A Roadmap for the Management of Fibromyalgia
Larry Culpepper, MD, MPH
Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
In the management of fibromyalgia, the patient plays the central role (AV 1). The primary care physician should work with the patient to identify a framework for treatment that targets the individual patient’s symptoms, incorporates the expertise of specialist collaborators, and uses community resources.
Fibromyalgia Management Roadmap
Patient responsibilities. Patients need to take responsibility for managing their disorder and must actively participate in all components of the treatment plan to have successful outcomes. Physicians educate patients and provide them with educational resources, encouraging patients to find out about the disorder and its treatment on their own. Understanding that fibromyalgia is a chronic condition that waxes and wanes will help patients to have realistic expectations about the course of their treatment. Patients also need to understand that, just as it has often taken years for their symptoms to develop, it will also take some time to find an optimal treatment strategy for them.
For the treatment plan to succeed, patients need to:
- educate themselves about fibromyalgia and the therapeutic resources available to them
- engage with the physician to prioritize target symptoms and treatment strategies
- clarify their life goals in relation to treatment, particularly in terms of functional recovery
- engage in a moderate, progressive exercise program with attainable goals
- eat well and monitor their weight gain
- practice good sleep hygiene.
Because of disability due to their symptoms, patients with fibromyalgia may have become socially isolated. If this is the case, encourage them to identify and pursue family and social activities to decrease their isolation. Inform patients of counseling or patient-led support groups, which can be helpful in this area.
Primary care provider responsibilities. Primary care physicians need to understand the diagnosis of fibromyalgia, know the pharmacologic and nonpharmacologic treatment options, and help patients to educate themselves about the disorder. Although physicians should be empathetic and supportive, a critical initial negotiation point with patients is ensuring that they remain responsible for their own treatment.
Physicians should encourage patients to increase their physical activity and to engage fully in their work and social roles. However, the importance of the proper pacing of activities should be reinforced so that patients do not overexert themselves and experience short-term setbacks because of the associated fatigue. Motivational interviewing, which enlists patients’ active participation in treatment as they pursue their life goals, may be more successful in encouraging a patient to engage in exercise than standard education (AV 2).1
Physicians should regularly monitor the patient’s symptoms by using scales that measure pain, fatigue, mood, sleep, and function (eg, the VAS for pain, the PHQ-9 for depression, and the FIQ for functional status). Because the care of patients with fibromyalgia is time-intensive, physicians should consider group visits and online CBT options for patients. In addition, primary care physicians can organize a multidisciplinary team to provide comprehensive and effective care for patients.
Multidisciplinary collaborator involvement. Because of the complex presentation of fibromyalgia and its various symptoms, multidisciplinary experts may need to be consulted to manage the condition. For example, rheumatologists, physical therapists, occupational therapists, pain specialists, and CAM practitioners can be consulted for help with continued pain-related symptomatology. Severe mood-related concerns may be addressed by mental health professionals; CBT may be useful in dealing with negative attitudes or bad habits.2 Longer forms of motivational interviewing can be provided by therapists or by nurses in the practice.
Community resources. Patients may find great benefit from exploring and engaging in community resources. These can be informal resources, such as finding a supportive partner within their own family or social network. Programs related to substance abuse may be useful if addiction or past opioid mistreatment is a concern. Other resources include pharmacists, online support groups, exercise programs, YMCA or YWCA or other fitness clubs, and weight loss programs. Helpful online resources include the National Fibromyalgia & Chronic Pain Association, the National Fibromyalgia Association, and the American Chronic Pain Association.
Patients with fibromyalgia can receive major therapeutic benefit from engaging in their own treatment and the full array of options available. Treatment should be delivered within a framework that considers the responsibilities and roles of the patient, the primary care physician, the multidisciplinary treatment team, and community resources. Patients are central to the fibromyalgia treatment roadmap and must educate themselves about the nature of the disorder and its management over time. Monitoring the patient’s progress, adjusting treatment over time, and helping the patient to increase activity and improve social and occupational functioning are part of the long-term therapeutic package that the physician should provide.
For Clinical Use
- Educate patients about fibromyalgia and help them accept their central role in treatment
- Encourage increased physical activity
- Regularly assess and monitor patients’ pain, fatigue, mood, sleep, and function
- Assemble a multidisciplinary team to manage the various symptoms of the patient
- Urge patients to use community and social resources to achieve functional goals
CAM = complementary and alternative medicine, CBT = cognitive-behavioral therapy, FIQ = Fibromyalgia Impact Questionnaire, PHQ-9 = 9-Item Patient Health Questionnaire, VAS = Visual Analog Scale, YMCA/YWCA = Young Men’s/Women’s Christian Association
- Jones KD, Burckhardt CS, Bennett JA. Motivational interviewing may encourage exercise in persons with fibromyalgia by enhancing self efficacy. Arthritis Rheum. 2004;51(5):864–867.
- Goldenberg DL. Multidisciplinary modalities in the treatment of fibromyalgia. J Clin Psychiatry. 2008;69(suppl 2):30–34.