Optimal management of Fibromyalgia (FMS) aims to improve symptoms by reducing severity and improving function and quality of life for the patient.  Treatment is more effective when done in combination with a start-low, go-slow basis.

Recommended Care integrates the four cornerstones of:

1. Education and the acquisition of self-management skills
2. Physical activity: tailored
3. Lifestyle adaptation
4. Pharmacological

Education

Education is a core step, it explains the condition; the diagnosis and treatment and management options and treatment outcomes. It also enables patients to participate in shared decision making and provides them with skills to participate in patient centred care planning during assessments. Education empowers patients to develop lifestyle skills, live within their energy limits and reduce stress to maximise the effectiveness of treatments.

Fibromyalgia Australia’s management programs are based on the Flinders Program 2012. 

Fibromyalgia-adapted programs provide additional up-to-date information on Fibromyalgia, particularly on the range of Fibromyalgia treatments available and use of multiple strategies to maximise function and quality of life. 

Management Programs assist people to make better-informed decisions through a greater understanding. They have been proven to empower patients to develop active coping skills for effective management over time.

Education and health coaching are part of care planning and annual reviews.

Topics to cover:

• Fibromyalgia is a multisystem condition, it includes a pain processing problem in the brain and possibly peripheral nerves.
• The importance of
  • monitoring, feedback and good communication
  • self-management and coping mechanisms
  • using multiple strategies

• Refer patient to:
  • Patient information sheets
  • Community groups and websites e.g.
    • Bridges and Pathways – provides links and information about the South Australian Fibromyalgia Patient Education Model
    • Fibromyalgia Australia – provides resources for patients to manage their condition
• Access to information for the patient, family, carers and colleagues

Physical activity

Exercise and movement are an integral part of pain management programs and important in maintaining function in Fibromyalgia. Early referral for a functional assessment and individually tailored programs based on the ‘start low, go slow‘ approach is important.

Health professionals supervising any exercise program need to be fully aware of the total illness load and the pathophysiology of FMS; in particular, the potential for exercise to flare the condition, taking into account the pain wind-up stress sensitivity of Fibromyalgia.

Many individuals will be unable to exercise until their Fibromyalgia is stabilised and the sensitivity of their pain system is dampened by other means. These include stabilising their condition, living within their energy envelope and medication as required.

In some patients improved pain control unfortunately continues to be elusive, so at most only very gentle exercise will be possible, implying that the common blanket recommendation for moderate intensity aerobic exercise in Fibromyalgia is unrealistic.

Referrals need to be to experienced providers including physiotherapists, occupational therapists, personal trainers and other Fibromyalgia specialist movement programs.

Low impact aerobic activities e.g. moderately paced walking, biking, swimming or water aerobics when introduced cautiously are the most successful interventions. Strength training, water exercises, Tai Chi and yoga may be of some help.

Our feedback suggests that the key to successful outcomes is developing individually tailored client-centred programs based on the principle of ‘Start low – go slow’ and responsive to the patient’s feedback.

Fibromyalgia Australia is working across Australia to develop a list of Fibro friendly providers for physical therapy and pain programs to support general practices and nurses in team care arrangements. If you would like your program to be included, please contact us.

Lifestyle adaptation

While group-based education and lifestyle programs are recommended, in some more complex cases FMS patients will benefit from one-to-one cognitive therapies.

These therapies help patients to adjust to the secondary issues that may arise from having a long-term multi-system and pervasive disorder that interferes with all facets of a patient’s life, including everyday activities and work. They also include a range of strategies to help reduce stress, promote a sense of well-being, and to improve self-esteem and maintain a quality of life.

These stress management techniques include:

• Pacing
• Mind-body techniques such as relaxation, distraction, meditation
• Physical activities like Tai Chi and Yoga
• Music therapy, prayer and hypnosis
• Problem-solving

Other symptom-domain treatments

Many of the associated symptoms of fatigue, sleep disturbance, cognitive difficulties, moods disorders also benefit from these approaches. While patient feedback suggests all FMS patients benefit from pacing, it is essential for those with predominant fatigue to pace themselves and stay within their energy envelope.

For residual insomnia not related to a primary sleep disorder, standard interventions are required and possible referral to a sleep clinic to rule out the possibility of comorbid sleep disorders.

Many patients with fibromyalgia have gut symptoms and may benefit from referral to a dietician.

Occupational therapy assessments provide advice on activities of daily living and adaptive equipment.

Pharmacological

General Principles

• Use in conjunction with non-pharmacological interventions. Drug therapy only has a supportive role in symptom management.
• Some patients either do not tolerate or benefit from drugs
• Emphasise that the aim is to reduce symptoms, including pain, but that no medication is likely to eliminate them. No treatments are universally effective, but medication may increase the patient’s ability to function and live a normal life.
• Do not give corticosteroids or opioids. Opioids have a poor clinical response and there is a risk of opioid-induced hyperalgesia which may worsen the condition.
• Start drugs at low doses.
• Choose the drug to manage the predominant symptoms. Sleep, pain and psychological distress are most amenable to drug therapy.
• Stop the drug if it provides no benefit.
• Drugs complement an active rehabilitation programme.
• Only consider medications if inadequate response to non-pharmacological interventions.

Pain Medication By Class

Magnesium: Increases the function of melatonin in promoting sleep. Assists in reducing muscle tension, anxiety and sometimes pain.

Paracetamol: Useful for headache and muscle-joint pain. First line medication but can cause liver problems if used in very high doses. It can also be used in combination with codeine for stronger pain or in conjunction with NSAIDS.

Tricyclics: e.g. Amitriptyline. Old fashioned antidepressants which must be taken regularly to prevent pain rather than for acute treatment of pain. May be beneficial for sleep. Lower starting doses are recommended as Fibromyalgia patients can be sensitive.

Seizure medications : These must be used with caution as the side effects may be significant.

Serotonin-norepinephrine reuptake inhibitors (SNRIs): A trial of SNRIs may be warranted as a small subgroup of patients will respond.

Non-steroidal anti-inflammatory drugs (NSAIDS): Used for any accompanying inflammation. To be taken with food to avoid stomach upsets and ulcers. Doctor to monitor liver and kidney function if these are regularly used.

Tramadol (Tramal, Zydol): Codeine strength pain relief which is variably tolerated and is thought to have a minimal risk of addiction if kept to modest doses. May cause ‘serotonin syndrome’ if taken with certain antidepressants or other drugs. It should be used with caution in conjunction with SSRIs such as Prozac and tricyclics.

Narcotics: Have potential for addiction. However, it is said that addiction rarely occurs when used intermittently to treat severe pain.

Benzodiazepines: e.g. Diazepam. Should be used cautiously for the relief of muscle cramps and spasms. Some sedation is likely, and the dose should not exceed 5 mgs three times daily in short courses only.

A combination of medications working via different mechanisms often gives the best results, implying synergism.

All CNS acting medications may cause withdrawal reactions if suddenly stopped.

Unfortunately, there exists a subgroup of Fibromyalgia patients who are unable to tolerate any medications, and it is hoped that early diagnosis and improved management of Fibromyalgia will minimise this group.