It’s been 20 years since the American College of Rheumatology (ACR) published the criteria for the classification of fibromyalgia (FM). This criteria requires pain in all four quadrants of the body for at least three months AND moderate pain sensitivity at a minimum of 11 of the 18 predetermined tender points.
As with any diagnostic criteria, especially those that cannot be based on a blood marker or similar test, there were problems with implementing the 1990 criteria. The authors of the new preliminary criteria, headed up by Frederick Wolfe, M.D., of Wichita, KS, contend:1
- Tender point counts are rarely performed in primary care where most FM diagnoses occur. Even when the count was performed, it was usually done incorrectly.
- Many physicians do not know how to examine for tender points and some simply refuse to do so.
- Outside of research, practitioners in the clinical setting often diagnose FM based on symptoms rather than tender point counts.
Twenty years experience with any set of diagnostic criteria is bound to illuminate its shortcomings. As you may have read in the March eNews Alert, there is a serious gender bias in how the 1990 criteria are used, making it much harder for men to receive this diagnosis and the available treatments.2 The tender point criteria also did a poor job of measuring symptom severity or charting the effectiveness of new treatments.
Although the new diagnostic criteria do away with the tender point concept and take into consideration the more common symptoms of fibromyalgia, it remains unknown whether primary care physicians will find them any easier to implement. The new ACR diagnostic criteria for fibromyalgia should still be viewed as preliminary. However, patients should be aware of what Wolfe and the ACR committee are proposing.
For starters, Wolfe’s editorial published online along with the new criteria in Arthritis Care and Research, makes two unflattering statements about fibromyalgia:
- “The ACR diagnostic criteria should not be seen as an endorsement of the legitimacy and existence of fibromyalgia—the criteria are neutral on that point.”3 He goes on to indicate that the “fibromyalgia wars” over whether FM is a real condition, or just the end of the spectrum showing how some people poorly respond to distress (it’s what Wolfe refers to as “fibromyalgianess”), remain unresolved.4
- “... one can now study fibromyalgia and fibromyalgianess without the requirement for belief in its existence.” Does this mean that Wolfe and other non-believers will enter the research field of FM? Time will tell. With the new criteria that is virtually a symptom checklist, Wolfe adds, “... it is now possible to study widespread pain, fibromyalgia, fibromyalgianess—indeed the whole spectrum of illness related symptoms, simply and inexpensively in survey research.” But this form of “study” is not likely to lead to biomarkers or effective new therapies, which is what FM patients need the most.
The new criteria appear in a one-page symptom checklist format that will hopefully be more suitable for use in the primary-care setting. A tender point evaluation is no longer required although a full physical exam is still recommended along with other diagnostic tests to identify causes for the patients’ symptoms besides FM. In place of the tender point count, patients (or their physician) may endorse 19 body regions in which pain has been experienced during the past week. This number is referred to as the Widespread Pain Index (WPI) and it is one of the two required scores needed for a doctor to make a diagnosis of FM.
The second part of the score required to assess the diagnosis of FM involves the evaluation of a person’s symptoms. The end result is a Symptom Severity score or SS score. The diagnosis is based on evaluating both the WPI score and the SS score. Overall, it takes into consideration the widespread nature of your pain and your other bothersome symptoms.
The greatest problem with the new criteria is that the authors do not state how severe the pain must be in order to check “yes” for that area. What if the pain is just a dull ache or intermittent? The criteria do not specify the intensity or quantity of pain that one must have in a given area over the past week to merit a “yes” answer. Quantifying the symptoms for the SS score is even more vague. In fact, the carefully selected non-FM control patients scored an average of 3 on a scale of 0 to 12, which is not far from the SS score requirements for FM.
On the downside, is it possible these new criteria may greatly increase the number of patients diagnosed with FM by diluting what is called “fibromyalgia.” Quite possibly, people with chronic, painful illnesses that do not involve widespread pain will meet the new diagnostic criteria. So you may want to ask: “Who might benefit from a larger, diluted pool of FM patients?” Perhaps all one has to do is look at who sponsored this study: Lilly Research Laboratories. Eli Lilly is the manufacturer of Cymbalta (duloxetine). If more patients are diagnosed with FM, then the pharmaceutical industry will definitely benefit.
What is Fibromyalgia?*
Symptoms: Each person suffering from FMS may present with a slightly different series of symptoms. However, the most common symptoms include the following: deep muscle aching or burning, muscle stiffness or twitching, fatigue and complaints of limbs feeling like "dead weight," difficulty concentrating or "brain fog," sleep disorders, irritable bowel syndrome, chronic headaches, temporomandibular joint dysfunction (TMJ), and multiple chemical sensitivities. Individuals with fibromyalgia may report increased symptoms from changes in the weather or barometric pressure or with increased personal stress.
Causes: There are various theories regarding the cause or onset of FMS. One event or a series of traumatic events to the body can trigger the dysfunction, but it can also be caused by long-term stress. Examples include auto accidents, severe infections, or the onset of another disease affecting the connective tissues.
The body is made up of connective tissue called fascia that winds its way like a silken web through the body, around muscles, bones, nerves, and even organs. With FMS, there are often unrecognized restrictions in the fascial system contributing to the pain syndrome.
**Diagnosis: In order to meet the diagnosis criteria for FMS, a physical examination (often performed by a rheumatologist) will reveal that a person has at least 11 out of a possible 18 tender points for a minimum duration of 3 months. It is important to be aware that FMS may be diagnosed along with co-existing conditions.
**See new diagnosis criteria at top of the page.
Treatment: There are various treatments aimed at assisting sleep, reducing pain, and curtailing the co-existing symptoms of fibromyalgia. A gentle hands-on approach with a combination of manual therapy and craniosacral therapy techniques address a number of the FMS symptoms. The goal is to assist the client back into healthy, everyday living.
Traditional vs. Complementary Techniques
Traditional therapies may focus on using modalities (such as electrical stimulation and ultrasound) to reduce localized symptoms and exercise to strengthen de-conditioned tissues.
However, the source of the symptoms is not always the site of the discomfort. Muscles cannot be strengthened to a functional state and tissues cannot relax until restrictions are released.
Treating clients with fibromyalgia requires an understanding of your special needs. By following a phased treatment regimen and customizing care to each individual, Sari Lewis, OTR/L, RCST® can help you relieve your symptoms of fibromyalgia and let you regain control of your life. Calming your tissues and nervous system with gentle hands-on therapy techniques is a primary goal in treating the varied symptoms of fibromyalgia.
"Sari~Thanks for all the tools you teach me to help me get through life...for the sensitive way you explain and give reason for my concerns and questions, for your intuitive way of knowing what I need before I even say it, for the feeling of complete trust, relaxation and relief in my physical and mental being." D.C.
At the Fibromyalgia Network website you can find information on fibromyalgia and chronic fatigue syndrome. Read about support groups, research information, advocacy, past newsletters, and more. I encourage you to contact the FM Network to learn more. http://www.fmnetnews.com
The Oregon Chapter of the Fibromyalgia Foundation has a website at http://www.myalgia.com/. Check out the information on FMS and Sjogrens, Lupus, and other related diagnoses.
The Fibromyalgia Network April 2005 edition summarized a study related to capillary blood flow and patients with FMS. Here is an excerpt from the review: ‘The authors hypothesize that the sympathetic branch of the peripheral nervous system is overly active, causing the blood vessels to constrict…In addition, non-drug therapies that enhance circulation tend to reduce FMS pain.’ http://www.arthritis-research.com/content/7/2/R209
Craniosacral therapy helps to calm the nervous system, improve fluid nutrition to the brain, spinal cord and tissues and increase blood flow and circulation.
*The 18 Tender Point Locations for FMS on "The Three Graces" Masterpiece.