Fibromyalgia: Management Strategies for Primary Care Providers

L. M. Arnold; K. B. Gebke; E. H. S. Choy

Disclosures

Int J Clin Pract. 2016;70(2):99-112. 

In This Article

Abstract and Introduction

Abstract

Aims: Fibromyalgia (FM), a chronic disorder defined by widespread pain, often accompanied by fatigue and sleep disturbance, affects up to one in 20 patients in primary care. Although most patients with FM are managed in primary care, diagnosis and treatment continue to present a challenge, and patients are often referred to specialists. Furthermore, the lack of a clear patient pathway often results in patients being passed from specialist to specialist, exhaustive investigations, prescription of multiple drugs to treat different symptoms, delays in diagnosis, increased disability and increased healthcare resource utilisation. We will discuss the current and evolving understanding of FM, and recommend improvements in the management and treatment of FM, highlighting the role of the primary care physician, and the place of the medical home in FM management.

Methods: We reviewed the epidemiology, pathophysiology and management of FM by searching PubMed and references from relevant articles, and selected articles on the basis of quality, relevance to the illness and importance in illustrating current management pathways and the potential for future improvements.

Results: The implementation of a framework for chronic pain management in primary care would limit unnecessary, time-consuming, and costly tests, reduce diagnostic delay and improve patient outcomes.

Discussion: The patient-centred medical home (PCMH), a management framework that has been successfully implemented in other chronic diseases, might improve the care of patients with FM in primary care, by bringing together a team of professionals with a range of skills and training.

Conclusion: Although there remain several barriers to overcome, implementation of a PCMH would allow patients with FM, like those with other chronic conditions, to be successfully managed in the primary care setting.

Introduction

Fibromyalgia (FM) is a common, potentially disabling, chronic disorder that is defined by widespread pain, often accompanied by fatigue and sleep disturbance, and associated with other symptoms including depression, cognitive dysfunction (e.g. forgetfulness, decreased concentration), irritable bowel syndrome (IBS) and headache.[1,2] In the general population, the estimated global prevalence of FM is 2.7% (4.2% female, 1.4% male).[2] In primary care, studies suggest that up to one in 20 patients has FM symptoms,[3] and this number is increasing as growing recognition of FM by patients leads to an upsurge in presentation for diagnosis and treatment.[4,5] The cause of FM is not known, but research studies suggest genetic predisposition and possible triggering events.[6]

Fibromyalgia continues to present a challenge for healthcare professionals (HCPs).[7] The extensive array of symptoms associated with, and gradual evolution of, FM make it difficult to diagnose in primary care settings,[7,8] and the condition is often under-diagnosed.[5] One study has shown that diagnosis of FM might take more than 2 years, with patients seeing an average of 3.7 different physicians during this time.[8] Although the American College of Rheumatology (ACR) has published diagnostic criteria for FM,[9,10] these are not widely used in clinical practice, and there remains a knowledge gap among some HCPs, particularly in the primary care setting.[7,8,11,12] In addition to diagnostic complexity, therapeutic management might be problematic,[13] and there is a lack of prescribing consistency between physicians.[14,15] Many patients might not receive treatment, and for those who do, repeated therapy switching, polypharmacy and discontinuation are common.[16] Some patients may also have unrealistic treatment expectations[17] and difficulty coping with their symptoms, which may contribute to struggles in managing their condition.

The aim of this review was to discuss the current and evolving understanding of FM, provide insights into the challenges around recognition and diagnosis, and recommend improvements in the management and treatment of FM. The review will highlight the role of the primary care physician, and the place of the medical home in FM management.

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