Fibromyalgia

Diagnosis/Definition

Chronic syndrome characterized mainly by widespread pain, unrefreshing sleep, disturbed mood, and fatigue. (American College of Rheumatology (ACR) 1990 criteria for the classification of Fibromyalgia)

Initial Diagnosis and Management

• Laboratory Testing. FM is not a diagnosis of exclusion, and thus laboratory tests and imaging studies play no role in establishing the diagnosis according to the 1990 ACR criteria.
• Basic laboratory studies, however, should be obtained to evaluate for potential underlying disease process.
• CBC, Chem 7, LFTs, ESR, and TSH.
• Laboratory and/or radiological tests for concomitant conditions, if clinically indicated by history and/or examination.
• Routine testing for rheumatoid factor (RF) or antinuclear antibodies (ANA) is not recommended.
• Extra evaluations should be reserved for a history suggestive of specific problems (i.e., sleep study for obstructive sleep apnea, testing for suspected infectious etiology, referral for primary psychiatric illness, etc.).

Ongoing Management and Objectives

• Optimize management of primary disease states and psychiatric illness if applicable. Rule out other disease process as clinically indicated (i.e., hypothyroidism).
• Educate the patient about FM.
• Validate symptoms.
• Emphasize nondestructive nature of FM.
• Focus on improving function, not complete eradication of symptoms.
• Discuss importance of mind–body relationships. Teach meditation and relaxation techniques. Consultation for biofeedback training may be ordered through neurology (M BIOFEEDBACK NEUROLOGY) for motivated individuals.
• Discuss drug and non-drug therapy options.
• Explain the importance of gentle life-long exercise.
• Inform about principles of sleep hygiene.
• Emphasize patient’s active role in any treatment.
• Recommend that the patient attend Fibromyalgia Self-Help Course. Course options include one 2 hour session directed at newly diagnosed FM or seven 2 hours sessions for more in-depth education. Courses can be scheduled by the patient through TRICARE without a formal consult.
• Recommend low impact aerobic exercise. Instruct the patient in the principles and methods of gradual incremental cardiovascular fitness. Low impact aerobic exercises such as walking, swimming, and stationary bike are the most successful. The goal should be 30 minutes of aerobic activity, 5 days per week. Physical therapy or exercise physiology consultations can be utilized if necessary.
• Institute medical therapy. CNS active medications such as amitriptyline, nortriptyline, and cyclobenzaprine should be tried.
• Lowest effective dose should be used; medications should be titrated upwards to effect. An adequate trial (4 weeks) should be attempted before considering the medication ineffective. If the patient fails a clinical trial of one medication or cannot tolerate the medication due to side effects, another trial with a similar medication should be attempted.
• NSAIDs are not effective alone; they may have a synergistic effect with CNS active medications. They may also be effective in musculoskeletal pain exacerbated by exercise.
• If the tricyclic class is unsuccessful alone, an AM dose of an SSRI with non-sedating properties should be added. As noted above, an adequate trial should be attempted.
• Narcotic medications should be avoided in the treatment of FM. Tramadol may be an effective pain medication (especially as an evening dose) but should be used with caution in patients on SSRIs, tricyclic antidepressants, or other cyclic compounds (such as cyclobenzaprine) due to increased risk of seizure. Tramadol should be avoided in patients with a prior history of seizures.

Indications for Specialty Care Referral

Patient is undergoing MEB.

Patient has attended the FM Self-Help Course and has failed medical management as recommended above.

When specific organic pathology is suspected (evidence of end organ damage or criteria present for systemic rheumatic illness such as SLE, RA, scleroderma, etc.)

Referral should not be given to merely confirm the diagnosis if a positive diagnosis has been made.