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. 


Abstract and Introduction


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.


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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Table 1.  Differences between the ACR 1990 (1) and the revised ACR 2010 (9) criteria for FM
1990 2010
History of widespread pain WPI ≥ 7 and SS ≥ 5
WPI 3–6 and SS ≥ 9
Pain of ≥ 3 months' duration Symptoms have been present at a similar level for ≥ 3 months
Pain in 11 of 18 tender points on digital palpation Patient does not have a disorder that would otherwise explain the pain
Widespread pain
• Pain on left side of body, right side of body, above waist, below waist and axial skeletal pain
WPI score
• The number of areas in which patient has had pain over the last week (six lower extremities, six upper extremities, seven axial skeleton)
• Final score: between 0 and 19
Tender points (all bilateral)
• Occiput, low cervical, trapezius, supraspinatus, second rib, lateral epicondyle, gluteal, greater trochanter, knee
SS score
• The sum of severity of fatigue, waking unrefreshed and cognitive symptoms, plus the severity of general somatic symptoms
• Each symptom is rated on a scale of 0–3, where 0 = no symptoms/problem and 3 = severe symptoms/problems
• Final score: between 0 and 12

ACR, American College of Rheumatology; FM, fibromyalgia; SS, symptom severity; WPI, Widespread Pain Index.

Table 2.  A comparison of FDA-approved pharmacological medications for FM (pivotal studies) (32, 49–51)
Drug FDA approval Mechanism of action Efficacy studies Primary end-points Dosing Adverse events*
Pregabalin 21 June 2007 Non-selective α2δ ligand • 14 weeks, randomised, double-blind, placebo-controlled
• 6 months, randomised, withdrawal
Pain reduction, improvements in PGIC and FIQ 300–450 mg/day; start at 75 mg bid (might increase to 150 mg bid within 1 week); max dose 225 mg bid Dizziness, somnolence, dry mouth, oedema, blurred vision, weight gain, abnormal thinking
Duloxetine 16 June 2008 SNRI • 3 months, randomised, double-blind, placebo-controlled
• 6 months, randomised, double-blind, placebo-controlled
Pain reduction, improvements in PGIC and FIQ 60 mg/day; start 30 mg/day for 1 week then increase to 60 mg/day Nausea, dry mouth, somnolence, constipation, decreased appetite, hyperhidrosis
Milnacipran 14 January 2009 SNRI • 3 months, randomised, double-blind, placebo-controlled
• 6 months, randomised, double-blind, placebo-controlled
Composite end-point that concurrently evaluated improvement in pain (VAS), physical function (SF-36 PCS) and patient global assessment (PGIC) 100 mg/day; start 12.5 mg/day, increasing incrementally to 50 mg bid in 1 week; maximum dose 100 mg bid Nausea, constipation, hot flush, hyperhidrosis, vomiting, palpitations, increased heart rate, dry mouth, hypertension

bid, twice daily; FDA, US Food and Drug Administration; FIQ, Fibromyalgia Impact Questionnaire; FM, fibromyalgia; PGIC, patient global impression of change; SF-36 PCS, Short-Form 36 Physical Component Summary; SNRI, serotonin-norepinephrine re-uptake inhibitor; VAS, visual analogue scale.
*The most commonly reported adverse events are shown. For full details, please refer to the prescribing information for each drug.

Table 3.  A comparison of non-pharmacological therapies for FM (4,6)
Treatment Regimen Reported outcomes Advantages Disadvantages
Patient education Provide core information about diagnosis, treatment and prognosis; manage expectations Can improve symptoms and functionality; might reduce disability levels • Can be carried out as part of normal consultations • Might need to be repeated during each consultation or require separate educational sessions
• Might be time-consuming
• Might require additional support staff to help provide education
Exercise Start low, go slow: build up to moderate activity over time Can improve physical function, quality of life and reduce symptoms of pain and depression • Easily incorporated into daily routine
• Even small increases in activity have been shown to be of value
• Might cause worsening of symptoms if exercise programme is begun too rapidly
• Access to exercise facilities might be limited
• Might require consultation with other HCPs (e.g. physical therapists)
CBT Face-to-face counselling, online self-help courses, books, CDs, FM Web sites Provides knowledge about FM and coping strategies. Can provide sustained improvements in FM symptoms, and reduce impact on daily life • Effective in one-on-one settings, small groups and via the Internet
• Internet-based programmes provide convenience for patients
• Most effective when combined with other treatments
• Access to mental health providers might be limited and might be costly
Sleep hygiene Optimise sleep environment and prioritise relaxing sleep routine Can improve pain scores and mental well-being • Easily incorporated into daily routine • Patient might be resistant to changes in routine (e.g. avoiding coffee at night, not watching television in bed)
CAM therapies Various: examples include tai chi, yoga, massage, diet, balneotherapy and acupuncture Can increase patient self-sufficiency and improve pain/functioning • Limited evidence for efficacy • Most CAM therapies have not been rigorously studied
• Limited access to some of these treatments in some communities
• Might be costly

CAM, complementary and alternative medicine; CBT, cognitive behavioural therapy; FM, fibromyalgia; HCP, healthcare professional.

Appendix.  Healthcare provider definitions.
Job title Responsibilities
Behavioural health worker Support staff worker who provides psychological therapeutic support to patients with behavioural health issues and psychological disorders; generally requires a qualification in psychology, social work, counselling or nursing
Care coordinator Liaises between patients and other healthcare professionals; ensures patients understand their medical condition and treatment, locates community resources and coordinates patient care services and referrals
Dietician An expert in human nutrition and the regulation of diet; advises people on what to eat to achieve health-related goals
Health coach An individual trained to assist patients by promoting coping behaviours, goal setting and overcoming negativity; generally requires a qualification in exercise science, nutrition, health care or wellness. Similar processes may also be performed by a psychotherapist
Healthcare professional (HCP) Any individual trained to provide healthcare services; may include physicians, nurses, therapists and support workers
Medical assistant A healthcare professional supporting physicians and other healthcare providers; they perform routine tasks and procedures such as measuring vital signs, collecting biological specimens, completing electronic medical records and scheduling appointments. Qualifications and requirements for certification vary between jurisdictions
Nurse practitioner An advanced practice registered nurse who has been trained to diagnose and manage acute illness and chronic conditions. A nurse practitioner may serve as a primary care provider; in the USA, depending upon which state they work in, nurse practitioners may or may not be required to practice under the supervision of a physician
Pharmacist Healthcare professional who understands the mechanisms and actions of drugs, side effects, drug interactions and monitoring requirements; they provide pharmaceutical information and oversee the dispensation of prescription medication as well as non-prescription or over-the-counter drugs. A further education qualification is required
Physical therapist Rehabilitation professional who manages patients with health conditions that limit their ability to move and perform functional activities
Physician assistant A healthcare professional who is licenced to practice medicine as part of a team with physicians and other providers; may be known as a physician associate in the UK. A physician assistant may conduct physical exams, order tests, diagnose and treat illnesses and perform medical procedures under the supervision of another physician
Primary care physician A physician who provides the first point of contact for a patient and continuing care of medical conditions; may be known as a general practitioner in English-speaking countries outside of the USA
Primary care provider A healthcare professional providing day-to-day health care in a primary care setting; may be a primary care physician, nurse practitioner or physician assistant
Psychiatrist A physician specialising in the diagnosis and treatment of mental disorders
Registered nurse A nurse who has undergone training and met the requirements to obtain a nursing licence
Specialist A physician or surgeon who has completed further medical education and training in a specific branch of medical practice


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Authors and Disclosures

L. M. Arnold1, K. B. Gebke2 and E. H. S. Choy3

1Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, USA
2Department of Family Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
3Department of Medicine, Cardiff University School of Medicine, Cardiff, UK

Correspondence to
Lesley M. Arnold, Department of Psychiatry, University of Cincinnati College of Medicine, 260 Stetson Street Suite 3200, Cincinnati, OH 45219, USA Tel.: + 1 513 558 4622 Fax: + 1 513 558 4280 Email:

Dr Arnold reports grants and personal fees from Daiichi Sankyo, Pfizer, Forest, and Theravance; personal fees from Dainippon Sumitomo Pharma, Purdue, Toray, Shire, Innovative Med Concepts, Ironwood, and Zynerba; and grants from Takeda, Tonix, Cerephex Corporation, and Eli Lilly and Company outside the submitted work. Dr Gebke reports personal fees from Pfizer outside the submitted work. Dr Choy reports personal fees from Daiichi Sankyo, Inc., during the conduct of the study and personal fees from Pfizer, Tonix, and Eli Lilly, outside the submitted work.

Funding and Acknowledgements
The funding for this article was provided by Daiichi Sankyo, Inc.; however, company personnel had no role in article design, manuscript preparation or publication decisions. The authors did not receive financial remuneration for the writing of this manuscript. The authors thank Sally-Anne Mitchell, PhD (ApotheCom, Yardley, PA) for editorial assistance with this manuscript. This assistance was funded by Daiichi Sankyo, Inc.

Author contributions
All authors contributed to the article conception, critical revision of each draft and approval of the final version.

Sidebar 1

Review Criteria

We reviewed the epidemiology, pathophysiology and management of fibromyalgia (FM) by searching English-language publications in PubMed, and references from relevant articles, published before May 2015. The main search terms were fibromyalgia, epidemiology, pathophysiology, diagnosis, primary care, secondary care, treatment and patient-centred medical home. We selected articles on the basis of quality, relevance to the illness and importance in illustrating current management pathways and the potential for future improvements.

Message for the Clinic

The management pathway for FM currently is often lengthy and complex, involving repeated clinic visits, unnecessary referrals and costly tests. The medical home, a patient-centred management framework which has been successfully implemented in other chronic diseases, might provide the key to reducing diagnosis time and improving patient outcomes. Effective approaches to helping practices adopt the medical home and tailor it to the needs of patients with FM will be important.

Sidebar 2

Case Study: Susan King

Patient: Susan King is a white female aged 45 years, married, with one child (a girl, currently 15 years of age)

Medical history: Susan has a history of migraines that started in adolescence. Susan also had some depressive episodes while in college but did not seek treatment and was never formally diagnosed. Just over 3 years ago, she was promoted to a more stressful position at work. Around the same time she began to suffer from widespread pain and symptoms of irritable bowel syndrome. These symptoms resulted in Susan having to take time off from work because of pain and fatigue. Depressive symptoms also recurred a couple of years ago, subsequent to the promotion and following several months of unexplained pain

Sidebar 3

Case Study: Susan King

Current symptoms: In addition to widespread pain, Susan reports regular sleepless nights, resulting in feeling unrefreshed and tired for most of the day. She feels that she is not 'clear-headed' and is unable to concentrate on regular tasks at times. Her fatigue means that she is so exhausted after work that she is unable to interact with her husband and daughter, or take part in normal social activities. Susan is also conscious that since she is sedentary at her job, she should make time for physical exercise. However, although she previously participated in regular aerobic exercise, she has not exercised in the past 9 months due to always feeling tired. With further enquiry, Susan remembers that during her childhood, her mother also had similar complaints

Sidebar 4

Case Study: Susan King


What: medical history, physical examination, basic laboratory tests. Who: primary care physician, nurse practitioner or physician assistant. Results discussed with team, and diagnosis relayed to patient by primary care physician

Sidebar 5

Case study: Susan King


What: Susan is asked by her PCMH team to prioritise the most important aspects of her life that require improvement. Who: primary care physician, nurse practitioner or physician assistant

Susan feels that if she had less fatigue, she would be able to cope much better with everything else that is going on Treatment recommendations

  1. What: information leaflets, details of a local support group, details for online self-help Web site. Who: registered nurse or care coordinator

  2. What: education on good sleep hygiene in an attempt to reduce sleep disruption. Who: behavioural health worker or health coach. Possible referral to sleep specialist

  3. What: encouragement to take up exercise again, starting out by simply increasing daily activity, and working up to rejoining her aerobics class in a few months' time. Who: primary care physician, health coach or medical assistant. Consider referral to a physical therapist to assist with planning and implementing a manageable routine of stretching and exercise to regain mobility and strength

  4. What: address diet, to try to improve the IBS symptoms. Avoid foods that trigger symptoms, restrict caffeine and alcohol intake, increase or decrease fibre intake to improve symptoms such as diarrhoea and constipation. Who: physician assistant, nurse practitioner or registered nurse. Possible referral to a dietician

  5. What: pharmacological treatment. Who: primary care physician, physician assistant, nurse practitioner, pharmacist. Options include a serotonin-norepinephrine re-uptake inhibitor (SNRI) which might improve both depressive and FM symptoms, or a selective serotonin re-uptake inhibitor (SSRI) to treat the depression alongside a drug with a different mechanism of action, such as an α2-δ ligand, to treat the FM pain. Possible referral to a psychiatrist if depressive symptoms do not improve or worsen