Fibromyalgia diagnosis and diagnostic criteria

Figures & data

Figure 1. Tender point locations for the American College of Rheumatology 1990 criteria for the classification of fibromyalgia.

Table I. The 1990 American College of Rheumatology criteria for the classification fibromyalgia (3).

1. History of 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 mid-point 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 will be said 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.

Table II. The American College of Rheumatology 2010 preliminary diagnostic criteria for fibromyalgia (2).

The American College of Rheumatology 2010 preliminary diagnostic criteria for fibromyalgia
Criteria:
A patient satisfies diagnostic criteria for fibromyalgia if the following three conditions are met:
1) Widespread Pain Index ≥ 7 and Symptom Severity Score ≥ 5 or Widespread Pain Index between 3 and 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 explain the pain
Ascertainment:
1) Widespread Pain Index (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, 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 the three 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^a in general, indicate whether the patient has:
0 = No symptoms
1 = Few symptoms
2 = A moderate number
3 = A great deal of symptoms
The Symptom Severity Score is the sum of the severity of the three symptoms (fatigue, waking unrefreshed, cognitive symptoms) plus the extent (severity) of somatic symptoms in general. The final score is between 0 and 12.

^aFor reference purposes, here is a list of somatic symptoms that might be considered: muscle pain, irritable bowel syndrome, fatigue/tiredness, problems thinking or remembering, muscle weakness, headache, pain/cramps in abdomen, numbness/tingling, dizziness, insomnia, depression, constipation, pain in upper abdomen, nausea, nervousness, chest pain, blurred vision, fever, diarrhea, dry mouth, itching, wheezing, Raynaud's, hives/welts, ringing in ears, vomiting, heartburn, oral ulcers, loss/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.

Barsky AJ, Borus JF. Functional somatic syndromes. Ann Intern Med. 1999;130:910–21.

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

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