ABSTRACT: Physicians treating patients with fibromyalgia syndrome (FMS) should rule out coexisting disorders and establish possible inducing factors. They can work with patients to address their symptoms by providing patient education, instilling a sense of self-worth, advising avoidance of disability and narcotic medications, offering instruction in sleep hygiene, establishing anxiety reduction measures, and recommending an exercise program. Patients who have special needs and refractory cases may benefit from referral to a musculoskeletal specialist. Physicians can best improve patients' prognosis and quality of life by addressing several issues: whether the FMS is primary or secondary, whether there are underlying psychosocial stressors, whether pain is regional or widespread, how to approach exercise for therapy, and determining which medications to use. (J Musculoskel Med. 2008;25:172-184)
Primary care physicians are the first line of triage for patients who have fibromyalgia syndrome (FMS). They are responsible for ruling out coexisting disorders and establishing possible inducing factors that may warrant specific management. Once these goals are accomplished, they can steer patients in a positive direction toward addressing their symptoms without becoming stigmatized. Providing patient education, instilling a sense of self-worth, advising avoidance of disability and narcotic medications, offering instruction in optimal sleep hygiene, establishing anxiety reduction measures, and recommending a comprehensive exercise and stretching program all may help this effort. Involving patients in management decisions has the potential to improve physician-patient interaction and, as a result, improve outcomes.1
Patients with early FMS that is diagnosed and managed in the primary care setting have a very good prognosis; more than half no longer meet the American College of Rheumatology criteria within 2 years.2 Those who have special needs (eg, counseling and local injections) and refractory cases may benefit from referral to a musculoskeletal specialist (eg, rheumatologist, neurologist, orthopedist, osteopath, or physical medicine and rehabilitation physician) to confirm the diagnosis in a single encounter or work with the primary care physician to treat the patient. Long-standing patients with FMS who have psychological issues (eg, bipolar illness or posttraumatic stress disorder [PTSD]) have a poorer prognosis, but the family physician or internist should remain the "captain of the ship" in directing treatment.
Primary care physicians can best manage FMS, and thereby improve patients' prognosis and quality of life, by addressing 5 key issues. In this article, we describe several cases of FMS that demonstrate the issues that frequently arise and how primary care physicians can address them with improved communication techniques to improve outcomes.
FMS is a syndrome, or group of symptoms that occur together, rather than a disease. It is characterized by chronic widespread musculoskeletal pain of at least 3 months' duration in all 4 quadrants of the body and is thought to be a "central sensitization syndrome"3 (afferent sensory inputs into the dorsal root ganglion of the spinal column overwhelm the "gated"protective mechanism). A "windup" phenomenon (hyperexcitability with a low discharge threshold that worsens with each sensory input) creates greater discomfort than is seen in most persons. Thin C unmyelinated fibers and large myelinated A fibers and autonomic B fibers carry signals that result in amplified pain, hypervigilance, and discomfort from sensations that most persons would find pleasurable (eg, gentle stroking). Other central sensitization syndromes include irritable bowel syndrome (IBS), irritable bladder syndrome, chronic pelvic pain, chronic fatigue syndrome, tension headache, and temporomandibular joint dysfunction syndrome.
The primary manifestations of FMS include altered sleep architecture, aching, and fatigue (Table 1). FMS affects 2% to 3% of the US population4; most patients are women, and the syndrome often develops during their reproductive years.
CASES AND ISSUES
Clinical case scenario #1
A 36-year-old white woman with a past history of postpartum depression and hypothyroidism presents in a primary care physician's office with a complaint of pain all over her body. The symptoms appeared to start 3 months earlier after the patient slipped and fell while shopping in a department store. The fall aggravated the low back pain that had started during her pregnancy 18 months earlier. During the following week, the pain had spread from her lower back up her spine and into her legs. Her sleep became progressively disturbed,and the pain spread to her shoulders, neck, and arms.
The patient's current medications include fluoxetine, 20 mg/d, and levothyroxine, 100 μg/d. Results of laboratory tests performed within the last 3 months showed a normal complete blood cell count, erythrocyte sedimentation rate, and thyroid-stimulating hormone level; results for rheumatoid factor and antinuclear antibodies were negative.
Issue #1: Is FMS primary or secondary?
- Bieber C, Müller KG, Blumenstiel K, et al. A shared decision-making communication training program for physicians treating fibromyalgia patients: effects of a randomized controlled trial. J Psychosom Res. 2008;64:13-20.
- MacFarlane GJ, Thomas E, Papageorgiou AC, et al. The natural history of chronic pain in the community: a better prognosis than in the clinic? J Rheumatol. 1996;23:1617-1620.
- Yunus MB. Fibromyalgia syndrome: clinical features and spectrum. J Musculoskel Pain. 1994;2:5-21.
- Wolfe F, Ross K, Anderson J, et al. The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum. 1995;38:19-28.
- Wallace DJ, Clauw DJ, eds. Fibromyalgia and Other Central Pain Systems. Philadelphia: Lippincott Williams & Wilkins; 2005.
- Wallace DJ, Clauw DJ, Hallegua DS. Addressing behavioral abnormalities in fibromyalgia. J Musculoskel Med. 2005;22:562-579.
- Aaron LA, Bradley LA, Alarcon GS, et al. Psychiatric diagnoses in patients with fibromyalgia are related to health care-seeking behavior rather than to illness. Arthritis Rheum. 1996;39:436-445.
- Wallace DJ, Gotto J. Hypothesis: bipolar illness with complaints of chronic musculoskeletal pain is a form of pseudofibromyalgia. Semin Arthritis Rheum. 2008;37:256-259.
- Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol 1: The Upper Extremities. Baltimore: Lippincott Williams & Wilkins; 1983.
- Ready LB, Kozody R, Barsa JE, Murphy TM. Trigger point injections vs jet injection in the treatment of myofascial pain. Pain. 1983;15:201-206.
- Jones KD, Deodhar P, Lorentzen A, et al. Growth hormone perturbations in fibromyalgia: a review. Semin Arthritis Rheum. 2007;36:357-379.
- Burckhardt CS. Nonpharmacologic management strategies in fibromyalgia. Rheum Dis Clin North Am. 2002;28:291-304.
- Barkhuizen A. Rational and targeted pharmacologic treatment of fibromyalgia. Rheum Dis Clin North Am. 2002;28:261-290.
Hallegua DS, Wallace DJ. Comprehensive management of fibromyalgia. J Musculoskel Med. 2005;22:382-391.