Key Practice Points in the Management of Fibromyalgia
Am Fam Physician. 2007 Jul 15;76(2):195-202.
This article exemplifies the AAFP 2007 Annual Clinical Focus on management of chronic illness.
In this era of evidence-based medicine, physicians often must make decisions where neither evidence nor consensus exists. This may explain why physicians often feel frustrated when faced with a patient with fibromyalgia. Fortunately, there is a growing body of evidence to assist in managing this chronic pain syndrome. A 2004 systematic review of fibromyalgia treatment options1 and the 2005 consensus guidelines from the American Pain Society2 help to define a clinical syndrome that is often vague in presentation and variable in response to treatment. Now that there is an evidence- and consensus-based practical approach to the diagnosis and management of fibromyalgia, a higher quality of care can be provided to patients with this syndrome.
Chakrabarty and Zoorob offer a clinical review of the diagnosis and management of fibromyalgia in this issue of American Family Physician.3 Additionally, there are several key points worth emphasizing for physicians who manage this challenging syndrome.
The American College of Rheumatology (ACR) published diagnostic criteria in 1990 for use in fibromyalgia research to ensure diagnostic consistency.4 Although these criteria are clinically useful, physicians should be aware that a diagnosis of fibromyalgia can be made if the history alone is highly suggestive of the diagnosis—even if the ACR's tender point criteria are not met.5
Emerging evidence suggests that fibromyalgia is a disorder of central pain processing. Dysregulation of the hypothalamic-pituitary-adrenal axis6 and altered activity of serotonin,7,8 norepinephrine, substance P,9 and other neurohormones have been implicated in the transmission of painful stimuli that may contribute to heightened pain sensitivity. This theory lends support to targeted central nervous system therapies, such as antidepressants and cognitive behavior therapy, which have the ability to modulate the pain response. The concept of altered central pain processing also explains why peripheral pain modulators (e.g., nonsteroidal anti-inflammatory drugs) are less effective unless a coexisting inflammatory disorder is also being treated. Screening for disorders that may initiate or exacerbate symptoms of fibromyalgia is critical. If comorbid disorders are not identified early and treated appropriately, therapies that target fibromyalgia only as a primary disorder may be ineffective (Table 110–16).
Table 1. Screening Questions for Fibromyalgia and Associated Conditions
Screening Questions for Fibromyalgia and Associated Conditions
Over the past two weeks, have you felt nervous, anxious, or “on the edge”?
Over the past two weeks, have you been unable to stop or control your worrying?
Chronic fatigue syndrome
Have you had more than six months of fatigue that is not relieved by rest and is severe enough to limit your daily activities?
Have you had any of the following symptoms: fever, sore throat, enlarged or painful nodes, muscle weakness or pain, headaches, joint aches, trouble concentrating, or sleep disturbance? Did any of these symptoms occur over several hours to days?
Over the past two weeks, have you felt “down,” depressed, or hopeless?
Over the past two weeks, have you had little interest or pleasure in doing things?
Have you had whole-body pain for a long time?
Are various parts of your body painful to touch?
Do you have trouble sleeping?
Do you feel tired more days than not, without an identifiable reason?
Irritable bowel syndrome
For three months or more in the past year:
Have you had abdominal pain or discomfort that is not relieved with a bowel movement? If so, has the pain or discomfort been associated with a change in stool frequency or appearance?
Do you have other symptoms such as heartburn, difficulty swallowing, nausea, feeling full soon after starting to eat, or bloating?
Restless legs syndrome13
Do you have uncomfortable or unpleasant leg sensations when sitting or lying down?
Do you have an urge to move when sitting or lying down?
Are your symptoms worse when you are lying down than when moving around?
Are your symptoms relieved by moving around or walking?
Are your symptoms worse at night?
Assess patient for elevated body mass index and hypertension.
Do you snore?
Does your snoring bother other people?
How often have others noticed pauses in your breathing while sleeping?
Are you tired after sleeping?
Are you tired during the day?
Have you ever fallen asleep while driving?
Do you have pain in your temples, face, temporomandibular joint, or jaws at least once a week?
Do you have pain at least once a week when you open your mouth wide or chew?
Fibromyalgia is considered a chronic pain syndrome; therefore, the same principles of treatment for other such syndromes should apply. This includes providing education about the diagnosis, setting realistic treatment goals, encouraging a multimodal approach to therapy (i.e., nonpharmacologic and pharmacologic treatment options), and using reliable tools to assess outcome measures.
Reliable tools should be used to assess pain and function before and after therapeutic interventions to determine their effectiveness. The Fibromyalgia Impact Questionnaire (see online figure) is one such tool that can be used to objectively measure the patient's response to therapeutic interventions.17 Other general tools for assessing outcome in chronic pain syndromes include the Graded Chronic Pain Scale18 and the Brief Pain Inventory.19
Patients with fibromyalgia often will seek complementary and alternative treatments. Although strong evidence is lacking for such therapies,20 it is important to be nonjudgmental and supportive, as long as the integrative therapy does not cause direct harm or interact with other treatments.
Much controversy surrounds the usefulness of opioids in the management of fibromyalgia, but few data exist on their effectiveness in this disorder. Physicians should be aware of the potential for opioid-induced hyperalgesia.21–23 As with any chronic pain syndrome, patients should be carefully selected for opioid therapy, and a plan should be in place for appropriate follow-up and monitoring for pain reduction, outcome improvement, side effects, and misuse.
Fibromyalgia should be treated as a chronic pain disorder, not as an acute exacerbation of pain. It is helpful to schedule regular visits when the patient is in a stable state as well as during exacerbations. Physician awareness of effective nonpharmacologic and pharmacologic therapies can minimize ineffective prescribing and patient frustration associated with failure of therapy. As growing evidence from well-designed studies becomes available, physicians can confidently employ a practical and evidence-based approach to this once ill-defined syndrome.
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