Evolving Diagnosis
Medscape: The thinking around diagnosing FM has changed recently, with the latest criteria no longer requiring the tender point counts they once did. How do the two of you now approach diagnosing the disorder?
Dr Clauw: Clinicians can use either the 1990[1] or 2010[2] diagnostic criteria, but these criteria were really meant to be used for research studies, not to diagnose individual patients in practice. This is true of most criteria. We generally recommend that physicians learn to recognize the pattern of widespread pain accompanied by fatigue, sleep, memory, and mood problems and then use the FM label when that is the most likely explanation of those symptoms. Clinicians are very comfortable diagnosing conditions such as osteoarthritis, chronic low back pain, and headache without knowing the formal research criteria for those diagnoses.
Dr Mease: I would like to expand on what Dan has alluded to. It is appropriate to remind ourselves about the difference between classification criteria, which the 1990 FM criteria are, and diagnostic criteria, which the 2010 preliminary American College of Rheumatology (ACR) criteria are intended to be ("preliminary" means proposed but not yet formally accepted before further evaluation occurs). Classification criteria are intended to identify subjects with enough similar features that they can be considered reliably classified for the purposes of research on their condition. Here specificity is more important than sensitivity (ie, more definitively includes correctly diagnosed persons and excludes those who do not have a condition). Classification criteria are often used for diagnostic purposes, as the 1990 criteria have been, but this was not the purpose of their original introduction.
What Fred Wolfe intended with the 2010 criteria was to create diagnostic criteria that were more user-friendly for clinicians to use in practice— for example, reliance on the tender point exam, which we know may be incorrectly applied in practice and be misleading in suggesting that FM is primarily a muscle or tendon problem as opposed to being primarily a problem with sensitization and dysregulation of the CNS. The new criteria rely more on pattern recognition of the constellation of chronic widespread pain along with other characteristic features such as fatigue, sleep disturbance, cognitive dysfunction, and irritable bowel symptoms—symptoms that may occur either as an independent entity or in association with other chronic illnesses such as rheumatoid arthritis or osteoarthritis.
Fred's work has shown us that there is a great deal of overlap between those who get positively identified with FM by the two criteria, but the newer criteria may be slightly more sensitive in picking up a broader group of patients that the clinician can then evaluate further to delineate how much of their symptom complex is due to FM and how much is due to coexistent conditions, and then treat appropriately.
Medscape Rheumatology © 2014 WebMD, LLC
Cite this: Daniel J. Clauw, Philip J. Mease, Bret S. Stetka. Fibromyalgia: The Latest in Diagnosis and Care - Medscape - Sep 17, 2014.
Comments