Updated Diagnostic Criteria for Fibromyalgia

Beyond Tender Points

Tender-point exams are no longer the only way to diagnose fibromyalgia. In 2010, the American College of Rheumatology 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 three 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 percent accurate, while their criteria caught it 88 percent of the time.

The 2010 Diagnostic Criteria

The 2010 criteria keep the requirements that other causes be ruled out and that symptoms have to have persisted 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 lists 19 areas of the body and you say where you've had pain in the last week. You get one 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:

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

Then, instead of looking for a hard score on each, there's some flexibility built in. That's due to the recognition 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.

This allows a diagnosis for people who have fewer painful areas but more severe symptoms, who may not have received a diagnosis with a tender-point exam.

Another important addition is consideration of 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. 

The newer method also recognizes the difference between "fatigue" and "waking unrefreshed," which is an important distinction.

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.

Here's a PDF of an appendix including the 2010 criteria. It includes the list of painful areas for the WPI and a long list of somatic symptoms that can 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.

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