The 2nd International Virtual Congress on Controversies in Fibromyalgia
(19-20 November 2020)





Update on Fibromyalgia Diagnosis, Criteria, Classification, Differential Diagnosis…




Piercarlo Sarzi-Puttini(ピエルカルロ サルツィ・プッティーニ)

L. Sacco University Hospital, Italy(L.サッコ大学病院、イタリア)



Even if physicians started to recognize fibromyalgia as a clinical entity decades ago1, it endures to be a controversial disease, even regarding its nosological classification. Diagnostic complexity is increased by the fact that it is characterized by a complex polysymptomatology, which can continuously evolve during the course of the disease in each single patient 2. Therefore, diagnostic and classification criteria are still developing.
The American College of Rheumatology criteria was the first to put some order in fibromyalgia diagnosis. In the 90s it was shortly been officially recognized as a discrete clinical entity; therefore, physicians needed to have a clear, exhaustive list of symptoms that could be present in these types of patients (ACR 2010 symptom severity scale3 is a clear example). Although comprehensive, these criteria were not very feasible in daily clinical practice. They started to be simplified in 2011 4, shortening the list of associated symptoms, and afterwards in 2016 5, emphasizing more the concept of “generalized pain”. Anyway, latest AAPT diagnostic criteria 6 tried to create a really feasible tool for physicians in order to facilitate fibromyalgia diagnosis. They divided the criteria in different dimensions. Dimension 1 includes core diagnostic criteria, which are three: (1) multisite pain defined as 6 or more pain sites from a total of 9 possible sites; (2) Moderate to severe sleep problems OR fatigue; (3) MSP plus fatigue or sleep problems must have been present for at least 3 months. Other dimensions can reinforce diagnostic conviction: common features, epidemiology, psychiatric comorbidities, functional consequences and risk factors can all be taken into account by the physicians and have all to be thoroughly investigated during the history taking.
Importantly, AAPT criteria emphasised the fact that the presence of other disorders does not exclude the existence of fibromyalgia as a comorbidity; in fact, many rheumatic diseases have a high prevalence in fibromyalgia population – the opposite also being true. However, there may be a significant reluctance to diagnose fibromyalgia by some physicians, because of a number of reasons 7: uncertainty about diagnosis, especially in the lack of specific biomarkers or pathognomonic signs, hesitancy in “labelling” a patient with a “stigmatizing” syndrome, and so on.


In contrast, in some cases other conditions can mimic fibromyalgia, mainly: rheumatic diseases of recent onset (polymyalgia rheumatica, rheumatoid arthritis, etc.), endocrine diseases (hypothyroidism, vitamin D deficiency), gastrointestinal diseases (celiac disease), infectious diseases (Lyme disease, hepatitis C) and the early stages of a malignancy such as metastatic cancer, leukemia and lymphoma .8 Specific laboratory tests and a thorough history taking should always be performed.


Finally, it is getting clearer that, even though diagnostic criteria are quite accurate in delineating the typical symptomatic profile of fibromyalgia patients, people suffering from fibromyalgia are actually divided into subpopulations on the basis of their main symptoms and of their symptoms progression 9,10. In particular, it is important to separate those patients whose main complaint is pain from those patients who have a prominent mood disorder component of their disease (mainly anxiety and depression). The creation of these, still hypothetical, patient subgroups in daily clinical practice would be of extreme utility from a therapeutic perspective.




アメリカリウマチ学会の基準は、線維筋痛症の診断にいくつかの順序を置くための最初のものであった。90年代にはまもなく、線維筋痛症は個別の臨床的実体として公式に認識されたため、医師はこれらのタイプの患者に見られる症状の明確で網羅的なリストを持つ必要があった(ACR 2010症状重症度尺度³は明確な例である)。






(1) 9つの可能な部位の合計から6つ以上の部位の痛みとして定義された多部位の痛み、


(2) 中等度から重度の睡眠問題または疲労、


(3) MSPプラス疲労または睡眠問題が少なくとも3ヶ月間存在していなければならない、















1. Bennett, R. M. Fibrositis: misnomer for a common rheumatic disorder. West. J. Med. 134, 405–413 (1981).


2. Walitt, B. et al. The longitudinal outcome of fibromyalgia: a study of 1555 patients. J. Rheumatol. 38, 2238–46 (2011).


3. Wolfe, F. et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res. 62, 600–610 (2010).


4. Wolfe, F. et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: A modification of the ACR preliminary diagnostic criteria for fibromyalgia. J. Rheumatol. 38, 1113–1122 (2011).


5. Wolfe, F. et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin. Arthritis Rheum. 46, 319–329 (2016).


6. Arnold, L. M. et al. AAPT Diagnostic Criteria for Fibromyalgia. J. Pain 00, 1–18 (2018).


7. Häuser, W., Sarzi-Puttini, P. & Fitzcharles, M.-A. Fibromyalgia syndrome: under-, over- and misdiagnosis. Clin. Exp. Rheumatol. 37 Suppl 1, 90–97 (2019).


8. Häuser, W., Perrot, S., Sommer, C., Shir, Y. & Fitzcharles, M.-A. Diagnostic confounders of chronic widespread pain: not always fibromyalgia. Pain reports 2, e598 (2017).


9. Vincent, A. et al. OMERACT-based fibromyalgia symptom subgroups: an exploratory cluster analysis. Arthritis Res. Ther. 16, 463 (2014).


10. Bartley, E. J., Robinson, M. E. & Staud, R. Pain and Fatigue Variability Patterns Distinguish Subgroups of Fibromyalgia Patients. J. Pain 19, 372–381 (2018).