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