By Christine Danella
Fibromyalgia & Chronic Pain LIFE
This article appears in the Nov/Dec 2011 issue of Fibromyalgia & Chronic Pain LIFE magazine, a publication of the National Fibromyalgia & Chronic Pain Association. Reprinted with permission from NFMCPA. For more information, visit www.fmcpaware.org.
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Once the hallmark for diagnosing fibromyalgia – Now a basis of controversy among the medical community

Tender point examinations have been a fact of life for fibromyalgia patients since The American College of Rheumatology (ACR) published the first set of fibromyalgia (FM) classification criteria in 1990. The intended use of these criteria was to identify patients to be included in research studies rather than to diagnose the illness. However, the 1990 paper did note that “the sensitivity of the criteria suggests that they may be useful for diagnosis as well as classification”(4). In the absence of other diagnostic tools, the 1990 classification criteria became the standard resource for diagnosis of FM.

During the past 20 years the problems with using these criteria as a diagnostic tool have become apparent. Focused entirely on pain and tenderness, the criteria disregarded symptoms of fatigue, non-restorative sleep, cognitive difficulties, and mood disorders, as well as other physical symptoms commonly seen in FM.

The most contentious aspect of the 1990 ACR criteria has been the tender point (TeP) exam. If a patient had less than the required 11 of 18 TeP’s but had a long history of other symptoms common to FM, could the diagnosis still be made? When response to treatment reduced the TeP count, did this patient still have fibromyalgia? Would the TeP examination be done correctly or not at all?

Recognizing these problems, a selected group of rheumatologists conducted a study to compare previously diagnosed FM patients with patients diagnosed with other non-inflammatory painful disorders. Their mission was to develop a set of criteria for clinical diagnosis of FM that did not require a tender point exam and that would provide a severity scale for FM symptoms. The results of that study were the basis for the Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity published in May 2010. Below is a comparison of the major characteristics of the 1990 vs. the 2010 criteria.

*A Proposed 2011modification would add the WPI and SS scales to create the FM Symptom Scale (FS) (9)
As the chart indicates, two scales for symptom identification and severity have replaced the tender point exam. Scores are determined by answers from questionnaires. The intent is for the physician to complete the questionnaire following an interview and physical examination. Although “appropriate clinical assessment” is suggested in the new criteria, it is not a requirement for diagnosis.

Why keep the tender point exam?
At stake is the concept of “tenderness” and/or hypersensitivity to pain, the seminal feature of fibromyalgia. Without it, FM reverts to being just another chronic pain condition. The legitimacy of FM as a distinct illness that organizations like the National Fibromyalgia Association have fought so hard to establish and to publicize for the benefit of FM patients may be in jeopardy.

Noted FM researcher Dr. Robert Bennett, in his article “Don’t Throw the Baby Out with the Bathwater” suggests that ”any potential criteria should not only include but demand a carefully structured physical examination rather than leaving it up to the physician’s discretion.” (3) His examination would encompass myofascial trigger points (MTP’s) as well as tender points. Located in many of the same places as the tender points described in the 1990 criteria, MTP’s have recently been found to be an important contributor to the FM pain experience.

In the absence of a TeP exam requirement, there is concern that time-constrained primary care physicians might rely on questionnaire results alone to diagnose FM. If the illness becomes self-reported, there is a danger that overlapping clinical conditions may be missed. Diseases that mimic or coexist with FM such as rheumatoid arthritis or Sjogren’s syndrome might be left untreated.

The use of questionnaires instead of TeP exams for diagnosis may greatly increase the reported incidence of FM. Although this benefits the individual patient seeking diagnosis, it could have negative results for the currently diagnosed FM population. As Dr. Jon Russell points out in the April, 2011 Fibromyalgia i-Newsletter, blind acceptance of a diagnosis made by a questionnaire could increase the prevalence of FM from 2 to nearly 10% of the population, the estimate of people in the general population who have chronic widespread pain. By diluting the patient population, less credence would be given to those who are truly ill. Finding their way to established and proven FM therapies may become more difficult.
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See tomorrow’s post for the second half of this article, which discusses why to eliminate tender points, how pain thresholds would be evaluated and the conclusion of the article.