshed and cognitive symptoms. An additional three points can be added to account for the extent of additional symptoms such as numbness, dizziness, nausea, irritable bowel syndrome or depression.  The final score is between 0 and 12.

To Be Diagnosed with the New Criteria...

To meet the criteria for a diagnosis of fibromyalgia a patient would 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 more.

Some criteria will remain unchanged.

• The symptoms must have been present for at least three months,

• And the patient does not have a disorder that would otherwise explain the pain.

The Criteria Development Process

To develop and test the new criteria, researchers performed a multicenter study of 829 previously diagnosed fibromyalgia patients and a control group of rheumatic patients with non-inflammatory disorders using physician physical and interview examinations. The data were processed by the National Data Bank for Rheumatic Diseases.

The authors note the study has a number of limitations. They recommend a follow-up test in the primary care setting that includes patients with other rheumatic conditions to determine the rate of misclassification that may occur.

The study was funded by Lilly Research Laboratories. Lilly Research Laboratories did not participate in the design of the study, see the results of the study, or review the manuscript or submitted abstracts
* “The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity.”  (Links to an abstract. Access to the full text of the article is fee-based.)

Source: Based on Rush University Medical Center news release, May 24, 2010

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Article Comments Post a Comment

Posted by: IanH
May 26, 2010
I was diagnosed with fibromyalgia because I was referred to a rheumatologist. I know I have Chronic Fatigue Syndrome as does my wife and daughter. Its just that I have more pain than them. They were both diagnosed as having Chronic Fatigue Syndrome, my daughter as having Multiple Chemical Sensitivity. The way I see it: I have an underlying, un-named immunological disease, one of the symptoms of which is fibromyalgia.
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Diagnosis of FM for SSDI
Posted by: eljulia
Jun 19, 2010
Especially as regards a disability claim, a clear diagnosis must be stated in your patient records with the date. The doctor I was sent to by SSDI did not even adequately do the tender point test--made kind and supportive remarks but did not put enough in writing or have results of the 18 point test to state in my record. Fortunately my personal doctors had done a better job. It would be great to have more criteria for diagnosis for MANY reasons, only 2 of which are for treatment prospects as well as for documentation if you are no longer able to hold down a 40 hour a week job. Bringing pain areas (I wish these had been stated in the article) and severity of lack of function for the time of testing would be helpful to a diagnosis that would go beyond the 18 possible tender points. For me a great day, pain-wise, may simply be that only my upper body is screaming, but even that is relief. The more documentation of symptoms the better when you try for disability. Plus, I'm unable to explain to even my family and closest friends how the cognitive issues affect me. Maybe if I can show them a print out from a doctor... ;-)
Reply Reply

Is the ACR best Specialty to Diagnose FM
Posted by: T.D. MacLam
Jul 5, 2010
While some rheumatologists may be good at properly diagnosing fibromyalgia, I propose that knowing what we do, ie.FM is a neuro-muscular brain disease with a multiplicity of other conditions, that NEUROLOGY is the most appropriate specialty to diagnose and treat FM. In my case, my internist and neurologist made initial diagnosis, which was confirmed by a pain specialist. In the almost two years between severe onset and diagnosis, I saw multiple specialists, (including a very competent rheumatologist who was just as puzzled as I). In the last few years my internist and neurologist have been most useful partners in treatment. I had had a relationship with the neurologist, who treated my frequent migraines. Thank goodness I had him!
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