Chapter

| 10 |

Fibromyalgia syndrome
Martin Offenbacher

10.1 EPIDEMIOLOGY
Fibromyalgia syndrome and mTrP frequently exist together. The principles, diagnosis and therapy of fibromyalgia syndrome are also known to any trigger point therapist.

Population studies have shown that 2025% of the

population suffers from regional musculoskeletal pain.

Chronic widespread pain (or chronic multilocular

musculoskeletal pain) has a frequency of 1011%.

Both forms of pain are more commonly found in

women (ratio 1.5:1).

The prevalence of fibromyalgia according to the criteria
(chronic widespread pain plus 11 out of 18 positive
tenderpoints) of the American College of
Rheumatology (ACR) of 1990 is reported to be about
2% of the population.
Fibromyalgia affects mainly women (ratio about 8:1).
In general medical practice up to 4% are fibromyalgia
patients, in rheumatological practices almost one in
five patients suffers from fibromyalgia.

Fibromyalgia and chronic widespread pain have an effect on

capacity to function, state of health and a patients capacity
for work, as well as making high demands on the health
services.

10.2 THE PATIENTS PATTERN

OF SYMPTOMS
Symptoms of fibromyalgia are:

pain,
sleep disorder,
tiredness,
muscle stiffness,
psychological symptoms.

Other commonly occurring symptoms are:

sensory disorders such as a burning sensation,

tingling or the feeling that the limbs are swollen
(differential diagnosis of neuropathy),

problems with concentration or capacity for awareness,

headaches (differential diagnosis of tension
headaches/migraine),

irritable bowel (differential diagnosis of irritable

colon),
irritable bladder,
tendency to hypertension,
high resting pulse,
reduced ability to withstand stress.

10.2.1 Investigation
Pain: changing location throughout the locomotor
apparatus; made worse by physical exercise,

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http://dx.doi.org/10.1016/B978-0-7020-4312-3.00010-6

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Section | 1 |

Introductory overview

monotonous or forced postures (even sitting, lying

down, standing) and other factors (e.g. stress, cold
weather); relieved by warmth and a good nights sleep.
Sleep disorder: difficulty getting to sleep or sleeping
through (waking several times because of pain and
restlessness), not refreshed in the morning.
Tiredness: tiredness during the day, state of exhaustion
(is often felt to be more stressful than pain).
Muscle stiffness: persisting for minutes up to hours
(also after sitting for a long time).
Psychological symptoms: depressive mood, anxiety,
stressful life events, psychosocial stress factors.

10.2.2 Inspection and physical

examination
The inspection is unproductive.
The clinical evaluation should include the whole
locomotor apparatus and a basic medical and
neurological examination.
Patients with fibromyalgia exhibit positive, i.e. painful,
tenderpoints on palpation of typical sites (according to
the ACR criteria) (see Fig. 10.1, Table 10.1).
Muscle shortening and incorrect posture as well as
excessive dermographism/dermatographic urticaria are
frequent clinical findings.

Besides the positive tenderpoints, fibromyalgia patients

usually have a lowered tenderness threshold, i.e. patients
report pain as a result of light pressure on palpation even
away from the tenderpoints. This phenomenon does not rule
out the diagnosis of fibromyalgia.

Fig. 10.1 Localisation of tenderpoints in fibromyalgia according

to the criteria of the ACR (from Wolfe et al. 1992) visualised by
using The Three Graces by Jean Baptiste Reynault (1793),
Louvre, Paris.

10.2.3 Laboratory tests

A standard medical rheumatological laboratory test will give
the first indications of the presence of possible differential
diagnoses (erythrocyte sedimentation rate (ESR), blood
count, thyroid hormones, electrolytes, parathormones, antinuclear antibodies, C-reactive protein, rheumatoid factor
and creatinine kinase).
The laboratory chemistry and machine-aided diagnosis
is normal if fibromyalgia syndrome is present. At the beginning of the disease this serves for further investigation of a
differential diagnosis or to rule out or find comorbidities in
later stages of fibromyalgia as well.
Peripheral pain generators should be identified both clinically and from the history. These include arthritis (e.g. coxarthritis and gonarthritis), vertebral column syndrome (e.g.
scoliosis, spinal canal stenosis, lumbar spine syndrome with
or without radiculopathy), mTrP, inflammatory joint disease, neuropathy, hypermobility, migraine, enthesopathy,
irritable colon.

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Some 1525% of patients have sleep apnoea syndrome.

An even higher percentage exhibit restless leg syndrome. If
there is any suspicion, appropriate investigations and therapy should be carried out.

10.3 DIAGNOSIS
The diagnosis of fibromyalgia is based on the ACR criteria
of 1990. These are as follows.

History of generalised pain. Definition: spontaneous

pain in the muscles, along the tendons and tendon

insertions typically located on the trunk and/or the
extremities or the jaw region which have been present
for at least 3 months at three or more different parts of
the body above and below the waist.
Evidence of pain at 11 out of 18 tenderpoints on
manual palpation. Definition: palpation with the

Fibromyalgia syndrome

Table 10.1 Tenderpoints in fibromyalgia

Occiput

Insertion sites of the suboccipital

muscles

Lower neck

Intertransversal spaces C5C7

M. trapezius

In the middle between the insertion of

the neck and the acromion

M. supraspinatus

Middle part over the spina scapulae

Second rib

Cartilage bone border

Lateral
epicondyle

2 cm distal from the epicondyle

Gluteal region

Upper lateral quadrant of the gluteal

region (over the lateral margin of the
gluteus maximus muscle)

Greater
trochanter
Knee

Posterior to the trochanteric

prominence
Medial fat pad proximal to the medial
knee joint space

fingers should be performed with a strength of about

4 kg/cm2. A tenderpoint is assessed as positive if the
patient reports that palpation is painful. Sensitive does
not necessarily mean painful. The tenderpoints can be
found at defined symmetrical anatomical locations
(see Table 10.1).

10.3.1 Differential diagnosis

If there is any clinical suspicion of a number of other diseases, these must be ruled out to exclude any differential diagnoses. These include:

inflammatory diseases caused by pathogens

(particularly hepatitis, borreliosis (Lyme disease),

human immunodeficiency virus),
inflammatory rheumatic disease (e.g. chronic
polyarthritis, seronegative spondyloarthropathy,
collagenosis, myositis, vasculitis, polymyalgia
rheumatica),
non-inflammatory diseases, particularly thyroid
function disorders, neoplasia or myopathy.

Chapter | 10 |

10.4 TREATMENT
10.4.1 General
The guidelines for fibromyalgia syndrome were adopted in
2008 with the cooperation of some of the authors of this
book (M. Offenbacher, D. Irnich, A. Winkelmann) and accepted by the Association of the Scientific Medical Societies
(AWMF) in Germany. They can be found on the AWMF
website (www.awmf.org/).
Effective treatment of patients with fibromyalgia requires a
biopsychosocial approach. It is the physicians job to arrange
management with the patient based on this approach.
Successful long-term management of this chronic disease
requires:

building a workable partnership between patient and

physician/therapist,

support for the patient in becoming an expert in the

daily management of his/her symptoms,

support for the patient in understanding his/her

symptoms. Symptoms often have several causes so the
therapy is variable as well.
Another important factor is that both patient and doctor
agree on a therapeutic course of action (shared decisionmaking).
There are general guidelines which should be taken into
account in the treatment of fibromyalgia:

safe diagnosis and identification of concomitant

diseases,

the disease must be explained to the patient and his/her

family,

individual treatment of each patient as there is no

specific therapy which will help each person to the

same extent,
avoidance of unnecessary diagnostic measures or
operations.

Advice for the patient plays an important role in treatment.

Important aspects of an education programme are:

explanation about the non-destructive nature of the

disease,

focus on improvement of function and not on healing,

formulation of realistic treatment aims as patients often
have expectations that are too high,

discussion of medical and non-medical therapeutic

options,

introduction to self-help (e.g. instructions on the use of

physical measures),

evidence of a significant connection between soma

Overlapping/features in common with fibromyalgia:
symptoms with depression, chronic fatigue syndrome,
somatoform pain disorders, irritable colon and multiple
chemical sensitivity. The demarcation is often difficult.

psyche (e.g. instruction in meditation and/or

relaxation techniques),
instruction on sleep hygiene,
explanation of the need for lifelong gentle physical
stamina training,

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Section | 1 |

Introductory overview

emphasis on the importance of the active role of the

patient in the management of treatment,

advice on planning a balanced day (alternating phases
of exercise and relaxation).

a strained muscle system leads to further pain and

stiffness,

economic sittingstandinglying down,

poor sleeping position (e.g. hyperflexion of the neck)

10.4.2 Medical treatment

The medical treatment possibilities for fibromyalgia are

limited.

Low-dose tricyclic antidepressants (e.g. amitriptyline

25 mg at night); aim: improved sleep and influence on

the pain threshold, side effects even at low dosage; the
effect is often lost after a year.
Analgesics: simple analgesics (favourable riskbenefit
profile); NSAIDs are of limited clinical benefit.

10.4.3 Non-medical treatment

Stamina training
Eighty per cent of fibromyalgia patients are physically unfit,
83% do not carry out any regular physical exercise, 29% do
not reach the anaerobic threshold. It is a vicious circle of
paininactivitydeconditioning. Regular endurance/stamina
training is associated with a positive outcome for fibromyalgia.
Practical considerations/instructions on performing endurance training:

can trigger pain in the shoulder and neck girdle;

recommendation: anatomically shaped neck pillow,
strengthen deconditioned muscles: ideally as part of
cardiovascular fitness training,
instructing the patient with regard to eccentric and
concentrated muscle work,
muscle extension: daily programme for all large muscle
groups and particularly shortened muscles, 515 min,
use of heat application when necessary (tense muscles)
using, e.g., hot bath, shower, volcanic mud,
avoidance of inactivity and planning of regular rest
breaks in the course of the day.

Physical measures
Massage and underwater massage: some patients react

with an increase in pain at too high an intensity (lymph

drainage is then better).
Heat therapy in any form (e.g. mudpacks, sauna, steam
bath).
Other procedures: Stanger (hydroelectric) bath,
carbonated baths and Kneipp (cold water) drench.
Cold chamber exposure: some patients feel some pain
reduction in the short term.

the aim should be to improve function, not to reduce

pain,

at the beginning, there is often an increase in pain and

tiredness as possible evidence of training too hard,

begin with gentle interval training in order to keep the

increase in pain low after training, the patient should

feel: I could have done more,
patients should increase training slowly up to three to
four times a week; the aim should be achieved in
612 months,
training should involve little stress on the joints (e.g.
ergometer training, walking or aquarobics),
minimisation of eccentric muscle work during training
in order to reduce microtrauma in the muscles and
nociceptive stimulation,
group training stimulates compliance and provides
positive feedback,
additional regular exercise programme at home is
necessary, including muscle extension/stretching, light
strength and endurance training,
regular training should become part of life.

The patient can carry out many of these procedures by

himself/herself. Warning: avoid creating a passive role for the
patient!

Psychotherapeutic procedures/relaxation
techniques
Psychotherapeutic procedures for overcoming pain
and disease with appropriate stress.

Use of relaxation techniques (e.g. autogenic training or

progressive Jacobsen relaxation); see also Ch. 24.

10.4.4 Other possibilities for

treatment
Acupuncture
There is a lack of quality studies.
However, it appears that acupuncture has a significant
effect on pain and the pain threshold.

Physiotherapy
Practical instruction/aspects of physiotherapy

avoid strain at work and in everyday life,

look out for incorrect posture and hypermobility; this
leads to muscle strain, increase in tiredness and
myofascial pain,

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The long-term effect and type of optimum treatment

(point combination and frequency) are unclear.

Tai chi and Qigong

Tai chi or Qigong with the aim of increasing body
awareness.

Fibromyalgia syndrome

Trigger point injections

Fibromyalgia patients have a number of
predominantly inactive mTrPs.

Few have symptomatic mTrPs requiring treatment.

The reaction to an mTrP injection is delayed in

fibromyalgia patients and pronounced and more

persistent than in patients with MPS, especially with
dry needling.
No more than three to four trigger points should be
treated per session.
Follow-up treatment programme (e.g. muscle
extension, heat applications, massage) is important.

Chapter | 10 |

Transcutaneous electrical nerve stimulation

(TENS)
An attempt at treatment is sensible for localised pain.

Multidisciplinary therapy integrating the above measures in a

balanced programme is most likely to be successful in the
treatment of fibromyalgia.

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