Guidelines for Fibromyalgia

Fibromyalgia

Guidelines for treatment: Patients and Physicians

 Summary prepared by Pat Morley-Forster, MD FRC(PC), Medical Director, St Joseph's Pain Management Program, Professor, Department of Anesthesia and Perioperative Medicine, Western University, London, Ontario.

This article summarize the 2012 Canadian Fibromyalgia Guidelines, a multi-page document with over 250 references and 35 recommendations from a panel of medical experts. It provides evidence-based information about fibromyalgia for patients, their families, and family doctors. One of the strongest recommendations is that family doctors should care for people with fibromyalgia within their primary care practice. The complete 2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome in Adults are available at http://www.canadianpainsociety.ca/pdf/Fibromyalgia_Guidelines_2012.pdf

What is Fibromyalgia?

Fibromyalgia is a syndrome consisting of a group of symptoms, the main one being pain, in several different areas of the body. Other major symptoms include:

  • fatigue
  • non-restorative sleep
  • low mood
  • forgetfulness
  • jaw pain (TMJ syndrome)
  • irritable bowel or bladder symptoms.

Specialized magnetic resonance imaging (MRI) studies in research trials have shown abnormalities in the way the brain processes pain at several levels in the brain and spinal cord. Often, people experience symptoms for years before the diagnosis is made. It is most common in women aged 40-60 years, though can affect both genders and all ages. Severity ranges from mild to severe, with symptoms changing over time.

What causes fibromyalgia?

In about 30 per cent of people with fibromyalgia, there has been a viral illness, an accident or a significant emotional trauma that has triggered the symptoms. There may also be a genetic susceptibility. Emotional distress may also contribute to feelings of widespread pain.

Problems in early childhood are suspected to be important as well as they may lead to development of a “fragile stress response system”. There is increasing evidence that fibromyalgia sufferers have a chemical imbalance in the central nervous system, although the cause is unknown.

How is fibromyalgia diagnosed?

The diagnosis is made clinically, that is by the history and a physical examination. By general consensus, the history (generalized pain, plus fatigue, plus sleep disturbance) is now considered to be more important than the physical examination. There is no blood test or X-ray to confirm fibromyalgia.

The physical examination often shows soft tissue tenderness at many points throughout the body. To the person with fibromyalgia, this can feel similar to joint pain, or arthritis. The number of tender points spontaneously varies over time and does not indicate either progression of the illness or degree of disability. Sensitivity to light touch, and burning pain is often present as well.

A definitive diagnosis is reassuring, and helps both the doctor and patient to stop looking for other causes and to focus on a plan of management. Once the diagnosis has been made, the number of visits to specialists and investigations has been shown to decrease.

Treatment

There is no cure, though symptoms of fibromyalgia can be managed. Treatment must be individualized and should include both medication and non-medication strategies such as heat, stretching exercises, and warm water pool exercises. It is very important that the person affected become an active participant in their care and try to live a healthy lifestyle with regular exercise, pacing of activity, healthy diet, regular sleep, and stress management. A combination of medications, at lower than usual doses, may be more effective and cause less side effects than higher doses of one single medication. Other treatments/strategies include:

  • Self-management strategies: People with fibromyalgia should pursue as normal a life as possible using pacing or a graded increase in activity to maintain function. It is useful to set goals so as to feel a sense of accomplishment when these are reached.
  • Psychological treatment: Individual counselling, plus group education, is useful because knowledge can change false and destructive beliefs about the pain and reduce fear of activity.
  • Exercise: Choose an activity that is enjoyable, easy to follow, convenient, and within your budget. Walking is often the activity of choice and is more likely to be successful with a committed walking partner. There are many other exercise options to consider. Don’t forget stretching regularly, light weights (1-3 pounds), exercise balls, or even dancing at home to your favorite music. The guidelines recommend a total of 150 minutes per week of aerobic activity, which may be broken up into 10 minute segments.  Note: Housework is not considered exercise.
  • Complementary and alternative therapies: While most people with fibromyalgia use complementary treatments, the results generally don’t show long-term effectiveness. Both massage and acupuncture contribute to a feeling of relaxation and short periods of pain relief, which is why people often stick with such treatments, if affordable for them.
  • Medications: There are a number of medications that may help with pain, but none will relieve the pain of fibromyalgia completely.

Also, medications will work much better when combined with an active lifestyle, good nutrition and stress management.  There is no single ideal drug. Combinations of different classes of medications at low doses often work better, with fewer side effects, than a large dose of one medication. The doctor should regularly evaluate how well medications are working and if side effects are present. Medication side effects may cause more problems than the fibromyalgia syndrome itself. It is not uncommon for people to find benefit from one medication for a while only to be disappointed when it loses its effectiveness.

Over-the-counter acetaminophen, and anti-inflammatory drugs, may help for acute flares, but should not be taken regularly.

The following medications have shown some benefit in relieving pain in research studies of fibromyalgia:

  • anticonvulsants – pregabalin, gabapentin
  • antidepressant-type drugs - amitriptyline, nortriptyline, duloxetine
  • muscle relaxant – cyclobenzaprine
  • Opioids: Major opioids (narcotics) like morphine are not recommended in the long-term management of fibromyalgia pain. Although the pain may initially respond to an opioid, it usually loses its effectiveness within a month or two leading to dose increases. Opioids like tramadol, tapentadol and Bu-Trans® patches are safer, long-term strategies to avoid the potential risk of addiction. 
  • lidocaine infusions: The local anesthetic, lidocaine, when given intravenously over 45 minutes may reduce the pain for to 2-4 weeks. It is only in your body for 12-18 hours after the infusions but seems to turn off the abnormal pain signaling of fibromyalgia for several weeks. This treatment has not been definitively proven by research trials.
  • ketamine: This can be given as an intravenous infusion, a gel, or a pill and is best reserved for severe flare-ups of pain.
  • cannabinoids (marijuana) - A cannabinoid pill, called nabilone, may help with sleep and pain. Plain forms of marijuana can be smoked or made into an edible form, such as cooking oil or tea. A medical doctor has to approve the medicinal marijuana licence and then the patient must obtain it from a licensed private grower.. As the by-products of smoking any substance are toxic to the lungs, and marijuana usually clouds thinking, this option should not be considered lightly.

Specialist care or family doctor?

The 2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome in Adults recommend that, in general, it is best for fibromyalgia patients to be followed by their family doctor rather than a specialist. A doctor, who has a long-standing association with the person with fibromyalgia and their family will have a better understanding of that individual’s personal strengths and stressors.

Other health disciplines such as nurses, physiotherapists, social workers, psychologists, kinesiologists, and dietitians are very helpful in teaching people how to cope with stress and to remain active, but to pace their activity. A family doctor can help access these other health professionals.

Continued care by a pain specialist or rheumatologist should be reserved for those patients who have more complex problems in addition to fibromyalgia.

What about work?

People with fibromyalgia who remain in the workforce have less severe symptoms and a better quality of life than those who go on disability. Remaining employed is more likely when the employer is able to make modifications in the work environment. Participation in a good rehabilitation program that focuses on improving function will help in promoting a return to work.

Summary

Although there is no cure for fibromyalgia at present, we now know it is a real illness. Many people do achieve reasonable control of their symptoms and are able to lead active and fulfilling lives. Those who are most successful in managing their pain and fatigue grow to understand the importance of activity, pacing, stress management and staying positive. This is why it is sometimes described as a “journey inwards.”


Acknowledgments:
Thank you to Noelia Perez-Fernandez and Cathy Rohfritsch, RN for their contributions to the design of this handout.

March 25, 2014