DÄ internationalArchive44/2009Fibromyalgia Syndrome—Classification, Diagnosis, and Treatment: In reply

Correspondence

Fibromyalgia Syndrome—Classification, Diagnosis, and Treatment: In reply

Dtsch Arztebl Int 2009; 106(44): 729-30. DOI: 10.3238/arztebl.2009.0729b

Häuser, W

LNSLNS We welcome the correspondence from readers and wish to take this opportunity to clarify and correct possible misunderstandings of the recommendations of the S3 guideline on fibromyalgia syndrome (FMS).

– The symptom complex “chronic pain in several regions of the body” without any explanatory organic disorder is a clinical reality. The unsolved problems of its classification and definition in the World Health Organization’s classification of diseases, which Mindach rightly points out, were dealt with extensively in the guideline.

– The “tender points” have not been abolished by the guideline (Judin) nor are they fundamentally unsuitable for the definition of FMS (Mindach). To make a clinical diagnosis of FMS, the guideline recommends using either the criteria of the ACR classification, which provide for the testing of the tender points, or the symptom based criteria defined by the guideline group (chronic widespread pain, and sensation of stiffness/swelling in hands, feet, or face, and physical or mental fatigue or sleep disturbances without tender point examination). These diagnostic criteria can be validly captured by means of a pain sketch and symptom questionnaire completed by the patients; they are therefore hardly “vague” (Judin). The selection of criteria was supported by expert consensus and by a survey of a large group of FMS patients about the key symptoms of FMS (1). Studies from Canada (2) as well as a current German multicenter study (Häuser et al, in preparation) point at a high rate of concordance of the diagnosis according to the ACR and symptom based (without tender point examination) criteria).

Judin’s statement, that FMS is undoubtedly vertebrogenic, was not confirmed by our systematic literature search.

The observation of “partly individual, partly unique idiosyncrasies” (Wörz)—namely, comorbidities, patients’ preferences regarding the availability and side effects of different therapeutic options—in the therapy of FMS was emphasized in the guideline in several places. Systematic review articles have confirmed Wörz’s clinical experience, that, in contrast to antidepressants, heat therapy for the entire body has no side effects. However, controlled studies are available only for mud baths and spa therapy. The differences in effect size between spa therapies and antidepressants with regard to pain reduction do not reach significance, however (3, 4).

The guideline has a dedicated chapter on complementary and alternative approaches. Mindach rightly comments that some of these methods—such as acupuncture and tai-chi, which were not recommended as monotherapy because of negative study results—might be considered in the context of a multicomponent approach (obligatory are activating approaches such as aerobic exercise and psychotherapeutic therapies). The basis for these open recommendations is laid out transparently in the guideline.

In sum, we believe that the guideline, as an agreement reached between groups that previously had widely diverging views of fibromyalgia syndrome, is of great value in the overall uniformly better provision of care for this large group of patients.
DOI: 10.3238/arztebl.2009.0729b


Dr. med. Winfried Häuser
Interdisziplinäres Zentrum
für Schmerztherapie/Innere Medizin I
(Gastroenterologie, Hepatologie, Stoffwechsel-
und Infektionskrankheiten, Psychosomatik)
Klinikum Saarbrücken gGmbH
Winterberg 1
66119 Saarbrücken, Germany
whaeuser@klinikum-saarbruecken.de

Conflict of interest statement
The author has received honoraria for speaking from Eli Lilly, Janssen-Cilag, Mundipharma, and Pfizer, and honoraria as an adviser to Eli Lilly and Pfizer, and travel expenses from Eli Lilly.
1.
Häuser W, Zimmer C, Felde E, Köllner V: Was sind die Kernsymptome des Fibromyalgiesyndroms? Umfrageergebnisse der Deutschen Fibromyalgievereinigung. Schmerz 2008; 22: 176–83. MEDLINE
2.
Katz RS, Wolfe F, Michaud K: Fibromyalgia diagnosis: a comparison of clinical, survey, and American College of Rheumatology criteria. Arthritis Rheum 2006; 54: 169–76. MEDLINE
3.
Häuser W, Bernardy K, Üceyler N, Sommer C: Treatment of fibromyalgia syndrome with antidepressants – a meta-analysis. JAMA 2009; 301: 198–209. MEDLINE
4.
Langhorst J, KLose P, Musial F, Häuser W: Efficacy of hydrotherapy in fibromyalgia syndrome – a meta-analysis of randomized controlled clinical trials. Rheumatology 2009; july 16: epub. MEDLINE
5.
Häuser W, Eich W, Herrmann M, Nutzinger D, Schiltenwolf M, Henningsen P: Fibromyalgia syndrome — classification, diagnosis, and treatment [Fibromyalgiesyndrom: Klassifikation, Diagnose und Behandlungsstrategien], Dtsch Arztebl Int 2009; 106(23): 383–91. VOLLTEXT
1. Häuser W, Zimmer C, Felde E, Köllner V: Was sind die Kernsymptome des Fibromyalgiesyndroms? Umfrageergebnisse der Deutschen Fibromyalgievereinigung. Schmerz 2008; 22: 176–83. MEDLINE
2. Katz RS, Wolfe F, Michaud K: Fibromyalgia diagnosis: a comparison of clinical, survey, and American College of Rheumatology criteria. Arthritis Rheum 2006; 54: 169–76. MEDLINE
3. Häuser W, Bernardy K, Üceyler N, Sommer C: Treatment of fibromyalgia syndrome with antidepressants – a meta-analysis. JAMA 2009; 301: 198–209. MEDLINE
4. Langhorst J, KLose P, Musial F, Häuser W: Efficacy of hydrotherapy in fibromyalgia syndrome – a meta-analysis of randomized controlled clinical trials. Rheumatology 2009; july 16: epub. MEDLINE
5. Häuser W, Eich W, Herrmann M, Nutzinger D, Schiltenwolf M, Henningsen P: Fibromyalgia syndrome — classification, diagnosis, and treatment [Fibromyalgiesyndrom: Klassifikation, Diagnose und Behandlungsstrategien], Dtsch Arztebl Int 2009; 106(23): 383–91. VOLLTEXT