Editorial

Criteria for fibromyalgia? What is fibromyalgia?

Limitations to current concepts of fibromyalgia and
fibromyalgia criteria
F. Wolfe

National Data Bank for Rheumatic Fibromyalgia is an arbitrarily and broad- In the seminal 1990 ACR criteria study,
Diseases and University of Kansas School ly defined disorder of widespread pain 16 physicians enrolled 135 cases of
of Medicine, Wichita, KS, USA. and multiple symptoms that is strongly primary fibromyalgia and 135 con-
Frederick Wolfe, MD influenced by culture, context and so- trol cases. The characteristics of these
Please address correspondence to: cial forces. The boundaries of fibromy- patients would form the basis of the
Dr Frederick Wolfe, algia are not always easy to discern. de facto case definition of fibromyal-
1035 N. Emporia, Suite 288, How many and which symptoms are gia (3). These study physicians were
67214 Wichita (KS), USA.
E-mail: [email protected]
required? How many painful sites are deeply influenced by the 1977 Smythe-
needed? How many tender points? Cri- Moldofsky paper that first proposed the
Received on February 12, 2017 and
accepted on February 24, 2017.
teria for fibromyalgia have served many use of tender points in diagnosis (7). It
purposes, the most important of which is should be no surprise that tender points
Clin Exp Rheumatol 2017; 35 (Suppl. 105):
S3-S5.
to characterise and define the disorder. were effective in diagnosing fibromy-
The definition of fibromyalgia has been algia, as the physicians referring cases
© Copyright Clinical and
Experimental Rheumatology 2017. malleable, however, because fibromyal- to the study relied on tender points for
gia “has no binding definition … and no their clinical diagnoses. Who is to say
Key words: fibromyalgia, criteria way of objectively testing for it” (1). that the prior Yunus criteria, which had
Readers may be surprised to know that a lower tender point requirement, did
well-regarded, major criteria sets for not identify fibromyalgia patients? If
fibromyalgia have identified different patients contributed to the 1990 criteria
groups of patients. Yunus’s 1981 cri- study had been referred using the Yu-
teria were cited >1000 times through nus criteria, it is certain that the 1990
1990 (2), but their minimal require- criteria would have been very different.
ment of 3 tender points and aching or Fibromyalgia criteria also substantial-
stiffness in 3 anatomic cites meant that ly changed the understood definition
many patients identified by these crite- of fibrositis in effect through 1980 by
ria would not have satisfied the 1990 adding to it. Moldofsky, a psychiatrist
American College of Rheumatology interested in sleep problems, added
(ACR) criteria for fibromyalgia that “unrefreshed sleep” to the Smythe and
required of least 11 tender points and Moldofsky criteria of 1977 (7). The
widespread pain (3). Although agree- ACR 1990 criteria added “widespread
ment between the ACR 1990 criteria pain” as a criterion-something never
and the ACR 2010 or modified 2011 required previously. Fibro fog, a hot
criteria is good (4, 5), the ACR 2010 term in the first decade of the 21st cen-
criteria let some patients into the diag- tury, produced 104 Google hits in the
nosis who had pain in only 3 anatomic 1990s and 13,800 hits in the following
areas. The most recent 2016 criteria 10 years. It was added to the 2010 cri-
revisions imposed a strict definition of teria as “cognitive difficulties.”
generalised pain, so as to avoid iden- In addition to simple definitional prob-
tifying patients with severe regional lems, the 1990 criteria always had
pain syndromes as having fibromyalgia problems with validity and reliabil-
(6). But the result of this change was to ity (6). Most primary care physicians
exclude 13.8% of 2010/2011 positive didn’t know how to or were unwill-
cases. (J Albin & F Wolfe, accepted for ing to perform the tender point ex-
publication) Thus, each set of criteria amination. In addition, tender points
modifications effectively changes the did not just measure pain threshold,
Competing interests: none declared. fibromyalgia case definition. they measured pain threshold and dis-

Clinical and Experimental Rheumatology 2017 S-3

EDITORIAL Fibromyalgia criteria / F. Wolfe

tress. Gracely called the tender point fibromyalgia criteria. When does fibro- ture of the fibromyalgia definition,
count “some unspecified combination myalgia begin or end? Fibromyalgia di- we should consider whether the
of tenderness and distress” (8). It has agnostic criteria are based on reaching “pain and distress” type of fibro-
also been called “a sedimentation rate a sufficient level of symptom severity. myalgia subject identified by Walitt
for distress” (9). Physicians who used However, persons with fibromyalgia in the general population should be
tender points invariably tested patients may have many symptoms and mul- considered de facto as part of the
after interviewing them and eliciting tiple interactions with physicians for fibromyalgia definition.
their symptoms. Tender points prob- years before fibromyalgia is diagnosed 7. As fibromyalgia is a socially con-
ably worked in expert hands because (16-18). Fibromyalgia often cannot be structed dimensional disorder, and
physicians adjusted their examinations distinguished from other similar dis- arbitrarily and inconsistently named
based on the information they obtained orders (19-21). Fibromyalgia may not and diagnosed, we should be wary
in the interview. The 2010/2011/2016 be diagnosed even if criteria are met, of accepting as sufficient current
(2010+) symptom based criteria also as physicians may choose not to diag- reductionist neurobiologic causal
have problems with reliability in the nose fibromyalgia, and use other terms explanations.
same way that all questionnaires that to characterise fibromyalgia symptoms
measure feelings do (10). (12, 22). References
Walitt et al. used the US National Health In 2017, 40 years after Smythe and 1. REED M, HERRMANN M: The Difficulties in
Interview Survey (NHIS) and surro- Moldofsky’s startling paper, it seems Developing and Implementing Fibromyalgia
Guidelines: INTECH Open Access Publish-
gate (a limitation) fibromyalgia crite- possible to summarise some aspects of er; 2012.
ria to investigate fibromyalgia in the fibromyalgia that came to be learned 2. YUNUS M, MASI AT, CALABRO JJ, MILLER
US population in 2016 (11, 12). They through applications of criteria to pa- KA, FEIGENBAUM SL: Primary fibromyalgia
found that 3/4 of patients reporting a tients and trials. (fibrositis): clinical study of 50 patients with
matched normal controls. Semin Arthritis
physician diagnosis of fibromyalgia did Rheum 1981; 11: 151-71.
not meet fibromyalgia criteria. What? 1. Fibromyalgia “has no binding 3. WOLFE F, SMYTHE HA, YUNUS MB, et al.:
Could it be that the tricky and difficult definition … and no way of objec- The American College of Rheumatology 1990
to use tender points were not applied, or tively testing for it” (1). Criteria for the Classification of Fibromyalgia.
Report of the Multicenter Criteria Committee.
the questionnaire of the 2010+ criteria 2. Fibromyalgia is a constructed dis- Arthritis Rheum 1990; 33: 160-72.
was not used by primary care physi- order, just as neurasthenia was. Its 4. WOLFE F, CLAUW D, FITZCHARLES MA, et
cians? Fibromyalgia, like beauty, may prevalence and acceptance depend al.: The American College of Rheumatology
be in the eye of the beholder (the clini- on factors largely external to the Preliminary Diagnostic Criteria for Fibromy-
algia and Measurement of Symptom Sever-
cian) who sees fibromyalgia straight on patient. ity. Arthritis Care Res 2010; 62: 600-10.
as pain and distress. It seems possible 3. Fibromyalgia is a dimensional dis- 5. WOLFE F, CLAUW D, FITZCHARLES MA, et
that the default clinical criteria now be- order (a continuum disorder) and al.: Fibromyalgia Criteria and Severity Scales
ing used in primary care medicine is makes perfect sense as such. Con- for Clinical and Epidemiological Studies: A
Modification of the ACR Preliminary Diag-
just the presence “pain and distress.” sidering it as a categorical disorder nostic Criteria for Fibromyalgia. J Rheumatol
It is important to remember that physi- runs into misclassification prob- 2011; 38: 1113-22.
cian determined fibromyalgia criteria, lems described above. The poly- 6. WOLFE F, CLAUW DJ, FITZCHARLES M-A, et
including the 1990 criteria, were con- symptomatic distress (PSD) scale al.: 2016 Revisions to the 2010/2011 fibro-
myalgia diagnostic criteria. Semin Arthritis
structed by physicians, not discovered of the 2010+ criteria to access the Rheum 2016; 46: 319-29.
by them. In that respect, fibromyalgia continuum. 7. SMYTHE HA, MOLDOFSKY H: Two contribu-
and fibromyalgia criteria have impor- 4. Comparing one end of the contin- tions to understanding of the “fibrositis” syn-
tant intellectual and social links to neu- uum with the other end (“normals” drome. Bull Rheum Dis 1977; 28: 928-31.
8. GRACELY RH, GRANT MA, GIESECKE T:
rasthenia of a previous century (13). vs. fibromyalgia) in a research Evoked pain measures in fibromyalgia. Best
Evidence exists that pharmaceutical study tells one very little about the Pract Res Clin Rheumatol 2003; 17: 593-609.
companies have influenced and in- disorder and its mechanisms. It is 9. WOLFE F: The relation between tender points
creased the diagnosis of fibromyalgia possible to make rules for this type and fibromyalgia symptom variables: evi-
dence that fibromyalgia is not a discrete dis-
by advertising and physicians educa- of almost always statistically sig- order in the clinic. Ann Rheum Dis 1997; 56:
tional activities (14, 15). Extensive ad- nificant comparison: every feeling, 268-71.
vertising including direct to patient ad- symptom, physical finding, neuro- 10. WOLFE F, FITZCHARLES MA, GOLDENBERG
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and Patient-Based Criteria for the Diagnosis
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are undiagnosed, but also those who fibromyalgia to “normal subjects.” 68: 652-9.
are undiagnosed and would never sat- 5. Fibromyalgia may not truly be a 11. WALITT B, NAHIN RL, KATZ RS, BERGMAN
isfy fibromyalgia criteria-those identi- syndrome, and it is important that MJ, WOLFE F: The prevalence and character-
istics of fibromyalgia in the 2012 National
fied in the Walitt study (11, 12). future mechanistic studies examine Health Interview Survey. PLoS One 2015;
Even with “good” criteria, there are the range and content of symptoms. 10: e0138024.
other problems with fibromyalgia and 6. Given the arbitrary and variable na- 12. WALITT B, KATZ RS, BERGMAN MJ, WOLFE

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Fibromyalgia criteria / F. Wolfe EDITORIAL

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