Chronic Widespread Pain (CWP) aka Fibromyalgia Syndrome (FMS)

Scope

Please refer to good review here on Versus Arthritis website (by a GP).

FMS is in essence the presence of chronic widespread pain, often with other chronic painful bodily symptoms and runs a fluctuating, relapsing and remitting course. It has an overall good prognosis and follow up studies have not revealed more serious diagnoses.

There is no doubt that patients with FMS are difficult management problem and their pain experience is real. There is a huge amount of neurobiological and imaging evidence that there is aberrant pain processing in subjects with CWP / FMS. This knowledge has not, however, led to new treatments.

Assessment

Signs and Symptoms

Chronic widespread pain, often associated with tender points, with symptoms lasting 3 months or more with no alternative explanation

  • fatigue
  • waking unrefreshed
  • cognitive symptoms
  • number of somatic symptoms

Differential Diagnoses

  • there is wide DD for patients with aches, pains & fatigue
  • Patients with other rheumatic disease, especially RA & SLE and often OA, may also have 'secondary' FMS

Investigations

  • FBC, UE, LFT, BONE TFT, CK
  • Plasma Viscosity(PV)/CRP
  • Glucose
  • Urinalysis for protein / blood
  • Consider Vitamin D if strong suspicion of deficiency

Management

Biopsychosocial and doctor-patient considerations:

  • explain FMS is a disorder of pain processing, not damage or disease ('software, not hardware' for the IT literate)
  • 'over sensitivity of the pain system' & 'volume dial in the pain relay centres has been wound up'
  • Promote a good Dr-patient relationship & incorporate patient's ideas, concerns and expectations
  • symptoms may worsen under times of psychosocial stress
  • explain active management often improves quality of life
  • Useful self help link for patients

Versus Arthritis - Fibromyalgia

Make a management plan

  • Patient education
  • Encourage self-management;
  • Graded exercise;
  • Prescribing options - 1st line low dose Tricyclic antidepressant e.g. Amitriptyline (Steroids / strong opioids not to be prescribed);
  • Consider counselling for anxiety / depression.

Important practice points:

  • Response rate to any medication is no more 1/3 improvement in under 50% of patients
  • Medications are no better than an active exercise programme
  • Strongly advise against prescribing strong opioids
  • Regular review & stop if ineffective after a few weeks.
  • Avoid polypharmacy
  • Patients often end up on 5 medications, numerous adverse effects and pain scores of 10/10!

Referral

Referral Criteria

Please describe the expectations you have of the referral – many patients are disappointed with the outcome of the clinic appointment i.e. confirmation of diagnosis and advice re: activity & exercise. Specialists have no specialist interventions over and above what has been described.

Consider referral if:

  • diagnostic uncertainty
  • new symptoms suggestive of a rheumatological problem

NOTE:

  • significantly uncontrolled FMS symptoms cannot be managed by a rheumatologist
  • If severe symptoms and poor response to therapy
    • refer to either Pain Clinic (Consultant) if medication advice required
    • refer to the Pain Management Rehabilitation Team (for an MDT pain management approach)

Supporting Information

Patient Information

Versus Arthritis - Fibromyalgia

Fibromyalgia Association

Fibro guide - self help-link

Pathway Group

This guideline has been signed off by the Eastern Locality on behalf of NEW Devon CCG.

Publication date:July 2016

 

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