From the Guidelines
In Canada, fibromyalgia assessment guidelines prioritize a comprehensive approach, focusing on prompt diagnosis and a full understanding of the condition, including pain, function, and psychosocial context, as outlined in the 2017 EULAR revised recommendations for the management of fibromyalgia 1. The assessment process should involve a multidisciplinary approach, combining non-pharmacological and pharmacological treatment modalities tailored to the individual patient's needs, including pain intensity, function, associated features, and patient preferences and comorbidities.
- Key components of the assessment include:
- Comprehensive medical history
- Physical examination
- Exclusion of other conditions that might explain symptoms
- Evaluation of pain, function, and psychosocial context
- Consideration of patient preferences and comorbidities The initial management should focus on non-pharmacological therapies, such as aerobic and strengthening exercise, cognitive behavioral therapies, and multicomponent therapies, as recommended by the EULAR guidelines with a strong level of evidence 1. The assessment process should also acknowledge the significant impact fibromyalgia has on quality of life and functional capacity, with regular reassessment recommended as symptoms may fluctuate over time.
- The EULAR guidelines emphasize the importance of shared decision-making with the patient, taking into account their individual needs and preferences, and prioritizing a graduated approach to management 1. It is essential to recognize fibromyalgia as a complex and heterogeneous condition, requiring a tailored approach to management, and to prioritize ongoing research to address the remaining gaps in knowledge, including the most effective types of exercise, combined pharmacological and non-pharmacological approaches, and characteristics of patients that predict response to specific therapies 1.
From the Research
Assessment Guidelines for Fibromyalgia in Canada
The assessment guidelines for fibromyalgia in Canada involve a comprehensive clinical evaluation to avoid under-, over-, or misdiagnosis 2. The key steps in the assessment process include:
- Screening for chronic widespread pain (CWP) in patients with chronic pain
- Evaluating the presence of additional major symptoms of fibromyalgia, such as unrefreshed sleep and fatigue
- Conducting a complete medical history and physical examination to consolidate the diagnosis or identify features that may point to other conditions
- Limited simple laboratory testing to screen for possible other diseases
- Using the 2016 criteria to further confirm the clinical diagnosis of fibromyalgia
Diagnostic Criteria and Tests
The diagnostic criteria for fibromyalgia syndrome (FMS) emphasize tender points and widespread pain as key features 3. The American College of Rheumatology (ACR) proposed preliminary diagnostic criteria for fibromyalgia in 2010, which abandoned the tender point count and placed increased emphasis on patient symptoms. A stepwise diagnostic work-up is recommended, including:
- Complete medical history and examination
- Basic laboratory tests to screen for inflammatory or endocrinology diseases
- Referral to specialists only in case of suspected somatic diseases
- Assessment of limitations of daily functioning and screening for other functional somatic symptoms and mental disorders
Clinical Characteristics and Medication Uses
Fibromyalgia patients newly prescribed amitriptyline, duloxetine, gabapentin, or pregabalin have similar clinical characteristics and medication use patterns 4. The most common comorbidities include back pain, hypertension, headache, depression, and sleep disorder. The median daily dose at the start of follow-up is typically low, and most patients remain on the same dose throughout the follow-up period. However, only one-fifth of patients continue the treatment for ≥1 year.
Canadian Guidelines
The 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome provide evidence-based recommendations for the diagnosis, management, and patient trajectory of individuals with fibromyalgia 5. The guidelines emphasize the importance of a comprehensive clinical assessment, healthy lifestyle practices, and multimodal management, including nonpharmacological and pharmacological strategies. The guidelines aim to provide health professionals with confidence in the complete care of patients with fibromyalgia and improve clinical outcomes.