Patient education on the nature of the condition has high efficacy for promoting self-management and shifting the locus of control towards the patient. This includes understanding the biology of pain, what can affect it, and what is understood of the pathophysiology of Fibromyalgia:

• Pain is a sensory and emotional experience. It is one of many protective mechanisms we have and compels us to do something to protect ourselves.
• Pain is a normal response to threat, but the amount of pain we experience does not relate directly to the severity of the injury, such as a paper cut.
• Fibromyalgia involves changes in pain signaling and processing that results in increased responsiveness to pain - analogous to a car alarm that is designed to prevent a break-in, but now goes off with a strong wind.
• Lifestyle interventions help turn down the pain alarm, including stress management, improving sleep, physical activity, and smoking cessation.

 For further suggested language for educating patients, go to http://TAPMIpain.ca/patient/

Self-management is essential. Active patient participation that encourages self-efficacy and social support helps facilitate the practice of health-promoting lifestyles, improving attitudes and coping skills (Recommendation 15). Encourage patients to pursue as normal a life as possible, maintaining or improving function with pacing and/or graded incremental activity (Recommendation 16).

 Self-management includes:

• Active participation (versus passive modalities such as massage therapy)
• Goal setting
• Having a daily action plan and a flare-management plan

 Online resources:

• http://tapmipain.ca/patient/managing-my-pain/pain-u-online/#/
• https://www.selfmanagementontario.ca/en/regionalsite
• Central LHIN

• Central East LHIN
• Central West LHIN
• Toronto Central LHIN
• Mississauga Halton LHIN
• Waterloo Wellington LHIN

Goal setting is an effective tool to change behaviour. Goals are concrete actions that should be achievable. The acronym SMART can help patients make effective and achievable goals.

• Specific: who, what, when, where, and how
• Measurable: cups, repetitions, minutes, number of times or days in a week
• Attainable: a change the patient feels at least 70% confident in achieving
• Realistic/Relevant: a change the patient feels is at least 70% important to them
• Time-bound: establish a time frame in which to achieve your goal

The goal-setting process should constantly be re-evaluated during follow-up. Goals should be adjusted if patients do not feel at least 70% confident that they can achieve it.

Complete the SMART GOAL SETTING exercise

Fibromyalgia Personal Care Plan

Exercise is the recommended first step of a multimodal treatment strategy. It is important for patients to participate in a graduated exercise program of their choosing to help improve pain, function, and global well-being (Recommendation 21). Patients should choose activities they find enjoyable, which improves patient participation.

People with persistent pain typically use one of three different activity patterns:

1. Avoidance. Typically during times of severe pain or flare. Leads to deconditioning, weaker and tighter muscles, decreased stamina, and increased pain alarm sensitivity.
2. Over-activity. During times when pain is improved, typically a “no pain, no gain” mindset. Often leads to flares and requires a longer rest and recovery period, which can be discouraging.
3. Paced. Helps maintain a certain level of function and avoid large swings in pain. Balancing activity and rest is individualized – it takes time to find what works for each patient.

Gradually increasing activity helps train the brain to realize that movement is not dangerous and does not cause tissue damage. Over time, this decreases perceived threat, thus decreasing pain. Other benefits of exercise include:

• Improved quality of life, decreased stress, depression, and anxiety
• Improved movement and function
• Better sleep, improved mood and memory
• Reduced nerve sensitivity, better immune function, and decreased inflammation
• Improved strength, stamina, and ability to participate in enjoyable activities
• Release of endorphins reduces pain signals

Graded exercise programs can include aerobic, stretching, and strengthening exercises:

• Aerobic: walking, cycling, swimming, pool exercises
• Stretching: yoga, Tai Chi, pilates, Qi Gong
• Strengthening: thera-bands, machines, mat exercises, etc.

Comorbid psychological disease affects pain, quality of life, and response to treatment. Untreated depression in particular is a barrier to optimal health status. Even without obvious signs of depression or anxiety, psychological interventions can be helpful in Fibromyalgia. Patients should be encouraged to acknowledge psychological distress and be informed about the negative impact this has on wellbeing (Recommendation 19). Psychological management helps improve overall well-being, as well as patient adherence to other management strategies such as exercise.

Cognitive behavioural therapy (CBT) improves pain-related behaviour and self-efficacy, thereby helping patients cope better with their pain. Even a short duration of CBT is useful and helps reduce fear of pain and activity (Recommendation 20). Other helpful psychological modalities include motivational interviewing, meditation-based stress reduction (MBSR), distraction, guided imagery, and group sessions incorporating education, exercise, and a psychological intervention.

Ms. PK is a 41-year-old woman who presents with a two-year history of persistent, generalized, widespread pain, worst in her neck and upper back that started after she was rear-ended while waiting at a red light. All investigations at the time of the accident were normal, including CT head, neck, and thorax, and rheumatologic work-up.

Her pain is described as aching and burning, and is constant, with associated headaches when pain is severe. It ranges from 6-9/10, averaging 8/10. Two years ago, the pain started in her neck and upper back, but has now progressed to include the low back, buttocks, and upper arms bilaterally. Aggravating factors include activity and stress. Alleviating factors include rest, massage, and heat packs.

Ms. PK sleeps poorly secondary to pain, with difficulty initiating and maintaining sleep. She frequently lays in bed in the evenings on her smart phone because of difficulty falling asleep. Other associated symptoms include difficulty with word finding and cognitive fogginess. Her mood is described as “poor and irritable”.

She has no significant past medical or surgical history, and no known drug allergies

On physical examination, her vital signs are stable. She is occasionally teary throughout interview, but otherwise cooperative. She displays a mildly antalgic gait but is able to walk on her heels and toes without difficulty. On inspection of her spine there is noticeable loss of lumbar and cervical lordosis. Lumbar, cervical, and shoulder ROM normal, but movement is painful in all directions. Palpation of cervical, thoracic and lumbar paraspinals, trapezius, scalenes, rhomboids, deltoids, and glutes reveals tenderness to palpation and recreation of patient’s pain. Certain areas create typical radiation patterns (www.triggerpoints.net). Power is 5/5 and reflexes are 2+/2 in the upper and lower extremities and symmetric. Sensory examination to soft touch and pinprick reveals non-dermatomal hyperalgesia and hyperesthesia over the neck and upper back

Her primary care practitioner has her complete the 2016 ACR questionnaire for the diagnosis of Fibromyalgia.  Her widespread pain index (WPI) is 9/19 and her symptom severity score (SSS) is 7/12.

Fibromyalgia is the most likely diagnosis for Ms. PK. No further investigations are currently required, but if there were other concerning features (for example, physical exam findings were most consistent of a peripheral neuropathy), further investigations could be considered.

Multimodal management was provided for Ms. PK, including:

1. Patient education.

She was educated regarding the diagnosis of Fibromyalgia as a central sensitization syndrome, and the management of these syndromes involving active participation in education, exercise, and psychological interventions, with a limited role for medications. She was also given information regarding the importance of good sleep hygiene to help improve her sleeping habits, which would improve her overall well-being.

2. Self-management.

The importance of self-management was discussed. She was encouraged to participate actively to improve self-efficacy, and to pursue as normal a life as possible with pacing and graded incremental activity. She was taught how to create SMART goals and prioritize the activities that are most important to her. She was also encouraged to create both a daily action plan and flare management plan for times when pain was severe.

3. Exercise.

Ms. PK was taught the importance of pacing and graduated physical activity to help improve her pain, maintain or improve her physical functioning, and improve her global well-being. Different exercise modalities were discussed, including aerobic, stretching, and strengthening. She was encouraged to pick the activities she found most interesting to help promote compliance.

4. Psychological management.

Even in the absence of overt psychopathology, Ms. PK will benefit from psychological management. She was provided with information regarding how even a short duration of psychological management helps improve overall well-being, as well as adherence to other management strategies such as exercise. Different psychotherapeutic modalities were discussed, including CBT, mindfulness, MBSR, and group therapy, and she was encouraged to look online for classes available through her local LHIN, or in person at her local community center.

5. Medication management.

Ms. PK was presented with information regarding the limited role of medications for the management of Fibromyalgia. However, as she is suffering with comorbid pain and sleep disturbance, a TCA was discussed as a first-line agent. She was provided with counseling regarding duration to treatment effect, dose titration, and sedative, psychotropic, and anticholinergic side effects. As nortriptyline is generally better tolerated due to a lesser side effect profile, she was initiated at 10 mg PO QHS for 2 weeks. She was educated that if morning grogginess was problematic, to take it earlier in the evening instead of immediately before bed. After 2 weeks, the dose was increased to 20 mg PO QHS, and then to 30 mg PO QHS another 2 weeks later.

Ms. PK returns to clinic after having been on nortriptyline 30 mg PO QHS for 6 weeks. Her pain control has improved slightly, as her pain is now averaging 6-7/10 (previously 8/10). She is able to initiate sleep more easily but is still waking up after 6 hours secondary to pain. She is engaging in aquatherapy, but requests further medication management to help her engage in exercise more easily. She is on the waitlist for a mindfulness course offered through her local community centre.

Management:

The limited role of medication management for the treatment of Fibromyalgia was reiterated with Ms. PK, with a 20-30% improvement in pain generally being expecting. As she was awaiting psychological therapy and still had difficulties with sleep, the addition of a gabapentinoid was discussed. She was counselled regarding sedative and weight gain side effects. Pregabalin was selected due to its better steady-state concentrations and easier dosing regimen. Nortriptyline was continued at 30 mg PO QHS. Pregablin was started at 25 mg PO QHS for 1 week, then increased to 25 mg BID. The dose could be further increased by 25 mg/dose every 2 weeks. She was counselled that she may not see benefit for up to two weeks at a therapeutic dose.

Ms. PK returns to clinic after having been on nortriptyline 30 mg PO QHS and pregablin 150 mg BID for 4 weeks. Her pain now ranges between 4-8/10, averaging 5/10. She reports improved sleep and overall quality of life, in conjunction with ongoing aquatherapy and psychotherapy, including mindfulness and cognitive-behavioural therapy.

Management:

The gains she has made were encouraged, and she was provided with education that flares and bad days would still happen. She was encouraged to continue building her daily action and flare management plans. She was told that no further medications needed, but she could consider PRN acetaminophen for flare management.