Fibromyalgia (fibromyalgia syndrome)

Fibromyalgia or fibromyalgia syndrome is a clinical picture that is associated with chronic pain, sleep disturbances and fatigue, as well as cognitive disorders and other non-specific symptoms.^1,2 The exact cause and development of fibromyalgia is still unclear, which is why treatment is based on the symptoms.³ In research, fibromyalgia is seen as a disorder of pain regulation that is probably triggered by various factors (genetics, hormones, immunology) and affects predominantly women.^2,4,5 Since 1990, diagnosis has been based primarily on the major diagnostic criteria defined by the American College of Rheumatology (ACR).⁶ Although there is currently no single treatment, both pharmacologic and nonpharmacologic therapeutic approaches are available to improve the quality of life of those affected.⁷
 

Fibromyalgia is a chronic pain disorder whose cause is unknown according to current knowledge. The disease does not appear to be due to a single factor, but to multiple physical and/or psychological factors, or to be exacerbated by them.³ In any case, fibromyalgia is considered to be a disorder of central pain regulation in which there is an increased sensitivity to pain, also known as central sensitization.^8,9 Fibromyalgia has been shown to be associated with altered pain and sensation processing in the central nervous system, and patients perceive even mild physical stimuli as more painful than healthy controls.¹⁰ In addition, psychological and social factors appear to contribute to the development or persistence of pain hypersensitivity.^11,12 Whether a genetic component plays a role in the etiology of fibromyalgia is still under debate.^13,14 A genome-wide linkage study of over 116 American families found that siblings of fibromyalgia sufferers had a 13.6-fold higher risk of developing the condition than the general population. In addition, a specific region on chromosome 17 in this study population was found to be significantly associated with fibromyalgia.¹⁵ Cross-sectional magnetic resonance imaging images show differences between the brains of fibromyalgia patients and those of healthy controls, including neuronal activity.¹⁶
 

Characteristic of fibromyalgia, in addition to chronic pain that affects several regions of the body and has been present for at least three months, are also very sensitive tender points (trigger points).¹ If the affected person feels 11 of 18 tender points to be painful during palpation and other inflammatory rheumatic diseases are ruled out, the suspicion of fibromyalgia hardens, especially if fatigue, sleep disturbances and cognitive disorders (fibro fog) occur at the same time.¹⁷ However, examination of tender points alone is no longer sufficient for the diagnosis of fibromyalgia, as a certain percentage of fibromyalgics have fewer than 11 painful tender points. For this reason, in 2010 the ACR issued an additional anamnestic questionnaire for fibromyalgia diagnosis that does not include tender points. First, the body is divided into a total of 19 sections using the Widespread Pain Index, and the patient indicates how many of these have been painful in recent weeks. In addition, the Symptom Severety Scale is used to assess the severity of symptoms such as fatigue, non-restorative sleep, and cognitive symptoms (impaired concentration and memory), as well as the occurrence of other physical complaints (including headache, dizziness, nausea).^6,18 Inflammatory parameters in the blood and imaging techniques are considered insufficient for the diagnosis of fibromyalgia, but are suitable for ruling out other diseases. Because fibromyalgia can co-occur with other diseases, a diagnosis of exclusion is not an option. In fact, in a 2011 study, approximately 17% of patients with osteoarthritis, 37% of patients with systemic lupus erythematosus, and 21% of patients with rheumatoid arthritis met the criteria for fibromyalgia diagnosis established by the ACR in 2010.¹⁹
 

The therapy of fibromyalgics is based on the symptoms and primarily serves to relieve pain and eliminate fatigue in order to improve the quality of life of the affected person. The nonpharmacologic approach to therapy primarily involves regular exercise. A 2017 systematic review and meta-analysis found that aerobic exercise and muscle training best increased the well-being of sufferers as well as relieved pain, and stretching exercises and aerobic exercise increased quality of life. Furthermore, the combination of strength and endurance training was found to reduce depression symptoms in sufferers the most.²⁰ A Cochrane Review of 13 studies with a total of 839 subjects also found that aerobic exercise positively affected pain, fatigue, physical functioning, stiffness, and health-related quality of life in adult fibromyalgia sufferers.²¹ There is also scientific evidence for the efficacy of massage, acupuncture, and electrotherapy for fibromyalgia treatment.^22,23,24 Psychological and behavioral interventions (including cognitive behavioral therapy) are also recommended because the condition can negatively impact the psyche.²⁵ 
 

Fibromyalgia is a chronic and incurable disease with an as yet unexplained pathogenesis. It is characterized by migrating pain in the muscles, around the joints and in the back, as well as general tenderness. In addition, those affected suffer from non-specific accompanying symptoms such as fatigue, sleep disturbances, morning stiffness, lack of concentration, listlessness and swollen extremities. An accompanying micronutrient therapy attempts to positively influence the symptoms and to reduce frequent accompanying symptoms - such as migraine and sleep disorders.
 

Coenzyme Q10 plays a key role in cellular energy production and is a central antioxidant in cells. In energy production, coenzyme Q10 provides those electrons needed in the mitochondrial respiratory chain for adenosine triphosphate synthesis. Clinical studies suggest that coenzyme Q10 status is too low in migraine. In clinical trials, supplementation of 1-3 mg coenzyme Q10/kg body weight significantly reduced migraine frequency and intensity.

Because magnesium stabilizes membranes and thus affects nerve conduction, magnesium deficiencies may contribute to the pathogenesis of migraine. Migraine patients often have suboptimal magnesium status and respond well to supplementation. In clinical trials, substitution of 600 mg of magnesium per day reduced both the duration and frequency of migraine attacks.

5-Hydroxytryptophan (5-HTP) is an intermediate stage in the endogenous conversion of the amino acid tryptophan into the neurotransmitter serotonin. Serotonin levels are closely related to psychological changes, such as depressive moods, anxiety and panic states, or aggression. It directly influences the sleep-wake rhythm, appetite control and pain sensation. 5-HTP substitution leads to more available serotonin in the synaptic cleft and accordingly has an antidepressant effect.

The B vitamins niacin, B₁ and B₆ are also indispensable for the successful course of serotonin synthesis.

S-adenosylmethionine (SAMe) is involved in the synthesis of important factors of brain metabolism - such as neurotransmitters and phospholipids.

Omega-3 fatty acids have an antidepressant effect by activating serotonergic neurotransmitters in the hippocampus and cortex. For the nutritive treatment of fibromyalgia-associated depression, depressive symptoms and moods, eicosapentaenoic acid (EPA) in particular plays an important role.

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2) Nihalani, N. D., Schwartz, T., Chlebowski, S. et al. 2006. Fibromyalgia. Psychiatry (Edgmont). 3(4): 44–60.
3) Institute for Quality and Efficiency in Health Care (IQWiG). 2018. What is known about the causes of fibromyalgia? InformedHealth.org
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11) Paschali, M. et al. 2021. Modifiable Psychological Factors Affecting Functioning in Fibromyalgia. J Clin Med. 10(4): 803.
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13) Park, D.-J., Lee, S.-S. 2017. New insights into the genetics of fibromyalgia. Korean J Intern Med. 32(6): 984–995.
14) Staud, R. 2009. Abnormal pain modulation in patients with spatially distributed chronic pain: fibromyalgia. Rheum Dis Clin North Am. 35(2):263-74.
15) Arnold, L. M. et al. 2013. The Fibromyalgia Family Study: A Genome-Scan Linkage Study. Arthritis Rheum. 65(4): 1122–1128.
16) Wiliams, D. A., Gracely, R. H. 2007. Biology and therapy of fibromyalgia. Functional magnetic resonance imaging findings in fibromyalgia. Arthritis Res Ther. 8(6): 224.
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18) Wolfe, F. et al. 2010. The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. Arthritis Care & Research. 62(5): 600-610.
19) Wolfe, F. et al. 2011. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol. 38(6):1113-22.
20) Sosa-Reina, M. D. et al. 2017. Effectiveness of Therapeutic Exercise in Fibromyalgia Syndrome: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Biomed Res Int. 2017: 2356346.
21) Bidonde, J. et al. 2017. Aerobic exercise training for adults with fibromyalgia. Cochrane Database of Systi Rev. 6(6):CD012700.
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24) Benlidayi, I. C. 2020. The effectiveness and safety of electrotherapy in the management of fibromyalgia. Rheumatol Int. 40(10):1571-1580.
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