Fibromyalgia

from Wikipedia, the free encyclopedia
Classification according to ICD-10
M79.7 Fibromyalgia (M79.7 since ICD-10-GM version 2005; previously M79.0)
ICD-10 online (WHO version 2019)
Tender paired tender points ( ACR )

Fibromyalgia or fibromyalgia syndrome (from Latin fibra 'fiber' , and from ' myalgia ', that is muscle pain, from ancient Greek μῦς mŷs , German ' muscle ' and ἄλγος álgos , German ' pain ' ) is a syndrome of widespread pain in various parts of the body, sleep disorders and increased exhaustion. In addition to these core symptoms, there are a number of accompanying symptoms such as morning stiffness and difficulty concentrating. Fibromyalgia is not an inflammatory disease, but primarily a disruption of pain perception and processing. The examination of painful pressure points ( tender points ) is often used to make a diagnosis . Most of those affected are women. The causes of the disease have not yet been clarified, but it is known that fibromyalgia patients are generally more sensitive to pain, known as central sensitization . Drug therapies are not established, the focus of treatment is on sports and exercise. Fibromyalgia used to be called soft tissue rheumatism , also known as muscle rheumatism , and is still called soft tissue rheumatism .

distribution

It is estimated that fibromyalgia syndrome affects around 0.5 to 5.8% of the population in Europe and North America. In Germany, around 2% of the population met formal criteria for fibromyalgia syndrome in 2013, with a balanced gender ratio. In clinical settings, “up to 80% of patients are women between the ages of 40 and 60”.

causes

It is believed unlikely that fibromyalgia could be attributed to a single causal factor or trigger. Multifactorial development models are currently being discussed for the origin of the disorder. It is likely that a combination of genetic predisposition and various psychological, social and biological influences leads to the disease.

Besides:

  • a vitamin D deficiency ,
  • the individual lifestyle (smoking, obesity and lack of physical activity),
  • psychological factors such as sexual abuse and physical violence in childhood, as well as sexual violence in adulthood,
  • depressive disorders.

For the individual factors, it is not clear to what extent they are causally related to the development of the disease.

Pathophysiology

The main factor in the development of fibromyalgia is nerve sensitization ( sensitization ), including central sensitization . This means that the processing of pain in the central nervous system is so disturbed that the brain perceives pain without a damaging stimulus being present, and that the pain threshold drops, which means that normally non-painful stimuli are perceived as painful. This assumption is based on various pathophysiological findings:

For example, decreased levels of serotonin metabolic products were found in the nervous water of the sick. In addition to serotonin, the role of other hormones and neurotransmitters such as those of substance P or the growth hormone somatotropin in the development of fibromyalgia is being investigated.

Tissue studies of the subcutaneous connective tissue in fibromyalgia patients indicate a change in the number and composition of the sensory nerve endings in this tissue layer. The number of free nerve endings seems to be significantly reduced compared to those who are not affected (“ small fiber pathology ”). At the same time, a special category of these nerve endings is particularly numerous. These are those that are related to the regulation of blood flow to the subcutaneous connective tissue and that are located near the so-called arteriole-venule shunts (AVS). These shunts are small vascular connections between arterioles and venules and enable the body temperature to be regulated in this tissue layer. It is assumed that the disturbances in temperature perception frequently observed in fibromyalgia patients are related to this altered innervation of the subcutaneous connective tissue.

Symptoms

The focus of the syndrome is chronic pain in several parts of the body, i.e. pain that lasts for several months, disturbed or unrefreshing sleep and fatigue or increased exhaustion . A study by the German Fibromyalgia Association found joint and muscle pain in different places as well as back pain, morning stiffness, "bruised" and the feeling of having slept poorly in the morning, as well as fatigue, poor performance, concentration disorders and forgetfulness as the most common complaints.

Fibromyalgia syndrome is often associated with depression . Between 62 and 86% of patients will show signs of depression at some point in their lives. Particularly in the case of the reported cognitive impairments (such as concentration and memory disorders), it is unclear to what extent they can be traced back to depression, anxiety or undesirable side effects of drugs that act in the central nervous system.

diagnosis

The diagnosis of fibromyalgia turns out to be quite difficult, since both x-rays and laboratory values ​​do not provide any clear information, even if they are helpful to rule out important differential diagnoses. The diagnosis is therefore based on the findings of the physical examination and the questioning of the patient ( anamnesis ).

Differential diagnoses

Before making a diagnosis of fibromyalgia syndrome, it is necessary to rule out some diseases that cause symptoms similar to fibromyalgia. Some of these, particularly inflammatory rheumatic diseases, are often associated with or preceded by fibromyalgia syndrome. The following differential diagnoses can be considered (list without claim to be exhaustive).

Laboratory diagnostics

If the anamnesis and the physical examination indicate the existence of one of the differential diagnoses mentioned above, further information can be obtained through a targeted examination of the blood, for example by determining hormones and inflammation parameters. Elevated inflammation levels in the blood ( blood sedimentation reaction , C-reactive protein ), for example, suggest an inflammatory disease - since fibromyalgia is not an inflammatory disease, no abnormalities are to be expected here. Further examinations should be based on the suspected disease; an indiscriminate determination of all possible laboratory values ​​is not recommended, as markers that indicate certain diseases (such as antinuclear antibodies or rheumatoid factors ) are positive even in people who do not suffer from such a disease at all which can steer the diagnosis in the wrong direction.

Clinical diagnostic criteria

Approximate location of pressure points ( tender points )

In 1990 the American College of Rheumatology (ACR) presented criteria for the first time to facilitate the diagnosis of fibromyalgia. Only the pain was taken into account: the person affected had to report widespread, persistent pain in several parts of the body. In addition, the ACR defined 18 “sensitive areas” or pressure points ( tender points ) that can typically be painful in fibromyalgia. According to the 1990 criteria, at least eleven of the 18 pressure points must be sensitive during the physical examination. The introduction of the criteria was welcomed by experts, but in practice they reached their limits. In primary care, pressure points were often not examined because doctors preferred to base their diagnosis on the other symptoms, or the pressure point examination was performed incorrectly, leading to incorrect diagnoses. Another weak point in the criteria came to light in patients whose condition improved. In these cases, the diagnosis of fibromyalgia could not be maintained if fewer than eleven tender points were painful in the course of the process .

In the light of the weaknesses of the tender points concept, the ACR published new criteria in 2010 that manage without examining the pressure points and are instead based on the assessment of the other core and accompanying symptoms. The number of painful body regions is determined by questioning the patient and an index between 0 and 9 is formed (“widespread pain index”, WPI). Then the severity of the symptoms is determined ("severity scale", SS): The other three main symptoms (exhaustion, unrefreshing sleep and cognitive limitations) are assigned scores from 0 (no complaints) to 3 (severe complaints) to classify their severity. The physical secondary symptoms are assigned scores from 0 (no symptoms) to 3 (many symptoms) to classify their extent. For this severity scale, adding up the four values ​​results in a final value between 0 and 12. The diagnosis of fibromyalgia syndrome can be made according to these criteria if the WPI is at least 7 and the symptom severity is at least 5, or if the WPI is between 3 and 6 but the symptom severity is at least 9.

The German treatment guidelines leave it open to the criteria according to which the diagnosis is made.

Differentiation from somatoform disorders

To this day, there is a controversy in science as to how to classify the fibromyalgia syndrome. Representatives of psychiatry assigned it to the somatoform disorders , which is due to the fact that patients with fibromyalgia meet the criteria of a somatoform disorder according to ICD-10 and DSM 4 , namely persistent physical symptoms without an underlying physical disease being able to be determined, as well as an influence the course of the disease through psychosocial factors. The majority of researchers, however, reject the classification of fibromyalgia as a somatoform disorder. This is justified on the one hand with the concept of the somatoform disorder, which assumes an emotional or psychological conflict as the underlying cause of the physical complaints and is therefore in principle a mental illness. Fibromyalgia is not based on such a conflict. On the other hand, the ICD and DSM criteria are criticized as vague and inconsistent. According to the scientific majority opinion, the fibromyalgia syndrome is a construct with biological, psychological and social influencing factors that overlaps with somatoform disorders, but is not to be understood as such. Another category in which the fibromyalgia syndrome is sometimes classified in the literature are the functional syndromes ( functional somatic syndrome ).

Sleep medicine aspects

Fibromyalgia is listed in the International Classification of Sleep Disorders (ICSD-2, 2005) in Appendix A and in the guideline for non-restful sleep / sleep disorders in the sleep disorders associated with diseases classified elsewhere, because those affected often because of their symptoms be referred to the sleep doctor.

The disorder of sleep is a consequence of the underlying disease, which must be recognized and treated as the cause of the sleep disorder. Specific sleep medical diagnostics are usually not required. In individual cases, sleep-wake rhythm disturbances corresponding to the irregular type have been described.

treatment

Fibromyalgia can only be influenced to a limited extent by medical measures and is mostly limited to symptomatic treatment. One treatment concept today is multimodal pain therapy based on the findings of modern pain research. The aim of the measures is to maintain or improve the functionality in everyday life and thus the quality of life as well as to reduce and / or alleviate the symptoms. Since the symptoms can be lifelong, treatment measures that can be carried out independently by those affected (self-management), which have little or no side effects and whose long-term effectiveness should be ensured, are particularly recommended. Today's concept usually includes patient training, the use of medication in connection with sports and functional training, physical therapies as well as psychotherapy and relaxation methods.

Medication

Since there is a lack of high-quality studies on drug therapy and the scientific evidence is consequently low, the international guidelines (from the Canadian Pain Society, the EULAR and the AWMF ) sometimes come up with different therapy recommendations.

The greatest experience is with the tricyclic antidepressant amitriptyline , which can be used for a limited period in the treatment of chronic pain as part of an overall therapy concept. Under certain circumstances, the anti- epileptic drugs pregabalin and gabapentin or the antidepressant duloxetine , which is also effective against neuropathic pain , can be used. From the group of antidepressants, fluoxetine or paroxetine are also often used. There are further individual, but not yet fully established, proofs of effectiveness from the group of antidepressants for sertraline , moclobemide , venlafaxine , mirtazapine and milnacipran . The latter has even received approval for the indication fibromyalgia in the USA, but not in Europe.

There is no evidence that the use of non-steroidal anti-inflammatory drugs (NSAIDs) is effective in fibromyalgia. Muscle relaxants are not recommended. The use of strong opioids is also not recommended. The weak opioid tramadol, on the other hand, is recommended in two current guidelines for pain reduction.

Move

Movement-oriented measures represent an important component in therapy. To reduce pain, moderate endurance training such as walking , cycling, swimming and aqua jogging , as well as functional training with exercises in dry and water aerobics , is recommended . There is also a recommendation for so-called meditative forms of movement, i.e. tai chi , chi gong and yoga . There is a graduated recommendation for moderate strength training. According to German guidelines, stretching exercises and vibration training can also be considered.

Physical therapies

The German guideline comes to positive recommendations for bath therapy applications, more precisely for bathing in hot water, mineral water and sea water ( Thalasso ). Because of the inadequate data situation, it does not make any statements about Stangerbad pools (“open recommendation”).

With regard to heat applications, the use of the bio sauna or infrared cabins can be considered. The benefits of whole-body heat applications (e.g. through heat packs) are unclear. The guideline advises against the use of cold chambers , but there are individual patients who benefit from them. There are other negative recommendations for hyperbaric oxygen therapy , laser therapy , magnetic field therapy and transcranial magnetic stimulation.

Relaxation methods

Relaxation techniques such as progressive muscle relaxation , autogenous training , meditation , laughter yoga and other techniques of stress management are recommended in combination with aerobic exercise. However, these procedures are unsuitable as the sole therapy.

Psychological measures

Psychological measures such as behavior therapy are recommended in the German guideline for certain clinical constellations, for example in the case of comorbid mental disorders. In previous studies, the effects of behavior therapy on pain, fatigue and health-related quality of life have been shown to be minor. The risk of side effects of behavior therapy in fibromyalgia is still unknown, and an increase in symptoms is believed to be possible.

Measures such as mindfulness-based stress reduction, relaxation procedures and therapeutic writing should not be used as the only therapy due to the poor evidence. Rather, such measures can be embedded in a multimodal therapy concept .

nutrition

There is no evidence that certain forms of nutrition (such as vegetarianism , veganism , gluten-free diet, therapeutic fasting ) have a positive influence on the symptoms. Exceptions are patients with gluten sensitivity , in whom gluten-free food can improve fibromyalgia symptoms, as well as overweight people who benefit from weight reduction. Diet supplements should be avoided.

history

Descriptions of musculoskeletal pain go back to the 16th century. Here led Guillaume de Baillou the rheumatism a collective term for musculoskeletal pain. The term muscular rheumatism came up in the 18th century . This was used for pain that was not caused by processes that destroy the joints (such as osteoarthritis or rheumatoid arthritis ), so the symptoms of fibromyalgia fell into this category along with other pain conditions. The polymyalgia rheumatica was formerly known as "muscular". From the 19th century, doctors began to describe various sub-forms of muscular rheumatism, although these early attempts at definition remained vague and made it difficult to distinguish between localized and generalized forms of pain. Over the course of the century, symptoms typical of fibromyalgia such as " tender points " have been described. The British neurologist William Richard Gowers , like many of his contemporaries, was convinced of the presence of inflammatory processes and coined the term fibrositis in 1904 , whereby the ending -itis in disease names stands for inflammation. At the end of the 1920s and 1930, other terms were proposed: myofasciitis , myofibrositis, and neurofibrositis , which continued to refer to an inflammatory process by their endings. This could never be proven in the following years, so that in 1976 the term fibromyalgia was proposed, which drops the idea of ​​an inflammatory cause and is still used today. Since the 1980s, the tender points , pain, sleep disorders and other complaints have been recognized as typical of fibromyalgia syndrome. With the publication of the classification criteria by the American College of Rheumatology in 1990, scientific exchange on fibromyalgia syndrome was made easier. The lack of reliable technical or laboratory diagnostic instruments has not only hindered research, but also leads to persistent doubts about the independence of fibromyalgia as a syndrome. Fibromyalgia syndrome, for example, is viewed poorly among doctors and medical students. Patients therefore suffer from the fact that they do not feel that their complaints are being taken seriously.

literature

Patient literature

  • Eva Felde, Ulrike S. Novotny: Pain Disease Fibromyalgia, this is how you quickly come to the correct diagnosis, successfully relieve your pain, with lots of valuable advice for everyday life, family and work . , ISBN 978-3-8304-3259-3 .
  • Wolfgang Brückle: Fibromyalgia. Finally recognize - treat properly. Trias, Stuttgart 2016. ISBN 978-3-432-10028-9 .
  • Eberhard Wormer: Fibromyalgia. Recognize the pain disorder and treat it successfully. Mankau, Murnau am Staffelsee 2014. ISBN 978-3-86374-171-6 .

Specialist literature

  • Winfried Hauser among others: Fibromyalgia syndrome: Classification, diagnosis and treatment strategies . In: Deutsches Ärzteblatt . No. 106 (23) , 2009, pp. 383-391 ( article online ).
  • Erin Lawson, Mark S. Wallace (Eds.): Fibromyalgia. Clinical Guidelines and Treatments . Springer, New York 2015. ISBN 978-3-319-15819-8 .
  • Dawn A. Marcus, Atul Deodhar: Fibromyalgia. A Practical Clinical Guide . Springer, New York 2011. ISBN 978-1-4419-1608-2 .
  • Michael Schäfer: On the history of the neurasthenia concept and its modern variants, Chronique Fatigue Syndrome, Fibromyalgia and multiple chemical sensitivity. In: Advances in Neurology and Psychiatry. Volume 70, 2002, pp. 572-580.
  • Ludwig Heilmeyer , Wolfgang Müller: The rheumatic diseases. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition ibid. 1961, pp. 309–351, here: pp. 342–346: The soft tissue rheumatism (fibrositis, muscular rheumatism, myalgia, panniculitis).

Guidelines

  • S3 guideline for fibromyalgia syndrome: definition, pathophysiology, diagnostics and therapy of the German Interdisciplinary Association for Pain Therapy (DIVS). In: AWMF online (as of 2017) long and short version as well as a "patient guideline" and an overview entitled "The most important things in a nutshell", which is aimed at people with fibromyalgia syndrome and their relatives and provides information in addition to the doctor's consultation.
  • GJ Maclarfane et al .: EULAR revised recommendations for the management of fibromyalgia. In: Annals of the Rheumatic Diseases. No. 76, pp. 318-328 ( online , PDF ).

Web links

Wiktionary: Fibromyalgia  - explanations of meanings, word origins, synonyms, translations
Commons : Fibromyalgia  - Collection of Images, Videos, and Audio Files

Individual evidence

  1. ↑ Sanam Kia, Ernet Choy: Update on Treatment Guideline in Fibromyalgia Syndrome with Focus on Pharmacology . In: Biomedicines . tape 5 , no. 2 , May 8, 2017, p. 20 , doi : 10.3390 / biomedicines5020020 , PMID 28536363 , PMC 5489806 (free full text) - (English, mdpi.com [accessed on May 20, 2018]).
  2. ↑ S3 guideline definition, pathophysiology, diagnosis and treatment of fibromyalgia syndrome of the German Pain Society. In: AWMF online (as of 2017) p. 16, 2nd update, accessed on May 20, 2018.
  3. ^ German pain society: definition, pathophysiology, diagnosis and therapy of fibromyalgia syndrome. S. 37. S3 guideline, 1st update from 2012. Online (PDF) , last accessed on July 5, 2018.
  4. ↑ S3 guideline definition, pathophysiology, diagnosis and treatment of fibromyalgia syndrome of the German Pain Society. In: AWMF online (as of 2017) p. 29 f., Accessed on October 7, 2019
  5. ↑ KC Fleming, MM Volcheck: Central sensitization syndrome and the initial evaluation of a patient with fibromyalgia: a review. In: Rambam Maimonides medical journal. Volume 6, number 2, April 2015, p. E0020, doi : 10.5041 / RMMJ.10204 , PMID 25973272 , PMC 4422459 (free full text) (review).
  6. ↑ N. Üçeyler et al .: Small fiber pathology in patients with fibromyalgia syndrome . In: Brain . tape 136 , no. 6 , 2013, p. 1857-1867 , PMID 23474848 (English).
  7. ↑ PJ Albrecht et al .: Excessive peptidergic sensory innervation of cutaneous arteriole-venule shunts (AVS) in the palmar glabrous skin of fibromyalgia patients: Implications for widespread deep tissue pain and fatigue . In: Pain Medicine . tape 14 , no. 6 , 2013, p. 895-915 , PMID 23691965 (English).
  8. ↑ S3 guideline definition, pathophysiology, diagnosis and treatment of fibromyalgia syndrome of the German Pain Society. In: AWMF online (as of 2017) p. 12, 2nd update, accessed on May 20, 2018.
  9. ↑ S3 guideline definition, pathophysiology, diagnosis and treatment of fibromyalgia syndrome of the German Pain Society. In: AWMF online (as of 2017) p. 12, 2nd update, accessed on May 20, 2018.
    W. Hauser, C. Zimmer, E. Felde, V. Köllner: What are the core symptoms of fibromyalgia syndrome? In: The pain . tape 22 , no. 2 , April 1, 2008, ISSN  0932-433X , p. 176–183 , doi : 10.1007 / s00482-007-0602-z ( springer.com [accessed May 20, 2018]).
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  11. ↑ S3 guideline definition, pathophysiology, diagnosis and treatment of fibromyalgia syndrome of the German Pain Society. In: AWMF online (as of 2017), p. 13, 2nd update, accessed on May 20, 2018.
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  13. ↑ Megan Strauchman, Mark W. Morningstar: Fluoroquinolone toxicity symptoms in a patient presenting with low back pain . In: Clinics and Practice . tape 2 , no. 4 , November 28, 2012, ISSN  2039-7275 , doi : 10.4081 / cp.2012.e87 , PMID 24765486 , PMC 3981197 (free full text). Beatrice Alexandra Golomb, Hayley Jean Koslik, Alan J Redd: Fluoroquinolone-induced serious, persistent, multisymptom adverse effects . In: BMJ Case Reports . tape
     2015 , October 5, 2015, ISSN  1757-790X , doi : 10.1136 / bcr-2015-209821 , PMID 26438672 , PMC 4600819 (free full text).
  14. ^ Omar H. Henriquez, Devin Peck: Fibromyalgia Diagnosis . In: Erin Lawson, Mark S. Wallace (Eds.): Fibromyalgia. Clinical Guidelines and Treatments . Springer, New York 2015. ISBN 978-3-319-15819-8 . P. 32.
  15. ^ Omar H. Henriquez, Devin Peck: Fibromyalgia Diagnosis . In: Erin Lawson, Mark S. Wallace (Eds.): Fibromyalgia. Clinical Guidelines and Treatments . Springer, New York 2015. ISBN 978-3-319-15819-8 . P. 26.
  16. ^ Omar H. Henriquez, Devin Peck: Fibromyalgia Diagnosis . In: Erin Lawson, Mark S. Wallace (Eds.): Fibromyalgia. Clinical Guidelines and Treatments . Springer, New York 2015. ISBN 978-3-319-15819-8 . P. 26.
  17. ↑ S3 guideline definition, pathophysiology, diagnosis and treatment of fibromyalgia syndrome of the German Pain Society. In: AWMF online (as of 2017), p. 16, 2nd update, accessed on June 16, 2018.
  18. ^ A b W. Hauser, P. Henningsen: Fibromyalgia syndrome: a somatoform disorder? In: European Journal of Pain . tape 18 , no. 8 , September 2014, ISSN  1532-2149 , p. 1052-1059 , doi : 10.1002 / j.1532-2149.2014.00453.x , PMID 24453056 . ( free full text on researchgate.net )
  19. ↑ Richard Mayou, Andrew Farmer: Functional somatic symptoms and syndromes . In: BMJ: British Medical Journal . tape 325 , no. 7358 , August 3, 2002, ISSN  0959-8138 , p. 265–268 , doi : 10.1136 / bmj.325.7358.265 , PMID 12153926 , PMC 1123778 (free full text).
  20. ↑ S3 guideline for non-restful sleep / sleep disorders of the German Society for Sleep Research and Sleep Medicine (DGSM). In: AWMF online (as of 2009)
  21. ↑ a b Sanam Kia, Ernet Choy: Update on Treatment Guideline in Fibromyalgia Syndrome with Focus on Pharmacology . In: Biomedicines . tape 5 , no. 2 , May 8, 2017, p. 20 , doi : 10.3390 / biomedicines5020020 , PMID 28536363 , PMC 5489806 (free full text) - ( mdpi.com [accessed November 24, 2019]).
  22. ^ German pain society: definition, pathophysiology, diagnosis and therapy of fibromyalgia syndrome. , P. 105 ff. S3 guideline, 2nd update from 2017. Online (PDF) , last accessed on May 20, 2018.
  23. ^ Lesley M. Arnold: Biology and therapy of fibromyalgia. New therapies in fibromyalgia. In: Arthritis research & therapy. Volume 8, number 4, 2006, p. 212, doi: 10.1186 / ar1971 , PMID 16762044 , PMC 1779399 (free full text) (review).
  24. ↑ Medknowledge: The antidepressant Milnacipran in fibromyalgia. ( Memento of January 8, 2016 in the Internet Archive ) 2010.
  25. ^ German pain society: definition, pathophysiology, diagnosis and therapy of fibromyalgia syndrome. , P. 117. S3 guideline, 2nd update from 2017. Online (PDF) , last accessed on May 20, 2018.
  26. ^ German pain society: definition, pathophysiology, diagnosis and therapy of fibromyalgia syndrome. , P. 117. S3 guideline, 2nd update from 2017. Online (PDF) , last accessed on May 20, 2018.
  27. ^ German pain society: definition, pathophysiology, diagnosis and therapy of fibromyalgia syndrome. , P. 61 ff. S3 guideline, 2nd update from 2017. Online (PDF) , last accessed on October 28, 2019.
  28. ^ German pain society: definition, pathophysiology, diagnosis and therapy of fibromyalgia syndrome. , P. 134. S3 guideline, 2nd update from 2017. Online (PDF) , last accessed on October 28, 2019.
  29. ^ German pain society: definition, pathophysiology, diagnosis and therapy of fibromyalgia syndrome. , P. 67. S3 guideline, 2nd update from 2017. Online (PDF) , last accessed on October 28, 2019.
  30. ^ German pain society: definition, pathophysiology, diagnosis and therapy of fibromyalgia syndrome. , P. 70 f. S3 guideline, 2nd update from 2017. Online (PDF) , last accessed on October 28, 2019.
  31. ^ German pain society: definition, pathophysiology, diagnosis and therapy of fibromyalgia syndrome. , P. 68. S3 guideline, 2nd update from 2017. Online (PDF) , last accessed on October 28, 2019.
  32. ^ German pain society: definition, pathophysiology, diagnosis and therapy of fibromyalgia syndrome. , P. 80. S3 guideline, 2nd update from 2017. Online (PDF) , last accessed on October 28, 2019.
  33. ^ German pain society: definition, pathophysiology, diagnosis and therapy of fibromyalgia syndrome. , P. 72. S3 guideline, 2nd update from 2017. Online (PDF) , last accessed on October 28, 2019.
  34. ^ German pain society: definition, pathophysiology, diagnosis and therapy of fibromyalgia syndrome. , P. 79. S3 guideline, 2nd update from 2017. Online (PDF) , last accessed on October 28, 2019.
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  36. ↑ S3 guideline fibromyalgia syndrome: Definition, pathophysiology, diagnosis and treatment of the German Association for Interdisciplinary pain therapy (DIVS). In: AWMF online (as of 2012)
  37. ^ German pain society: definition, pathophysiology, diagnosis and therapy of fibromyalgia syndrome. , P. 97. S3 guideline, 2nd update from 2017. Online (PDF) , last accessed on June 1, 2018.
  38. ^ German pain society: definition, pathophysiology, diagnosis and therapy of fibromyalgia syndrome. , Pp. 136, 139 f. S3 guideline, 2nd update from 2017. Online (PDF) , last accessed on November 24, 2019.
  39. ↑ Ludwig Heilmeyer , Wolfgang Müller: The rheumatic diseases. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition, ibid. 1961, pp. 309–351, here: p. 342: Intramuscular fibrositis (“myositis”, “muscular rheumatism”).
  40. ↑ F. Fatma Inanici, Muhammad B. Yunus: History of fibromyalgia: Past to Present. In: Current Pain and Headache Reports. 8, 2004, p. 369, doi : 10.1007 / s11916-996-0010-6 .
  41. ^ Dawn A. Marcus, Atul Deodhar: Fibromyalgia. A Practical Clinical Guide . Springer, New York 2011. ISBN 978-1-4419-1608-2 . Pp. 3-7.