Diagnosis of Fibromyalgia

ACR Criteria 1990

Widespread pain in combination with tenderness in 11 or more of the 18 specific tender point sites – so called tender points are defined as the main symptoms according by the American College of Rheumatology (ACR) and were presented as the fibromyalgia diagnostic criteria in 1990; see the excerpt → diagnostic criteria of fibromyalgia 1990 (pdf file, one page) or one can download the full publication of the Multicenter Criteria Committee: Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al.: The American College of Rheumatology 1990 Criteria for Classification of Fibromyalgia (pdf file, 14 pages, 4.1 MB).

I. Generalized 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.

II. Tender Points

Pain in 11 or more of the 18 specific tender point sites

(9 symmetric pairs of tender points) examined by making a pressure by thumb or index finger. Locality of tender points proposed by ACR is as follows:

• 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 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.

Diagnosis of fibromyalgia is difficult. It is estimated that it takes more than five years from first symptoms to the final diagnosis in the USA.

The figure shows average time needed to get diagnosis of different diseases with joint pain. Abbreviations: RA - rheumatoid arthritis, AO - osteoarthritis, Ank. spond. - ankylosing spondylitis, JRA - juvenile rheumatoid arthritis, SLE - systemic lupus erythematosus, HPOA - hypertrophic osteoarthropaty. Click to figure to get it magnified.

Important! The questionnaire does not substitute diagnosis made by experienced physician. The patient should not diagnose himself or herself. Patient should always consult his/her doctor in order to establish diagnosis and treatment plan. This questionnaire should give you insight in new clinical fibromyalgia diagnostic criteria.

ACR Criteria 2010

The group of medical doctors and specialists: Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, Russel AS, Russel IJ, Winfield JB, and Yunus MB has published Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity in Arthritis Care & Research in May 2010 (Vol. 62, No. 5, May 2010, pp 600–610)
→ Diagnostic Criteria for Fibromyalgia (pdf file 0.1 MB, 10 pages).

This criteria set has been approved by the American College of Rheumatology (ACR) Board of Directors as Provisional.

A patient fulfils diagnostic criteria for fibromyalgia if the following 3 conditions are met:

• Widespread Pain Index (WPI) ≥ 7 and Symptoms Severity (SS) scale score ≥ 5 or WPI ≥ 3-6 and SS sale score ≥9 points
• Symptoms have been present at a similar level for at least 3 months.
• The patient does not have a disorder that would otherwise explain the pain.

Click the figure to magnify

1. Widespread Pain Index Determination

This index is based on number areas in which patient has had pain over the last week. In how many areas has the patient had pain? Score will be between 0 and 19. The list covers 9 pairs of bilateral sites corresponding to the previous (tender points) and new unilateral (axial) sites: neck, chest, abdomen, upper back, lower back and new bilateral site: jaw.

2. Symptom Severity Score Determinationn

This comprises three groups of symptomms: (1) Fatigue, (2) Waking unrefreshed, (3) Cognitive symptoms. One has to indicate level of symptom severity over the past week using the following four level scale.

• 0 = None
• 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, lifedisturbing problems

3. Somatic Symptoms

Somatic symptoms to be taken into consideration when evaluating fibromyalgia intensity. The additional points are added for the number of symptoms as follows: 0 – for no somatic symptoms, 1 – for from 1 to 10 somatic symptoms, 2 – for from 11 to 24 somatic symptoms, 3 – for 25 and more somatic symptoms. List of the somatic symptoms to be taken into consideration: