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  • 1990 ACR Criteria
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1990 American College of Rheumotology (ACR) Classification Criteria: Overview

The 1990 ACR Classification Criteria requires the assessment of 2 key elements:

  1. Presentation of chronic widespread pain* for 3 months or more in all 4 quadrants of the body1, as well as a range of symptoms:
    • Allodynia: a heightened sense of pain in response to normal stimuli (eg, a hug or handshake)2
    • Hyperalgesia: (eg, when a small pinprick causes a sharp, stabbing pain)3
  2. Pain in at least 11 of 18 tender points upon palpation as assessed by the Manual Tender Point Exam1
    • Use the checklist to determine if a patient fits the ACR criteria for Fibromyalgia4
* Widespread pain is defined as pain above and below the waist, on the left and right sides of the body, and in the axial skeleton.

References

  1. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990;33(2):160-172.
  2. Staud R. Biology and therapy of fibromyalgia: pain in fibromyalgia syndrome. Arthritis Res Ther. 2006;8(3):208-214.
  3. Dubinsky RM, Kabbani H, El-Chami Z, Boutwell C, Ali H. Practice parameter: treatment of postherpetic neuralgia. Neurology. 2004;63:959-965.
  4. Sinclair JD, Starz TW, Turk DC. The manual tender point survey. National Fibromyalgia Association Web site. Available at:
    http://www.fmaware.org/site/News2?page=NewsArticle&id=6263.
    Accessed September 18, 2009.

Use the following checklist to determine whether a patient fits the American College of Rheumatology (ACR) criteria for a diagnosis of fibromyalgia.3

How to perform the ACR Tender Point exam:

  • Locate each tender point visually and then with light palpation
  • Use the thumb pad of your dominant hand to apply pressure perpendicularly
  • Gradually increase thumb pressure until you reach a pressure of 4 kg/cm2 (enough to whiten your fingernail)
  • Each survey site should be pressed once for a total of 4 seconds
  • After applying pressure at the site, ask patient whether there was any pain and ask her/him to rate the intensity of pain on a scale of 0 to 10
  • Evaluate control locations (over the thumb, mid-forearm, or forehead) for pain

Check all conditions that apply.

  • ____ The patient has experienced chronic widespread pain for 3 months or more in all 4 quadrants

Widespread pain is defined as:

  • Pain above and below the waist
  • Pain on the left and right sides of the body
  • Pain in the axial skeleton

(All 3 conditions above must be met to fit the definition of widespread pain.)

  • ____ The patient experiences pain on palpation in at least 11 of the 18 tender points on the 3-D model.

Click on the tender points and control points for additional information.

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Forehead control point4

  • Use the control points to reveal the baseline of the patient’s pain perception
  • Patient should be seated with the head in neutral position
  • Support the back of the head with the examiner’s non-dominant hand
  • Press perpendicularly into the center of the forehead

Right occiput4

  • The patient should sit at the end of the exam table
  • The patient's head should be loosely flexed forward approximately thirty degrees
  • Support the head with the examiner's non-dominant hand on the forehead
  • Move the examining thumb up midline of the neck to the nuchal ridge, then laterally on thumb-width in the insertion of the suboccipital muscles on the occiput
  • Press this point just below the nuchal ridge

Left occiput4

  • The patient should sit at the end of the exam table
  • The patient's head should be loosely flexed forward approximately thirty degrees
  • Support the head with the examiner's non-dominant hand on the forehead
  • Move the examining thumb up midline of the neck to the nuchal ridge, then laterally on thumb-width in the insertion of the suboccipital muscles on the occiput
  • Press this point just below the nuchal ridge

Right trapezius tender point4

  • The patient should sit at the end of the exam table with the head in neutral position
  • Identify the midpoint of the upper border of the trapezius
  • Press down

Left trapezius tender point4

  • The patient should sit at the end of the exam table with the head in neutral position
  • Identify the midpoint of the upper border of the trapezius
  • Press down

Right supraspinatus tender point4

  • The patient should sit at the end of the exam table
  • Press immediately above the scapular spine near the medial border of the scapula

Left supraspinatus tender point4

  • The patient should sit at the end of the exam table
  • Press immediately above the scapular spine near the medial border of the scapula

Right gluteal tender point4

  • The patient should sit at the end of the exam table
  • Position one hand loosely on the iliac crest; the thumb falls naturally on the survey site on gluteus medius, just lateral to gluteus maximus
  • Press perpendicularly with the examining thumb

Left gluteal tender point4

  • The patient should sit at the end of the exam table
  • Position one hand loosely on the iliac crest; the thumb falls naturally on the survey site on gluteus medius, just lateral to gluteus maximus
  • Press perpendicularly with the examining thumb

Right low cervical tender point4

  • The patient should sit at the end of the exam table
  • Identify the tip of the mastoid process and the cricoid cartilage (C6) below the thyroid cartilage
  • Move the thumb straight down from the mastoid process to C5-C7 range (cricoid level)
  • Support the other side of the neck
  • Press toward the opposite shoulder

Left low cervical tender point4

  • The patient should sit at the end of the exam table
  • Identify the tip of the mastoid process and the cricoid cartilage (C6) below the thyroid cartilage
  • Move the thumb straight down from the mastoid process to C5-C7 range (cricoid level)
  • Support the other side of the neck
  • Press toward the opposite shoulder

Right second rib tender point4

  • The patient should sit at the end of the exam table
  • Find the sternal notch, move down to the angle of Louis
  • Move to the first palpable rib (second rib), one thumb width lateral to manubrium sterni
  • Press the upper border
  • Support the patient's back

Left second rib tender point4

  • The patient should sit at the end of the exam table
  • Find the sternal notch, move down to the angle of Louis
  • Move to the first palpable rib (second rib), one thumb width lateral to manubrium sterni
  • Press the upper border
  • Support the patient's back

Right lateral epicondyle tender point4

  • The patient should sit at the end of the exam table
  • Support the forearm with the examiner's non-dominant hand
  • Press over the muscle 2 cm distal to the lateral epicondyle

Left lateral epicondyle tender point4

  • The patient should sit at the end of the exam table
  • Support the forearm with the examiner's non-dominant hand
  • Press over the muscle 2 cm distal to the lateral epicondyle

Right forearm control point4

  • Use the control points to reveal the baseline of the patient's pain perception
  • Patient should be seated with the examiner at the side
  • Support the forearm with the examiner's non-dominant hand
  • Press over the muscle at junction of distal and middle third of forearm

Left thumb control point4

  • Use the control points to reveal the baseline of the patient's pain perception
  • Patient should be seated with the examiner at the side
  • Support the thumb with the examiner's non-dominant hand
  • Press the entire nail area of the left thumb
  • Do NOT squeeze the thumb between the examiner's thumb and forefinger

Right greater trochanter tender point4

  • Patient should lie on left side, leg loosely flexed at the hip and knee
  • Press perpendicularly on thumb-width posterior to the trochanteric prominence

Left greater trochanter tender point4

  • Patient should lie on right side, leg loosely flexed at the hip and knee
  • Press perpendicularly on thumb-width posterior to the trochanteric prominence

Right knee tender point4

  • The patient lies on his/her back with the feet slightly apart
  • Press just above the joint line at the medial fat pad

Leftt knee tender point4

  • The patient lies on his/her back with the feet slightly apart
  • Press just above the joint line at the medial fat pad
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