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tender point count was associated with increased medical care usage in addition to an increased number of physical symptoms.

32
it may not interest of a patient to be bromyalgia, especially in the presence of other musculoskeletal pain for which there are potential solutions42 For classification
purposes, a "diagnosis of inclusion" may be appropriate, even though it may still influence the outcome and conclusions drawn from such research. For a cohort of the
intermediate and long-term outcomes of fibroin patients seen at least once in specialty clinics concluded that the progwas very poor. Although did not examine the
results of treatment at these centers, patients with fibromyalgia
continued to demonstrate and functional clinical it is
abnormalities48 pos
sible that clinicians did not consider the other
of widespread pain as the ACR criteria were applied. Perhaps, the patients were not evaluated for the presence of
or other difand did not receive the
syndrome, ferential
most
treatment For clinical purposes, the
diagnosis of should be made as a
of exclusion." It is not sufficient to all
reflect a clinician's attitude that fibromyalgia does not but assures patients of the most treatment. The medical and theramanagement should focus primarily on the
other diagnoses and not resort to patients how to manage their fiThis was illustrated by Poduri and
met the ACR criteria and who was diagnosed with fibromyalgia, but who in fact
suffered from drug-related immediate
and required
treatment accordingly.
To overcome some of the clinical limitations of the ACR criteria, Muller and Muller develdiagnostic criteria for fibromyal 57 When 11 of 18 tender points must be
painful with 4 kg/cm2 for fulfilling the ACR Muller and iv1i.iller required 12 of 24 points to be tender when with a force of 2
found that their method
when proposed method 58 In summary, the Muller and Muller criteria
.. pain in in the course
of tendons or at tendon insertions in at least
three of the trunk and extremi
ties for at least three months.
.. Decreased threshold with a visible
response following pressure of
2 kg/cm' of l out of 24 tenderIn addition, Muller and Muller
the fulfillment of secondary including
autonomic symptoms, functional limitations,
and The
of three autonomic and three functional symp
toms would further support the of fi
bromyaJgia. Autonomic symptoms may include
cold hands or feet, excessive mouth,
orthostatic
arrhythmia, and tremor. Functional
limitations may include sleep disturbances, gas
trointestinal and cardiac problems, pares
Miiller and of fibromyof
should be made only as a
exclusion.
In of extensive research efforts, there
are no objective laboratory studies that confirm the diagnosis of The ACR criteria were developed
several other cIinicaI including and The reliance on a definition consensus and the lack of a well-defined concept of pathophysiology have resulted in critical
opposition to the fibromyalgia construct. The ACR criteria have been criticized as being arbitrary and at risk for circular reasoning and tautology. It appears that the
same criticism would apply to the Muller and Muller criteria.
60
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