Fibromyalgia diagnostic criteria

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Aditya Ganti M.B.B.S. [2]

## Overview

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The most widely accepted set of diagnostic criteria for fibromyalgia was developed in 2010 by the Multicenter Criteria Committee of the American College of Rheumatology. A patient satisfies diagnostic criteria for fibromyalgia if the following 3 conditions are met:[1][2][3][4]

* Widespread pain index (WPI) > 7 and symptom severity (SS) scale score >5 or WPI 3–6 and SS scale score >9
* 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

## Diagnostic Criteria

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The most widely accepted set of diagnostic criteria for fibromyalgia was developed in 2010 by the Multicenter Criteria Committee of the American College of Rheumatology.[1][2][3][4] and updated in 2016[5].

These criteria are not well used in clinical practice[6].

Competing criteria are by a collaboration between the US Food and Drug Administration (FDA) and the American Pain Society (APS) called the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks (ACTTION). These criteria are called the ACTTION-APS Pain Taxonomy (AAPT)[7]. These criteria have been criticized for not including a summary assessment of severity[8].

* Multisite pain (MSP) "defined as 6 or more pain sites from a total of 9 possible sites"
* "Moderate to severe sleep problems OR fatigue"
* "MSP plus fatigue or sleep problems must have been present for at least 3 months"

### Criteria as of 2016

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A patient satisfies American College of Rheumatology) ACR 2016 diagnostic criteria for fibromyalgia if the following 3 conditions are met[5]:

* Pain in at least 4 of 5 regions
* Widespread pain index (WPI) >= 7 and symptom severity (SS) scale score >=5 or WPI >= 4 and SS scale score >= 9
* Symptoms have been present at a similar level for at least 3 months

#### Ascertainment

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1\. 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.
* Areas for pain are: shoulder girdle, left hip (buttock and trochanter), left jaw, left upper back, shoulder girdle, right hip (buttock and trochanter), right jaw, right lower back, upper arm, left upper leg, left chest, neck, upper arm, right upper leg, right abdomen, right lower arm, left lower leg, left lower arm, and right lower leg

2\. Somatic symptoms (SS) scale score: For each of the 3 symptoms below, 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

Symptoms:

* Fatigue
* Waking unrefreshed
* Cognitive 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.

#### History of criteria

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The American College of Rheumatology criteria over time: ACR1990[9]

* "widespread pain" defined as "axial plus upper and lower segment plus left- and right-sided pain"
* "tenderness at 11 or more of the 18 specific tender point sites"

ACR2000/2011[4][2]

* Dropped requirement for widespread pain
* Removed requirement for physical examination for tender points and replaced with self-report
* Added fibromyalgia severity score (FSS)

ACR2016[5]

* Added "generalized pain criterion to insure that regional pain syndromes are not captured by the criteria". This criterion is pain in at least 4 of 5 regions. The five regions are 4-quadrant plus axial:
* Left upper region: jaw, shoulder girdle, upper arm, lower arm
* Right upper region: jaw, shoulder girdle, upper arm, lower arm
* Left lower region: hip (buttock, trochanter), upper leg, lower leg
* Right lower region: hip (buttock, trochanter), upper leg, lower leg
* Axial region: neck, upper back, lower back, chest, abdomen

In 2016, authors of the ACR 2016 criteria have proposed shortening the WPI by "combining 4-region pain and a total pain site score ≥7"[10].

## References

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1. ↑ 1.0 1.1 Wang SM, Han C, Lee SJ, Patkar AA, Masand PS, Pae CU (2015). "Fibromyalgia diagnosis: a review of the past, present and future". Expert Rev Neurother. 15 (6): 667–79. doi:10.1586/14737175.2015.1046841. PMID 26035624.
2. ↑ 2.0 2.1 2.2 Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB (2011). "Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia". J. Rheumatol. 38 (6): 1113–22. doi:10.3899/jrheum.100594. PMID 21285161.
3. ↑ 3.0 3.1 Atzeni F, Cazzola M, Benucci M, Di Franco M, Salaffi F, Sarzi-Puttini P (2011). "Chronic widespread pain in the spectrum of rheumatological diseases". Best Pract Res Clin Rheumatol. 25 (2): 165–71. doi:10.1016/j.berh.2010.01.011. PMID 22094193.
4. ↑ 4.0 4.1 4.2 Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB, Yunus MB (2010). "The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity". Arthritis Care Res (Hoboken). 62 (5): 600–10. doi:10.1002/acr.20140. PMID 20461783.
5. ↑ 5.0 5.1 5.2 Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RL; et al. (2016). "2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria". Semin Arthritis Rheum. 46 (3): 319–329. doi:10.1016/j.semarthrit.2016.08.012. PMID 27916278.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
6. ↑ Wolfe F, Schmukler J, Jamal S, Castrejon I, Gibson KA, Srinivasan S; et al. (2019). "Diagnosis of Fibromyalgia: Disagreement Between Fibromyalgia Criteria and Clinician-Based Fibromyalgia Diagnosis in a University Clinic". Arthritis Care Res (Hoboken). 71 (3): 343–351. doi:10.1002/acr.23731. PMID 30724039.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
7. ↑ Arnold LM, Bennett RM, Crofford LJ, Dean LE, Clauw DJ, Goldenberg DL; et al. (2019). "AAPT Diagnostic Criteria for Fibromyalgia". J Pain. 20 (6): 611–628. doi:10.1016/j.jpain.2018.10.008. PMID 30453109.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
8. ↑ Wolfe F (2019). "Letter to the editor, "Fibromyalgia Criteria"". J Pain. 20 (6): 739–740. doi:10.1016/j.jpain.2019.02.002. PMID 30765303.
9. ↑ Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL; et al. (1990). "The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee". Arthritis Rheum. 33 (2): 160–72. doi:10.1002/art.1780330203. PMID 2306288.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
10. ↑ Wolfe F, Butler SH, Fitzcharles M, Häuser W, Katz RL, Mease PJ; et al. (2019). "Revised chronic widespread pain criteria: development from and integration with fibromyalgia criteria". Scand J Pain. doi:10.1515/sjpain-2019-0054. PMID 31596726.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)