Preface: Back to the Future

Preface This entire special issue of the Journal of Musculoskeletal Pain [JMP] is devoted to presentation of what will likely to be called the Canadian Consensus Document on Fibromyalgia Syndrome [FMS] (1). The document encompasses a very broad scope, involving a clinical case definition, diagnosis, and management of FMS. In addition, the importance of research findings within the FMS construct has prompted the inclusion of a section regarding what is known about the pathogenesis of FMS. The history of the development of this document, which was supported by Health Canada, is outlined in a companion editorial (2) by its physician editors and the lay group coordinator of the project. The clinical case definition proposed by the Expert Consensus Panel (1) chosen by Health Canada is based on the reasonable judgment of Panel members who have considerable experience with FMS in academic and community environments. In the same way that the Delphi of the 1990 ACR Criteria study were properly entrusted to know the disorder based on their extensive clinical experience, so the Panel members, in their composite wisdom, were considered to perceive what was likely to prove to be useful in the community. This undertaking can be viewed as a the next step in a long-term plan. Since the development of the American College of Rheumatology [ACR] 1990 Classification Criteria for the Fibromyalgia Syndrome (3), it has been clear that eventually it would be necessary to determine what to include in a clinical case definition for use in community medicine. The ACR Criteria were developed to guide the uniform selection of FMS patients for entry into research studies. The ACR Criteria have made it possible for a reader of FMS research to have confidence that studies done separately in Wichita, Peoria, Boston, Portland, and San Antonio were evaluating comparable patients. The same applies to studies performed in Europe and Asia that have espoused the ACR Criteria. On the other hand, there has been no certainty that the 1990 ACR Criteria would properly identify all of the affected individuals in a community clinic while properly excluding those who should not be given this diagnosis. The 1990 ACR Criteria utilized statistical analysis to establish a somewhat arbitrary cut in the number [at least 11 affected of 18 anatomically-named] of body sites, called tender points [TePs], that were unusually sensitive to deep digital palpation pressure and were required for a patient to enter a FMS research study. That was a reasonable approach to standardizing enrollment in pivotal research about a Delphi-defined disorder. On the other hand, some (4) have argued that it is improper to use the 1990 ACR criteria for diagnosis in community medical practice. Of course, physicians in clinical practice have applied the 1990 ACR criteria diagnostically because body pain is such a major clinical problem and there is nothing more precise than the 1990 ACR Criteria for identifying patients with FMS. Nothing comparable has been created and or validated for use in community medicine. Frankly, the only reason anyone really cares what physicians diagnose in the confines of their practices is that the diagnosis of FMS can then take on legal [compensation] implications for which