Diagnosing, Managing, and Treating Fibromyalgia in Primary Care

Primary care providers often treat and manage fibromyalgia. The average age of onset of fibromyalgia is 30 to 50 years, and prevalence increases with age. Children and adolescents also can be diagnosed with fibromyalgia, though the estimated incidence rate is low. Fibromyalgia was the topic of discussion at this afternoon’s session.

Speaker Larry Culpepper, MD, MPH, who is a professor of family medicine at Boston University School of Medicine, spoke about diagnosing, managing, and treating fibromyalgia.

Diagnosing Fibromyalgia

“Fibromyalgia tends to present within a constellation of pain amplification syndromes,” Dr Culpepper said. Chronic fatigue syndrome, regional pain syndromes, and somatoform disorders are highly common comorbidities.

The Widespread Pain Index (WPI) and Symptom Severity (SS) score can help diagnose fibromyalgia, though diagnostic criteria have changed over time (see Figure 1, click the image to enlarge).

Criteria are much easier and simpler now. Common features include generalized tenderness of soft tissues and muscles, dyscognition or “fibrofog,” musculoskeletal stiffness typically in the early morning and improving as the day goes on, fatigue, sleep problems, and environmental sensitivity or hypervigilance.

Fibromyalgia seems to be a central nervous system condition but might have endocrine, infectious disease, or psychiatric etiologies, to name a few.

“The key characteristic is soft tissue and muscle tenderness and pain,” Dr Culpepper said. “As opposed to joint pain, bone pain, and so forth.”

Managing Fibromyalgia

To prepare your practice for managing patients with fibromyalgia, you should initiate open discussion with staff regarding attitudes toward fibromyalgia patients; obtain necessary assessment, monitoring, and patient teaching tools; and develop a multidisciplinary network of health care providers to support the care of patients, Dr Culpepper suggested. You may choose to include a rheumatologist, psychiatrist or psychologist, and/or a cognitive behavioral therapist.

The next step is to set realistic goals that address specific symptoms. Consider the patient’s goals, pain, sleep disturbances, fatigue, mood disorders, and activity. Educate the patient on what fibromyalgia is (it is centralized pain and not related to an infection, spasm, or circulatory problem), give the patient ownership of fibromyalgia, and share the responsibility for his or her outcome of care, Dr Culpepper said.

During follow-up visits, make sure to evaluate treatment progression, efficacy, and adverse events. Also keep in mind the patient’s physical activity, barriers to adherence, and comorbidities. Then, you will be able to adjust the treatment regimen as needed. See Figure 2 (click the image to enlarge) for some examples of patient monitoring tools.

Treating Fibromyalgia

Nonpharmacological treatments include patient education, aerobic exercise, cognitive behavioral therapy, strength training, hypnotherapy, biofeedback, or balneotherapy. Pharmacologic therapies include antidepressants, gabapentinoids, and analgesics.

“What we have are medications we can use to help control symptoms, but then the nonpharmacologic therapies are ones that help patients reactivate their lives and get back to much fuller life experiences,” Dr Culpepper said. “So, it’s important to use both.”

Physical activity and cognitive behavioral therapy are staples of care for patients with fibromyalgia. Physical activity is, in fact, the only recommended treatment. There are currently no drugs approved by the US Food and Drug Administration for treating fibromyalgia.

—Amanda Balbi

Reference:

Culpepper L. Fibromyalgia update 2020. Talk presented at: Practical Updates in Primary Care 2020; December 4-5, 2020; Virtual.