Table 4.

Comparison of the recommendations of the Canadian, German, and Israeli guidelines on the clinical diagnosis of FMS.

	Canada	Germany	Israel
History of a typical cluster of symptoms	Diffuse body pain that has been present for at least 3 months, with symptoms of fatigue, sleep disturbance, cognitive changes, mood disorder, and other somatic symptoms to variable degree	Chronic widespread pain and fatigue (physical and/or mental) and sleeping problems/unrefreshed sleep	Presence of pain in muscles, joints, connective tissues, various areas of the upper and lower limbs, neck, shoulders, and upper and lower back Typical symptoms of sleep disturbances, difficulty falling asleep, frequent awakening during the night, disturbed sleep patterns, and unrefreshing sleep Chronic fatigue complaints throughout the day Difficulties with concentration and memory
Exclusion	Other illness explaining the symptoms	Somatic disease sufficiently explaining the symptoms; the diagnosis of a mental disorder does not exclude the diagnosis of FMS	Other disorders explaining the symptoms have been ruled out. FMS may develop in coexistence with additional disorders, be they somatic, inflammatory, psychiatric, or otherwise
Recommended methods for exclusion of a somatic disease	Complete physical examination Full blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), creatine phosphokinase (CPK), and thyroid stimulating hormone (TSH)	Obtaining history of pharmacological agents used Complete physical examination Complete blood count, C-reactive protein (CRP), serum calcium, creatine phosphokinase (CPK), and thyroid stimulating hormone (TSH)	Complete physical examination Complete blood count, renal function tests (creatinine and urea), serum calcium and phosphorous levels, liver function tests, creatine phosphokinase (CPK), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), thyroid stimulating hormone (TSH) and vitamin D
Further tests	Any additional laboratory or radiographic testing should depend on the clinical evaluation in an individual patient that may suggest some other medical condition	Only in case of clinical hints pointing at a somatic disease	At the discretion of the physician performing the evaluation, based on clinical hints pointing at a somatic disease. (low threshold for serological tests e.g., ANA and RF)
Tender point examination	Specific tender point examination is not required, but examination of soft tissues for generalized tenderness should be done	Facultative	No requirement to document number of tender points; however, assessment of tenderness recommended as part of physical examination
Screening for mental disorders	Mental disorder can be expected in three quarters of persons with FMS	Recommended	Recommended
Diagnostic criteria	American College of Rheumatology (ACR) 2010 preliminary diagnostic criteria	ACR 1990 classification criteria or ACR 2010 modified diagnostic criteria AWMF criteria	Clinical diagnosis, based on above evaluation