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Fibromyalgia syndrome and connective tissue disorders were found to be highly associated in terms of both prevalence and symptoms.
Overlapping symptomology and diagnostic prevalence of fibromyalgia syndrome (FMS) and connective tissue disorders, such as hypermobile Ehlers-Danlos Syndrome (hEDS), Generalized Joint Hypermobility (GJH), and Hypermobility Spectrum disorders (HSD), were reported in a study published in Seminars in Arthritis & Rheumatism.1 Investigators urge clinicians to reflect on both diagnoses to ensure an accurate diagnosis and management plan.
“In the absence of clear understanding of some musculoskeletal conditions and in the presence of similarities of definitions, pathogenesis, and symptomatic features in musculoskeletal practice, it is necessary to understand concomitant diagnoses in potentially overlapping conditions,” investigators explained.
Investigators systematically searched the bibliographic electronic database MEDLINE to identify observational research studies in which adult patients were screened for FMS and hEDS, HSD, and GJH and were compared regarding musculoskeletal and non-musculoskeletal manifestations, as well as diagnostic prevalence. Study quality was evaluated by 2 reviewers using the National Institute of Health (NIH) Quality Assessment tool for case control studies and the Jonna Briggs Critical Appraisal checklist for the single group studies.
Of the 85 potential studies identified, 11 were ultimately included (9 case-control studies and 2 single group studies). According to the NUH Quality Assessment tool, 3 studies were rated as “poor,” 4 were rated as “fair,” and 2 were rated as “good.” Using the Joanna Briggs Institute checklist, 1 study was rated as “moderate” quality and the other was deemed “high” quality.
A concomitant diagnosis of hEDS/HSD and FMS ranged from 68%-88.9%, while GJH and FMS prevalence ranged from 8%-62.4%. Both the prevalence and severity of patient-reported and objective features were similar between those with hEDS/HSD and FMS, such as joint swelling, joint pain, neurological symptoms, muscle weakness, gastrointestinal issues, pain, function, and quality of life. For those with GHS and FMS, similarities of shared symptoms included pain, psychological impact, total myalgia score, and tender points count.
The study was limited by not having a previous similar systemic review for comparison. Further, the risk of bias, which was only rated as “low” in 3 of the studies, should be noted. Although the structure of the review was divided into hEDS/HSD, which are often symptomatic, and GJH, which is often asymptomatic, most of the reviewed studies evaluated patients who had a primary diagnosis of FMS. Investigators note that they could not ascertain whether the clinician’s background, experience, and knowledge of connective tissue disorders could impact diagnosis. Therefore, future research should focus on examining this aspect, as it is highly recommended that screening for both conditions should be considered, and clinicians can then make a diagnosis on a case-by-case basis and personalize management plans.
“FMS and connective tissue disorders were found to be highly associated in terms of prevalence and symptomatic features,” investigators concluded. “Therefore, clinicians should be aware of the potential overlap between FMS and hEDS/HSD and GJH. The diagnosis of these conditions relies on widespread pain, however, considering tender points in the examination could lead to the diagnosis of FMS, and considering joint hypermobility in the examination could lead to the diagnosis of hEDS/HSD.”
Alsiri N, Alhadhoud M, Alkatefi T, Palmer S. The concomitant diagnosis of fibromyalgia and connective tissue disorders: A systematic review [published online ahead of print, 2022 Nov 17]. Semin Arthritis Rheum. 2022;58:152127. doi:10.1016/j.semarthrit.2022.152127