Newer Diagnostic Criteria of Fibromyalgia and Its Clinical Implications

Shin-Seok Lee

doi:10.4078/jrd.2011.18.3.153

Journal List > J Rheum Dis > v.18(3) > 1063904

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Lee: Newer Diagnostic Criteria of Fibromyalgia and Its Clinical Implications

Review

J Rheum Dis 2011;18(3):153-160.

Published online: 31 September 2011

DOI: https://doi.org/10.4078/jrd.2011.18.3.153

Newer Diagnostic Criteria of Fibromyalgia and Its Clinical Implications

Shin-Seok Lee

Department of Rheumatology, Chonnam National University Medical School, Gwangju, Korea

Received 1 September 2011 Accepted 12 September 2011

Abstract

Since Smythe and Moldofsky proposed the first modern definition of fibromyalgia (FM), a number of different classification and diagnostic criteria have emerged. Among these criteria, the 1990 American College of Rheumatology (ACR) classification criteria have been the most widely ac-cepted in both research and clinical settings. The 1990 ACR criteria were originally established as inclusion criteria for research purposes and were not intended for clinical diagnosis, but have become the de facto diagnostic criteria in clinical settings. However, an improved clinical case definition for FM, using diagnostic criteria that can be used by both primary care physicians and specialists has been desired for a long time. For this, Wolfe and col-leagues developed several sets of diagnostic criteria and their last one received the endorsement of ACR, which is now known as the 2010 ACR diagnostic criteria. Unfortu-nately, the new criteria have been criticized as being in-consistent, nonspecific, and lacking the ability to recognize FM concurrent with other diseases. Further studies are needed to assess the acceptance, reliability, and val-idity of the new criteria in epidemiologic and clinical studies.

Keywords: Fibromyalgia, Diagnostic, Criteria

References

1. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombar-dier C, Goldenberg DL, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990; 33:160–72.

2. Goldenberg DL. Diagnosis and differential diagnosis of fibromyalgia. Am J Med. 2009; 122(12 Suppl):S14–21.

3. White KP, Nielson WR, Harth M, Ostbye T, Speechley M. Does the label "fibromyalgia" alter health status, function, and health service utilization? A prospective, with-in-group comparison in a community cohort of adults with chronic widespread pain. Arthritis Rheum. 2002; 47:260–5.

4. Annemans L, Wessely S, Spaepen E, Caekelbergh K, Caubère JP, Le Lay K, et al. Health economic consequ-ences related to the diagnosis of fibromyalgia syndrome. Arthritis Rheum. 2008; 58:895–902.

5. Gowers WR. Lecture on Lumbago: Its Lessons and Analogues: Delivered at the National Hospital for the Paralysed and Epileptic. Br Med J. 1904; 1:117–21.

6. Hench PK. Nonarticular rheumatism, 22nd rheumatism review: review of the American and English literature for the years 1973 and 1974. Arthritis Rheum. 1976; 19:S1081–9.

7. Smythe HA, Moldofsky H. Two contributions to understanding of the "fibrositis" syndrome. Bull Rheum Dis. 1977; 28:928–31.

8. Anch AM, Lue FA, MacLean AW, Moldofsky H. Sleep physiology and psychological aspects of the fibrositis (fibromyalgia) syndrome. Can J Psychol. 1991; 45:179–84.

9. Smythe HA. Nonarticular rheumatism and the fibrositis syndrome. Hollander JL, McCarthy DJ, editors. Arthritis and Allied Conditions. 9th ed.Philadelphia: Lea & Febiger;1979.

10. Yunus M, Masi AT, Calabro JJ, Miller KA, Feigenbaum SL. Primary fibromyalgia (fibrositis): clinical study of 50 patients with matched normal controls. Semin Arthritis Rheum. 1981; 11:151–71.

11. Yunus MB, Masi AT, Aldag JC. Preliminary criteria for primary fibromyalgia syndrome (PFS): multivariate analysis of a consecutive series of PFS, other pain patients, and normal subjects. Clin Exp Rheumatol. 1989; 7:63–9.

12. Lautenschläger J, Brückle W, Seglias J, Müller W. Localized pressure pain in the diagnosis of generalized ten-domyopathy (fibromyalgia). Z Rheumatol. 1989; 48:132–8.

13. Fitzcharles MA, Boulos P. Inaccuracy in the diagnosis of fibromyalgia syndrome: analysis of referrals. Rheumatology (Oxford). 2003; 42:263–7.

14. Clauw DJ, Crofford LJ. Chronic widespread pain and fibromyalgia: what we know, and what we need to know. Best Pract Res Clin Rheumatol. 2003; 17:685–701.

15. Wolfe F. Pain extent and diagnosis: development and val-idation of the regional pain scale in 12,799 patients with rheumatic disease. J Rheumatol. 2003; 30:369–78.

16. Katz RS, Wolfe F, Michaud K. Fibromyalgia diagnosis: a comparison of clinical, survey, and American College of Rheumatology criteria. Arthritis Rheum. 2006; 54:169–76.

17. Wolfe F, Rasker JJ. The Symptom Intensity Scale, fibromyalgia, and the meaning of fibromyalgia-like symptoms. J Rheumatol. 2006; 33:2291–9.

18. Wilke WS. New developments in the diagnosis of fibromyalgia syndrome: say goodbye to tender points? Cleve Clin J Med. 2009; 76:345–52.

19. Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010; 62:600–10.

20. Wolfe F. How to use the new American College of Rheumatology fibromyalgia diagnostic criteria. Arthritis Care Res (Hoboken). 2011; 63:1073–4.

21. Vanderschueren S, Van Wambeke P, Morlion B. Fibromyalgia: do not give up the tender point count too easily: comment on the article by Wolfe et al. Arthritis Care Res (Hoboken). 2010; 62:1675.

22. Thompson EN. Diagnostic criteria for fibromyalgia: comment on the article by Wolfe et al. Arthritis Care Res (Hoboken). 2010; 62:1674–5.

23. Wolfe F, Ross K, Anderson J, Russell IJ. Aspects of fibromyalgia in the general population: sex, pain threshold, and fibromyalgia symptoms. J Rheumatol. 1995; 22:151–6.

24. Yunus MB, Inanici F, Aldag JC, Mangold RF. Fibromyalgia in men: comparison of clinical features with women. J Rheumatol. 2000; 27:485–90.

25. Toda K. Preliminary diagnostic criteria for fibromyalgia should be partially revised: comment on the article by Wolfe et al. Arthritis Care Res (Hoboken). 2011; 63:308–9.

26. Smythe HA. Unhelpful criteria sets for "diagnosis" and "assessment of severity" of fibromyalgia. J Rheumatol. 2011; 38:975–8.

27. Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RS, et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol. 2011; 38:1113–22.

Table 1.

Smythe and Moldofsky criteria (1977)

1. Chronic aching, non-restorative sleep, a marked morning stiffness, fatigue
2. Tender points in at least 12 out of 14 sites

Adapted from reference (7).

Table 2.

Smythe criteria (1979)

1. Widespread aching of more than 3 months duration
2. Local tenderness at 12 of 14 specified sites
3. Skin roll tenderness over the upper scapular region
4. Disturbed sleep, with morning fatigue and stiffness
5. Normal ESR, SGOT, RF, ANA, muscle enzyme and sacroiliacfilms

Adapted from reference (9).

Table 3.

Yunus criteria (1989)

1. Major criteria
Presence of 2 or more of 6 historical variables (hurt all over, pain at 7 or more sites, general fatigue, poor sleep, anxiety/tension, irritable bowel syndrome), plus 4 or more of 14 specified tender points^∗
2. Minor criteria
Presence of 3 or more of 6 historical variables, plus 2 or more tender points
3. Obligatory criteria
A. Presence of pain or stiffness or both, at 4 or more anatomic sites (counting unilateral or bilateral involvement as onesite) for 3 months or longer
B. Exclusion of an underlying condition which may be responsible for the overall features of fibromyalgia

^∗ Upper mid-trapezius, lower sternomastoid muscle, lateral pec-toral muscle, mid supraspinatus muscle, upper lateral gluteal region, greater trochanteric region, medial fatty pad of the knee. Sensitivity of 92% and specificity of 94% for rheumatic conditions. Adapted from reference (11).

Table 4.

Lautenschlä ger criteria (1989)

1. Spontaneous pain in at least three body regions
2. Multiple tender points >11 out of 24 sites

In doubtful cases, additional vegetative and functional symptoms should be considered. Sensitivity of 95% and specificity of 96% for the cut-off in the tender point. Adapted from reference (12).

Table 5.

The American College of Rheumatology 1990 criteria for the classification of fibromyalgia^∗

1. History of chronic widespread pain.
Definition. Pain is considered widespread when all of the following are present: pain in the left side of the body, pain in the right side of the body, pain above the waist, and pain below the waist. In addition, axial skeletal pain (cervical spine or anterior chest or thoracic spine or low back) must be present. In this definition, shoulder and buttock pain is considered as pain for each involved side. “Low back” pain is considered lower segment pain.
2. Pain in 11 of 18 tender point sites on digital palpation
Definition. Pain, on digital palpation, must be present in at least 11 of the following 18 sites: Occiput: Bilateral, at the suboccipital muscle insertions.
Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7.
Trapezius: bilateral, at the midpoint of the upper border.
Supraspinatus: bilateral, at origins, above the scapula spine near the medial border.
Second rib: bilateral, at the second costochondral junctions, just lateral to the junctions on upper surfaces.
Lateral epicondyle: bilateral, 2 cm distal to the epicondyles.
Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle.
Greater trochanter: bilateral, posterior to the trochanteric prominence.
Knee: bilateral, at the medial fat pad proximal to the joint line.
Digital palpation should be performed with an approximate force of 4 kg.
For a tender point to be considered "positive" the subject must state that the palpation was painful. "Tender is not to be considered “painful.”

^∗ For classification purposes, patients are considered to have fibromyalgia if both criteria are satisfied. Widespread pain must have been present for at least 3 months. The presence of a second clinical disorder does not exclude the diagnosis of fibromyalgia. Adapted from reference (1).

Table 6.

Survey criteria (2003) and Symptom Intensity Scale (2006)

1. Regional pain scale is composed of 19 nonarticular regions. “Please indicate below the amount of pain and/or tenderness you have had over the past 7 days in each of the joint and body areas listed below”.
Jaw (left)	Upper arm (left)
Jaw (right)	Upper arm (right)
Chest	Upper back
Abdomen	Hip (left)
Forearm (left)	Hip (right)
Forearm (right)	Shoulder (left)
Upper leg (left)	Shoulder (right)
Upper leg (right)	Neck
Lower leg (left)	Lower back
Lower leg (right)
2. Fatigue visual analog scale. “Please indicate current level of fatigue”. Survey criteria: Regional pain scale score was ≥8 and VAS score for fatigue was ≥6. Symptom Intensity Scale score: [Fatigue VAS+(Regional pain scale score/2)]/2^∗

^∗ A score of >5.25 differentiated fibromyalgia from other rheumatic disease, identifying 95% of patients who satisfied the Survey criteria. Adapted from reference (15,17).

Table 7.

The 2010 American College of Rheumatology diagnostic criteria

Criteria
A patient satisfies diagnostic criteria for fibromyalgia if the following 3 conditions are met:
1. Widespread pain index (WPI) ≥7 and symptom severity (SS) scale score ≥5 or WPI 3–6 and SS scale score ≥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; Hip (buttock, trochanter), left; Jaw, left; Upper back
Shoulder girdle, right; Hip (buttock, trochanter), right; Jaw, right; Lower back
Upper arm, left; Upper leg, left; Chest; Neck
Upper arm, right; Upper leg, right; Abdomen
Lower arm, left; Lower leg, left
Lower arm, right; Lower leg, right
2. SS scale score:
Fatigue
Waking unrefreshed
Cognitive symptoms
For the each of the 3 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
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.

^∗ Somatic symptoms that may be considered include muscle pain, irritable bowel syndrome, fatigue/tiredness, thinking or remembering problems, 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. Adapted from reference (19).

Table 8.

Fibromyalgia Criteria and Severity Scale (2011)

Criteria
A patient satisfies modified ACR 2010 fibromyalgia diagnostic criteria if the following 3 conditions are met:
1. Widespread Pain Index ≥7 and Symptom Severity Score ≥5 or Widespread Pain Index between 3–6 and Symptom Severity Score ≥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 sufficiently explain the pain.
Ascertainment
1. Widespread Pain Index (WPI): Note the number of 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, Lt.; Hip (buttock, trochanter), Lt.; Jaw, Lt.; Upper Back
Shoulder girdle, Rt.; Hip (buttock, trochanter), Rt.; Jaw, Rt.; Lower Back
Upper Arm, Lt.; Upper Leg, Lt.; Chest; Neck
Upper Arm, Rt.; Upper Leg, Rt.; Abdomen
Lower Arm, Lt.; Lower Leg, Lt.
Lower Arm, Rt.; Lower Leg, Rt.
2. Symptom Severity Score: Fatigue; Waking unrefreshed; Cognitive symptoms.
For the each of these 3 symptoms, 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.
The Symptom Severity Score is the sum of the severity of the 3 symptoms (fatigue, waking unrefreshed, and cognitive symptoms) plus the sum of the number of the following symptoms occurring during the previous 6 months: headaches, pain or cramps in lower abdomen, and depression (0–3). The final score is between 0 and 12. Adapted from reference (27).

TOOLS

Similar articles