Fibromyalgia (FM) is a challenging condition, but the management of patients with FM is becoming facilitated by new medications that act in what are thought to be some of most important pathophysiological features in this syndrome. However, it is of pivotal importance that an interdisciplinary approach is used to improve pain, fatigue, sleep and other domains to improve quality of life. Here, we present elements of management that the solo practitioner can tackle, focussing in the formally approved drugs for FM and other drugs commonly used in this condition. Further, the elements of an ideal multidisciplinary team are presented, and on how to incorporate their recommendations for the treatment of FM.
Fibromyalgia (FM) is becoming a more manageable condition, due not only to the current use of more rational, evidence-based pharmacological therapy but also from the growing recognition that the focus of the therapy must go beyond pain. These broader foci include several domains important to the patient, such as fatigue, non-restorative sleep, concentration problems and a wide array of co-morbidities now referred to as central sensitivity syndromes .
Notably, when one analyses the three current Food and Drug Administration (FDA)-approved medications for the treatment of FM, it is evident that they act in the main pathophysiological feature of FM. Specifically, they target the central nervous system (CNS) to minimise a phenomenon termed central sensitisation, which augments pain and other sensory input to the CNS . The first purpose of this article is to propose an office-based management plan based on the three major medications approved by the FDA for use in FM (the ‘anchor drugs’) – pregabaline, duloxetine and milnacipran, and the use of additional drugs such as tramadol that may provide a more symptom-base, personalised treatment. In addition, this article will provide a practical approach in how a single health-care provider can incorporate recommendations from interdisciplinary providers to optimise function and manage co-morbidities.
By definition, no single surgery or round of medications will cure any chronic illness – including FM – and treatments for these conditions are ongoing and life long. A biopsychosocial treatment schedule has proved to be the best approach for regaining an optimal quality of life when living with FM . The ultimate goal of health treatment is to reduce symptoms, promote physical fitness and optimise the ability to perform activities of daily living. One health-care provider alone may not maximally accomplish this breadth of goals. If geographically feasible, an interdisciplinary team of providers is generally required for the best treatment outcome. More likely, however, a single provider will initiate and carry out recommendations from a carefully selected cast of medical providers.
Assembling a treatment team – the primary provider or solo practitioner
A single primary provider who can prescribe medications is the cornerstone of the treatment team. This might be a rheumatologist, nurse practitioner, physician’s assistant, family practice physician, internist, osteopathic physician or a physiatrist. The primary provider will be responsible for making the diagnosis, prescribing medications and managing recommendations from other specialists. Initially, the most critical role of the primary provider is to accurately diagnose FM and rule out other conditions that may present similarly. Later, the role of the primary provider turns to management of the chronicity of FM and identification of co-morbid conditions.
Once a diagnosis of FM is made, pharmacologic treatment is usually started.
In a review of the pharmacologic treatment of FM, Boomershine and Crofford suggest that the three FDA-approved drugs could now be used as the initial and main treatment (‘anchor drugs’) and the older approaches, although still important, could be added later. There are no head-to-head studies of these agents or consensus concerning which agent to initiate first.
There are at least two major phenomena that occur in patients with FM – the amplification of ascending sensory input, where drugs like anticonvulsants may intervene, and defects in the diffuse noxious inhibitory control system (DNIC), where SNRIs (serotonin–norepinephrine reuptake inhibitors) may exert action (See Fig. 1 ). This is of course an oversimplification, but it demonstrates that there are at least two complementary strategies to control symptoms. Unfortunately, there is no easy way to demonstrate which defect is more prominent in an individual patient, but a careful analysis of the subject’s complaints can help the health professional to use the anchor drugs with regard to rationale polypharmacy, weighing their potential side effects as well.
Differential diagnosis
As FM is no longer considered a diagnosis of exclusion, there is no need for an extensive work-up when the condition is suspected. However, this should not prevent the health professional from performing an extensive interview and complete physical examination, as most of the differential diagnosis can be ruled out on clinical basis only. Care should be taken to not over- or under-diagnosis FM.
The usual thought that hypothyroidism can mimic FM must be put in perspective, as thyroid problems are very common in the general population, and it is more likely that the patient has both FM and a thyroid condition. The treatment with thyroid hormone supplementation rarely helps the FM symptoms, especially in FM patients with just above the cutoff for thyroid disturbance (sub-clinical hypothyroidism) .
The judicious use of laboratory testing could help in other specific problems, such as hyperparathyroidism, polymyalgia rheumatica and multiple myeloma. There is an increasing interest in vitamin D deficiency as cause for chronic widespread pain such as FM, but the findings are not conclusive. However, as in the case of hypothyroidism, the finding and correction of these abnormalities can reflect with an improvement in the individual’s general health .
The most important tests to be avoided in FM patients are the ‘rheum panels’, mainly the ones including autoantibodies, as this is still a major cause of misdiagnosis and further unnecessary work-up. Complete blood counts are useful to rule out anaemia and bone marrow suppression. Chemistry panels are helpful to verify functionality of the liver and kidney as medication dosages may need to be tailored in some patients.
Management with ‘anchor drugs’
Pregabalin is a neuromodulator that acts by binding the alpha-2-delta region of voltage-gated calcium channels, reducing calcium influx in the synaptic terminal and with that, reducing the release of excitatory neurotransmitters, such as glutamate and substance P . In this way, pregabalin acts in one of the well-established problems in FM, the amplification of the nociceptive impulse. Pregabalin is approved for the treatment of FM, neuropathic pain and in some countries, for the management of generalised anxiety disorder and as adjuvant medication for seizures.
The indicated dosage for the treatment of FM is 300–450 mg daily, divided in two doses, but many clinicians start pregabalin in smaller, nightly doses. There seems to be a specific benefit for sleep with this compound . Anxiety is very common in patients with FM as well, and as patients with both conditions will almost always present with initial insomnia, pregabalin offers a rational choice in these cases. The dosages can then be increased to the recommended ones, but dose escalation may be limited by side effects, such as weight gain, oedema and dizziness that is generally self-limiting by time.
The two other FDA-approved medications for the treatment of FM are duloxetine and milnacipran. Duloxetine is also FDA approved for depression, generalised anxiety disorder and painful diabetic neuropathy, and milnacipran is approved for the management of major depression in Europe and Japan .
Both medications are serotonin–norepinephrine reuptake inhibitor antidepressants (SNRIs). Their action is thought to be based in the improved function of the descending inhibition or DNIC, which relies on serotoninergic and noradrenergic inhibitory neurons acting in the spinal dorsal horn .
Duloxetine trials have demonstrated that 70% of its effect in pain is accounted for by analgesic rather than antidepressant action of the drug . Nevertheless, it is a good choice for patients with FM, depression and anxiety. FM dosage is 60 mg once a day, and usually it is started with the 30-mg dosage. Duloxetine seems to have a neutral effect in sleep, so additional measures at sleep time are advisable (see below).
The doses recommended for milnacipran are 50 mg twice a day to 100 mg twice a day. Perhaps due to milnacipran’s higher adrenergic effect, there was a significant improvement in fatigue and fibro-fog, especially at the 200-mg dose .
Venlafaxine and desvenlafaxine are SNRIs such as duloxetine, and theoretically would be an option for FM, but existing studies are negative. Interestingly, strategies with venlafaxine were found to be of benefit in a primary-care-based study for pain associated with depression, leading some to question the low dose that was tested in FM subjects .
Pain management
The three compounds already discussed received FDA indication in large part due to reduction in pain, as this is the main therapeutic domain to be alleviated in this syndrome. Nevertheless, other options for pain treatment should also be addressed.
Tramadol is indicated by FDA for pain and is the most studied opioid-like analgesic in FM. In more recent articles, it is listed apart from the opioids, for its weak actuation in the opioid μ-receptors coupled with its capacity to inhibit serotonin and noradrenalin re-uptake. FM studies were done with the isolated drug and with its combination with acetaminophen, which contains 25% less active tramadol . The most common side effects with tramadol are nausea, vomiting and pruritus. Fortunately, the potential for drug abuse is negligible. However, there is a theoretical risk for seizures and serotoninergic syndrome when tramadol is combined with selective serotonin re-uptake inhibitors (SSRIs), SNRIs, monoamine oxidase inhibitors (MAOIs) and tryptans, though few cases have been described .
It is well known that FM is a condition that responds poorly to common analgesics . Moreover, most of the patients had already been taking over-the-counter (OTC) analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) long before seeking professional help .
However, as FM is mainly a painful condition, there is still a role for NSAIDs and other analgesics in its management. For example, some clinicians recommend NSAIDs for patients at the beginning of an exercise programme or physical therapy to increase exercise tolerance. Even in patients who already tried OTC analgesics, there may be a benefit from an around-the-clock schedule of acetaminophen, as contrary to an ‘as-needed’ basis. Although a patient with concurrent long-standing significant osteoarthritis will have some benefit, overall FM response to NSAIDs and acetaminophen is generally inadequate. Moreover, daily use of these agents may present gastrointestinal and hepatic risks in the long term.
Another pain treatment option for FM is opioids. However, opioids are now less used in FM patients, not only because of the launching of more effective ‘anchor’ drugs but also because of a general lack of sustained response. In fact, there may be a saturation of the opioid receptors in patients with FM, which is currently under investigation as an explanation for dose escalation and tolerance with these substances over time .
Gabapentin was also studied in FM . The doses, with some efficacy in FM, ranged from 1200 mg to 2400 mg a day. Though the numbers of patients tested fall far short of the pregabalin trials, the effect sizes appear similar. Gabapentin can be an option, especially when pregabalin is not available.
Management of peripheral and other central pain generators
Patients with FM can develop other sources of musculoskeletal pain, and the proper treatment of these is crucial. Peripheral sources of pain, especially chronic pain, increase FM symptoms as they have the potential to increase the wind-up phenomenon in the spinal cord . In other words, the already sensitised FM patient will perceive the pain from other sources (e.g., gut, bladder, jaw, head and periphery) with increased intensity, adding to the disease burden.
Some sources of peripheral pain may be easily identified, such as concomitant osteoarthritis, for example. However, pain originating from bursae and tendons can be confounded with tender points, as their locations can be contiguous. Careful physical examination can help and the judicious use of imaging methods, such as ultrasound, can also be useful in differentiating pain source.
Arguably the most common source of peripheral pain in FM patients is myofascial pain, characterised by the presence of trigger-points in the musculature. There is great superposition of trigger points and tender points, but training and experience can help to better identify the former . One other difference between both points is of therapeutic advantage: trigger points tend to respond to injections of anaesthetics, with improvement of symptoms at both local and referred sites.
Management of fatigue
Fatigue is a major complaint of FM patients ; the proper management of sleep disturbances and the patient’s engagement in physical rehabilitation are the best strategies for long-term management of fatigue. Also of note, when depression is present, is the difficulty in differentiating FM-related fatigue from that of mood disorders. Another condition that is related to fatigue is neurally mediated hypotension . This abnormality must be considered when dizziness, near syncopal episodes and tachycardia are present in the patient evaluation, indicating autonomic dysfunction. ‘Fibrofog’ is a vague term used by patients to describe the presence of memory and attention abnormalities, usually also related to the sensation of fatigue.
Medications commonly used in narcolepsy have been studied for the treatment of fatigue in FM patients . Modafinil is FDA approved for the treatment of excessive somnolence associated with narcolepsy, shift workers and sleep apnoea. It can be useful if fatigue is preventing the patient to start physical rehabilitation. The initial dosage is 50 mg in the morning and can be escalated to 400 mg daily. There is a risk of abuse and drug interactions with modafinil and other compounds. Methylphenidate is a more cost-effective option, but it has not been studied in FM.
Sleep management
The professional who deals with FM patients must assess every aspect of the patient’s sleep. A good sleep history must be obtained, and advice for sleep hygiene, such as sleeping in a private room, is first line. Questionnaires can be used to rule out specific problems, such as sleep apnoea and restless legs syndrome (RLS) .
The classic nighttime, small doses of amitriptyline or cyclobenzaprine (tricyclic agents) are still the most popular first approach to treat delayed sleep onset in FM, but they are more likely to help sleep disturbances than other FM symptoms . In general, the usual FM patient will not tolerate higher doses of these agents because of sedation and cholinergic side effects, and they are only effective in the lower doses in approximately 30% of cases. Other agents can be used instead of trycyclics. Trazodone, although not formally tested, is a sedating antidepressant that is usually well tolerated. Hypnotics agents such as zolpidem, zoplicone and eszoplicone can also be used. Benzodiazepines should be used cautiously as they may disrupt sleep architecture unlike hypnotics, which exert their effect mostly through the BZ1 receptor.
Sodium oxybate is a schedule III compound approved by FDA for the treatment of cataplexy and excessive daytime sleepiness. Recently, sodium oxybate was shown to improve not only sleep but also other features of FM, including pain and fatigue in phase III FM trials. Sodium oxybate is prescribed online through a central pharmacy to minimise the possibility of diversion. Other challenges in using sodium oxybate are that it is dosed twice nightly, due to an extremely short half-life, and insurance reimbursement often requires extensive prior authorisation .
Restless legs syndrome (RLS) is extremely common in patients with FM , and also one of the most gratifying problems to be identified and properly treated. The full discussion of RLS management and differentiation from short-fibre neuropathy can be found in some excellent reviews . Dopamine agonists such as pramipexole are effective as first-line therapy for RLS, and maybe have an additional effect concerning FM symptoms, but this would be unlikely in the smaller dosages used for RLS .
Sleep apnoea must be ruled out in FM patients as a cause for excessive daytime sleepiness. A polysomnogram (PSG) exam should be ordered only when specific sleep problems are suggested by clinical evaluation. The oft-quoted ‘alpha intrusion’ is not pathognomonic of FM, and FM should not be diagnosed by PSG findings. Therefore, some clinicians limit referral for PSG for those patients suspected of having sleep apnoea or disorders other than insomnia.
Management of depression and anxiety
Depression and anxiety should be discussed in almost every FM visit. Depression is present in 30% of the patients at the time of diagnosis and in 50–60% sometime during their lifetime . To consider FM as a purely ‘psychosomatic’ condition, secondary to depression is inappropriate from the pathophysiological point of view and unhelpful for its management. However, to ignore mood abnormalities in FM and to fail to treat them properly is also an error. Specifically, mood problems interfere with pain perception, can worsen sleep problems and can further reduce motivation for physical conditioning. There is also evidence that anxiety can be as common as depression in FM patients, and post-traumatic stress disorder (PTSD) occurs with higher prevalence in FM patients compared with the general population .
Other antidepressants have also been tested in FM, besides trycyclics and duloxetine. When used alone, fluoxetine was helpful for pain only in higher dosages . The combination of fluoxetine in the morning with small doses of amitriptyline at night was more effective than each drug taken alone . Other SSRIs such as citalopram , escitalopram, paroxetine and sertraline were not effective for pain, but as with fluoxetine, could be used to treat associated depression.
Assembling a treatment team – key players
Key members of the long-term management team include a physical therapist (PT), an occupational therapist (OT), a speech therapist (ST), a clinical exercise specialist (CES), a psychologist and a registered dietician (RD). Optimally, they are employed by the same institution or health-care practice and can then work together efficiently on evaluation, treatment and ongoing care. In a solo practice, however, interdisciplinary case conferences for integrated care are generally not conducted. The interdisciplinary team members’ skill sets are both complementary and overlapping. Therefore, it is critical that the primary provider is knowledgeable of what each player of this team has to offer, and try to recruit them according to his/her local possibilities. One way team members might divide treatment and care is as follows:
The physical therapist (PT)
For the FM patient, a PT can evaluate and treat regional pain, balance issues and discuss energy conservation to manage fatigue. Treatments employed by PTs may include rehabilitation exercise, manual therapies, neurosensory balance analyses, gait analyses, corrective orthotics fitting and a multitude of management strategies for long-term self-care . They can also teach patients a variety of myofascial release techniques including spray and stretch. Spray-and-stretch technique requires a prescription from the provider for ethyl chloride cooling spray. The PT can teach patients to spray the medication on selected muscles, which allows painfully taut muscle bands to be stretched with less discomfort . Finally, PTs may administer ultrasound therapies combined with relaxation techniques to reduce pain from regional syndromes, including temporomandibular joint dysfunction and chronic back pain .
The occupational therapist (OT)
An OT can provide many of the same services as a physical therapist, but commonly will focus more on physical modifications to workplace, home or activities of daily living. Some PTs/OTs will divide the care of FM patients so that large muscle/joints are evaluated and managed by the PT while smaller muscles/joints are evaluated by the OT. In addition to providing individually fitted wrist splints and rehabilitative exercises, the OT might train the patient in things such as how to keep the body aligned in a neutral position and avoid hypermobility postures during normal activity . The OT also has ergonomic expertise and can recommend a variety of equipment to ease pain and promote optimal posture. Moreover, the OT is particularly well versed in creating an optimal work environment. They can help clarify whether an employee can physically tolerate standing for prolonged periods of time, can perform repetitive tasks and explain the need for that employee to take short, frequent stretch breaks. At home, they can help patients think twice about where they store commonly used items in the kitchen, how to hang pictures, do housework and remind their patient of the need to pace themselves to avoid triggering a symptom flare. They are often the providers who suggest modifications such as vocational rehabilitation or suggest that patients consult with their provider regarding handicapped parking stickers or even disability .
The clinical exercise specialist (CES)
The CES is a fitness professional who has advanced training in working with special populations, including those with chronic illnesses. A CES well versed in FM exercise will minimise eccentric muscle work, limit repetitive movements, programme for a variety of fitness levels, be sensitive to excessive sensory stimulation and distraction and minimise fall risk .
In this developing field, the CES works as a bridge between the medical clinic and a home or public exercise setting where ongoing post-rehabilitative workouts can take place. They provide guidance that takes into account the recommendations of the primary provider, the PT, the OT and the ST. The CES may work as a specialised in-home personal trainer or lead special population classes in a general exercise setting. They also work as medical research study team members, providing physical function testing or leading strictly defined study-based group exercise. They are an important link in knowledge and communication, encouraging a client with FM to seek direction and further treatment planning from the primary provider or other members of the treatment team .
The speech therapist (ST)
The ST is a communications expert who can also evaluate cognitive difficulties such as ‘fibro-fog’ and differentiate them from cognitive deficits related to dementia, post-stroke or head trauma. FM patients often report great distress about their perceived cognitive decline, and so the ability to improve cognitive function is typically welcomed as life enhancing . The ST will recommend a variety of non-pharmacologic strategies to maximise cognitive abilities and provide mental exercises to help enhance memory. Some of these strategies include establishing easily recalled routines, rehearsal, placing reminder notes, forming memory associations, decreasing multi-tasking and reducing distractions.
The psychologist
The psychologist is one of many health-care providers who can help maximise the quality of life in someone with a chronic illness. Similarly, psychiatric mental health nurse practitioners (PMHNPs) and medical social workers (MSWs) possess some of the same skill set. All can generally offer counselling related to cognitive behavioural strategies. These strategies are often beyond the scope of the primary health-care provider. Cognitive behavioural strategies may be difficult for all patients to access. Therefore, primary providers may choose these therapists for their most distressed patients . For many with FM, therapies can include fatigue control, decreasing catastrophic thinking, realistic expectations, time-based pacing and boundary setting. There are many other types of counselling styles or modalities that these professionals can employ, depending on the needs of the patient or family they are treating.
The registered dietician (RD)
The RD is helpful in FM because many people’s quality of life will improve through dietary change. The RD can help people learn not only what foods to avoid or minimise (monosodium glutamate, for example), but also how to introduce new foods into the diet and how to really enjoy those new foods. In FM, obesity is often a problem, fuelled in part by the sporadic nature of FM flare cycles and the resulting disruption of an exercise routine. The RD can individualise an eating plan based on each patient’s food preferences. In general, they discourage ‘diets’ and emphasise healthier eating for the long run. They also try to strip away moral value from food, by discouraging naming certain foods ‘good’ or ‘bad’. Instead, they focus on which foods to eat often and which foods to enjoy less frequently or in smaller amounts. Another role of the RD is to help people with concurrent food intolerances, such as coeliac disease and lactose intolerance .
The co-morbidity specialists
There are a plethora of conditions associated with FM, most of them related to a general body hypersensitivity, such as tension-type headache and migraines, irritable bowel syndrome, interstitial cystitis/painful bladder syndrome, pelvic pain, higher sensitivity for odours, lights and sounds, dizziness and tinnitus . Others who can bring optimal care are the medical providers who specialise in the common co-morbidities of FM, now more commonly termed central sensitivity syndromes . It is critical, however, that the co-morbidity specialist be chosen carefully, with a preference for those who understand the critical role of central sensitisation and related pathophysiologic underpinnings of the co-morbidities common in FM. Otherwise, treatments may include unnecessary surgical intervention and organ-specific therapies that are less than optimal.
The gastroenterologist
Up to 70% of persons with FM meet Rome criteria for irritable bowel syndrome . The shared pathophysiology between FM and irritable bowel syndromes are striking . Ideally, the gastroenterologist would screen for other gastrointestinal (GI) conditions such as inflammatory bowel disease or coeliac disease, symptomatic diverticulitis and peptic ulcer disease. Therefore, many patients who are then diagnosed by a gastroenterologist with irritable bowel syndrome find it reassuring that their GI distress is not caused by a malignancy or other progressive illness.
The urologist or gynaecologist
An urologist or gynaecologist may be helpful for patients with severe irritable bladder, prostadynia and a wide variety of pelvic pain syndromes. Many times specialists are aware of pharmacologic and non-pharmacologic therapies for the treatment of recalcitrant urogynaecologic ailments . For example, some patients find some degree of relief from irritable bladder with a combination of prescription medications used concurrently with suprapubic transcutaneous nerve stimulation and bladder retraining . A gynaecologist or urogynaecologist may also have expertise in managing pelvic pain syndromes such as endometriosis, severe dysmenorrhoea, vulvodynia and vulvar vestibulitis. There is a growing awareness of abdominal myofascial pain generators in these patients . Urogynaecologic conditions severely impact not only the patient’s quality of life, but spill over into their sexual relationships. Moreover, lack of libido is not uncommon in FM .
Gynaecologists are also expert in peri-menopausal or post-menopausal hormone replacement. This is particularly critical if hot flashes are interrupting the already fragmented sleep of the FM patient.
The endocrinologist
An endocrinologist might be called upon for a patient with FM in some occasions, most likely to evaluate and treat hormone deficiencies such as low insulin-like growth factor (IGF-1) and testosterone. Growth hormone (GH) deficiency has been described in FM . Those providers who chose to replace GH may prefer to do so under the endocrinologist’s guidance. Another hormone replacement that is sometimes used in FM is testosterone. Many older patients on chronic opioid analgesics have low levels of testosterone and experience fatigue and muscular deconditioning . Endocrinologists can often help patients weigh the risks versus benefits of testosterone replacement therapy.
The neurologist
A neurologist may be called to rule out other conditions that worry patients. For example, many young women with FM become concerned that they may actually have multiple sclerosis. A neurologist is adroit at identifying a variety of neurodegenerative or immune-mediated diseases often through specific questions in the patient’s history and neuromuscular physical examination techniques. The more common problem encountered by people with FM that is treatable by a neurologist is chronic headache. Decreasing the frequency and severity of headaches may not only improve the patient’s quality of life, but might, in turn, help reduce the central pain of FM . Patients with FM commonly report numbness, tingling and superficial pain in their extremities. Careful examination may note lack of motor abnormalities that are common in peripheral neuropathies. Nonetheless, neurologists are often asked to evaluate patients for peripheral neuropathy in an electromyography (EMG) laboratory. Although tarsal and carpal tunnel are over-represented in FM, large-fibre peripheral neuropathy is not thought to be common .
The orthopaedic surgeon and neurosurgeon
Every person with FM has spine pain, as it is part of the diagnostic criteria, but FM patients are referred for spine evaluation by the primary provider when neurologic signs and ‘severe’ symptoms are evident. Outcomes for spinal surgery designed to eliminate pain, when done in the absence of neurological signs, may be disappointing to the patient. For instances, neurosurgeons are sometimes asked to evaluate persons with FM for Chiari malformation, as a small number of patients with FM have anatomic abnormalities consistent with a Chiari malformation confirmed by clinical signs. Research has also demonstrated a lack of correlation between clinical examinations and MRI findings of Chiari malformation . Therefore, neurosurgery to ‘cure’ most people with FM is not typically recommended. An emerging line of evidence worthy of follow-up is the notion that a subset of people with FM has positional cervical spinal cord compression, though the optimal treatment of these patients remains unclear .
The psychiatrist
A psychiatrist can be helpful with drug management for patients with co-morbid mood disorders that do not respond to the standard therapies used in primary care. Depression (unipolar and bipolar), anxiety disorder and post-traumatic stress disorder are more common in FM than in the general population . Many psychiatrists are also expert in prescribing sleep medications, once sleep apnoea is ruled out. Persons with axis II disorders should be managed by a psychiatrist. To date, personality disorders are not thought to be over-represented in FM .
Patient education
Education about FM is invaluable in patient management. Education can occur individually between the provider and patient, in support groups, or through carefully selected books, media and Internet sites. The primary provider is tasked with providing education regarding the validity of the FM diagnosis and the non-destructive nature of the condition on muscle. The provider outlines a rational treatment plan focussing on minimising symptoms and restoring functionality. It is disheartening to learn that it is generally not possible to return to the state of health experienced before the onset of FM; most symptoms can never be totally eradicated. It is helpful to monitor symptoms and physical functioning with self-report FM-specific tools such as the Revised Fibromyalgia Impact Questionnaire. Having patients complete such a questionnaire always allows them to see how they are progressing, based on their own self-report .
Having realistic expectations about the amount of relief possible from medications (generally 30–50%) is important for learning to cope with a new lifestyle reality. The primary provider will be supportive but realistic in terms of the lifelong nature of FM. Touted ‘cures’ can be discussed between the primary provider and the patient, but ultimately, treatment choices and financial decisions belong to the patient.
Armed with a treatment team and knowledge about the disorder, the patient can begin to make lifestyle modifications. For severely affected persons, this may mean reducing the hours of work done inside and outside the home . Patients with invisible chronic illnesses, including FM, often get little support because they do not look sick. Patients often feel guilty about how FM has limited their lives and how it affects their family and friendships. To manage their disorder, they must learn to be more assertive in declining extra tasks and invitations. In well-managed FM, fatigue control becomes an important strategy. This means on occasion limiting chores to those that are most essential, or deciding on just one of several possible activities. Energy-saving techniques can include simple changes such as sitting during showering or while brushing teeth.
A patient who is active in the management of his/her FM is critical. Passive persons with FM who expects a provider will cure them will be disappointed . Proactive patients will explore cognitive behavioural strategies along with rational complementary and alternative therapies, while participating in exercise, and maintaining a nutritious diet rather than relying on medications alone .
In summary, using the anchor drugs for FM while incorporating recommendations from interdisciplinary providers is fundamental in optimising outcomes in FM. The ‘solo practitioner’ will shoulder the burden of medication adjustments and provide rational and timely referrals. The other key treatment team members are assembled as additional advisors for optimal daily living, while the specialist team makes recommendations for the care of co-morbidity challenges. However, the most important person for a successful life is the patient, who becomes the well-informed advocate for his/her own health.
In brief, many patients with FM can be managed by solo practitioners without referral to a subspecialist. This article provides a comprehensive overview of the type of referral and consultation options that are available to a wide range of FM patients. When subspecialists are indicated, they can be located through large academic health facilities or through a carefully selected network of providers. Concerning more isolated areas, such as rural settings, referring providers will not likely be housed in one facility. Most critical would be a local access to providers such as physical therapists who will require multiple appointments; whereas travel to a physician subspecialist for a single consultation is acceptable. It is essential for the primary provider to establish his/her own network of professionals for whom the patient can be referred, even if only once, for proper advice. Regular written communication among providers will also ensure that patients receive coordinated comprehensive care.
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