Scandinavian Journal of Rheumatology
ISSN: 0300-9742 (Print) 1502-7732 (Online) Journal homepage: http://www.tandfonline.com/loi/irhe20
The Prevalence of Fibromyalgia and Widespread Chronic Musculoskeletal Pain in the General Population S. Jacobsen & S. R. Bredkjær To cite this article: S. Jacobsen & S. R. Bredkjær (1992) The Prevalence of Fibromyalgia and Widespread Chronic Musculoskeletal Pain in the General Population, Scandinavian Journal of Rheumatology, 21:5, 261-262, DOI: 10.3109/03009749209099237 To link to this article: http://dx.doi.org/10.3109/03009749209099237
Published online: 12 Jul 2009.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=irhe20 Download by: [McMaster University]
Date: 21 April 2016, At: 00:53
Letters to the editor References 1. Healey LA, Wilske KR. Evaluating combination drug ther-
apy in rheumatoid arthritis, J Rheumatol 1991; 18: 641-2. 2. Hansen TM, Krugger P, Elling H et al. Do,uble blind pla-
Downloaded by [McMaster University] at 00:53 21 April 2016
cebo controlled trial of pulse treatment with methylprednisolone combined with disease modifying drugs in rheumatoid arthritis. Br Med J 1990; 301: 268-70. 3 . Neumann V, Hopkins R, Dixon J , Watkins A , Bird H, Wright V. Combination therapy with pulses methylprednisolone in rheumatoid arthritis. Ann Rheum Dis 1985; 44: 747-5 1 .
4. Iglehardt IW, Sutton JD, Bender JC et al. Intravenous pulsed steroids in rheumatoid arthritis: a comuarative dose study. J Rheumatol 1990; 17: 159-62. 5 . Arnett FC, Edworth SM, Bloch D A et al. The American Rheumatism Association 1987 revised criteria for the classification of Rheumatoid Arthritis. Arthritis Rheum 1988; 31: 315-24. 6. Ferraz MB, Atra E. Rheumatiod arthritis and the measurement properties of the physical ability dismension of the Stanford Health Assessment Questionnaire. Clin Exp Rheumatol 1989; 7 : 3 4 1 4 .
The Prevalence of Fibromyalgia and Widespread Chronic Musculoskeletal Pain in the General Population
Sir, Much attention has lately been drawn towards diffuse chronic nonarticular pain under the description of fibromyalgia. The prevalence of fibromyalgia in primary care patients was shown to be 2% (1). In rheumatologic settings the prevalence has been estimated to be about 5% (2). Recently an epidemiologic study on fibromyalgia in the general population was presented in this journal (3) where the prevalence of, fibromyalgia among women aged 20-49 years was found to be 10.5% using the classification criteria set out by The American College of Rheumatology in 1990 (ACR-90) (4).The ACR-90 criteria consist of two parts; the first part includes criteria for widespread pain and the second part includes a tender point count, where 11 out of 18 locations have to be painful at palpation. A prevalence of 10.5% is amazingly high as the authors also point out themselves. Having seen many fibromyalgia patients one may ask if the general population really is that ill or if there could be any methodological explanations for the finding of such a high prevalence. How was fibromyalgia actually classified in the study? The authors describe that diagnosis was based on the examination of subjects complaining of continous pain and/or stiffness for at least three months in the joints, muscles, back or all over, followed by a clinical demonstration of the prerequisite number of tender points. This implies that subjects with longstanding pain or stiffness in a single region were candidates for further fibromyalgia examination. The part of the examination during which subjects
were asked for widespread pain as defined by the ACR-90 has not been described in the paper. One might thus expect the first part of the ACR-90 criteria not to be satisfied in all subjects identified as having fibromyalgia. To give some additional perspectives on the prevalence of widespread chronic musculoskeletal pain (WCMP), a retrospective analysis on data from a health survey from 1986/87 was carried out. Six-thousand randomly selected danish citizens, living in Denmark and who were more than 15 years of age were invited to participate by the Danish Institute for Clinical Epidemiology (5). 4753 (80%) subjects agreed to participate and were representative of the overall Danish adult population with regard to gender, age, social status and geography. The occurrence of widespread pain in the musculoskeletal apparatus was investigated by analysing if subjects had stated chronic pain in the following three regions; 1) shoulderheck girdle, 2) back and low back, and 3) arms, hands, legs, knees, hips or other joints. Known specific medical conditions associated with musculoskeletal pain were also extracted. Less bothersome WCMP was indicated by 4.8% of the participants and 2.6% of the participants indicated severe WCMP. Eighty percent of those with severe WCMP related their symptoms to specific medical conditions, which were osteoarthritis (35%), back disease (25%), rheumatoid arhritis (6%), other specified musculoskeletal conditions (12%) and other specified medical conditions (22%). Thus, 0.5% of the participants stated se261
Downloaded by [McMaster University] at 00:53 21 April 2016
Letters to the editor vcre WCMP without any specific medical condition being related. More women than men suffered from WCMP, which was particular significant in the age group 45-66 years. The prevalence of fibromyalgia in a Swedish population survey was 1.8% for females aged 50-70 years (6). The Swedish women were older than the women in the Norwegian study, but due to the chronicity of the condition one would.not expect a significant decline in prevalence with increasing age. We thus conclude that the Swedish findings and the prevalences for WCMP in this retrospective analysis do not support the finding of a general female fibromyalgia prevalence of about 10% as seen in Arendal, Norway. This calls for further epidemiologic studies in the overall population. The distinction between primary and secondary-concomitant fibromyalgia is abolished in the ACR-90 criteria for fibromyalgia. However, for purposes of clinical diagnosis and therapy, fibromyalgia syndromes should be appropriately classified (7). Moreover, the fibromyalgia patients which have been described in the literature during the past ten years, may represent a distorted picture of the possible multiplicity of fibromyalgia due to selection bias (8). As such epidemiologically based patient studies are also necessary to expand our present limited understanding of the fibromyalgia syndrome.
References 1. Hartz A , Kirchdoerfer E. Undetected fibrositis in primary care practice. J Fam Pract 1987; 25: 365-9. 2. Wolfe F, Cathey MA. Prevalence of primary and secondary fibrositis. J Rheumatol 1983; 10: 965-8. 3. Forseth KO, Gran JT. The prevalence of fibromyalgia among women aged 20-49 years in Arendal, Norway. Scand J Rheumatol 1992; 21: 74-8. 4. 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: 160-72. 5. Rasmussen NK, Groth MV, Bredkjrer SR, et al. Healrh and morbidity in Denmark 1987 ( I n danish). Copenhagen, The Danish Institute for Clinical Epidemiology, 1988. 6. Jacobson L, Lindgarde F, Manthorpe R. The commonest rheumatic complaints of over six weeks duration in a twelve-month period in a defined Swedish population. Scand J Rheumatol 1989; 18: 353-60. 7. Yunus MB. Fibromyalgia syndrome: A need for uniform classification (Editorial). J Rheumatol 1983; 10: 841-4. 8. Wolfe F. Selection bias in fibrositis study (Letter). Arthritis Rheum 1982; 25: 1390. Correspondance to: S6re.n Jacobsen, Department of Rheumatology, Hvidovre Hospital, DK-2650 Hvidovre, Denmark Received 25 May 1992 Accepted 23 June 1992
S. Jacobsen
S. R. Bredkjm
REPLY Sir, We agree with Drs. Jacobsen and Bredkjm that a prevalence of 10. 5% of fibromyalgia is surprisingly high. Prior to this investigation we anticipated a prevalence figure of about 3 4 % of fibromyalgia among females aged 20-49 yrs. Our Danish colleagues look for possible explanations to our results. First, contrary to most population surveys, our study (1) was specifically constructed to determine the prevalence of fibromyalgia. Such studies may tend to overestimate the occurrence of the disease studied as the participants for various reasons may want to “help” the investigators. On the other hand, individuals invited to participate, but who do not have musculoskeletal complaints, may not return the questionnaire, thus contributing to the large non-response group. Consequently, positive 262
responders (persons with complaints) may have been overrepresented among participants of our survey. Secondly, as pointed out in the paper, the difference between our results and those of previous studies may have partly resulted from a varied application of the criteria employed. A possible source of error could have been the determination of tender paints. Only one investigator was involved in the clinical examination so a possible overestimation of the tender points cannot be completely ruled out. A reexamination of the cases diagnosed as fibromyalgia will hopefully be done in the very near future, and clarify this point. Thirdly, although we agree with Drs. Jacobsen and Bredkjar that a 10% prevalence of fibromyalgia is exceptionally high, we do still believe that it is much higher than that determined in Denmark
ISSN: 0300-9742 (Print) 1502-7732 (Online) Journal homepage: http://www.tandfonline.com/loi/irhe20
The Prevalence of Fibromyalgia and Widespread Chronic Musculoskeletal Pain in the General Population S. Jacobsen & S. R. Bredkjær To cite this article: S. Jacobsen & S. R. Bredkjær (1992) The Prevalence of Fibromyalgia and Widespread Chronic Musculoskeletal Pain in the General Population, Scandinavian Journal of Rheumatology, 21:5, 261-262, DOI: 10.3109/03009749209099237 To link to this article: http://dx.doi.org/10.3109/03009749209099237
Published online: 12 Jul 2009.
Submit your article to this journal
Article views: 10
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=irhe20 Download by: [McMaster University]
Date: 21 April 2016, At: 00:53
Letters to the editor References 1. Healey LA, Wilske KR. Evaluating combination drug ther-
apy in rheumatoid arthritis, J Rheumatol 1991; 18: 641-2. 2. Hansen TM, Krugger P, Elling H et al. Do,uble blind pla-
Downloaded by [McMaster University] at 00:53 21 April 2016
cebo controlled trial of pulse treatment with methylprednisolone combined with disease modifying drugs in rheumatoid arthritis. Br Med J 1990; 301: 268-70. 3 . Neumann V, Hopkins R, Dixon J , Watkins A , Bird H, Wright V. Combination therapy with pulses methylprednisolone in rheumatoid arthritis. Ann Rheum Dis 1985; 44: 747-5 1 .
4. Iglehardt IW, Sutton JD, Bender JC et al. Intravenous pulsed steroids in rheumatoid arthritis: a comuarative dose study. J Rheumatol 1990; 17: 159-62. 5 . Arnett FC, Edworth SM, Bloch D A et al. The American Rheumatism Association 1987 revised criteria for the classification of Rheumatoid Arthritis. Arthritis Rheum 1988; 31: 315-24. 6. Ferraz MB, Atra E. Rheumatiod arthritis and the measurement properties of the physical ability dismension of the Stanford Health Assessment Questionnaire. Clin Exp Rheumatol 1989; 7 : 3 4 1 4 .
The Prevalence of Fibromyalgia and Widespread Chronic Musculoskeletal Pain in the General Population
Sir, Much attention has lately been drawn towards diffuse chronic nonarticular pain under the description of fibromyalgia. The prevalence of fibromyalgia in primary care patients was shown to be 2% (1). In rheumatologic settings the prevalence has been estimated to be about 5% (2). Recently an epidemiologic study on fibromyalgia in the general population was presented in this journal (3) where the prevalence of, fibromyalgia among women aged 20-49 years was found to be 10.5% using the classification criteria set out by The American College of Rheumatology in 1990 (ACR-90) (4).The ACR-90 criteria consist of two parts; the first part includes criteria for widespread pain and the second part includes a tender point count, where 11 out of 18 locations have to be painful at palpation. A prevalence of 10.5% is amazingly high as the authors also point out themselves. Having seen many fibromyalgia patients one may ask if the general population really is that ill or if there could be any methodological explanations for the finding of such a high prevalence. How was fibromyalgia actually classified in the study? The authors describe that diagnosis was based on the examination of subjects complaining of continous pain and/or stiffness for at least three months in the joints, muscles, back or all over, followed by a clinical demonstration of the prerequisite number of tender points. This implies that subjects with longstanding pain or stiffness in a single region were candidates for further fibromyalgia examination. The part of the examination during which subjects
were asked for widespread pain as defined by the ACR-90 has not been described in the paper. One might thus expect the first part of the ACR-90 criteria not to be satisfied in all subjects identified as having fibromyalgia. To give some additional perspectives on the prevalence of widespread chronic musculoskeletal pain (WCMP), a retrospective analysis on data from a health survey from 1986/87 was carried out. Six-thousand randomly selected danish citizens, living in Denmark and who were more than 15 years of age were invited to participate by the Danish Institute for Clinical Epidemiology (5). 4753 (80%) subjects agreed to participate and were representative of the overall Danish adult population with regard to gender, age, social status and geography. The occurrence of widespread pain in the musculoskeletal apparatus was investigated by analysing if subjects had stated chronic pain in the following three regions; 1) shoulderheck girdle, 2) back and low back, and 3) arms, hands, legs, knees, hips or other joints. Known specific medical conditions associated with musculoskeletal pain were also extracted. Less bothersome WCMP was indicated by 4.8% of the participants and 2.6% of the participants indicated severe WCMP. Eighty percent of those with severe WCMP related their symptoms to specific medical conditions, which were osteoarthritis (35%), back disease (25%), rheumatoid arhritis (6%), other specified musculoskeletal conditions (12%) and other specified medical conditions (22%). Thus, 0.5% of the participants stated se261
Downloaded by [McMaster University] at 00:53 21 April 2016
Letters to the editor vcre WCMP without any specific medical condition being related. More women than men suffered from WCMP, which was particular significant in the age group 45-66 years. The prevalence of fibromyalgia in a Swedish population survey was 1.8% for females aged 50-70 years (6). The Swedish women were older than the women in the Norwegian study, but due to the chronicity of the condition one would.not expect a significant decline in prevalence with increasing age. We thus conclude that the Swedish findings and the prevalences for WCMP in this retrospective analysis do not support the finding of a general female fibromyalgia prevalence of about 10% as seen in Arendal, Norway. This calls for further epidemiologic studies in the overall population. The distinction between primary and secondary-concomitant fibromyalgia is abolished in the ACR-90 criteria for fibromyalgia. However, for purposes of clinical diagnosis and therapy, fibromyalgia syndromes should be appropriately classified (7). Moreover, the fibromyalgia patients which have been described in the literature during the past ten years, may represent a distorted picture of the possible multiplicity of fibromyalgia due to selection bias (8). As such epidemiologically based patient studies are also necessary to expand our present limited understanding of the fibromyalgia syndrome.
References 1. Hartz A , Kirchdoerfer E. Undetected fibrositis in primary care practice. J Fam Pract 1987; 25: 365-9. 2. Wolfe F, Cathey MA. Prevalence of primary and secondary fibrositis. J Rheumatol 1983; 10: 965-8. 3. Forseth KO, Gran JT. The prevalence of fibromyalgia among women aged 20-49 years in Arendal, Norway. Scand J Rheumatol 1992; 21: 74-8. 4. 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: 160-72. 5. Rasmussen NK, Groth MV, Bredkjrer SR, et al. Healrh and morbidity in Denmark 1987 ( I n danish). Copenhagen, The Danish Institute for Clinical Epidemiology, 1988. 6. Jacobson L, Lindgarde F, Manthorpe R. The commonest rheumatic complaints of over six weeks duration in a twelve-month period in a defined Swedish population. Scand J Rheumatol 1989; 18: 353-60. 7. Yunus MB. Fibromyalgia syndrome: A need for uniform classification (Editorial). J Rheumatol 1983; 10: 841-4. 8. Wolfe F. Selection bias in fibrositis study (Letter). Arthritis Rheum 1982; 25: 1390. Correspondance to: S6re.n Jacobsen, Department of Rheumatology, Hvidovre Hospital, DK-2650 Hvidovre, Denmark Received 25 May 1992 Accepted 23 June 1992
S. Jacobsen
S. R. Bredkjm
REPLY Sir, We agree with Drs. Jacobsen and Bredkjm that a prevalence of 10. 5% of fibromyalgia is surprisingly high. Prior to this investigation we anticipated a prevalence figure of about 3 4 % of fibromyalgia among females aged 20-49 yrs. Our Danish colleagues look for possible explanations to our results. First, contrary to most population surveys, our study (1) was specifically constructed to determine the prevalence of fibromyalgia. Such studies may tend to overestimate the occurrence of the disease studied as the participants for various reasons may want to “help” the investigators. On the other hand, individuals invited to participate, but who do not have musculoskeletal complaints, may not return the questionnaire, thus contributing to the large non-response group. Consequently, positive 262
responders (persons with complaints) may have been overrepresented among participants of our survey. Secondly, as pointed out in the paper, the difference between our results and those of previous studies may have partly resulted from a varied application of the criteria employed. A possible source of error could have been the determination of tender paints. Only one investigator was involved in the clinical examination so a possible overestimation of the tender points cannot be completely ruled out. A reexamination of the cases diagnosed as fibromyalgia will hopefully be done in the very near future, and clarify this point. Thirdly, although we agree with Drs. Jacobsen and Bredkjar that a 10% prevalence of fibromyalgia is exceptionally high, we do still believe that it is much higher than that determined in Denmark
