Fibromyalgia syndrome, primary M79.90

Rheumatological disease which is often difficult to diagnose (form: soft tissue rheumatism), accompanied by diffuse, multilocular, chronic pain syndrome with typical pain points (tender points). Mostly vegetative or functional disorders.

Not limited to certain sociological and ethnic groups. Approx. 0.7 to 3.2% of the population are affected by this disease. w:m=9:1; familial clustering (genetic disposition + psychosocial aspects); risk factors are associated rheumatic diseases (>50%).

Most frequently in women between 30 and 60 years of age, but also in older patients.

Severe pain in the area of tendons (especially at tender points) and muscles. Pain is often over a large area, but can also be localized to specific points in some sufferers. The pain quality is often described as tearing and pulling. Patients often feel that the painful soft tissues are diffusely swollen; small compactions of subcutaneous fat are felt as painful nodules. Frequently difficult vegetative (cold acras, xerostomia, hyperhidrosis, tremor) or functional symptoms (sleep disturbances, fatigue, dysesthesias, migraine, globus sensation, stiffness sensation, gastrointestinal complaints, respiratory and cardiac complaints).

Fibromyalgia and psoriatic arthritis (PsA): Alsawy N et al (2021) found fibromyalgia in 38.3% of 60 patients with PsA. Other studies showed that the prevalence of fibromyalgia in PsA ranges from 17% to 64%. PsA patients with fibromyalgia are predominantly female, and are more likely to suffer from symmetric polyarthritis than patients without fibrom yalgia. Fibromyalgia patients also have significantly higher scores for enthesopathies, poorer sleep quality, greater fatigue, and lower quality of life (Littlejohn GO 2021; Ulutatar F et al. 2021). However, no differences are demonstrated between groups in objective measures of disease activity, such as C-reactive protein, number of swollen joints, and number of dactylitis (Littlejohn GO 2021).

• Criteria according to ACR: Pain symptoms in at least 3 body regions (division left/right side of the body, above and below the belt line) over at least 3 months with 11 painful tender points out of 18 tested tender points.
• Tenderpoints:
• Occiput bds. (tendon attachments of the subocc. muscles)
• Ligamenta transversaria C5-C7 bds.
• M. trapezius on the shoulder saddle bds.
• M. Supraspinatus bds. at the middle edge of the spina scapulae
• Bone-cartilage border of the 2nd rib bds.
• Epicondylus lateralis elbow bds.
• Crista iliaca bds.
• Trochanter major bds.
• Pes anserinus at the knee bds.
• Palpations of the tender points must be performed with great compressive force (approx. 4 kg). To verify a positive tender point, the patient must confirm that pain was felt. To verify the fibromyalgia syndrome, the findings can be corroborated by palpation of non-pressure painful tender points.
• Pressure indolent control points:
• middle of the forehead, 2 cm supraorbital
• Clavicle - transition lateral/middle third
• middle of forearm, between radius and ulna dorsally, 5 cm above the wrist
• Thumbnail
• Thenar middle (ball of the thumb)
• M. biceps femoris (middle thigh)
• Tuber calcanei (transition from the heel to the sole of the foot).

Inflammatory and degenerative spinal and joint diseases such as polymyalgia rheumatica

Myopathies

Chronic fatigue syndrome

Panniculitis (nodular painful indurations)

Panniculitides in the context of pancreatic disorders or sarcoidosis

Psychoses

lupus erythematosus

Scleroderma

dermatomyositis.

Disease pattern that is difficult to treat. Therapy approaches with psychosomatic therapy, physical applications and intensive patient education are in the foreground.

Antidepressants (e.g. amitriptyline 10-50 mg/day) can bring improvement. For sleep induction, e.g. 1-2 mg flunitrazepam (Rohypnol) can be given.

Pain therapy (see also WHO stage I-III): In severe relapses, 40 mg of Prothipendyl (Dominal forte) can be tried additionally 1-2 times/day in combination with stage I drugs.

In case of gastrointestinal side effects, administration of cyclooxygenase (COX-2) inhibitors ( coxibe) instead of stage I drugs, e.g. celecoxib (Celebrex) 200-400 mg/day.

1. Alsawy N et al. (2021) Fibromyalgia in patients with psoriatic arthritis: impact on disease activity indices, fatigue and health-related quality of life. Int J Rheum Dis 24: 189- 196.
2. Doherty M, Jones A. (1995) ABC of rheumatology. Fibromyalgia syndrome. Br Med J 310: 386-369
3. Ehrlich GE (2003) Fibromyalgia, a virtual disease. Clin Rheumatol 22: 8-11
4. Littlejohn GO (2021) Fibromyalgia and psoriatic arthritis: partners together. Int J Rheum Dis 24:141-143.
5. Ulutatar F et al (2021) Fibromyalgia in patients with psoriatic arthritis: relationship with enthesopathy, sleep, fatigue and quality of life. Int J Rheum Dis 24: 183- 188.
6. Van Houdenhove B (2003) Fibromyalgia: a challenge for modern medicine. Clin Rheumatol 22: 1-5
7. Fitzcharles MA, Boulos P (2003) Inaccuracy in the diagnosis of fibromyalgia syndrome: analysis of referrals Rheumatology (Oxford) 42: 263-267.