What is the recommended approach for diagnosing and assessing fibromyalgia?

Fibromyalgia Diagnosis and Assessment Template

The diagnosis of fibromyalgia should follow the American College of Rheumatology (ACR) criteria, which includes assessment of widespread pain index (WPI), symptom severity scale (SS), and evaluation of symptoms present for at least 3 months without another disorder explaining the pain. 1

Diagnostic Criteria

2010/2016 ACR Criteria (Current Standard)

1. Widespread Pain Index (WPI) - Count of painful body regions (0-19)
2. Symptom Severity Scale (SS) - Rating of:
   • Fatigue
   • Waking unrefreshed
   • Cognitive symptoms
   • Somatic symptoms in general
3. Diagnostic Thresholds:
   • WPI ≥ 7 and SS ≥ 5, OR
   • WPI 3-6 and SS ≥ 9
4. Duration: Symptoms present at similar level for at least 3 months
5. Exclusion: No other disorder that would otherwise explain the pain

Screening Tool

• Consider using the Fibromyalgia Rapid Screening Tool as an initial assessment for patients with diffuse chronic pain 2

Clinical Assessment Components

Pain Assessment

• Document distribution of pain (must be widespread - affecting multiple body regions)
• Characterize pain quality (typically described as aching, burning, stabbing)
• Assess pain intensity using standardized scales (0-10)
• Evaluate pain triggers and alleviating factors

Associated Symptoms Evaluation

• Fatigue: Severity, pattern, impact on daily activities
• Sleep disturbances: Unrefreshing sleep, insomnia, sleep quality
• Cognitive dysfunction ("fibro fog"): Memory problems, concentration difficulties
• Mood disorders: Screen for depression and anxiety
• Additional symptoms to document:
  • Headaches
  • Irritable bowel symptoms
  • Temperature sensitivity
  • Raynaud's phenomenon
  • Paresthesias
  • Sensitivity to environmental stimuli (lights, sounds, smells)

Physical Examination

Tender Point Examination

• While no longer required for diagnosis per updated criteria, may still be clinically useful
• Traditional examination includes 18 specific tender points
• Apply approximately 4 kg of pressure (amount needed to blanch the examiner's nail bed) 1
• Document number of positive tender points (≥11/18 was classic criteria)

General Examination

• Musculoskeletal assessment for other conditions
• Neurological examination to rule out neuropathies
• Joint examination to exclude inflammatory arthritis
• Skin examination for rashes suggesting connective tissue disease

Laboratory and Imaging Studies

• Limited testing is indicated - fibromyalgia is a clinical diagnosis 2, 3

• Recommended baseline tests:

  • Complete blood count
  • Comprehensive metabolic panel
  • Thyroid function tests
  • Erythrocyte sedimentation rate or C-reactive protein
  • Creatine kinase (if myopathy suspected)
  • Vitamin D level (optional)

• Imaging: Not routinely recommended unless specific pathology is suspected

Differential Diagnosis Considerations

• Rheumatologic conditions:

  • Inflammatory arthritis (rheumatoid arthritis, spondyloarthropathies)
  • Polymyalgia rheumatica
  • Connective tissue diseases (lupus, Sjögren's syndrome)

• Neurological conditions:

  • Multiple sclerosis
  • Myasthenia gravis
  • Peripheral neuropathies

• Endocrine disorders:

  • Hypothyroidism
  • Hyperparathyroidism
  • Adrenal insufficiency

• Other conditions:

  • Myofascial pain syndrome
  • Chronic fatigue syndrome
  • Depression with somatic symptoms

Functional Assessment

• Daily activities impact: Document specific limitations
• Work status and limitations
• Sleep quality assessment
• Psychological functioning
• Quality of life measures: Consider using Fibromyalgia Impact Questionnaire (FIQ)

Documentation Essentials

• Comprehensive symptom history with duration
• Detailed pain distribution map
• WPI and SS scores
• Functional limitations
• Comorbid conditions
• Previous treatments and responses

Common Pitfalls to Avoid

• Overreliance on tender points: Updated criteria focus on symptom patterns rather than tender point count
• Excessive testing: Extensive laboratory tests and imaging are not required 4
• Diagnosis of exclusion mindset: Fibromyalgia is a positive diagnosis, not merely a diagnosis of exclusion 3
• Missing comorbidities: Carefully assess for overlapping conditions like irritable bowel syndrome, migraines, and mood disorders 2
• Failing to validate symptoms: Acknowledge the reality of symptoms and provide reassurance about the condition

Follow-up Assessment

• Regularly monitor symptom severity
• Assess treatment adherence, especially to exercise programs
• Evaluate functional improvement
• Screen for new or worsening symptoms
• Adjust treatment plan based on response

This template provides a structured approach to diagnosing and assessing fibromyalgia based on current guidelines, emphasizing the importance of comprehensive symptom evaluation while avoiding unnecessary testing.