Patients with fibromyalgia benefit from a positive, multimodal approach, say Dr Asim Suleman and Dr Adrian Dunbar
- Fibromyalgia is a clinical diagnosis. Examination and history-taking usually reveals chronic widespread pain that has been present for more than 3 months
- Examination, diagnosis, and management should be carried out in the primary care setting
- There is no confirmatory test for fibromyalgia. Testing to rule out other pathologies should be kept to a minimum and may include the following blood tests:
- full blood count
- erythrocyte sedimentation rate
- thyroid function test
- creatine kinase
- rheumatoid factor
- GPs should establish a diagnosis as soon as possible. Referral to secondary care is no longer routinely advised
- Healthcare professionals should be educated, open, honest and not display negative attitudes
- Treatment is usually multimodal—the aim should be to improve patient outcomes by reducing symptoms and maintaining function
- Non-pharmacological strategies are extremely useful
- Self-management and self-efficacy should be strongly encouraged
- Psychological evaluation and/or counselling may be helpful
- Healthcare practitioners should encourage patients to remain as part of the workforce, as evidence is strongly in favour of work being beneficial to health.
Mera pura jism meh dard hota hai, said the first patient of the day. Roughly translated, this means, ‘Doctor, my whole body hurts.’ Chronic widespread pain can present a challenge to a doctor’s investigative and clinical skills, impacting negatively on the doctor–patient relationship. In a survey of more than 1300 primary care physicians, conducted across 13 different European countries, 84% of the doctors surveyed perceived chronic, non-malignant pain as one of the most challenging conditions to treat. 1 This would suggest that clinicians lack the training and appropriate skills to feel confident in managing patients with chronic pain.
Fibromyalgia is thought to be underdiagnosed in the population.2,3 It is more commonly diagnosed in women than in men. Most of the patients diagnosed in clinics are likely to be between the ages of 40 and 60 years.4 The prevalence of fibromyalgia increases with age.5 The incidence in adults in the UK is thought to be between 2% and 5%.6 As well as experiencing widespread chronic pain, patients usually present with a combination of other co-morbidities, for example, fatigue, abdominal pain, and sleep and mood disturbances.7,8
Fibromyalgia is a recognised disease of unknown aetiology. Recent research suggests that it occurs as a result of dysfunction of pain regulatory mechanisms in the peripheral and central nervous system.9 There is no diagnostic test for fibromyalgia, so clinicians need to rely on skills learnt whilst they were students: a thorough history and clinical examination is imperative.
The American College of Rheumatology (ACR) seminal 1990 paper,10 revised in 2010,11 detailed the diagnostic criteria for fibromyalgia. Chronic widespread pain is common, along with associated symptoms of fatigue and other somatic features. In the 2010 revision, the ACR detailed three key criteria for the diagnosis of fibromyalgia:11
- presentation of widespread pain for more than 3 months
- assessment of the number of painful body areas
- assessment of additional symptoms, including cognitive ailments.
The current consensus is that the diagnosis of fibromyalgia can be made in primary care and should not be seen as a diagnosis of exclusion.12,13 Blood tests to rule out other pathologies include those listed in the Key points box. Conditions such as hypothyroidism, polymyalgia rheumatica and inflammatory arthropathies can often present with similar symptoms.
The ACR criteria were reviewed in 2012 (along with other evidence-based information) by the Canadian Pain Society and the Canadian Rheumatology Association who published the Canadian Pain Society and Canadian Rheumatology Association recommendations for rational care of persons with fibromyalgia.14 A summary of the recommendations is given in the Key points box on p.3.
Referral to secondary care
The Canadian guideline14 has reinforced support for clinical diagnosis of fibromyalgia in primary care. Similarly, the guideline recommends that the condition should be managed in the primary care setting by generalist GPs and those with a specialist interest in pain management. GPs have the skills, relationships with patients and the resources to manage affected individuals in primary care. It could be argued that only treatment-resistant cases should be referred to secondary care. In my experience as a GP with a special interest in pain management, this is rarely necessary. The treatments and interventions available to GPs in primary care are sufficient to manage even the most difficult of cases. If, however, there is diagnostic uncertainty, then onward referral to musculoskeletal and pain specialists is indicated.
Diagnostic uncertainty can arise when there are overlapping symptoms with other rheumatological and musculoskeletal conditions. If there is a need for a multidisciplinary team approach (such as specialist physiotherapists and psychologists), then this could also warrant a referral, depending on the commissioned services available.
The management of fibromyalgia has changed over the years but the current consensus is that patients will benefit from a multidisciplinary approach.14–17
In 2008, the European League Against Rheumatism (EULAR) recommended treatments that included:
- heated-pool treatment18
- tailored exercise19
- cognitive behavioural therapy (CBT).20
Research suggests that CBT reduces pain, negative mood and disability. The improvements shown were present at long-term follow up (6 months).
The Canadian guideline strongly recommends:14,21
- self-management and self-efficacy
- regular exercise (aerobic, muscle-strengthening and stretching).
Essentially, self-management and self-efficacy allow the patient to increase their self-confidence in controlling their pain and managing exacerbations. An external locus of control (i.e. the belief that events in one’s life, whether good or bad, are caused by uncontrollable factors) is associated with less favourable outcomes. See Box 1 for some key points for patients self-managing chronic pain, and Box 2 for some useful sources of patient information. Evidence for complementary and alternative medicine in fibromyalgia is weak.21
I encourage my patients with fibromyalgia to remain in the workforce. The evidence suggests that patients who remain in work have generally less severe symptoms and a better quality of life.22,23 It is highly likely that ‘fibromyalgia’ would be deemed disabling under the provisions of the Equality Act 2010.24
Recommendations for pharmacological interventions from EULAR included:18
- antidepressants (e.g. fluoxetine, amitriptyline, duloxetine)
- anticonvulsants with pain-modulating properties (e.g. gabapentin, pregabalin).
The Canadian guideline recommends that sleep, mood and fatigue problems need to be addressed as well as pain management and that:14
- combinations of drugs with different modes of actions can be efficacious
- it is recommended to start with low doses and to titrate slowly
- monitoring of efficacy and side-effects is vital to improve outcomes and patient compliance
- ineffective medications should be discontinued.
It should be noted that the following drugs are not licensed in the UK for the treatment of fibromyalgia:
They are, however, licensed in other countries such as the USA and Canada. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information.25
Box 2: Useful sources of information for patients*
- Arthritis UK: www.arthritisresearchuk.org/arthritis-information/conditions/fibromyalgia.aspx
- FibroAction: www.fibroaction.org
- Self management UK: www.selfmanagementuk.org
- Pain toolkit: www.paintoolkit.org
Patients need to know that there is no cure for fibromyalgia. The aim should be to manage symptoms and improve patient self-efficacy and self-management.
Pharmacological treatments that have the most robust evidence-base include:
- amitriptyline 26
- duloxetine 29
Services are scanty for disadvantaged communities (such as those that include non-English speaking people). This is likely to have an impact on primary care services as studies suggest patients with fibromyalgia reported higher rates of illness and have increased use of healthcare resources.4 Only with education, evidence-based management, and increased awareness of the population of people with fibromyalgia will the stigma attached to this complicated and common condition be overcome. G
- Fibromyalgia is a common clinical syndrome that can be effectively diagnosed and managed in primary care, although GPs seem reluctant to do this
- Local care pathways for the diagnosis, investigation, and management of fibromyalgia may help GPs feel more confident in managing this condition in primary care:
- these pathways could be enforced with an education programme for GPs
- NHS Choices has useful material and links to patient support groups for patients with fibromyalgia (see www.nhs.uk/Conditions/Fibromyalgia/Pages/SelfHelp.aspx); see also the authorâ€™s suggestions
- Clinical commissioning groups:
- could consider funding some community-based support groups for fibromyalgia to help patients understand and self-manage their condition, and reduce the impact on health services
- should include a section on the pharmacological management of fibromyalgia in local formularies with advice on prescribing drugs
(often off-licence) and their acquisition costs.
- Johnson M, Collett B, Castro-Lopes J. The challenges of pain management in primary care: a pan-European survey. J Pain Res 2013; 6: 393–401.
- Chakrabarty S, Zoorob R. Fibromyalgia. Am Fam Physician 2007; 76 (2): 247–254.
- Vincent A, Lahr B, Wolfe F et al. Prevalence of fibromyalgia: a population-based study in Olmsted County, Minnesota, utilizing the Rochester Epidemiology Project. Arthritis Care Res (Hoboken). 2013; 65 (5): 786–792.
- Hughes G, Martinez C, Myon E et al. The impact of a diagnosis of fibromyalgia on health care resource use by primary care patients in the UK: an observational study based on clinical practice. Arthritis Rheum 2006; 54 (1): 177–183.
- Wolfe F, Ross K, Anderson J et al. The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum 1995; 38 (1):19–28.
- Papageorgiou A, Silman A, Macfarlane G. Chronic widespread pain in the population: a seven year follow up study. Ann Rheum Dis 2002; 61 (12): 1071–1074.
- Arnold L, Hudson J, Keck P et al. Comorbidity of fibromyalgia and psychiatric disorders.
J Clin Psychiatry 2006; 67 (8): 1219–1225.
- Goldenberg D. Fibromyalgia: why such controversy? Ann Rheum Dis 1995; 54 (1): 3–5.
- Fitzcharles M, Ste-Marie P, Pereira J; Canadian Fibromyalgia Guidelines Committee. Fibromyalgia: evolving concepts over the past 2 decades. CMAJ 2013; 185 (13): E645–E651.
- Wolfe F, Smythe H, Yunus M et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990; 33 (2): 160–172.
- Wolfe F, Clauw D, Fitzcharles M et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res 2010; 62: 600–610.
- Fitzcharles M, Ste-Marie P, Goldenberg D, et al. 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary. Pain Res Manag 2013; 18 (3): 119–126.
- Rahman A, Underwood M, Carnes D. Fibromyalgia. BMJ 2014; 348: g1224.
- Fitzcharles M, Ste-Marie P, Goldenberg D et al. Canadian Pain Society and Canadian Rheumatology Association recommendations for rational care of persons with fibromyalgia. A summary report. J Rheumatol 2013; 40 (8): 1388–1393.
- Cedraschi C, Desmeules J, Rapiti E et al. Fibromyalgia: a randomised, controlled trial of a treatment programme based on self management. Ann Rheum Dis 2004; 63 (3): 290–296.
- Sarzi-Puttini P, Buskila D, Carrabba M et al. Treatment strategy in fibromyalgia syndrome: where are we now? Semin Arthritis Rheum 2008; 37 (6): 353–365.
- Burckhardt C. Multidisciplinary approaches for management of fibromyalgia. Curr Pharm Des 2006; 12 (1): 59–66.
- Carville S, Arendt-Nielsen S, Bliddal H et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis 2008; 67 (4): 536–541.
- Busch A, Barber K, Overend T et al. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev. 2007; 4: CD003786.
- Bernardy K, Klose P, Busch A et al. Cognitive behavioural therapies for fibromyalgia. Cochrane Database Syst Rev 2013; 9: CD009796.
- Fitzcharles M, Ste-Marie P, Goldenberg D et al. 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome. Available at: www.canadianpainsociety.ca/pdf/Fibromyalgia_Guidelines_2012.pdf
- White D, Faull K, Jones P. An exploratory study of long-term health outcomes following an in-patient multidisciplinary program for people with fibromyalgia syndrome. Int J Rheum Dis. 2009; 12 (1): 52–56.
- Reisine S, Fifield J, Walsh S, Feinn R. Do employment and family work affect the health status of women with fibromyalgia? J Rheumatol 2003; 30 (9): 2045–2053.
- Equality Act 2010. Available at: www.legislation.gov.uk/ukpga/2010/15/contents (accessed 10 March 2014).
- General Medical Council. Good practice in prescribing and managing medicines and devices. London: GMC, 2013. Available at: www.gmc-uk.org/guidance/ethical_guidance/14316.asp (accessed 10 March 2014).
- Moore R, Derry S, Aldington D et al. Amitriptyline for neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev 2012; 12: CD008242.
- Wiffen P, Derry S, Moore R et al. Antiepileptic drugs for neuropathic pain and fibromyalgia —an overview of Cochrane reviews. Cochrane Database Syst Rev. 2013; 11: CD010567.
- Moore R, Wiffen P, Derry S, McQuay H. Gabapentin for chronic neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev 2011; 3: CD007938.
- Scholz B, Hammonds C, Boomershine C. Duloxetine for the management of fibromyalgia syndrome. J Pain Res 2009;
- Moore R, Straube S, Wiffen P et al. Pregabalin for acute and chronic pain in adults. Cochrane Database Syst Rev 2009; 3: CD007076. G