1. Fibromyalgia – how to assess and manage
Anna Moverley
November 2017

2. What we will cover What is fibromyalgia? How do we diagnose it?
How do we manage it?
What are the indications for referral, what information is needed on the referral and what investigations are needed?

3. Why is fibromyalgia important?
Most common cause of generalized MSK pain in women aged between 20yrs and 55yrs
‘Acquiring a diagnosis of fibromyalgia may lead to increased illness behaviour, dependence on health care providers and increased health care costs’ Kroese 2013, Annals of Rheum

4. Associated disorders Depression Anxiety Irritable bowel syndrome
Bladder irritability
Obstructive sleep apnoea
Restless legs
And many more

5. What is fibromyalgia and how do we diagnose it?

6. What is it? Widespread pain to muscles and joints Fatigue
Non-restorative sleep
Cognitive disturbance

7. And…
Absence of findings on physical examination and laboratory investigations that would explain symptoms

8. How do we diagnose it?

9. 1990 ACR classification criteria
Wolfe et al Arthritis Rheum. 1990;33(2):160
Widespread pain, above and below the diaphragm, left and right sides of body
In combination with more than 11/18 tender points as below:

10. Tender points

11. Tender points Insertion sub occipital muscle Mid trapezium muscle
Supra-spinatous tendon origin
Under lower SCM muscle
Near 2nd intercostal muscle
2cm distal from lateral epicondyle
Prominence of greater trochanter
Knee medial fat pad
Upper outer quadrant buttock
Control points
Thumb
Mid forearm
Mid forehead

12. 2010 ACR diagnostic criteria (preliminary)
All 3 criteria must be met:
Widespread pain index (WPI) 7 or above and symptoms severity (SS) (SS) score 5 or above, or WPI 3-6 and SS 9 or above
Symptoms at similar level for at least three months
Absence of any other diagnosis to explain symptoms

14. WPI Unilateral Bilateral (one point for each side) Neck Upper arm
Upper back
Lower arm
Lower back
Shoulder girdle
Chest
Greater trochanter
Abdomen
Jaw
Upper leg
Lower leg

15. SS Fatigue graded (0-3) Waking unrefreshed (0-3)
Cognitive symptoms (0-3)
Where
0 = no symptoms
1 = mild symptoms
2 = moderate symptoms
3 = severe symptoms

16. SS Somatic symptoms in general None = 0 Mild = 1 Moderate = 2
Great deal of them = 3
Where somatic symptoms include muscle pain, constipation, Raynaud’s, painful urination, abdominal cramps, dry mouth, sun sensitivity etc

17. FIQ Original score published in 1991
Cumbersome scoring algorithm including reversal of one question and standardisation of first 13
Revised 2009

18. The Revised Fibromyalgia Impact Questionnaire
Domain 1 directions: For each of the following nine questions, check the one box that best indicates how much your fibromyalgia made it difficult
to do each of the following activities over the past 7 days:
Brush or comb your hair No difficulty Very difficult
Walk continuously for 20 minutes No difficulty Very difficult
Prepare a homemade meal No difficulty Very difficult
Vacuum, scrub, or sweep floors No difficulty Very difficult
Lift and carry a bag full of groceries No difficulty Very difficult
Climb one flight of stairs No difficulty Very difficult
Change bed sheets No difficulty Very difficult
Sit in a chair for 45 minutes No difficulty Very difficult
Go shopping for groceries No difficulty Very difficult
Domain 2:
Fibromyalgia prevented me from accomplishing goals for the week Never Always
I was completely overwhelmed by my fibromyalgia symptoms Never Always

19. The Revised Fibromyalgia Impact Questionnaire
Domain 3 directions: For each of the following 10 questions, check the one box that best indicates the intensity of your fibromyalgia symptoms
over the past 7 days:
Please rate your level of pain No pain Unbearable pain
Please rate your level of energy Lots of energy No energy
Please rate your level of stiffness No stiffness Severe stiffness
Please rate the quality of your sleep Awoke rested Awoke very tired
Please rate your level of depression No depression Very depressed
Please rate your level of memory problems Good memory Very poor memory
Please rate your level of anxiety Not anxious Very anxious
Please rate your level of tenderness to touch No tenderness Very tender
Please rate your level of balance problems No imbalance Severe imbalance
Please rate your level of sensitivity to loud noises, bright lights, odours,
and cold No sensitivity Extreme sensitivity

20. How do we manage fibromyalgia?

21. Pain relief
Anti-depressants especially TCAs
Physiotherapy and allied health professional input (?CBT)
Encouragement/education

22. EULAR recommendations
Full understanding of fibromyalgia requires comprehensive assessment of
Pain
Function
Psychosocial context

23. Pharmacological interventions
Tramadol is recommended for the management of pain in fibromyalgia (Ib A)
Simple analgesics such as paracetamol and other weak opioids can also be considered in the treatment of fibromyalgia
Corticosteroids and strong opioids are not recommended (IV D)

24. Tropisetron, pramipexole and pregabalin reduce pain and are recommended for the treatment of fibromyalgia (Ib A)
Tropisetron, a serotonin 5HT3 receptor antagonist, has been discontinued in the UK
Pramipexole is indicated for restless legs

25. Antidepressants: amitriptyline, fluoxetine, duloxetine, milnacipran, moclobemide and pirlindole reduce pain and often improve function, therefore they are recommended for the treatment of fibromyalgia (Ib A)

26. Amitryptiline as mainstay?
Often started at low dose and titrated up, given at evening time
If ‘hangover’, try giving it earlier in the evening (6pm)
Nortriptyline may also be useful
Dosulepin is useful but not evidence based

27. Non-pharmacological
Heated pool treatment with or without exercise is effective in fibromyalgia (IIa B)
Individually tailored exercise programmes, including aerobic exercise and strength training can be beneficial to some patients with fibromyalgia (IIb C)
Cognitive behavioural therapy may be of benefit to some patients with fibromyalgia (IV D)

28. Other therapies such as relaxation, rehabilitation, physiotherapy and psychological support may be used depending on the needs of the individual patient (IIb C)

29. What are the indications for referral , what information is needed, and what investigations are needed?