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No More Tender Points? Part II

This is the continuation of the article from yesterday’s post.

Why eliminate the tender point exam?
The most cogent argument for eliminating the tender point exam as a diagnostic criteria is that it just isn’t being used. The clinical evaluation of tender points is an acquired skill that is not taught in medical school. It requires a very specific amount of pressure in very specific locations. Studies have revealed that the tender point exam was only rarely performed in the primary care setting, the site of most FM diagnoses. When it was performed at all, it was done incorrectly.

Because FM symptoms come and go, a person could have more or less than 11 of the required 18 tender points on any given day. This leads to underdiagnosis, delayed diagnosis and delayed treatment.

The reluctance of primary care doctors to perform or interpret TeP exams results in numerous referrals to other healthcare providers, namely rheumatologists, to confirm the diagnosis. The unfortunate reality is that there just aren’t enough skillful providers available to confirm each and every diagnosis in a timely manner. The resultant delay in diagnosis increases stress, time and cost to the patient. Five years is the average length of time it takes to receive a diagnosis today.

Dr. Daniel Clauw in his FMAware article entitled “Time to Move Forward” argues that “the tender point exam is biased against males and has reinforced the notion that FM occurs only in middle-aged distressed females.”(12) Of the FM cases diagnosed using the 1990 ACR criteria, 80-90% are women. Men are less likely to present with the required number of tender points due to their naturally higher pain tolerance. The result is inaccurate reporting of the number of males who have the illness.

Regardless of whether mood disorders such as depression or anxiety are primary or secondary (a concern of the authors of the 2010 Criteria) the fact is that psychiatrists routinely see patients with fibromyalgia. The philosophy of their specialty is not to physically examine their patient. Thus, they were excluded from making an FM diagnosis by the tender point exam requirement.

Without the requirement of a TeP exam, many more people will be diagnosed. Receiving a diagnosis in and of itself is a great relief to the patient. Not only is it the first step toward effective treatment, it also improves the feeling of satisfaction with health and healthcare.

If not Tender Points, then what?
There is little argument that a simple, accurate and rapid measurement of pain threshold should be included in the new criteria. Several studies have compared methods for such assessment. To date, none has been found to be superior to the TeP examination for speed, simplicity, or cost effectiveness. It has been noted, however, that examining as few as three tender points could give as accurate a result as examining all 18.

Now that it is understood that FM is a central nervous system disorder, central sensitization testing has been suggested as a possible addition to or substitute for the tender point exam. According to Dr. Clifford Woolf, Professor of Neurology and Neurobiology at Harvard Medical School, “Diagnostic criteria to detect central sensitization will assist in selecting treatments that normalize central neural activity.”(11)

Such an assessment could be accomplished through the use of electrical stimulation to measure the nociceptive reflex that correlates to the pain sensation. Another suggestion is to measure pain tolerance by use of the cold pressor test, done by immersing a hand into an ice bath. In the absence of sophisticated equipment, central sensitivity could be assessed in a clinical setting with a blood pressure cuff.

For now, the only accepted standard for diagnosing FM remains the 1990 ACR criteria. Only time will tell how well the 2010 preliminary criteria will perform in the clinical setting and whether they will be adopted as is. Another possibility would be a modification of the newer criteria to include a test for tenderness or central sensitization and/or to substitute the newer FS scale for the two measurement scales included thus far.

A third possibility would be to add the 2010 criteria to the existing 1990 criteria. Authors of the new criteria initially state in their report that the 2010 diagnostic criteria weren’t meant to replace the 1990 ACR. However, the same report also says that if the diagnostic criteria perform well, the 1990 ACR classification criteria might be withdrawn. If the 2010 Preliminary Diagnostic Criteria are adopted as written, the TeP exam may become a thing of the past.

There is no question that the diagnostic criteria for FM are currently in a state of flux. Given the extensive discussions on the issue among noted FM specialists, chronic pain patients who were previously disqualified from FM diagnoses by the tender point requirement may wish to consult with their doctors again in the future.

Fibromyalgia & Chronic Pain LIFE magazine cover


Written by Christine Danella, Author
Tender Points: A Fibromyalgia Memoir
Available on www.fmspubs or

Wolfe F, Clauw D, Fitzcharles MA, et al. The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. Arthritis Care Res (Hoboken). 2010:62(5):600-610.
Fitzcharles MA, Boulos P. Inaccuracy in the diagnosis of fibromyalgia syndrome: analysis of referrals. Rheumatology (Oxford) 2003;42:263-7.
Bennett R. Don’t Throw the Baby out with the Bathwater, Fibromyalgia AWARE Volume 23, pp 19-24.
Bennett R. Opinion on Preliminary Guidelines for the Clinical Diagnostic Criteria for Fibromyalgia, Practical Pain Management, July 1, 2010.
Russell J. Reviewing the Proposed Diagnostic Criteria for Fibromyalgia, Fibromyalgia i-Newsletter, Issue 1.
Arnold L, Clauw D, McCarberg B. Improving the Recognition and Diagnosis of Fibromyalgia. Mayo Clinic Proceedings May 2011, vol. 86 No. 5, pp 457-464.
Argoff C. Should Psychiatrists Manage Pain? Medscape 2/24/2010.
King S. Diagnosing Fibromyalgia: Development of New Criteria, Psychiatric Times, Vol. 28 No.3, April 1, 2011.
Wolfe F, Clauw D, Fitzcharles MA et al. Fibromyalgia Criteria and Severity Scales for Clinical and Epidemiological Studies: A Modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. The Journal of Rheumatology, June 1, 2011, vol. 38 No. 6 1113-1122.
Wolfe F, Smythe H, Yunus M, Bennett R, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee, Arthritis Rheum, 1990 Feb;33(2):160-72.
Woolf D, Central sensitization: Implications for the Diagnosis and Treatment of Pain. Journal of the Int’l Assn. for the Study of Pain, March 2011. Vol52, Issue 3, pp 2-15.
Clauw D. Time to Move Forward. Fibromyalgia AWARE, Vol 23, pp 19-24.
Tastekin N, Birtane M, Uzunca K. Which of the three different tender points assessment methods is more useful for predicting the severity of fibromyalgia syndrome? Rheumatol Int. 2007 Mar,27(5):447-51.
Desmeules JA, Cedraschi C, et al. Neurophysiologic Evidence for a Central Sensitization in Patients with Fibromyalgia. ARTHRITIS & RHEUMATISM May 2003,Vol 48, No. 5, pp 1420-29.
Toda K, The Modification of the American College of Rheumatology Diagnostic Criteria for Fibromyalgia should be supplemented and revised. Journal of Rheumatology, 2011; 38:9.


Comment from Displaced
Time November 29, 2011 at 4:34 pm

Very interesting post! I wish they would find a way to concretely diagnose FMS. I remember my first tender point examination had me glued to the ceiling trying to get away from the doctor! Thanks
Displaced recently posted: The Universe at work…


kathy Reply:

yeah, I was on the floor cursing the doc . telling him to warn me next time he wants to touch me. I warn everyone if they want to touch me to ask first, except my grands. I take the pain for love


Felicia Fibro Reply:

It would be much more pleasant (and hopefully more accurate) if there were a blood marker or something, huh?! I agree, the tender point exams are very painful – for days!


Comment from Sabrina N
Time November 30, 2011 at 8:14 pm

I’ll never forget the time I was sitting on the exam table and the doctor pushed on a tender point and my legs shot up and I kicked him accidentally :P He didn’t do that from the front ever again.
It was simply another validation of how important it is to check.
Thank you for the article Felicia, this really helps SO many people understand what’s happening with the new criteria :)


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