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Home: Related Disorders: FMS: The Copenhagen Declaration

The Copenhagen Declaration

Most researchers now believe FMS and CFS are one and the same. This was published in J Musculoskel Pain vol. 1(3+4) in 1994

Fibromyalgia - The Copenhagen Declaration

Last week the "Copenhagen Declaration" established fibromyalgia as a diagnosis. The document(1) stems from the 2nd World Congress on Myofascial Pain and Fibromyalgia, held in Copenhagen from August 17 to 20. The diagnosis has been incorporated in WHO's tenth revision (1992) of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), which comes into force an Jan 1, 1993. Fibromyalgia (with fibrositis) appears in ICD-10 as "M79-O Rheumatism, unspecified", one of the many soft-tissue disorders not specified elsewhere. The new document defines fibromyalgia as a painful, non-articular condition predominantly involving muscles, and as the commonest cause of chronic, widespread musculoskeletal pain. Onset of symptoms occurs usually between the age of 20 and 40 years, mainly in women.

Diagnostic criteria were defined by the American College of Rheumatology (ACR) in 1990(2). The ACR conducted blinded study with 558 patients (of which 265 were control patients) in 16 centres in the United States and Canada, and concluded that fibromyalgia could be diagnosed clinically by a history of widespread pain in combination with pain in 11 or more out of 18 specified tender points in muscular tissue. The 18 tender points are nine bilateral pairs from occiput (at the suboccipital muscle insertions) to knee at the medial fat pad proximal to the joint line.

The Copenhagen Declaration recommends the adoption of the two criteria established by ACR for research purposes, since they work as a standardising protocol. However, it enhances ACR's definition into a pragmatic and clinical perspective: "the diagnosis is commonly entertained in the presence of unexplained widespread pain or aching, persistent fatigue, generalized (morning) stiffness, non-refreshing sleep, and multiple tender points. Most patients with these symptoms have 11 or more tender points. But a variable proportion of otherwise typical patients may have less than 11 tender points at the time of the examination." Besides, says the document, fibromyalgia is often "part of a wider syndrome encompassing headaches, irritable bladder, dysmenorrhoea, cold sensitivity, Raynaud's phenomenon, restless legs, atypical patterns of numbness and tingling, exercise intolerance and complaints of weakness." "I believe this is a strong document," says Bente Danneskiold-Samsoe, president of the congress. "Many of the patients will not have to be considered as hypochondriacs any more." Fibromyalgia, which has a prevalence of 0.6% in Denmark, is often accompanied by symptoms of depression and anxiety(3). Although the aetiology is unknown, members of the consensus panel tended to rule out psychological distress as a cause of the muscular pain and tenderness in fibromyalgia. It could be the other way around, suggests the declaration: psychological state could be mainly an effect of the pain patients suffer.

Muscle biopsy has revealed important morphological changes but no characteristic ones, and other tests (eg serum levels of muscle enzymes, electromyography, exercise testing and nuclear magnetic resonance spectroscopy ) have not been helpful. Laboratory tests can be important to rule out conditions that mimic fibromyalgia, such as hypothyroidism, polymyalgia rheumatica, or generalized osteoarthritis. Regional myofascial pain syndrome can be excluded clinically because it is associated with limited pain distribution.

"With the Copenhagen Declaration, these people will now have better chances that governments and insurance companies accept their conditions as a cause for invalidity pensions and early retirement," says Finn Kamper-Jorgensen, of the Danish Institute for Clinical Epidemiology, chairman of the consensus panel(4).

Claudio Csillag

(1) The Copenhagen Declaration. Available from Bente Danneskiold-Samsec, Department of Rheumatology, Frederiksberg Hospital, Ndr Fasanvej 57, DK-2000 Frederiksberg, Denmark.

(2) Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the calssification of fibromyalgia. Arth and Rheum 1990: 33 (no 2); 160-72.

(3) Prescott E, Jacobsen S, Kjeller M, et al. Prevalance of fibromyalgia in the adult Danish population. Scand J Rheumetol 1992; supplement 94.

  1. Other members were Liv Anne Andreassen (Norway), Robert M. Bennett (USA), Dag Bruuagaard (Norway), Bente Danneskiold-Samsec (Denmark), Alfonse T. Masi (USA), and Janine Morgall (Denmark). The expert panel contributing to the declaration was: Ann Bengesson (Sweden), Robert M. Bennett (Cchairman, USA), Anders Bjelle (Sweden), C.S. Burckhart (USA), Don L. Goldenberg (USA), K.G. Henriksson (Sweden), Saren Jacobsen (Denmark), Marijke van Santen-Hoeufft (the Netherlands), Henning Vaeroy (Norway), and Frederick Wolfe (USA).

    Modified January 9, 2003

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