Welcome to the Fibromyalgia Module
The purpose of this module is to increase confidence in managing Fibromyalgia in the primary care setting. According to the 2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome, the primary care physician should establish a diagnosis of Fibromyalgia as early as possible, without need for confirmation by a specialist, and communicate this diagnosis to the patient (Recommendation 5). The guidelines also suggest that in caring for persons with Fibromyalgia, healthcare professionals should be educated regarding the pathogenesis of Fibromyalgia (Recommendation 10).
What is Fibromyalgia?
Fibromyalgia is one of the most commonly encountered chronic pain conditions. It was previously thought to be an ill-defined condition with a predominantly peripheral musculoskeletal pathology. Newer research has shown abnormalities in pain processing both centrally and peripherally. Fibromyalgia is characterized by generalized body pain and associated conditions such as fatigue, non-restorative sleep, cognitive dysfunction, mood disturbances and pain related somatic symptoms.
The pathophysiology is not well understood, however we know that there are a number of changes in both the peripheral and central nervous systems that result in amplified sensitivity to external stimuli. In the peripheral nervous system there may be enhanced pain receptor activity. In the central nervous system, there are changes in both the spinal cord and the brain. In the spinal cord, there is enhanced ascending facilitation and impaired descending inhibition of pain signals. In the brain, there are changes both functionally and anatomically.
The estimated prevalence of Fibromyalgia is 2-8% worldwide. Canadian prevalence rates are approximately 2-3%. There is a strong female predominance, although estimates vary widely between 60-90%. It can affect both genders and all ages, but is most commonly seen in women in the third to fifth decade. There is also a strong genetic predisposition, and siblings of patients with Fibromyalgia have a 13.6 fold risk of developing Fibromyalgia compared to the general population. Twin studies suggest genetic contribution may be as high as 50%.
In this module you will learn:
- The diagnosis and management of Fibromyalgia.
- When to refer to a specialist
- When to order investigations on a Fibromyalgia patient
- How to manage Fibromyalgia.
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
Pain is the primary complaint. It must be present for at least 3 months. Pain often begins in a localized area and may initially be intermittent, but then progressively becomes more persistent. Pain is described as aching, burning or generalized “tenderness”. Pain can be modulated by factors such as weather or stress.
Fatigue is reported to be present in over 90% of FM patients, and is the most common associated complaint. There may be some overlap with chronic fatigue syndrome, however, pain is more prominent in patients with Fibromyalgia.
Poor sleep negatively impacts fatigue, affect, and pain, with improvement in these parameters when sleep specifically is addressed. Other sleep disorders such as restless leg syndrome or sleep apnea may also occur in patients with FM.
Cognitive dysfunction associated with Fibromyalgia or “fibrofog” includes poor working memory, spatial memory alterations, free recall, and verbal fluency.
Mood disorder, including depression and/or anxiety, is present in up to 75% of patients. Fibromyalgia also shares similar genetic risk factors with depression.
Pain-related somatic symptoms
These include irritable bowel syndrome, migraine headaches, severe menstrual pain, lower urinary tract symptoms, myofascial facial pain, and temporomandibular pain.
Non-pain related symptoms
Up to 97% of Fibromyalgia patients report sexual dysfunction. They are at increased risk of developing posttraumatic stress disorder (PTSD). Cigarette smoking increases symptom severity.
This is a group of behaviours that include feelings of helplessness, rumination, and magnification that increase patient perceptions of pain.
- Reduced self-efficacy
- Health-related anxiety
2012 Canadian Fibromyalgia Guidelines:
Fibromyalgia fluctuates over time. It should be diagnosed in individuals with widespread pain present for at least 3 months, in addition to other somatic symptoms such as fatigue, sleep disturbance, cognitive changes, or mood disorders, not explainable by some other illness (Recommendation 1).
- Pain is the primary complaint and must be present for at least 3 months.
- Non-pain complaints are common.
- Fatigue, non-restorative sleep, cognitive dysfunction, and depression and/or anxiety are very commonly associated with Fibromyalgia.
- Smoking cigarettes amplifies pain severity in Fibromyalgia.
- Maladaptive behaviour such as catastrophizing increases patient perception of pain.
No specific features on physical examination are diagnostic of Fibromyalgia.
- Tender points (as described in the 1990 and 2010 ACR diagnostic criteria) are no longer required to confirm a clinical diagnosis of Fibromyalgia (Recommendation 3), although multiple tender points with typical radiation patterns may be present (http://www.triggerpoints.net).
- Musculoskeletal and neurological physical examinations in Fibromyalgia are usually normal, except for soft tissue tenderness on pressure (Recommendation 2).
- Patients may exhibit multiple conditioned pain behaviours secondary to pain and deconditioning, such as maladaptive postures or gait, and kinesiophobia (fear of movement).
- No specific features on physical examination are diagnostic of Fibromyalgia.
- Neuromuscular examination is usually normal except for soft tissue sensitivity to pressure sensation.
- Tender points may be present but are not required to confirm a clinical diagnosis.
Some conditions can present similarly to Fibromyalgia, such as:
- Endocrine disease. Hypothyroidism.
- Rheumatic disease. Early inflammatory arthritis, spondyloarthropathies, myositis, primary generalized osteoarthritis, or polymyalgia rheumatica.
- Neurological disease. Myopathy, neuropathies, or multiple sclerosis.
- Psychological disease. Depression.
- Drug-related. Statins, aromatase inhibitors, and bisphosphonates.
- Infectious disease. Lyme disease, hepatitis C infection, and human immunodeficiency virus.
Fibromyalgia is a clinical diagnosis. There are no confirmatory laboratory investigations for Fibromyalgia. While the research setting has identified objective neurophysiologic abnormalities, these are not available in clinical practice for either the diagnosis or care of patients with Fibromyalgia (Recommendation 11).
To rule out conditions that can present similarly, testing should be limited to a full blood count, ESR, CRP, creatine kinase, and thyroid stimulating hormones, unless other medical conditions are likely based on clinical evaluation (Recommendation 4). A low titre positive antinuclear antibody (ANA) is present in 10% of the normal population. This is not predictive of future connective tissue disease and is not a recommended screening test for Fibromyalgia. Avoid repeat investigations after diagnosis unless indicated by new signs and symptoms (Recommendation 5).
- Endocrine, rheumatic, neurologic, and malignant conditions may present similarly to Fibromyalgia and should be included in the differential diagnosis.
- There are no confirmatory laboratory tests in Fibromyalgia.
- Testing should be limited to a complete blood count, ESR, CRP, creatine kinase, and TSH unless otherwise indicated.
- Repeat investigations after diagnosis should be avoided, unless driven by new symptoms or signs.
- Red flags should prompt further investigation.
- Fibromyalgia is not a diagnosis of exclusion.
According to the 2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome, the primary care physician should establish a diagnosis of Fibromyalgia as early as possible, without need for confirmation by a specialist, and communicate this diagnosis to the patient (Recommendation 5). Delay in Fibromyalgia diagnosis leads to adverse outcomes, personal, health-related, and financial.
Diagnosis and management of Fibromyalgia should concentrate in the primary care setting, with access to a multidisciplinary team if possible (Recommendation 8). There is no clear advantage for specialist care, which should be reserved for patients with complex comorbidities or who have failed primary care (Recommendation 9).
The 2016 diagnostic criteria as established by the American College of Rheumatology can be administered by any physician and has only 2 components:
- Widespread Pain Index (WPI)
- Symptom Severity Scale (SSS)
Two different thresholds for the WPI and SSS recognizes that symptoms such as fatigue may be a more predominant feature in some patients, rather than widespread pain.
Source: American College of Rheumatology
- Diagnosis and management of Fibromyalgia should concentrate in the primary care setting.
- The primary care physician should establish a diagnosis of Fibromyalgia as early as possible, without need for confirmation by a specialist.
- The 2016 ACR diagnostic criteria has only two components, the WPI and SSS.
- Different thresholds for diagnosis recognizes that some patients may present predominantly with symptoms such as fatigue instead of pain.
No cure for Fibromyalgia currently exists. Health care practitioners should acknowledge pain and suffering and avoid over-medicalization of Fibromyalgia patients. Treatment is directed towards symptom management and optimizing function. Self-management using a multimodal approach focusing on individual symptoms and with close monitoring is ideal (Recommendation 13). Fostering strong patient-centered loci of control will improve self-efficacy and response to treatment. Patients should be encouraged to identify specific goals regarding their health status and quality of life, with re-evaluation of these goals during follow-up (Recommendation 14).
Main treatment should be multimodal with a non-pharmacologic focus:
- Patient education
- Self-management skills, including goal setting, action plans, and flare management plans
- Psychological management strategies, such as cognitive behavioural therapy (CBT)
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).
- Active participation (versus passive modalities such as massage therapy)
- Goal setting
- Having a daily action plan and a ﬂare-management plan
- Central 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
Action Plan and Flare Management Plan Examples
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:
- Avoidance. Typically during times of severe pain or flare. Leads to deconditioning, weaker and tighter muscles, decreased stamina, and increased pain alarm sensitivity.
- 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.
- 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.
Psychological management strategies
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.
- Patient education on the nature of the condition has high eﬃcacy for promoting self-management and shifting the locus of control towards the patient.
- Active patient participation that encourages self-efficacy and social support helps facilitate the practice of health-promoting lifestyles, improving attitudes and coping skills.
- Encourage patients to pursue as normal a life as possible, maintaining or improving function with pacing and/or graded incremental activity.
- Goal setting is an effective tool to change behaviour. Goals are concrete actions that should be achievable.
- The acronym SMART (Specific, Measurable, Attainable, Realistic/Relevant, Timely) can help patients set achievable goals.
- Goals should be adjusted if patients do not feel at least 70% confident that they can achieve it.
- Goals should be constantly re-evaluated during follow-up.
- Daily personal care plans and flare management plans improve patient self-efficacy, especially in times when pain is severe.
- 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.
- Comorbid psychological disease affects pain, quality of life, and response to treatment.
- Even without obvious signs of depression or anxiety, psychological interventions can be helpful in Fibromyalgia.
Evidence for pharmacologic therapies is poor, and patient expectations should be managed. Pharmacologic therapy is used as an adjunct to non-pharmacologic therapy. It is important to identify the most bothersome symptoms(s) to help design a targeted treatment strategy (Recommendation 24). Ideally, a single pharmacologic agent can address multiple symptoms. However, physicians should be aware of the categories of agents available to treat Fibromyalgia and not confine treatments to a single class of medications (Recommendation 26).
- Antidepressants (TCAs and SNRIs)
- NSAIDs and Acetaminophen
Tricyclic antidepressants (TCAs)
Serotonin and norepinephrine help mediate descending inhibition to decrease sensory input from the periphery. Serotonin also has roles in regulating mood and mediating Stage 4 sleep. Norepinephrine is involved in regulating attention and memory. Studies have demonstrated decreased CSF concentrations of serotonin in Fibromyalgia
TCAs inhibit both serotonin and norepinephrine reuptake. Amitriptyline has been the most extensively studied and has signiﬁcant beneﬁt with both pain reduction, fatigue, and sleep. However, it is often less well tolerated than Nortriptyline due to side eﬀects. TCAs are most helpful for patients with comorbid sleep dysfunction and fatigue. Patients should be counselled that they may not see benefit for 6-8 weeks after reaching the optimal dose.
Amitriptyline or Nortriptyline initiation and titration:
- Start at 10 mg PO qHS
- Increase by 5-10 mg PO every 1-2 weeks as tolerated
- Recommended dosage for pain management is 10 - 50 mg/day, although some studies suggest no additional beneﬁt at > 25 mg/day
Dose adjustment in renal insufficiency:
- No speciﬁc dose adjustment necessary
Dose adjustment in hepatic insufficiency:
- Use with caution
- Lower initial dose by 50% and be cautious with dose titration
- In poor metabolizers, recommend avoiding use due to increased risk for adverse eﬀects
Side eﬀects of TCAs:
- Dry mouth
- Daytime drowsiness - recommend taking earlier in the evening if morning drowsiness is a signiﬁcant concern
- Mental clouding
- Be wary of anticholinergic side effects in the elderly
Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)
SNRIs also inhibit both serotonin and norepinephrine reuptake. Duloxetine has been the most studied, and signiﬁcantly improves pain in ﬁbromyalgia. It is most helpful in patients with comorbid depression or generalized anxiety. Patients should be counselled that they may not see benefit for 4-6 weeks after reaching the optimal dose.
Duloxetine initiation and titration:
- Start at 30 mg PO daily
- Increase by 30 mg every 1-2 weeks as tolerated
- Optimal dosing is 60 - 90 mg/day. Studies have shown no diﬀerence at doses > 90 mg/day, and many patients are unable to tolerate doses > 60 mg/day
Dose adjustment in renal insuﬃciency:
- Avoid use in severe impairment (eGFR < 30 mL/min)
Dose adjustment in hepatic insufficiency:
- Duloxetine is extensively metabolized by the liver
- Avoid use in patients with chronic liver disease or severe cirrhosis
Side eﬀects of duloxetine:
- Drowsiness (~10%) - recommend qHS dosing
- Alertness (~10%) - recommend qAM dosing
- Duloxetine is metabolized via the CYP450 2D6 pathway, which also metabolizes around 25% of clinically used drugs
- Risk of serotonin syndrome when using in conjunction with tramadol, TCAs, or SSRIs. Symptoms are variable (agitation, ﬂushing, sweating, tremor), and treatment is mainly supportive.
- Increased risk of serotonin syndrome with increased age and higher doses
Pregabalin and Gabapentin are structurally similar to γ-aminobutyric acid (GABA) but exert their analgesic eﬀect by binding to voltage-gated calcium channels in the CNS, reducing calcium inﬂux and the release of neurotransmitters such as substance P and glutamate. They are useful in Fibromyalgia to manage both pain and sleep disturbance but are less eﬀective for fatigue.
Pregabalin initiation and dose titration:
- Start at 25 mg PO QHS for 1-2 weeks then increase to 25 mg PO BID
- Increase by 25 mg/dose every 1-2 weeks as tolerated
- Maximum daily dosing is 300 mg PO BID (600 mg/day), but some studies suggest there is no additional beneﬁt > 450 mg/day
Pregabalin dose adjustment in renal insufficiency:
- Pregabalin dosing in renal insuﬃciency is adjusted according to the target dose with normal renal function (e.g. target dose 450 mg/day when CrCl > 60 is equivalent to a dose of 50-75 mg/day when CrCl < 15). See table below:
Pregablin dose adjustment in hepatic insufficiency:
- No adjustment necessary
Gabapentin initiation and dose titration:
- Start at 100 mg PO QHS for 1-2 weeks then increase to 100 mg PO TID
- Increase by 100 mg/dose every 1-2 weeks as tolerated
- Maximum daily dosing is 3000 mg/day in divided doses
Gabapentin dose adjustment in renal insuﬃciency:
- Gabapentin is similarly dose-adjusted in renal insuﬃciency, according to the table below:
Gabapentin dose adjustment in hepatic insuﬃciency:
- No adjustment necessary
In most trials, medications were studied as single agents.
- Despite limited data, these medications are typically used concurrently in clinical practice in patients who respond poorly to a single agent
- Small studies have shown that patients receiving duloxetine in combination with pregabalin had improved pain compared to either agent alone
- Pregabalin and Gabapentin have few medication interactions and can be safely used in combination with TCAs, SNRIs, and SSRIs
- However, there are also more side eﬀects associated with dual therapy
Use of opioids is controversial and discouraged in the 2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome. Patients with Fbromyalgia likely have abnormal endogenous opioidergic activity (elevated levels of endogenous opioids in the CSF, opioid receptor down-regulation, and decreased mu-opioid receptor binding), which contributes to poor response to opioid medications. Side eﬀects such as drowsiness, mental clouding, dizziness, nausea, and constipation also limit eﬃcacy. There is increased risk for significant long-term adverse effects, including increased mortality, addiction, dependence, reduction of testosterone, and opioid-induced hyperalgesia.
Tramadol is a weak opioid with combined mu-receptor agonism and serotonin and norepinephrine reuptake inhibition. Tramadol may be beneﬁcial but there is potential for interaction with other medications, causing serotonin syndrome. A trial of a weak opioid such as tramadol should be reserved treatment of moderate to severe pain unresponsive to other modalities (Recommendation 29). It should ideally be used for flare-ups and breakthrough pain, with avoidance of daily use to help prevent development of tolerance. Strong opioid use is discouraged. Patients who continue to use opioids should show improved pain and function, and healthcare providers should monitor for efficacy, side effects, and aberrancy (Recommendation 30).
NSAIDs and Acetaminophen
NSAIDs act peripherally to reduce inﬂammation, but pain in Fibromyalgia is not nociceptive. A recent Cochrane review recommended against the use of NSAIDs for the management of Fibromyalgia. However, the 2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome recommends using NSAIDs at the lowest possible dose for the shortest possible time in concurrent conditions, such as osteoarthritis (Recommendation 28). Any concurrent inﬂammatory or mechanical MSK condition should be treated appropriately, and may involve the use of NSAIDs
Acetaminophen helps modulate the endogenous cannabinoid system and works as a serotonin receptor agonist, so is postulated to be beneﬁcial in the treatment of Fibromyalgia. There is no direct evidence for or against acetaminophen. In line with the World Health Organization set-up analgesic ladder, acetaminophen may be useful in some patients, but with attention to safe dosing (Recommendation 27).
Cannabinoid use for pain relief is controversial and long-term effects are unknown. A trial may be considered in Fibromyalgia patients, especially with simultaneous significant sleep disturbance (Recommendation 31).
Naltrexone is an opioid antagonist. Use in Fibromyalgia management at low doses (5 mg/day) has been evaluated in small studies, which have shown 20-30% of patients achieve significant reduction compared to placebo. Currently it is not available in Canada at doses smaller than 50 mg/day, therefore needs to be compounded. In Ontario, this works out to an approximate cost of $100 per month. Larger studies are required before recommendations can be made.
- Evidence for pharmacologic therapies is poor, and patient expectations should be managed.
- Pharmacologic therapy is used as an adjunct to non-pharmacologic therapy.
- It is important to identify the most bothersome symptoms(s) to help design a targeted treatment.
- Physicians should be aware of the categories of agents available to treat Fibromyalgia and not confine treatments to a single class of medications.
- TCAs are most helpful for patients with comorbid sleep dysfunction and fatigue.
- Duloxetine is most helpful in patients with comorbid depression or generalized anxiety.
- Gabapentinoids are useful to manage both pain and sleep disturbance but are less eﬀective for fatigue.
- Most trials studied medications as single agents. Gabapentinoids can be safely added to TCAs or SNRIs, but there is increased risk of medication side effects.
- Use of opioids is controversial and discouraged. Side eﬀects such as drowsiness, mental clouding, dizziness, nausea, and constipation also limit eﬃcacy
- Opioids increase risk for significant long-term adverse effects, including increased mortality, addiction, dependence, reduction of testosterone, and opioid-induced hyperalgesia.
- A trial of a weak opioid such as tramadol should be reserved treatment of moderate to severe pain unresponsive to other modalities
- Strong opioid use is discouraged. Patients who continue to use opioids should show improved pain and function, and healthcare providers should monitor for efficacy, side effects, and aberrancy.
- NSAIDs should be used at the lowest possible dose for the shortest possible time in concurrent conditions, such as osteoarthritis.
- In line with the World Health Organization set-up analgesic ladder, acetaminophen may be useful in some patients, but with attention to safe dosing.
- Cannabinoid use for pain relief is controversial. A trial may be considered in Fibromyalgia patients, especially with simultaneous significant sleep disturbance.
- Naltrexone, an opioid agonist, has shown significant pain reduction in 20-30% of patients at low doses. Larger studies are required before recommendations can be made.
There are many challenges in Fibromyalgia management that have been outlined in the previous sections. These include:
- An unclear and evolving aetiopathogenesis
- Balancing over-medicalization with missing organic disease
- Signiﬁcant concurrent psychological comorbidities, requiring a biopsychosocial approach to management
- The need to manage coexisting disease which may present similarly
- Managing patient expectations
- There are limitations to pharmacologic therapy
Despite this, there is no clear advantage for specialist care (Recommendation 9).
Pain specialist management should be reserved for the following conditions:
Patient motivated to complete in person MOH funded self management program
Patient motivated to complete 3 hour patient education session
Patient motivated to complete Psychological group services: MBSR, CBT or ACT
Difficulty weaning off high dose opioid therapy (high dose is over 90 mg Morphine equivalents per day).
Patients are motivated to convert opioids to safer buprenorphine options,
Patients have pain in a well defined dermatomal distribution.
Patients require pre operative pain optimization or post operative pain management or opioid weaning.
Well functioning patient with spinal stenosis not improving with conservative management.
Rheumatological specialist referral should only be considered when blood work and symptoms are in keeping with a known rheumatologic disorder.
- Fibromyalgia management has multiple challenges.
- Specialist care has not been shown to offer any clear advantage.
Ms. PK – Case
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.
Ms. PK – Diagnosis and Management
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:
- 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.
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.
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.
- 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.
- 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 – Follow-Up #1
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.
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 – Follow-Up #2
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.
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.
- Diagnosis and management of Fibromyalgia should concentrate in the primary care setting.
- The primary care physician should establish a diagnosis of Fibromyalgia as early as possible, without need for confirmation by a specialist.
- Multimodal treatment is ideal, and includes patient education, self-management, exercise, and psychological therapy.
- Active patient participation is essential to improving pain and well-being.
- Pharmacologic management has limited benefit, and agents should be chosen to target specific symptoms. Doses should be titrated slowly.
- Gabapentinoids can be safely added to TCAs or SNRIs.
Fibromyalgia is one of the most commonly encountered chronic pain conditions with an estimated 2-3% prevalence in Canada. Although the pathophysiology is not well understood, changes to both the peripheral and central nervous systems result in amplified sensitivity to external stimuli. The 2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome suggest that the primary care physician should establish a diagnosis of Fibromyalgia as early as possible, without need for confirmation by a specialist, and communicate this diagnosis to the patient (Recommendation 5). In caring for persons with Fibromyalgia, healthcare professionals should be educated regarding the pathogenesis of Fibromyalgia (Recommendation 10).
No specific features on physical examination are diagnostic of Fibromyalgia, and neuromuscular examination is usually normal except for soft tissue sensitivity to pressure sensation. Tender points may be present but are not required to confirm a clinical diagnosis. The 2016 ACR diagnostic criteria has only two components, the WPI and SSS, which can easily be administered by any health care professional.
Multimodal management is key in the treatment of Fibromyalgia, and includes patient education, self-management, exercise, and psychological management. Active patient participation is important to promote self-efficacy and shift the locus of control towards the patient. Patients should be encouraged to pursue as normal a life as possible, maintaining or improving function with pacing and/or graded incremental activity. Evidence for pharmacologic therapies is poor, and patient expectations should be managed. Pharmacologic therapy is used as an adjunct to non-pharmacologic therapy. It is important to identify the most bothersome symptoms(s) to help design a targeted treatment. Medication options include antidepressants (TCAs and SNRIs), gabapentinoids, opioids, cannabinoids, NSAIDs, acetaminophen, and naltrexone. In general, only a 20-30% improvement in pain is expected with the use of medications. Where possible, engage patients in interdisciplinary management. Specialist care has not been shown to offer any clear advantage.
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