Top Tips on managing fibromyalgia
Dr Alex Allinson’s advice on what GPs can do to diagnose fibromyalgia and manage the chronic pain
Dr Alex Allinson's advice on what GPs can do to diagnose fibromyalgia and manage the chronic pain
1 Although the pathogenesis is still in doubt, diagnostic criteria for fibromyalgia are now established and validated. It's a common condition affecting 1-3% of the population. Most sufferers are in their 40s or 50s and about 90% are female. International studies have shown a marked similarity in symptoms across both developed and developing countries. A primary care diagnosis is vital to reassure patients that they have a chronic, but not progressive, disease.
2 Fibromyalgia is a syndrome predominantly of chronic pain. The key feature is extreme tenderness over symmetrically distributed pressure points. Pressure should be firm enough to cause the examiner's finger to blanch, which will elicit a withdrawal response in fibromyalgia. Areas to check are:
• over the lower cervical spine
• posterior base of the skull
• midway along the supraspinatus muscle
• midway along the trapezius muscle
• the pectoralis insertion at the second costochondral junction
• the lateral epicondyle
• the upper-outer quadrant of the buttock
• the greater trochanter
• the medial fat pad of the knee.
Hyperalgesic withdrawal at 11 or more of these 18 points is diagnostic. See diagram above.
3 Fatigue and non-restorative sleep help to distinguish fibromyalgia from other chronic pain conditions. The fatigue is after exertion and limits patients' ability to care for themselves in extreme cases. Lack of non-REM sleep means patients don't complain of insomnia or early morning waking but wake up tired and unrefreshed.
4 There is no diagnostic test for fibromyalgia but it is vital to exclude other conditions such as hypothyroidism, osteomalacia and inflammatory disorders. Routine investigations should include FBC, U&Es, LFTs, calcium levels and alkaline phosphatase, CRP, ESR, auto-immune screen and creatinine kinase.
5 If the blood tests are normal and the clinical picture fits, be confident about the diagnosis. Referral to a rheumatologist is rarely useful except for validation. The Arthritis Research Campaign publishes an excellent patient information leaflet – see www.arc.org.uk. Reassure that it is not a progressive condition, but one that can be managed and lived with.
6 Patients will often have already looked at various alternative treatments. The internet is unfortunately awash with offers of magical cures. Patients may have been recommended to have restriction diets, tried taking guaifenesin – a compound used commercially as a decongestant – or been prescribed thyroxine online even though they may have a normal TFT. Many take ginkgo biloba to aid circulatory problems, and valerian to help restore sleep and combat anxiety. The results from massage and acupuncture tend to be shortlived and disappointing.
7 Conventional analgesics such as paracetamol, opiates and NSAIDs are rarely helpful. Fibromyalgia is thought to be caused by an abnormality in the central processing of pain stimuli. Localised steroid injections at pressure point sites give only short-term relief. Tramadol is probably the most helpful analgesic in trials. SSRIs such as fluoxetine can be helpful even when depression is not obviously present. Low-dose amitriptyline – 25mg to 75mg at night – can be very helpful with pain and sleep disturbance but patients with fibromyalgia tend to be more sensitive to adverse effects of medication and I would recommend starting on a low dose and gradually titrating upwards.
8 Two drugs have recently been licensed in the US specifically for the treatment of fibromyalgia. Pregabalin (Lyrica) has been used successfully for neuropathic pain from a range of causes and its twice-daily administration with a gradually increasing dose can be helpful in a proportion of patients. Duloxetine (Cymbalta) is an SNRI that has also been shown to help with disorders of central pain perception, although nausea is a common adverse effect.
9 Exercise prescriptions and CBT have been proven to work. Studies have shown a consistent improvement at 12 months after a programme of exercise on prescription. There is still some debate about the comparative benefits of graded exercise, where a patient follows a set programme, and paced exercise where the programme is adapted to the patient's level of fatigue. CBT has been found to be very helpful. By countering negative illness behaviour and encouraging a more positive outlook, it can improve functioning and aid recovery.
10 One of the most important roles a GP can play is active diagnosis, explanation and support through reassurance and education. Self-help groups can help overcome feelings of isolation and frustration as well as give practical advice on issues such as benefits and local support.
Dr Alex Allinson is a GP on the Isle of Man and medicolegal adviser to UKFibromyalgia.
Competing interests: Dr Allinson has attended conferences organised by, and received an honorarium from, Pfizer
Hypalgesic withdrawal at 11 of these 18 points is diagnostic of fibromyalgia Fibromyalgia diagnostic points