New Canadian Guidelines for Diagnosing and Treating Fibromyalgia
For the first time, researchers in Canada have published a set of guidelines to help family physicians with the diagnosis and treatment of fibromyalgia. The new guidelines, which are laid out in a clear, easily understandable format on the National Guidelines Website, can be very helpful for patients as well.
"One million Canadians have fibromyalgia and the time has come to take their suffering seriously. This is a real condition that greatly impacts patients and their families. Finally there are national guidelines to help diagnose and treat this syndrome," says Dr. John Pereira, a study co-author from the University of Calgary's Faculty of Medicine and a physician at the Calgary Chronic Pain Centre.
2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome
A news release about the new guidelines noted, "Fibromyalgia is usually diagnosed by rheumatologists but due to the high prevalence of the disease many patients are not able to seek advice from a specialist. Therefore, primary care physicians are best positioned to take over this role, as recommended by the 2012 Canadian Fibromyalgia Guidelines. In the review, the authors provide evidence-based tools for primary care physicians to make the diagnosis and manage the condition long-term."
"We are the first ones to develop guidelines that look at diagnosis, treatment and follow-up of fibromyalgia," says Dr. Mary-Ann Fitzcharles, corresponding author from the Research Institute of the MUHC and MUHC's rheumatologist. "Currently, there is no cure for fibromyalgia but the guidelines set out the most appropriate management strategy."
The guideline authors recommend non-pharmaceutical interventions such as exercise, relaxation techniques and cognitive behavioral therapy as well as medications tailored to the individual patient. The main treatment goal is to improve quality of life by alleviating the most troublesome symptom(s), with pain recognized as the most common and serious.
The essence of the guidelines' recommendations is as follows:
FM represents a composite of symptoms, with body pain present as the pivotal symptom.
There is a spectrum of severity which associates with functional outcome, with fluctuating symptoms over time.
The diagnosis of FM is clinical, not one of exclusion, not needing specialist confirmation, and requires only limited laboratory testing.
A physical examination is required to exclude other conditions presenting with body pain, but tender point examination is not required to confirm the diagnosis.
There is no confirmatory laboratory test and excessive testing is strongly discouraged.
Ideal care for most patients is in the primary care setting.
Treatments should be multimodal, incorporating non-pharmacologic and pharmacologic strategies, with focus towards reduction of symptoms and improvement of function.
Patients must be active participants in their healthcare and non-pharmacologic strategies are imperative.
Patient-tailored management that is symptom-based is recommended.
In the absence of an ideal pharmacologic treatment, an agent impacting multiple symptoms is desirable.
Doses of medications lower than those used in clinical trials and combination of medications may facilitate adherence.
Emphasis on healthy lifestyle practices, maintenance of function including retention in the workforce, periodic assessment for the need for continued medication, and evaluation of efficacy/side effects of ongoing treatments is recommended.
New symptoms should be evaluated according to good clinical practice to exclude another illness without summarily attributing symptoms to FM.
Overall I think these guidelines are pretty good. Their goal is to teach family doctors about FM so they can treat FM patients without referring them to a specialist. The result should be more and better care for Canadians with fibromyalgia.
One recommendation in the guidelines I don't completely agree with is discouraging the use of the tender point exam for diagnosis. Instead they recommend using the ACR's proposed 2010 diagnostic criteria, which relies only on the patient's identification of painful areas and description of the severity of other related symptoms. I understand why they chose to go that way - because sometimes doctors are hesitant to learn how to do the tender point exam properly. But until we have a definitive diagnostic blood test or other laboratory test, I still think there's a place for the hands-on tender point exam.
That issue aside, I think these guidelines are definitely a step in the right direction. They recognize the seriousness of fibromyalgia and hopefully will help FM patients in Canada get the best treatment possible.
Fitzcharles MA, et al. 2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome. National Guidelines Website.