Fibromyalgia (FM)

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This clinical tool supports primary care clinicians in recognizing, assessing, diagnosing and managing Fibromyalgia (FM). FM is classified as a chronic pain condition and presents with widespread pain and other associated, often severe, symptoms that may significantly impact quality of life. FM is a medical, not psychological, condition. While there is no cure, reduced symptom severity and improved quality of life may be achieved through accurate diagnosis, detailed assessment and targeted management. 

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Clinical presentation and assessment

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Fibromyalgia (FM) is a disease characterized by widespread musculoskeletal pain which is nociplastic in nature and can be very disabling, and other associated symptoms such as sleep disturbances, fatigue, and impaired cognitive and physical function. Symptoms vary from person to person and may fluctuate from day to day.1-6 

Common symptoms1-4

Adapted from the Royal College of Physicians’ The diagnosis of Fibromyalgia syndrome: UK clinical guidelines, 2022

Practice point: Patients may not describe widespread pain when initially asked and may only report focal pain or their current most prominent pain. It is important to ask directly about pain felt elsewhere in the body. Pain may also move to different areas of the body from one day to the next or even hour to hour.4

 Other symptoms can vary between patients and may indicate other diagnoses:1-4

  • Headaches/migraines 
  • Subjective swelling (e.g., of hands) 
  • Dry mouth/Sicca syndrome 
  • Joint hypermobility  
  • Dermographism  
  • Raynaud’s phenomenon 

Conduct a comprehensive assessment of patients presenting with symptoms associated with FM. Assessment of FM can be carried out over a series of appointments. 

Practice point4

Set the scene – Acknowledge the patient’s situation and the breadth of symptoms they may be experiencing. Acknowledge the fluctuations and flare-up of symptoms, which can vary from day-to-day or even hour to hour. Regional pain can become widespread, causing everyday activities (i.e., walking) to become painful and difficult. Allow sufficient time as the complex constellation of symptoms may take more time than available at the first appointment, so it is best practice to arrange timely follow-up appointments as needed. Allow for in-person appointments, as assessing important cues and information virtually or over the phone may be difficult.

Differential diagnosis and comorbid conditions

Adapted from the Royal College of Physicians’ The diagnosis of Fibromyalgia syndrome: UK clinical guidelines, 2022

A diagnosis of FM does not imply that every new symptom experienced by the patient is attributable to FM. 2 It is important to navigate these symptoms and investigate where appropriate.

Conducting laboratory or radiographic analysis should depend on the individual patient’s clinical evaluation which may suggest some other medical condition.1,4  

FM is not a diagnosis of exclusion. The diagnosis of FM does not exclude the presence of other clinically important illnesses.4 Many symptoms of FM overlap with symptoms of other medical conditions including ME/CFS, rheumatoid arthritis and systemic lupus erythematosus.

Practice point: If a patient with suspected FM describes experiencing moderate or severe fatigue, they should be evaluated for ME/CFS. The presence of this co-morbid condition impacts the approach to the management of FM symptoms.7

Diagnosis

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If FM is suspected, use the 2016 revisions to ACR 1990/2010 diagnostic criteria. This involves calculating the patient’s level of symptom severity and widespread pain index to diagnose FM.1,2 Use the Royal College of Physicians FM Diagnostic Worksheet to assist with assessment and diagnosis. 

A diagnosis of FM is confirmed when all the following criteria are met: 

Generalized pain, defined as pain in at least 4 of 5 regions, is present  

Symptoms have been present at a similar level for at least 3 months  

Widespread pain index (WPI) ≥ 7 and symptom severity scale (SSS) score of ≥ 5 OR WPI of 4-6 and SSS score of ≥ 9 

Diagnostic code
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Diagnostic code7

In Ontario the diagnostic code is 726 (fibromyalgia), with the associated time-based billing code K037.

Specialist referral

In cases of diagnostic uncertainty (complicated by inflammatory rheumatological or neurological symptoms, presence of multiple health conditions, etc.), patients can be referred to a specialist to confirm diagnosis. Referral options typically include a rheumatologist and/or pain specialist.4 

Management

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Practice point: There is no curative treatment for FM. Management aims to reduce symptom severity and improve the patient’s quality of life. Develop a personalized and supportive management plan with the patient, considering their needs and preferences.    

Addressing a patient’s priority symptoms is important to managing the overall condition. This may include both non-pharmacological and pharmacological approaches.7

Clinical accommodation and disability support

Beyond the non-pharmacological and pharmacological management strategies outlined below, patients whose symptoms significantly affect their ability to work may require disability income support. Some patients with FM will need some form of disability support and will need their clinician’s assistance in obtaining it. The presentation of symptoms can look different from patient to patient and can present on different timelines. It is important to keep this in mind during assessment and when providing corresponding documentation for disability claims.  

Non-pharmacological management

Non-pharmacological therapies are integral to the FM management approach. Consider the patient’s clinical status and general condition when recommending non-pharmacological therapies. Assess the benefits and potential risks of various strategies, factoring in pain intensity, functional status, symptom experiences, patient preferences, and any comorbidities.3 Strategies include: 

Patient education3

Provide educational resources to help patients understand pain, common symptoms and management options. 

Physical and occupational therapies1,7
  • Aerobic resistance training, low-impact aerobics, restorative exercise or strengthening movements.
  • Occupational therapy, which may include supports for activities of daily living (ADLs) (i.e., adjustments in home or work environments). 
  • Hydrotherapy (water-based exercise, aquatic physical therapy, thermal therapy). 

In individuals with comorbidities such as ME/CFS, the functional and exercise limitations imposed by other conditions must be considered in program design. See Management section of CEP’s ME/CFS tool. 

Mental health and wellbeing supports1
  • Cognitive-behavioural therapy (CBT) program for chronic pain management, hypnosis, guided imagination, or therapeutic writing. 
  • For sleep-related issues, consider services offering OHIP-funded CBT for insomnia. 
Complementary and alternative therapies1,3
  • Acupuncture. 
  • Mind-body treatments, mindfulness and meditative movement (Tai chi, Yoga, Qi gong).

If beneficial to the patient, consider referring them to a chronic pain clinic that specializes in the management of chronic pain conditions. 

Pharmacological management5,6,8-13

Consider pharmacological strategies, administered concurrently with patient education and non-pharmacological therapies, based on patient symptoms and preferences. Drug combinations may be considered for patients who do not respond to monotherapy under careful observation and consideration of adverse effects. 

Practice point: Start with a low dose and up-titrate slowly to efficacy based on tolerance limitations. Achieving efficacy at low doses may help avoid side effects and medication burden.3

References

  • [1]

    Ariani A, Bazzichi L, Sarzi-Puttini P, Salaffi F, Manara M, Prevete I, et al. The Italian Society for Rheumatology clinical practice guidelines for the diagnosis and management of fibromyalgia Best practices based on current scientific evidence. Reumatismo. 2021 Aug 3;73(2):89–105.

  • [2]

    Rivera Redondo J, Díaz Del Campo Fontecha P, Alegre de Miquel C, Almirall Bernabé M, Casanueva Fernández B, Castillo Ojeda C, et al. Recommendations by the Spanish Society of Rheumatology on Fibromyalgia. Part 1: Diagnosis and Treatment. Reumatol Clin. 2021 Apr 27;S1699-258X(21)00058-9.

  • [3]

    Evcik D, Ketenci A, Sindel D. The Turkish Society of Physical Medicine and Rehabilitation (TSPMR) guidelines recommendations for the management of fibromyalgia syndrome. Turk J Phys Med Rehab. 2019;65(2):111–23.

  • [4]

    Royal College of Physicians. The diagnosis of fibromyalgia syndrome: UK clinical guidelines [Internet]. 2022. Available from: https://link.cep.health/pvifm2

  • [5]

    Migliorini F, Maffulli N, Eschweiler J, Knobe M, Tingart M, Colarossi G. Pharmacological management of fibromyalgia: a Bayesian network meta-analysis. Expert Rev Clin Pharmacol. 2022 Feb;15(2):205–14.  

  • [6]

    Aitcheson N, Lin Z, Tynan K. Low-dose naltrexone in the treatment of fibromyalgia: A systematic review and narrative synthesis. Aust J Gen Pr. 2023;52(4):189–95.

  • [7]

    Expert Opinion.

  • [8]

    AA Pharma Inc. Product monograph: Elavil® [Internet]. 2018 [cited 2023 Dec 5]. Available from: https://link.cep.health/pvifm5

  • [9]

    AA Pharma Inc. Product monograph including patient information: Tramadol [Internet]. 2018 [cited 2023 Dec 5]. Available from: https://link.cep.health/pvifm6

  • [10]

    Arnold LM, Goldenberg DL, Stanford SB, Lalonde JK, Sandhu HS, Keck PE, et al. Gabapentin in the treatment of fibromyalgia: a randomized, double-blind, placebo-controlled, multicenter trial. Arthritis Rheum. 2007 Apr;56(4):1336–44.

  • [11]

    BGP Pharma ULC. Product monograph: Lyrica® [Internet]. 2023 [cited 2023 Dec 5]. Available from: https://link.cep.health/pvifm7

  • [12]

    Eli Lilly Canada Inc. Product monograph: Cymbalta® [Internet]. 2023 [cited 2023 Dec 5]. Available from: https://link.cep.health/pvifm8

  • [13]

    Pfizer Canada Inc. Product monograph: Neurontin® [Internet]. 2018 [cited 2023 Dec 5]. Available from: https://link.cep.health/pvifm9