Activity 7: Fibromyalgia in Family Medicine: Challenges in Pain Management

Recommendation #1: Base the clinical diagnosis of fibromyalgia on the presence of widespread pain, defined as pain in all 4 body quadrants and axial pain, for at least 3 consecutive months. The only physical examination criterion for diagnosis is the presence of excess tenderness of at least 11 of 18 muscle-tendon sites obtained on manual tender point examination.
Source: Guidelines for the management of fibromyalgia syndrome pain in adults and children. American Pain Society Practice Guidelines Series, No. 4, 2005.
Website: http://www.ampainsoc.org/pub/cp_guidelines.htm
Strength of Evidence: B

Recommendation #2: Tramadol is recommended for the treatment of pain in fibromyalgia.
Source: Carville S, et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis 2008;67:536-541.
Website: http://ard.bmj.com/content/67/4/536.full
Strength of Evidence: A

Recommendation #3: Simple analgesics such as acetaminophen and other weak opioids can also be considered in the treatment of fibromyalgia. Corticosteroids and strong opioids are not recommended.
Source: Carville S, et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis 2008;67:536-541.
Website: http://ard.bmj.com/content/67/4/536.full
Strength of Evidence: D

Recommendation #4: Antidepressants such as amitriptyline, fluoxetine, duloxetine and milnacipran reduce pain and often improve function; therefore, they are recommended for the treatment of fibromyalgia.
Source: Carville S, et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis 2008;67:536-541.
Website: http://ard.bmj.com/content/67/4/536.full
Strength of Evidence: A

Recommendation #5: Pregabalin reduces pain and is recommended for the treatment of fibromyalgia.
Source: Carville S, et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis 2008;67:536-541.
Website: http://ard.bmj.com/content/67/4/536.full
Strength of Evidence: A

Recommendation #6: Provide all patients with basic information on fibromyalgia and treatment options, and educate them about pain management and self-management programs as an initial part of treatment.
Source: Guidelines for the management of fibromyalgia syndrome pain in adults and children. American Pain Society Practice Guidelines Series, No. 4, 2005.
Website: http://www.ampainsoc.org/pub/cp_guidelines.htm
Strength of Evidence: A

Recommendation #7: Incorporate cognitive behavioral therapy into a multimodal treatment approach to reduce pain, enhance self-efficacy and improve function.
Source: Guidelines for the management of fibromyalgia syndrome pain in adults and children. American Pain Society Practice Guidelines Series, No. 4, 2005.
Website: http://www.ampainsoc.org/pub/cp_guidelines.htm
Strength of Evidence: A

Recommendation #8: Encourage and support people with fibromyalgia to perform moderately intense aerobic exercise two to three times per week.
Source: Guidelines for the management of fibromyalgia syndrome pain in adults and children. American Pain Society Practice Guidelines Series, No. 4, 2005.
Website: http://www.ampainsoc.org/pub/cp_guidelines.htm
Strength of Evidence: A

Recommendation #9: Encourage people with fibromyalgia to perform muscle-strengthening exercise two times per week.
Source: Guidelines for the management of fibromyalgia syndrome pain in adults and children. American Pain Society Practice Guidelines Series, No. 4, 2005.
Website: http://www.ampainsoc.org/pub/cp_guidelines.htm
Strength of Evidence: B

Recommendation #10: Offer clinician-assisted treatments, such as therapeutic massage, which may be helpful for pain relief.
Source: Guidelines for the management of fibromyalgia syndrome pain in adults and children. American Pain Society Practice Guidelines Series, No. 4, 2005.
Website: http://www.ampainsoc.org/pub/cp_guidelines.htm
Strength of Evidence: B

Download PDF with Recommendations

Approved and off-label medications for chronic pain: Download PDF

The file (OpCalc.prc) is an equianalgesic opioid calculator. This PDA tool allows easy and accurate conversion when switching from one opioid medication to another opioid and uses standard equianalgesic dosing.
Download Opiate Calculator for Palm OS, Pocket PC (Windows Mobile) and PC Windows: OpCalc.prc

Installation Instructions
RediReader for Palm OS
RediReader for Pocket PC

 

Presentation Slides for Fibromyalgia in Family Medicine: Challenges in Pain Management.

Arnold LM.  Biology and Therapy of Fibromyalgia.  New Therapies in Fibromyalgia.  Arthritis Res Ther 2006;8:212.

Bennett RM, Kamin M, Karim R, et al.  Tramadol and Acetominophen Combination Tablets in the Treatment of Fibromylgia Pain: A Double Blind, Randomized, Placebo-Controlled Study.  Am J Med 2003;114:537-545.

Bennett RM, Schein J, Kosinski MR, et al.  Impact of Fibromyalgia Pain on Health-Related Quality of Life Before and After Treatment with Tramadol/Acetominophen.  Arthritis Rheum 2005;53:519-527.

Bosseau L, Wells G, Tugwell P, et al.  Ottawa Panel Evidence-Based Clinical Practice Guidelines for Strengthening Exercises in the Management of Fibromyalgia.  Physical Therapy 2008;88(7):857-871 and 873-886.

Chakrabarty S, Zoorob R.  Fibromyalgia.  Am Fam Physician 2007;76:247-254.

Gracely RH, Petzke F, Wolf JM, et al.  Functional Magnetic Resonance Imaging Evidence of Augmented Pain Processing in Fibromyalgia.  Arthritis Rheum 2002;46:1333-1343.

Hauser W. J Pain 2010 (in press).

Lautenschlager J.  Present State of Medication Therapy in Fibromyalgia Syndrome.  Scand J Rheumatol 2000;29 (suppl 113):32-36.

Marcus DA. Chronic Pain: A Primary Care Guide to Practical Management. Humana Press, 2009.

Marcus DA. Fibromyalgia: Diagnosis and Treatment Options.  Gender Medicine 2009;6:139-151.

Marcus DA and Deodhar A.Fibromyalgia: A Primary Care Guide to Practical Management. Springer, 2010.

Rowbotham MC.  What is a "Clinically Meaningful" Reduction in Pain.  Pain 2001;94:131-132.

Wolfe F, Smythe HA, Yunus MB, et al.  The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia.  Report of the Multicenter Criteria Committee. Arthritis Rheum 1990;33:160-172.

 
 

 

 

 

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