It's important for people with Fibromyalgia, pain management personnel, general healthcare providers, and disability benefits administrators to understand Fibro tender points. However, it's just as important to keep updated on research and diagnostic criteria. Since 2010, tender points have not been the most important component to qualify for a diagnosis of FM.
The original 1990 Fibromyalgia Diagnostic Criteria didn't start out as such. It was developed to ensure a homogeneous participant pool for clinical trials. It relied heavily on the presence of tender points. Researchers found that this criterion was flawed because approximately 1/4 of pwf diagnosed in doctor's offices didn't meet the clinical trial criteria. (1)
The last incarnation of the Diagnostic criteria was
adopted in 2016. See the chart below for the
differences over the years. The important thing to know is that Tender Points (see the graphic above) are no longer an integral component of diagnosis and that having another condition that produces chronic pain does not inhibit a diagnosis of Fibromyalgia.
The American College of Rheumatology (ACR), established RESEARCH criteria to be used for diagnosing clinical trial participants in 1990. They weren't originally meant to be used to diagnose patients in clinical settings. A major criterion was pain in 11 out of 18 tender points. In 2010, The ACR established new preliminary DIAGNOSTIC criteria for FM to be used by treating healthcare professionals. The new criteria have eliminated the tender point requirements.
The 2010 ACR diagnostic criteria were:
1. Pain and symptoms over the past week, based on:
a. The total number of painful areas out of 18 parts of the
body plus the ...
b. Level of severity of the following symptoms:
•Fatigue
•Waking unrefreshed
•Cognitive (memory or thought) problems
2. Symptoms lasting at least three months
3. No other health problems that would explain the pain and other symptoms. [2]
“I remember the long drawn out battle with my employer over disability pension. Among the plethora of complaints [defenses] used by my employer was that upon examination, I did not consistently exhibit the 11 out of 18 tender points. Prior to 2010, it didn’t matter how many other symptoms a person had, it didn’t matter how severe those symptoms were – if the person did not have 11 out of 18 tender points, they were not diagnosed with FM. I am so glad the ACR removed this arbitrary maximum requirement.” Sabrina Dudley-Johnson aka Fibro Diva
In 2010 The American College of Rheumatology established the new preliminary diagnostic criteria eliminating the need for a physical tender point exam because:
1. The majority of physicians charged with diagnosing and treating people with FM in real day-to-day clinical settings [50% of whom are now primary care physicians [3]] were either . . .
(a) not conducting a tender point exam, or
(b) were performing the exam incorrectly.
2. The 1990 Classification criteria, although commonly used for diagnosis – more specifically commonly used to deny disability benefits, were established for research, not a diagnosis. [4]
3. The 1990 ACR criteria did not acknowledge the importance of many symptoms now recognized as “key fibromyalgia features”, and,
4. “Patients who improved or whose symptoms and tender points decreased could fail to satisfy the ACR 1990 classification definition." [5]
The 1990 criteria also required the presence of pain in all four quadrants of the body and along the axial skeleton. The 2010 preliminary criteria only require pain in three areas even if they are all in the same quadrant. The 2010 Fibromyalgia Diagnostic Criteria was considered a physician-assessed estimate of somatic symptoms prone to misclassification. Researchers reported that the 2010 criteria were flawed "because inflammatory and other painful disorders were excluded, (and thus) the new criteria cannot be applied to patients with RA, systemic lupus erythematosus, or other conditions". [6] It has long been established that Fibro can be concomitant with other pain producing conditions as either Primary (the pwf is diagnosed with Fibromyalgia first and then develops one or more other pain conditions at a later date), or, Secondary (the pwf is diagnosed with a chronic pain condition and later on develops FM).
The 2011 FM Diagnostic Criteria relied heavily on patient self-reporting of number and severity of symptoms which led to the development of a Fibromyalgia Symptom Scale. Dr. Neha Garg, et. al. opined that even though this scale "was found to be the best univariate predictor of FMS ... removing the physician from the diagnosis-making process and relying on patients to fill out questionnaires to self-diagnose a condition has its own problems." [7]
The 2016 FM Diagnostic Criteria combines the 2010 and 2011 criteria. Fredrick Wolfe et. al. established the most recent diagnostic criteria stating, " Fibromyalgia may now be diagnosed in adults when all of the following criteria are met:
i) Widespread pain index (WPI) ≥7 and symptom severity scale (SSS) score ≥5 OR WPI 4–6 and SSS score ≥9.
ii) Generalized pain, defined as pain in at least 4 of 5 regions, is present.
iii) Symptoms have been present at a similar level for at least 3 months.
iv) A diagnosis of fibromyalgia is valid irrespective of other diagnoses. A diagnosis of fibromyalgia does not exclude the presence of other clinically important illnesses." [8]
Endnotes
(1) New and Modified Fibromyalgia Diagnostic Criteria
By Neha Garg, MD and Atul Deodhar, MD
http://www.rheumatologynetwork.com/fibromyalgia/new-and-modified-fibromyalgia-diagnostic-criteria
(2) What and Where Are the Tender Points of Fibromyalgia?
By Starla Rich
https://fibromyalgia.newlifeoutlook.com/tender-points/
(3) Ibid.
(4) Ibid.
(5) 2016 Revisions to the 2010/2011 Fibromyalgia Diagnostic Criteria
By Frederick Wolfe, et. al.
http://acrabstracts.org/abstract/2016-revisions-to-the-20102011-fibromyalgia-diagnostic-criteria/
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