Hands On 7, Autumn 2010

This season’s topic is fibromyalgia. I was pleased to see this as goodness knows I could use some ideas on what to do for fibromyalgia patients other than refer them to rheumatology, but about the only possibly useful idea I seem to have come away with is that heated pool treatment, with or without exercise, is effective. I say ‘possibly useful’ because I don’t have a clue how I’d arrange heated pool treatment, other than writing to a rheumatologist to see whether they know. However, it seems I can always just advise patients to take warm baths, which comes under the more impressive-sounding title of balneotherapy.

Other non-pharmacological management strategies which can sometimes be helpful include individually tailored exercise programmes (these can include aerobic exercise and strength training, in case any patients ask), CBT, relaxation, rehabilitation, physio (hello? Don’t exercise programmes come under the heading of physio?), and advice on sleep hygiene. Modify and tailor work to the level the patient can manage (hooray, I love the fit notes!)

Tramadol is the recommended medication for pain management. Paracetamol and other weak opioids can be considered, but strong opioids are not recommended, and nor are steroids. NSAIDs aren’t mentioned. There is evidence that amitriptyline, fluoxetine, duloxetine, milnacipran (what?), moclobemide and pirlindole (whatawhat?) are helpful in reducing pain and often in improving function. Tropisetron, pramipexole, and pregabalin are also often recommended. Don’t get carried away by the proved efficacy of all those meds, though – a solely pharmacological approach that does not take other factors into account is probably not going to get very far. Instead, we should aim for a holistic, tailor-made approach (cue mental image of tailor snipping holes in clothes).

As part of this holistic tailor-made approach, assess the patient’s disability level, using the Fibromyalgia Impact Questionnaire. And don’t forget those PHQ-9s for the associated depression (or perhaps a HAD, since anxiety can also be a factor).

I’m getting ahead of myself. How do we diagnose it in the first place? It seems we no longer have to prod trigger points (what’s this ‘we’ business, paleface? OK, we no longer have to refer them to the rheumatologists to get trigger points prodded) but can use a questionnaire. Investigations include all the ones I’d have done anyway (FBC, PV, CRP, calcium profile, and TFTs) plus glucose, ANA, RF, urinalysis for protein and blood, and I’d also add Vitamin D although that wasn’t on their list.

And what is it? A disorder of central pain processing, apparently. This explanation was, unsurprisingly, much better received by patients than claims that it’s ‘all in your mind’ – as tested by a study that used the delightful concept of ‘number needed to offend’, or NNO. I was interested to see that the ‘all in your mind’ explanation had an NNO as high as 2 – to put that in English, it means that only half the fibromyalgia patients receiving that explanation were offended by it. I’d have expected that nearly all of them would be.

There you go – I was too negative at the start. Lots of helpful ideas there. I think I’ll still refer patients, though, if only to make sure I’m not missing any other diagnosis and to see whether the rheumatologist has more access to the various services that can be helpful. But at least I now know what sorts of things to be doing when they’re bounced back to me.


About Dr Sarah

I'm a GP with a husband and two young children.
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