New Diagnostic Criteria for Fibromyalgia. You Should Must Be Aware

Tender-point exams are no longer the only way to diagnose fibromyalgia — the American College of Rheumatology has provisionally accepted alternate criteria for diagnosing the condition and gauging the severity of symptoms.

The diagnostic criteria doctors have been using were established in 1990.  Once other possible causes of symptoms were eliminated, diagnosis was based purely upon pain.  It had to be on both sides of the body, both above and below the waist, along the axial skeleton (head, throat, chest, spine), and also in at least 11 of 18 specific spots on the body that are called tender points.

  Symptoms have to have been present for at least 3 months.

The tender-point exam has always been controversial for several reasons.  First, it was originally intended as a qualifier for clinical studies, not as a diagnostic tool.  Second, it’s subjective because it relies on a patient’s self-reported pain.  Third, because symptoms fluctuate so much, the number of tender points may vary greatly from one exam to another.

Until we have a diagnostic test that’s based on blood markers or imaging, we probably won’t have a perfect diagnostic test.  (This is true of many diseases, especially neurological ones.)  Still, researchers believe they’ve come up with something that works better — they say when the looked at a group of previously diagnosed fibromyalgia patients, the tender-point exam was about 75% accurate, while their criteria caught it 88% of the time.

 

New Diagnostic Criteria

The new criteria keep the requirements that other causes be ruled out and that symptoms have to have persisted for at least 3 months.

  They also includes 2 new methods of assessment, the widespread pain index (WPI) and the symptom severity (SS) scale score.

The WPI lists 19 areas of the body and you say where you’ve had pain in the last week.  You get 1 point for each area, so the score is 0-19.

For the SS scale score, the patient ranks specific symptoms on a scale of 0-3.

  These symptoms include:

  • Fatigue
  • Waking unrefreshed
  • Cognitive symptoms
  • Somatic (physical) symptoms in general (such as headache, weakness, bowel problems, nausea, dizziness, numbness/tingling, hair loss)

The numbers assigned to each are added up, for a total of 0-12.

This next part is really interesting to me.  Instead of looking for a hard score on each, there’s some flexibility built in, which recognizes the fact that fibromyalgia impacts us all differently, and that symptoms can fluctuate.

For a diagnosis you need EITHER:

  1. WPI of at least 7 and SS scale score of at least 5, OR
  2. WPI of 3-6 and SS scale score of at least 9.

What this does is allow for people with fewer painful areas but more severe symptoms to be diagnosed.

Something else I really like about this is that it finally includes cognitive symptoms!  For many of us, “fibro fog” is as debilitating or even more debilitating than pain, yet the old criteria didn’t even mention it.  It also recognizes the difference between “fatigue” and “waking unrefreshed,” which I believe is an under-recognized distinction in the medical community.

A quick note about “somatic symptoms”: strictly speaking, somatic means physical.  The term has gotten a bad rap in the fibromyalgia community because it’s been used to suggest our symptoms are the result of somatization, which means “physical manifestations of a psychological illness.”  On its own, however, the word somatic does not imply a psychological basis.

The full article on the new criteria isn’t yet available for free online, but a PDF of an appendix including these criteria is.  It has the list of painful areas for the WPI and a long list of somatic symptoms that could be considered.

If you’re undiagnosed or tentatively diagnosed, you may want to take that to your doctor.  Be sure to let him/her know that it’s from the American College of Rheumatology and was published in Arthritis Care & Research.

New Fibromyalgia Diagnosis

Fibromyalgia is a tough condition to diagnose. So far, we don’t have a lab test that’s fully accepted by the medical community, and no scans or images can nail down a diagnosis, either. Because of that, fibromyalgia is what’s called a “diagnosis of exclusion.”

That means before doctors can diagnose it, they need to rule out a host of other conditions with similar symptoms.

Eliminating Possibilities

Typically, before a doctor diagnoses fibromyalgia, you can expect them to order blood tests for multiple conditions.

These can include:

  • hypothyroidism (low thyroid hormone)
  • infections
  • polymyalgia rheumatica
  • rheumatoid arthritis
  • lupus.

Doctors may also order other lab and imaging tests, depending on your symptoms.

Who Diagnoses Fibromyalgia?

Fibromyalgia is typically diagnosed and treated by rheumatologists, although some neurologists and general practitioners also diagnose it. Even so, it can be difficult to find a doctor who’s willing and able to effectively diagnose and treat fibromyalgia.

The American College of Rheumatology (ACR) in 1990 established the first diagnostic criteria for fibromyalgia.

Then, in May 2010 the ACR put out new provisional criteria, not to replace the old ones but to address certain limitations. The goal was to provide a more practical approach that allows doctors to get a better understanding of your unique set of symptoms as well as how sick you are overall.

Both sets of criteria are considered perfectly valid and acceptable for diagnosing fibromyalgia.

Doctors can use whichever one they’re most comfortable with, or they may even use both of them.

1990 Fibromyalgia Diagnostic Critieria

Under the 1990 criteria, pain was the only symptom mentioned. Once other possible conditions were ruled out, a fibromyalgia diagnosis required:

  • Pain in all four quadrants of the body and in the axial skeleton (bones of the head, throat, chest and spine) that’s been present on a more or less continuous basis for at least three months.
  • Pain in at least 11 of 18 tender points, which are specific spots on the body that hurt when pressure is applied. (See the illustration above for the location of tender points.)

The tender-point exam has long been criticized for being too subjective, and not all doctors are comfortable with their ability to administer the exam. Some studies showed it was only accurate about 75 percent of the time, as well.

2010 Fibromyalgia Diagnostic Criteria

The new fibromyalgia diagnostic criteria take into account many more symptoms and have a built-in way for doctors to monitor your symptom severity. They also provide some flexibility; one weakness of the tender point exam is that your pain threshold can fluctuate, meaning you’ll have different results at different times. The researchers behind this method say the new criteria are about 88 percent accurate.

As with the old criteria, other possible conditions must be ruled out, and symptoms must have been present for at least three months.

They also include two new methods of assessment: the widespread pain index (WPI) and the symptom severity (SS) scale score.

The WPI is a list of 19 areas of the body. All you have to do is indicate which of those areas you’ve had pain in over the past week.

Each “yes” is one point, so the score ranges from 0-19.

For the SS scale score, the patient ranks specific symptoms on a scale of 0-3. These symptoms include:

  • fatigue
  • waking unrefreshed
  • cognitive symptoms (aka fibro fog)
  • somatic (physical) symptoms in general (such as headache, weakness, bowel problems, nausea, dizziness, numbness/tingling, hair loss)

The numbers assigned to each are added up, for a total of 0-12.

For a diagnosis, you need either:

  1. WPI of at least 7 and SS scale score of at least 5, OR
  2. WPI of 3-6 and SS scale score of at least 9

A PDF document with the full criteria is available online.

It includes the 19 areas in the WPI and a longer list of somatic symptoms: Fibromyalgia Diagnostic Criteria.

After the Diagnosis

Once you’re diagnosed with fibromyalgia, it’s time to start exploring treatment options. This can also be a long and complicated process, but the good news is that now you know what you’re fighting, which gives you a place to start.

 

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