Establishing the diagnosis
First, confirm whether the diagnosis of fibromyalgia is already an established condition, or whether the patient has self-diagnosed and is coming to seek help with diagnosis.
Diagnosis should have been undertaken by a specialist such as a rheumatologist or GP with a specialist interest, as the fibromyalgia has no diagnostic tests and is a diagnosis of exclusion.
Fibromyalgia syndrome (FMS) is characterised by the presence of chronic widespread pain, often combined with other multiple symptoms, in the absence of any currently demonstrable pathology.
Fibromyalgia can co-exist with a large number of other conditions such as irritable bowel syndrome (IBS), migraine, premenstrual syndrome (PMS), chronic fatigue and non-cardiac chest pain. These are known as ‘medically-unexplained symptoms’. Some clinicians believe that fibromyalgia is just one of this spectrum of functional somatic disorders.1
Diagnostic criteria have been established by the American Society for Rheumatology and these involve the discovery of tender points over various parts of the body. These criteria have recently been streamlined to account for the fact that fibromyalgia syndrome is a collection of symptoms, rather than a discrete entity including a degree of chronic pain in various parts of the body associated with fatigue, waking unrefreshed, cognitive symptoms and somatic symptoms.2
Pathologies that could mimic some of the symptoms, such as vitamin D deficiency, should be excluded. If the patient is still in the diagnostic phase, blood tests should be organised.
These should include a full biochemical and haematological profile (FBC, U&E, LFT, bone enzymes, TFT, ESR and CRP, protein electrophoresis) and also vitamin D levels and parathyroid hormone levels, rheumatoid factor and anti-nuclear antibodies, and sometimes ferritin, vitamin B12 and folate if there is anaemia and /or neurological symptoms. Generally, a rheumatoid factor has to be more than three times the normal for it to be significant.
The patient should be referred to a specialist to exclude other treatable causes of widespread pain and establish a definite diagnosis of FMS.
Management of patients already diagnosed with FMS
If the patient has already been diagnosed with FMS, it is likely that they will have been treated either pharmacologically or by using physical therapies.
Establish the presenting complaint for this consultation. What has caused the patient to come to the surgery? Is their FMS out of control or are there other problems in their life causing a deterioration in symptoms?
Exclude an organic cause for deterioration, such as new onset diabetes which can cause worsening of fatigue, and also to enquire about yellow flags such as co-existing depression, illness in a relative which may be having an impact on the patient.
If the patient is experiencing a genuine flare-up of their FMS symptoms, it is worth considering management strategies and discussing them with the patient, to see if anything else could be tried. The Fibromyalgia Impact Questionnaire (FIQ) is a useful and well-validated tool for assessing functional abilities, patient status and progress. It can be accessed online and can be used during a GP consultation. Assessment of associated anxiety and depression is also part of this process and GPs will be familiar with the use of the PHQ-9 questionnaire for the latter.
Common management strategies for FMS are based on the European League against Rheumatism Guidelines3 and are divided in general, non-pharmacological and pharmacological recommendations.
General recommendations include:
- Comprehensive assessment of pain, function and psychosocial context
- Optimal treatment within a multidisciplinary approach tailored to the patient
Non-pharmacological management of FMS should include:
- Hydrotherapy
- Exercise programmes
- CBT
- Relaxation, rehabilitation and psychological therapies, physiotherapy.
Pharmacological therapies could include:3
- Tramadol
- Simple analgesia with paracetamol and weak opioids
- Antidepressants such as amitriptyline, fluoxetine, duloxetine, moclobemide, pirlindole.
- Pramipexole, pregabalin.
The role of the GP
Support from the GP and primary care team is as important as pharmacological treatments. 4 FMS is a long-term condition and the GP is best-placed to manage the patient and the disease. About 25% of patients will recover from FMS and it is worth stressing this to patients early in their disease.
Support patients to remain at work. The thrust of documents such as Dame Carol Black’s ‘Working for a healthier tomorrow’ and the NICE guidelines on long-term sickness absence and incapacity for work is to encourage early intervention with return-to-work plans and the use of cognitive behavioural therapy (CBT), coping strategies, counselling, solution-focused group sessions, exercise programmes and workplace modifications for patients with chronic musculoskeletal pain and disability.5,6
Patient resources
The National Fibromyalgia Society and local support networks such as Fibromyalgia UK play an important role. Arthritis Research UK also provides patients information leaflets. Health trainers are well-placed to support FMS patients to achieve more activity like the graded exercise programme mentioned above. Health trainers are often provided free of charge by local Health and Well-Being Boards.
| Tips for the ten-minute consultation |
|---|
| Establish basic facts about the presenting complaint and what is already known about the patient’s condition. |
| Avoid panic on the doctor’s part (heart-sink patient). |
| Avoid issuing an FP10 for more medication, as a knee-jerk response. |
| Make it clear that you are not dismissing the patient. |
| Listen to their concerns and expectations or ideas, concerns and expectations (ICE). |
| Arrange a follow-up when you are better acquainted with the patient’s records and have more time. |
| Remember that there will always be a management strategy which has not been tried already, like supportive follow-up consultations to establish a better rapport and gain the patient’s trust. |
Dr Louise Warburton, a GPSI in musculoskeletal medicine, Shropshire Community Health NHS Trust, senior lecturer, Keele University, and president of the Primary Care Rheumatology Society
References
1. Hatcher S, Arroll B. Assessment and management of medically unexplained symptoms. BMJ 2008;336(7653):1124-8
2. Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010;62:600-10.
3. Carville SF, Arendt-Nielsen S, Biddal H et al; EULAR. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis 2008;67(4):536-41.
4. Arthritis Research UK. Hands On. Autumn 2010
Further resources
- RCGP Publications. Musculoskeletal disorders in Primary Care. Editor Louise Warburton. RCGP. March 2012
- Patient information leaflets at www.arthritisresearchuk.org.
- Fibromyalgia Impact Questionnaire (FIQ) www.myalgia.com/FIQ/FIQ_questionnaire.pdf
