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Fibromyalgia Syndrome (FMS)

 

A diagnosis of fibromyalgia can be made in primary care and there are no additional management strategies available in Rheumatology that are not accessible in primary care.

As there is no secondary care commissioned service for patients with fibromyalgia in Cornwall -

Referrals for fibromyalgia will be rejected. 

 

Diagnosis

A diagnosis of fibromyalgia should be considered in patients presenting with widespread musculoskeletal pain without clinical signs of inflammatory arthritis. 

  1. Symptoms have been present for at least 3 months.
  2. Widespread pain index (WPI) 7 or more, symptom severity (SS) scale  score 5 or more or WPI 3 or more and SS scale score 9 or more.
  3. Generalised pain in 4 or 5 body regions (right upper limb, left upper limb, right lower limb, left lower limb, spine).
  4. Have no alternative explanation.

 

Widespread pain index (WPI):

WPI notes the number of areas in which the patient has had pain in the last week, see below diagram

Symptom Severity Score: 

Trigger points are not required to make a diagnosis of fibromyalgia but can help confirm your diagnosis (press with just enough pressure to blanch your fingertip – a hyperalgesic response is a positive test).



Investigations

Typically investigations are normal in fibromyalgia.

Consider FBC, U&E, LFT, bone profile, CRP, TFT to rule out other pathologies. 

Only consider RF if strongly suspicious of rheumatoid arthritis.

ANA is not recommended unless there is strong clinical suspicion of an autoimmune connective tissue disease (ANA positive in up to 20-30% of healthy individuals).

Note that a high BMI may be a cause of mildly elevated CRP.

 

Management

Management should focus on non-pharmacological therapies as these are more effective than pharmacological treatments with strong emphasis on patient education at avoiding drug reliance.

 

Non-pharmacological

  • Explain fibromyalgia is a disorder of pain processing & direct to self-help resources
  • Promote graded aerobic exercise (evidence indicates graduated aerobic exercise improves pain, depression, physical function and quality of life) 
  • Psychological therapy (cognitive behavioural therapy, mindfulness, relaxation techniques)
  • Pacing
  • Sleep hygiene advice
  • Fit note for workplace adaptations.

 

Pharmacological

  • Amitriptyline 10-25mg OD (1 in 3 patients report a 30% reduction in pain, small effect on sleep and fatigue.  Increased dose of no benefit)
  • Duloxetine up to 60mg OD (1 in 6 patients report a 30% reduction in pain, small effect on sleep and minimal effect on fatigue.  Increased dose of no benefit)

 

AVOID:

  • Pregabalin/Gabapentin – drug addition and withdrawal effects (1 in 9 patients report a 30% improvement in pain, minimal effect on sleep or fatigue).  Use of Pregabalin or Gabapentin for fibromyalgia strongly discouraged.
  • Tramadol – opioid addition and withdrawal effects (Minimal evidence of pain, sleep or fatigue improvement).  Strongly discouraged.
  • NSAIDs – no evidence of improved outcome compared to placebo.  Not recommended for use in fibromyalgia (may help with co-existing symptoms of osteoarthritis).

 

Patient information:

 

 

References:

EULAR Guidelines Fibromyalgia 2016, https://ard.bmj.com/content/76/2/318

NICE KTT21, Medicine optimisation in Chronic Pain, https://www.nice.org.uk/advice/ktt21/chapter/Evidence-context#opioid-medicines-in-chronic-pain

 

 

Contributors:

Dr Tim Jenkinson (Consultant Rheumatologist, RCHT)

Dr Bridgitte Wesson, GP & Kernow RMS Rheumatology Guideline Lead