Treatment Guideline Chart

Fibromyalgia is a clinical syndrome wherein the patient experiences generalized pain and fatigue that cannot be explained by the presence of any other disorder.
It is often considered to be psychosomatic or psychogenic in nature.
It is found in approximately 2% of the population and the prevalence increases with age, most common in women 20-55 year of age

Fibromyalgia Diagnosis


  • Diagnosis is based primarily on history of widespread pain, defined as axial, bilateral, upper and lower body pain, for at least 3 consecutive months
  • Pain assessment with particular focus on the type, quality, source, location, duration, time course, pain affect and effects on patient’s quality of life
  • Evaluate severity of other symptoms
  • Refer patients with suspected mood disorders for formal psychological testing
  • Evaluate for conditions that mimic, complicate or coexist with fibromyalgia: Hypothyroidism, ankylosing spondylitis, tendonitis, bursitis, systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), osteoarthritis (OA), polymyalgia rheumatica, irritable bowel syndrome, chronic fatigue syndrome, temporomandibular dysfunction, vulvodynia and irritable bladder
  • Review social and development history
  • Previous treatment and efficacy, opioid prescription

Physical Examination

  • Perform a complete joint exam, manual muscle strength testing and neurological exam
  • Perform manual tender point exam on the 18-paired muscle-tendon sites including the control areas (eg thumbnail, forehead, mid forearm) with pressure that is approximately 4 kg/cm2
  • Can be influenced by external factors
  • Usually within normal limits except for soft tissue tenderness
  • Repeated physical exams are generally avoided unless there are new reported symptoms or findings

Laboratory Tests

  • There are no pathognomonic lab tests or imaging studies for fibromyalgia
  • Lab tests should only be performed to exclude associated disease or illness that may mimic, complicate or coexist with fibromyalgia
    • CBC to rule-out infectious etiologies and multi-system disease
    • Erythrocyte sedimentation rate (ESR) is almost always elevated in polymyalgia rheumatica
    • Creatine phosphokinase (CPK) is elevated in inflammatory myopathy
    • Thyroid function tests, LFT, C-reactive protein (CRP)
  • Overnight polysomnogram is performed in patients suspected of sleep disorders


Classification Criteria

  • The 2016 revision to the 2010/2011 American College of Rheumatology (ACR) classification criteria have been used in most clinical and therapeutic trials
  • Based on expert opinions regarding the optimal historical and physical findings that could differentiate patients with fibromyalgia  from those with other rheumatic disease and forms of chronic pain
  • A diagnosis of fibromyalgia is given to patients who have all the following conditions:
    • Widespread pain index (WPI) ≥7 and symptom severity scale (SSS) score ≥5 or WPI of 4-6 and SSS score of ≥9
    • Pain in at least 4-5 regions or generalized pain is present 
    • Symptoms present at a similar level for at least 3 months
    • Diagnosis of fibromyalgia does not exclude the presence of other disorders or coexistent conditions
  • It does not require a physical or tender point exam, but does provide a scale for measurement of the severity of symptoms that are characteristic of fibromyalgia
    • Tender points, when associated with other functional disorders, may be useful in diagnosis
  • Particularly useful in clinicians who are inexperienced in performing tender point exam or as additional points in difficult cases
  • Combine the widespread pain index (WPI) and the symptom severity scale (SSS) score for making the diagnosis
    • WPI is a measure of the number of painful body regions from a defined list of 19 areas
      • Shoulder girdle, left
      • Shoulder girdle, right
      • Lower arm, left
      • Lower arm, right
      • Hip (buttock, trochanter), left
      • Hip (buttock, trochanter), right
      • Upper arm, left
      • Upper arm, right
      • Lower leg, left
      • Lower leg, right
      • Upper leg, left
      • Upper leg, right
      • Jaw, left
      • Neck
      • Upper back
      • Lower back
      • Abdomen
      • Chest
    • SSS score is the sum of the severity of the 3 symptoms (fatigue, unrefreshed sleep and cognitive symptoms) plus the sum (0-3) of the following symptoms (headache, cramps or pain in the lower abdomen and depression) that the patient experienced during the previous 6 months
      • Scale for the level of severity for each of the 3 symptoms over the past week:
        Score Symptoms
         0 No problem
         1 Slight or mild problems, generally mild or intermittent
         2 Moderate, considerable problems, often present and/or at a moderate level 
         3 Severe, pervasive, continuous, life-disturbing problems 

        Reference: Dymon TE. Fibromyalgia. Ambulatory Care Self-Assessment Program. 2015.

      • Final score is between 0 and 12
      • The SSS score allows assessment of patients with current or previous fibromyalgia, and in those in whom the classification criteria have not been applied
      • It is particularly useful in longitudinal evaluation of patients with marked symptom variability
    • Fibromyalgia severity (FS) scale is the sum of WPI and SSS and ranges from 0 (no symptoms) to 31 (most severe symptoms)
      • 92-96% of patients with scores ≥12 will satisfy the criteria for fibromyalgia and FS score will provide an approximate measure of fibromyalgia severity
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