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==Diagnosis== The American College of Rheumatology publishes the most widely used diagnostic criteria for fibromyalgia.<ref name="ACR2010" /><ref name="FibroBasics" /> Tender points, not [[trigger point]]s, are used to diagnose fibromyalgia.<ref>{{Cite web | url = http://www.healthcentral.com/chronic-pain/c/662034/176031/fibromyalgia-trigger/ | title = The Difference Between Fibromyalgia Tender Points and Myofascial Trigger Points - Chronic Pain {{!}} HealthCentral | last = Cooper | first = Celeste | date = May 8, 2015 | website = healthcentral.com|language=en-US|archive-url=|archive-date=|access-date=2018-08-09}}</ref> In fibromyalgia, painful areas of the body will be both above and below the waist, and on both sides of the body. (See: 1990 ACR and 2010 ACR images above right depicting tender points.) It is important for clinicians to check for other conditions that could be causing pain such as [[hypothyroidism]], rheumatoid arthritis, lupus, osteoarthritis, ankylosing spondylitis, and polymyalgia rheumatica.<ref>{{Cite news |url =https://www.webmd.com/fibromyalgia/guide/fibromyalgia-diagnosis-and-misdiagnosis#1 | title = How Is Fibromyalgia Diagnosed?|work=WebMD|access-date=2018-08-12|language=en-US}}</ref> ===United States=== ==== 2010 American College of Rheumatology (ACR) Criteria ==== The new ACR criteria for fibromyalgia assesses: * [[#WPI|Widespread Pain Index]] (WPI), which replaces the older tender points assessment, and * [[#SS|Symptom Severity Score]] (SS), which assesses somatic symptoms other than pain<ref name="ACR2010" /> =====<span id="WPI">Widespread pain index===== There are 19 areas in the widespread pain index (WPI) in the newer ACR criteria.<ref name="masscfids" /><ref name="ACR2010" /> [[File:Widespread Pain Index Areas with numbers.svg|200px|thumb|right|'''WPI''' 19 areas of pain. Count 1 point for each area of pain present at least once a week.<ref name="Firdous2012" /><ref name="ACR2010" /><ref name="excerpt" /><br> Image source: [https://commons.wikimedia.org/wiki/File:Widespread_Pain_Index_Areas_with_numbers.svg#/media/File:Widespread_Pain_Index_Areas_with_numbers.svg Wikimedia Commons] by author Jmarchn. License: CC-by-sa-3.0.]] This '''Widespread Pain Index (WPI)''' is scored out of 19, and is one of the two required scores needed for a doctor to make a diagnosis of fibromyalgia, and is considered in combination with the SS score.<ref name="Firdous2012" /><ref name="ACR2010" /> =====<span id="SS">Symptom severity</span>===== The Symptom Severity score ranks each of the following groups of fibromyalgia symptoms on a scale of 0-3, giving a SS score out of 12: *[[Fatigue]] *[[Unrefreshing sleep|Waking unrefreshed]] *[[Cognitive dysfunction|Cognitive symptoms]] *Somatic (physical) symptoms in general (such as [[headache]], weakness, [[Gastrointestinal system|bowel problems]], [[nausea]], [[dizziness]], [[numbness]]/[[Paresthesia|tingling]], [[hair loss]], [[Dry eye syndrome|dry eyes]], [[Raynaud's syndrome|Raynaud's phenomenon]], painful urination, and more.<ref name="Firdous2012" /><ref name="ACR2010" /> [[File:WPI SS Fibro.JPG|600px|thumb|center|Table 2: '''SS''' scale score. Add a 4th column for Somatic (physical) symptoms in general (such as Headache, weakness, bowel problems, nausea, dizziness, numbness/tingling, hair loss, dry eyes, Raynaud's phenomenon, painful urination, and more)<ref name="Firdous2012" /><ref name="ACR2010" /> The patient ranks specific symptoms on a scale of 0-3. The numbers assigned to each column are added up, for a total of 0-12.<ref name="Firdous2012" /><br> Source: Jahan F, Nanji K, Qidwai W, Qasim R. Fibromyalgia Syndrome: An Overview of Pathophysiology, Diagnosis and Management. Oman Med J 2012 May; 27(3):192-195. doi: 10.5001/omj.2012.44 license: CC-BY-NC]] A fibromyalgia diagnosis is based on both the '''WPI''' score and the '''SS''' score either: *'''WPI''' of at least 7 and '''SS''' scale score of at least 5, ''or'' *'''WPI''' of at least 4 and '''SS''' scale score of at least 9 *with symptoms present for at least three months<ref name="Firdous2012" /><ref name="ACR-rev" /> The 2010 American College of Rheumatology (ACR) proposed diagnostic criteria for fibromyalgia<ref name="ACR2010" /><ref name="excerpt" /> was modified in 2011,<ref name="2016revision" /> with the modification being validated in 2013 and published in 2014.<ref name="prelim2010">{{Cite journal | last = Bennett | first = Robert M. | last2 = Friend | first2 = Ronald | last3 = Marcus | first3 = Dawn | last4 = Bernstein | first4 = Cheryl | last5 = Han | first5 = Bobby Kwanghoon | last6 = Yachoui | first6 = Ralph | last7 = Deodhar | first7 = Atul | last8 = Kaell | first8 = Alan | last9 = Bonafede | first9 = Peter| date = 2014 | title = Criteria for the diagnosis of fibromyalgia: validation of the modified 2010 preliminary American College of Rheumatology criteria and the development of alternative criteria| url = https://www.ncbi.nlm.nih.gov/pubmed/24497443|journal=Arthritis Care & Research|volume=66|issue=9 | pages = 1364–1373|doi=10.1002/acr.22301|issn=2151-4658|pmid=24497443|via=}}</ref> In September 2016, another revision was been made.<ref name="ACR-rev">{{Cite news |url =http://acrabstracts.org/abstract/2016-revisions-to-the-20102011-fibromyalgia-diagnostic-criteria/ | title = 2016 Revisions to the 2010/2011 Fibromyalgia Diagnostic Criteria - ACR Meeting Abstracts | last = | first = | date = Sep 28, 2016|work=ACR Meeting Abstracts|access-date=2018-08-09|archive-url=|archive-date=|language=en-US}}</ref> =====Take the online Fibromyalgia test ===== This [https://www.fibromyalgiaforums.org/get-help/online-fibromyalgia-test online test by fibromyalgiaforums.org] uses the ACR 2010 Criterion to help diagnose fibromyalgia. =====Tender point test phased out ===== The older 1990 criteria's tender point examination was replaced because men often do not seem to form the tender points needed for diagnosis.<ref name="men">{{Cite news |url =http://www.webmd.com/fibromyalgia/features/how-fibromyalgia-affects-men#2 | title = How Fibromyalgia Affects Men: Symptoms and Diagnosis|work=WebMD|access-date=2018-08-09|language=en-US}}</ref> The 2010 proposed criteria correctly diagnosed more men, with a female:male ratio of 2:1.<ref name="medscape">{{Cite web | last = Boomershine | first = Chad | date = Nov 4, 2017 | title = Fibromyalgia: Practice Essentials, Background, Pathophysiology| url = http://emedicine.medscape.com/article/329838-overview#a5 | website = Medscape | pages = |via=}}</ref> Tender point examination was also problematic because "considerable skill is needed to correctly check for a patient's tender points (i.e., digital palpation that is done with certain amount of applied pressure)", but this technique was not taught at most medical schools.<ref name="NBK279092" /><ref name="masscfids">{{Cite web | url = https://www.masscfids.org/8-resource-library/diagnosis/266-tender-points-might-no-longer-be-used-for-diagnosis-of-fibromyalgia#2 | title = Tender Points might no longer be used for diagnosis of Fibromyalgia | last = Proskauer | first = Charmian | date = Feb 5, 2011 | website = [[Massachusetts ME/CFS & FM Association]]|language=en-GB|archive-url=|archive-date=|access-date=2018-08-09}}</ref> :The new standards were designed to: :*eliminate the use of a tender point examination :*include a severity scale by which to identify and measure characteristic FM symptoms :*utilize an index by which to rate pain<ref name="masscfids" /> ====1990 ACR criteria==== [[File:Fibro_Tender_Points.png|400px|thumb|right|<span id="ACR1990-image">1990 ACR Diagnostic Criteria: 18 Tender Points</span><ref name="ACR1990">{{Cite journal | last = Wolfe | first = Frederick | author-link = Frederick Wolfe | last2 = Smythe | first2 = Hugh | authorlink2 = | last3 = Yunus | first3 = Muhammad | authorlink3 = Muhammad Yunnus | last4 = Bennett | first4 = Robert | authorlink4 = | last5 = Bombardier | first5 = Claire | authorlink5 = | last6 = Goldenberg | first6 = Don | authorlink6 = | last7 = Tugwell | first7 = Peter | author-link7 = | last8 = Campbell | first8 = Stephen | last9 = Abeles | first9 = Micha | author-link9 = |others=P Clark; A Fam; S Farber; J Fiechtner; CM Franklin; R Gatter; D Hamaty; J Lessard; A Lichtbroun; A Masi; G McCain; WJ Reynolds; T Romano; IJ Russell; R Sheon | date = 1990 | title = The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia| url = https://www.rheumatology.org/Portals/0/Files/1990_Criteria_for_Classification_Fibro.pdf | journal=Arthritis and Rheumatism| publisher = The American College of Rheumatology|volume=33|issue=2 | pages = 160-172|quote=|via=}}</ref><ref name="excerpt2">{{Cite web | url = https://www.rheumatology.org/Portals/0/Files/1990%20Fibromyalgia_Excerpt.pdf | title=1990 Fibromyalgia Excerpt | last = Wolfe | first = Frederick | authorlink = Frederick Wolfe | date = 1990 | website = American College of Rheumatology|archive-url=|archive-date=|access-date=}}</ref><br>Image source: [https://commons.wikimedia.org/wiki/File:Tender_points_fibromyalgia_svg.svg WikiMedia Commons], authors Sav vas and Jmarchn, license: CC0 / public domain.]] *1990, [http://www.rheumatology.org/Portals/0/Files/1990_Criteria_for_Classification_Fibro.pdf The American College Of Rheumatology 1990 Criteria For The Classification Of Fibromyalgia]<ref name="ACR1990" /><ref name="excerpt2" /> "American College of Rheumatology guidelines suggest that people with fibromyalgia have pain in at least 11 of these tender points when a doctor applies a certain amount of pressure."<ref name="NBK279092" /><ref name="masscfids" /> ====US Social Security Administration ==== The United States [[Social Security Administration]] (SSA) accepts a diagnosis of FM with either the 2010 or 1990 ACR criteria.<ref name="ACR1990" /><ref name="excerpt2" /><ref name="ACR2010" /><ref name="excerpt" /><ref name="ssa">{{Cite web | url = https://www.ssa.gov/OP_Home/rulings/di/01/SSR2012-02-di-01.html | title = Social Security Ruling: SSR 12-2p | last = ORDP | last2 = OPPS | first = | date = Jul 25, 2012 | website = ssa.gov|language=en|archive-url=|archive-date=|access-date=2018-08-09}}</ref> {{See also|Fibromyalgia disability process}} ==== Sleep studies==== [[Sleep dysfunction]] is often involved in FM. Treating a sleep disorder or sleep problems may help with FM symptoms, for example [[fatigue]]. [[Sleep apnea]], [[restless legs syndrome]] and [[nocturnal myclonus]] are often found in fibromyalgia patients, and waking unrefreshed is a diagnostic symptom of fibromyalgia.<ref name="NBK279092">{{Cite book | last = Kaltsas | first = Gregory | last2 = Tsiveriotis | first2 = Konstantinos | date = 2000|editor-last = Feingold|editor-first = Kenneth R.|editor2-last = Anawalt|editor2-first = Bradley|editor3-last = Boyce|editor3-first = Alison|editor4-last = Chrousos|editor4-first = George|editor5-last = de Herder|editor5-first = Wouter W.|editor6-last = Dhatariya|editor6-first = Ketan|editor7-last = Dungan|editor7-first = Kathleen|editor8-last = Hershman|editor8-first = Jerome M.|editor9-last = Hofland|editor9-first = Johannes | title = Endotext [Internet]|chapter=Fibromyalgia|chapter-url=http://www.ncbi.nlm.nih.gov/books/NBK279092/|location=South Dartmouth (MA)| publisher = MDText.com, Inc.|pmid=25905317}}</ref><ref name="ACR2010" /> A diagnosed sleep disorder is also helpful if one needs to [[Fibromyalgia disability process|file for disability]]. ====Brain scans==== Brain scans are a potential aid to help diagnose fibromyalgia.<ref name="Hackshaw2021">{{Cite journal | last = Hackshaw | first = Kevin V. | author-link = | date = Feb 2021 | title = The Search for Biomarkers in Fibromyalgia| url = https://www.mdpi.com/2075-4418/11/2/156|journal=Diagnostics|language=en|volume=11|issue=2 | pages = 156|doi=10.3390/diagnostics11020156|pmc=PMC7911687|pmid=33494476|access-date=|quote=|via=}}</ref><ref name="HashmiTrial">{{Cite web | last = Hashmi | first = Javeria | date = 2020-03-11|others=Nova Scotia Health Authority | title = Brain Imaging Study on Biomarkers for Fibromyalgia| url = https://clinicaltrials.gov/ct2/show/NCT03910010}}</ref> A small study by López-Solà et al. (2017) using a combination of [[functional magnetic resonance imaging|fMRI]] brain scans and artificial intelligence (machine learning) correctly diagnosed 95% of fibromyalgia patients.<ref name="Lopez2017" /> A number of brain imaging studies have found significant results in patients with fibromyalgia, including a [[Functional magnetic resonance imaging|fMRI]] study that found patients with FM "have measurable pain signals in their brains, from a gentle finger squeeze that barely feels unpleasant to people without the disease"<ref name="Gracely2002" /> and MR/PET imaging by Loggia et al 2015 found [[neuroinflammation]] due to [[Glial cell|glial]] activation.<ref name="Loggia2015" /> {{See also|Fibromyalgia notable studies}} ====Blood tests and biomarkers==== EpicGenetics developed the '''FM/a test''' blood test to diagnose FM in 2017 - and announced a linked treatment trial involving the BCG vaccine soon after; the trial has since been suspended indefinitely.<ref name="controversy2021" /><ref name="fmtest">{{Cite web | url = http://fmtest.com/ | title = Home | last = |website=EpicGenetics' FM/a® Test is FDA-compliant and has successfully diagnosed patients with fibromyalgia since 2012.|language=en-US|access-date=2019-03-25}}</ref><ref name="FMa test" /> Dr Denise Faustman at Massachusetts General Hospital, who was due to conduct the trial, stated that the test should never have been marketed as a requirement for the treatment trial, and that no patients were ever recruited to the trial.<ref name="FMa test" /> The FM/a test continues to be marketed despite the suspension of the linked treatment trial,<ref name="FMa test" /> and the fact that only two studies have been published using the test - the last being published in 2015.<ref name="PMC3534336" /><ref name="PMC4435905" /> The evidence base supporting the use of the test has been reported to be weak, and no studies have assessed whether the test can correctly determine which patients have fibromyalgia and have some fibromyalgia symptoms that are explained by another diagnosis.<ref name="controversy2021" /> One study did not include any men.<ref name="PMC3534336" /> IsolateFibromyalgia, IQuity's RNA based blood test for fibromyalgia, was first announced in 2018 but no peer-reviewed studies have been published. A '''non-invasive eye test''' has found eye abnormalities in people with fibromyalgia, with Garcia et al 2016 finding reduced retinal nerve fiber layer (RNFL) thickness, raising hopes of a non-invasive eye test may help diagnose FM.<ref name="Garcia2016">{{Cite journal | last = Garcia-Martin | first = Elena | last2 = Garcia-Campayo | first2 = Javier | last3 = Puebla-Guedea | first3 = Marta | last4 = Ascaso | first4 = Francisco J. | last5 = Roca | first5 = Miguel | last6 = Gutierrez-Ruiz | first6 = Fernando | last7 = Vilades | first7 = Elisa | last8 = Polo | first8 = Vicente | last9 = Larrosa | first9 = Jose M. | date = 2016-09-01 | title = Fibromyalgia Is Correlated with Retinal Nerve Fiber Layer Thinning | url =https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5008644/|journal=PLoS ONE|volume=11|issue=9| pages = e0161574|doi=10.1371/journal.pone.0161574|issn=1932-6203|pmc=5008644|pmid=27584145}}</ref> The findings were confirmed by Cordón et al 2021, who found that disease severity and reduced quality of life were associated with reduced RNFL.<ref name="Cordon2021">{{Cite journal | last = Cordón | first = B. | last2 = Orduna | first2 = E. | last3 = Viladés | first3 = E. | last4 = Garcia-Martin | first4 = E. | last5 = Garcia-Campayo | first5 = J. | last6 = Puebla-Guedea | first6 = M. | last7 = Polo | first7 = V. | last8 = Larrosa | first8 = J.M. | last9 = Pablo | first9 = L.E. | date = 2021-07-02 | title = Analysis of Retinal Layers in Fibromyalgia Patients with Premium Protocol in Optical Tomography Coherence and Quality of Life | url =https://doi.org/10.1080/02713683.2021.1951301|journal=Current Eye Research|volume=0|issue=0 | pages = 1–11|doi=10.1080/02713683.2021.1951301|issn=0271-3683|pmid=34213409}}</ref> The test requires optical coherence tomography (OCT), which is fast and non-invasive.<ref name="Cordon2021" /> At present, there is no eye test in clinical use for diagnosing FM. In 2019, Hackshaw and colleagues found a unique metabolic fingerprint using a blood spot test that distinguished between fibromyalgia, rheumatoid arthritis and lupus, which they suggested could act as a diagnostic biomarker for FM.<ref name="Hackshaw2019">{{Cite journal | last = Hackshaw | first = Kevin V. | last2 = Aykas | first2 = Didem P. | last3 = Sigurdson | first3 = Gregory T. | last4 = Plans | first4 = Marcal | last5 = Madiai | first5 = Francesca | last6 = Yu | first6 = Lianbo | last7 = Buffington | first7 = Charles A.T. | last8 = Giusti | first8 = M. Mónica | last9 = Rodriguez-Saona | first9 = Luis | date = 2019-02-15 | title = Metabolic fingerprinting for diagnosis of fibromyalgia and other rheumatologic disorders |url =https://www.jbc.org/article/S0021-9258(20)40006-7/abstract|journal=Journal of Biological Chemistry|language=English|volume=294|issue=7 | pages = 2555–2568|doi=10.1074/jbc.RA118.005816|issn=0021-9258}}</ref> [[Heart rate variability]] (HRV) measured by ECG is a possible fibromyalgia biomarker, since it is reduced in people with FM, but heart rate is affected by many different factors so this may be problematic.<ref name="Hackshaw2021" /> === ICD Diagnostic code=== '''ICD-10''' The [[World Health Organization]] (WHO) International Classification of Diseases (ICD) lists FM as a "disease of the [[musculoskeletal system]] and connective tissue", under the code M79.7 (WHO ICD-10 Version: 2016).<ref name="ICD10">{{Cite web | url = http://apps.who.int/classifications/icd10/browse/2016/en#/M79.7 | title = ICD-10 Version:2016 | last = World Health Organization | first = | author-link = World Health Organization | date = 2016 | website = [[World Health Organization]]|at=M79.7 Fibromyalgia|language=en|archive-url=|archive-date=|access-date=2018-09-15}}</ref> The WHO's ICD-10 does not refer to FM as a syndrome and it is not classified in the category for [[Medically unexplained physical symptoms|medically unexplained symptoms]].<ref name="icd10us" /><ref name="ICD10" /> *'''M79.7 Fibromyalgia''' ::Fibromyositis ::Fibrositis ::Myofibrositis<ref name="ICD10" /> In 2015, the [[United States|US]] finally adopted ICD-10 and FM as a diagnosis.<ref name="icd10us">{{Cite web | url = http://www.icd10data.com/ICD10CM/Codes/M00-M99/M70-M79/M79-/M79.7 | title = 2018 ICD-10-CM Diagnosis Code M79.7: Fibromyalgia | website = icd10data.com|language=en|access-date=2018-08-09 | date = 2018 | last = World Health Organization | first = |archive-url=|archive-date= | authorlink = World Health Organization}}</ref><ref>{{Cite news |url =http://nationalpainreport.com/the-health-care-industry-finally-recognizes-fibromyalgia-8827637.html | title = The Health Care Industry Finally Recognizes Fibromyalgia | last = Liptan | first = Ginevra | date = 2015-09-30|work=National Pain Report|access-date=2018-08-09|archive-url=|archive-date=|language=en-US}}</ref> '''ICD-11 (2019)''' The [[ICD-11]] (2019) has diagnostic code ''MG30.1 Chronic widespread pain'', and changed the category from a [[:Category:Musculoskeletal diseases and disorders|Musculoskeletal disease]], to the ''General signs and symptoms category'', sometimes referred to as [[Medically unexplained physical symptoms]].<ref name="ICD11">{{Cite web | url = https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/849253504 | title = ICD-11 - Mortality and Morbidity Statistics|website=[[World Health Organization]]|language=en|access-date=2018-08-09}}</ref> *'''MG30.01 Chronic widespread pain''' '''Parent''' ::MG30.0 Chronic primary pain '''Description''' <blockquote>Chronic widespread pain (CWP) is diffuse pain in at least 4 of 5 body regions and is associated with significant emotional distress (anxiety, anger/frustration or depressed mood) or functional disability (interference in daily life activities and reduced participation in social roles). CWP is multifactorial: biological, psychological and social factors contribute to the pain syndrome. The diagnosis is appropriate when the pain is not directly attributable to a nociceptive process in these regions and there are features consistent with nociplastic pain and identified psychological and social contributors.<ref name="ICD11" /></blockquote> '''Inclusions''' :*Fibromyalgia '''Exclusions''' :*Acute pain (MG31)<ref name="ICD11" />
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