How to use the new American College of Rheumatology fibromyalgia diagnostic criteria

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How to Use the New American College of Rheumatology Fibromyalgia Diagnostic Criteria

To the Editors:

Prior to the publication of the American College of Rheumatology (ACR) 2010 Preliminary Fibromyalgia (FM) Diagnostic Criteria (1), diagnosis was simple, provided one knew how to perform the tender point examination. The examiner determined if the patient had widespread pain and then performed a 60-second examination of tender points as described by the ACR 1990 classification criteria (2).

The ACR 2010 criteria made diagnosis easier by eliminating the tender point examination, but made it more difficult by requiring evaluation of symptoms. The ACR 2010 criteria altered the case definition of FM by recognizing that symptoms were a central part of the syndrome. In doing this, the criteria imposed a special burden on the examiner: the necessity to interview the patient in detail sufficient to understand the extent and severity of the symptoms. The ACR 2010 criteria provided rules for categorizing symptom severity and making a diagnosis, but did not precisely define how symptom severity was to be ascertained, leaving this to the clinician. The authors were purposeful about this: clinicians had guidelines, but could use methods of ascertainment that were appropriate for their clinical setting and manner of practice. In general, the authors felt that a comprehensive patient interview and physical examination were required and could provide the requisite diagnostic criteria information.

There is some complexity in the ascertainment and scoring of the ACR 2010 criteria and because of this some clinicians have requested forms that could be used to help in the diagnostic process. Below we provide the web site access to download such forms.

Before using the forms please pay careful attention to the following. The ACR 2010 criteria do not permit self-diagnosis, and any diagnosis based primarily on self-report is not valid. Practically, that means that the patient cannot be presented with a checklist of symptoms that will be scored for a diagnosis. However, it is possible for the physician to use forms to gather information that can be used as part of the diagnostic process.

The count of painful regions can be determined in a number of ways. The physician can simply interview the patient and record the locations of pain (FM Criteria Worksheet. Available at URL: http://www.arthritis-research.org/sites/default/files/FM%20Criteria%20Work%20Sheet.pdf). Another way to get painful region data is to ask the patient to complete a checklist of painful regions (FM Patient Pain Location Report. Available at URL: http://www.arthritis-research.org/sites/default/files/FM%20Patient%20Pain%20Location%20Report.pdf) or to use a manikin checklist. It is perfectly appropriate to ask patients to complete such a checklist if it appears that there are many painful areas.

By contrast, the severity of 4 criteria symptoms (fatigue, unrefreshed sleep, cognitive problems, and somatic symptoms) must represent the physician's rating after a clinical evaluation. That means the severity scores cannot simply represent the results of a patient questionnaire. If a patient questionnaire were to be used, that would in effect default the entire diagnostic determination to the patient, something that is not allowed by the ACR 2010 criteria.

One way to approach these symptoms is with an open-ended question such as, “Are you having problems with fatigue? Waking up tired? Thinking or remembering things?” Then followup with more detailed inquiries. Visual analog scales or other patient self-report questionnaires regarding these symptoms can also be used as the start of the evaluation process. Remember that the physician's score represents the physician's assessment of the patient's symptoms, and this assessment could be different from the patient's assessment.

The evaluation of the extent of somatic symptom reporting cannot and must not be accomplished by simply counting up symptoms. The ACR 2010 criteria provided a list of symptoms as examples. It was neither intended nor appropriate to use this list to count symptoms. The regular “review of systems” will often be sufficient to determine somatic symptom extent.

An overview of the criteria, their implementation, and interpretation has been prepared as slides by Mary-Ann Fitzcharles, MD. These slides along with the FM Criteria Worksheet and FM Patient Pain Location Report are available for download at URL: www.arthritis-research.org/research/fibromyalgia-criteria.

Frederick Wolfe MD*, * National Data Bank for Rheumatic Diseases and University of Kansas School of Medicine, Wichita, KS.

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