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

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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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
OR
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
Definitions
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

References

  1. 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: 160–72.

  2. Queiroz LP. Worldwide epidemiology of fibromyalgia. Curr Pain Headache Rep 2013; 17: 356.

  3. Glennon P. Fibromyalgia syndrome: management in primary care. Rep Rheum Dis 2010; series 6: 1–6.

  4. Arnold LM, Clauw DJ, Dunegan LJ, Turk DC. A framework for fibromyalgia management for primary care providers. Mayo Clin Proc 2012; 87: 488–96.

  5. Arnold LM, Clauw DJ, McCarberg BH. Improving the recognition and diagnosis of fibromyalgia. Mayo Clin Proc 2011; 86: 457–64.

  6. Clauw DJ. Fibromyalgia: a clinical review. JAMA 2014; 311: 1547–55.

  7. Hadker N, Garg S, Chandran AB et al. Primary care physicians' perceptions of the challenges and barriers in the timely diagnosis, treatment and management of fibromyalgia. Pain Res Manag 2011; 16: 440–4.

  8. Choy E, Perrot S, Leon T et al. A patient survey of the impact of fibromyalgia and the journey to diagnosis. BMC Health Serv Res 2010; 10: 102.

  9. Wolfe F, Clauw DJ, Fitzcharles MA et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res 2010; 62: 600–10.

  10. Wolfe F, Clauw DJ, Fitzcharles MA et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol 2011; 38: 1113–22.

  11. Gulec H, Sayar K, Yazici GM. The relationship between psychological factors and health care-seeking behavior in fibromyalgia patients. Turk Psikiyatri Dergisi 2007; 18: 22–30.

  12. Briones-Vozmediano E, Vives-Cases C, Ronda-Perez E, Gil-Gonzalez D. Patients' and professionals' views on managing fibromyalgia. Pain Res Manag 2013; 18: 19–24.

  13. Hayes SM, Myhal GC, Thornton JF et al. Fibromyalgia and the therapeutic relationship: where uncertainty meets attitude. Pain Res Manag 2010; 15: 385–91.

  14. Robinson RL, Kroenke K, Mease P et al. Burden of illness and treatment patterns for patients with fibromyalgia. Pain Med 2012; 13: 1366–76.

  15. McNett M, Goldenberg D, Schaefer C et al. Treatment patterns among physician specialties in the management of fibromyalgia: results of a cross-sectional study in the United States. Curr Med Res Opin 2011; 27: 673–83.

  16. Robinson RL, Kroenke K, Williams DA et al. Longitudinal observation of treatment patterns and outcomes for patients with fibromyalgia: 12-month findings from the reflections study. Pain Med 2013; 14: 1400–15.

  17. O'Brien EM, Staud RM, Hassinger AD et al. Patient-centered perspective on treatment outcomes in chronic pain. Pain Med 2010; 11: 6–15.

  18. Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA 2004; 292: 2388–95.

  19. Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B, Riley JL III. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain 2009; 10: 447–85.

  20. Vincent A, Lahr BD, Wolfe F et al. Prevalence of fibromyalgia: a population-based study in Olmsted County, Minnesota, utilizing the Rochester Epidemiology Project. Arthritis Care Res 2013; 65: 786–92.

  21. Clauw DJ, Arnold LM, McCarberg BH. The science of fibromyalgia. Mayo Clin Proc 2011; 86: 907–11.

  22. Phillips K, Clauw DJ. Central pain mechanisms in chronic pain states–maybe it is all in their head. Best Pract Res Clin Rheumatol 2011; 25: 141–54.

  23. Staud R. Abnormal endogenous pain modulation is a shared characteristic of many chronic pain conditions. Expert Rev Neurother 2012; 12: 577–85.

  24. Crofford LJ. Fibromyalgia. Atlanta, GA: American College of Rheumatology, 2013.

  25. Mease P. Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment. J Rheumatol Suppl 2005; 75: 6–21.

  26. Arnold LM, Hudson JI, Hess EV et al. Family study of fibromyalgia. Arthritis Rheum 2004; 50: 944–52.

  27. Perrot S, Winkelmann A, Dukes E et al. Characteristics of patients with fibromyalgia in France and Germany. Int J Clin Pract 2010; 64: 1100–8.

  28. Haviland MG, Banta JE, Przekop P. Fibromyalgia: prevalence, course, and co-morbidities in hospitalized patients in the United States, 1999–2007. Clin Exp Rheumatol 2011; 29: S79–87.

  29. White LA, Birnbaum HG, Kaltenboeck A et al. Employees with fibromyalgia: medical comorbidity, healthcare costs, and work loss. J Occup Environ Med 2008; 50: 13–24.

  30. Clark P, Paiva ES, Ginovker A, Salomon PA. A patient and physician survey of fibromyalgia across Latin America and Europe. BMC Musculoskelet Disord 2013; 14: 188.

  31. Ablin J, Fitzcharles MA, Buskila D et al. Treatment of fibromyalgia syndrome: recommendations of recent evidence-based interdisciplinary guidelines with special emphasis on complementary and alternative therapies. Evid Based Complement Altern Med 2013; 2013: 485272.

  32. Briley M. Drugs to treat fibromyalgia – the transatlantic difference. Curr Opin Investig Drugs 2010; 11: 16–8.

  33. Hauser W, Thieme K, Turk DC. Guidelines on the management of fibromyalgia syndrome – a systematic review. Eur J Pain 2010; 14: 5–10.

  34. Price C, Lee J, Taylor AM, Baranowski AP. Initial assessment and management of pain: a pathway for care developed by the British Pain Society. Br J Anaesth 2014; 112: 816–23.

  35. Wells AF, Arnold LM, Curtis CE et al. Integrating health information technology and electronic health records into the management of fibromyalgia. Postgrad Med 2013; 125: 70–7.

  36. Lauche R, Hauser W, Jung E et al. Patient-related predictors of treatment satisfaction of patients with fibromyalgia syndrome: results of a cross-sectional survey. Clin Exp Rheumatol 2013; 31: S34–40.

  37. Annemans L, Wessely S, Spaepen E et al. Health economic consequences related to the diagnosis of fibromyalgia syndrome. Arthritis Rheum 2008; 58: 895–902.

  38. Hughes G, Martinez C, Myon E, Taieb C, Wessely S. The impact of a diagnosis of fibromyalgia on health care resource use by primary care patients in the UK: an observational study based on clinical practice. Arthritis Rheum 2006; 54: 177–83.

  39. Staud R. Chronic widespread pain and fibromyalgia: two sides of the same coin? Curr Rheumatol Rep 2009; 11: 433–6.

  40. Haliloglu S, Carlioglu A, Akdeniz D, Karaaslan Y, Kosar A. Fibromyalgia in patients with other rheumatic diseases: prevalence and relationship with disease activity. Rheumatol Int 2014; 34: 1275–80.

  41. Davis JA, Robinson RL, Le TK, Xie J. Incidence and impact of pain conditions and comorbid illnesses. J Pain Res 2011; 4: 331–45.

  42. Ahmad J, Tagoe CE. Fibromyalgia and chronic widespread pain in autoimmune thyroid disease. Clin Rheumatol 2014; 33: 885–91.

  43. Ablin JN, Buskila D. "Real-life" treatment of chronic pain: targets and goals. Best Pract Res Clin Rheumatol 2015; 29: 111–9.

  44. Podolecki T, Podolecki A, Hrycek A. Fibromyalgia: pathogenetic, diagnostic and therapeutic concerns. Pol Arch Med Wewn 2009; 119: 157–61.

  45. Bennett RM, Jones J, Turk DC, Russell IJ, Matallana L. An internet survey of 2,596 people with fibromyalgia. BMC Musculoskelet Disord 2007; 8: 27.

  46. Mease PJ, Dundon K, Sarzi-Puttini P. Pharmacotherapy of fibromyalgia. Best Pract Res Clin Rheumatol 2011; 25: 285–97.

  47. Sanchez RJ, Uribe C, Li H et al. Longitudinal evaluation of health care utilization and costs during the first three years after a new diagnosis of fibromyalgia. Curr Med Res Opin 2011; 27: 663–71.

  48. Lee J, Ellis B, Price C, Baranowski AP. Chronic widespread pain, including fibromyalgia: a pathway for care developed by the British Pain Society. Br J Anaesth 2014; 112: 16–24.

  49. Lyrica (pregabalin) capsules, CV; Lyrica (pregabalin) oral solution, CV, [package insert]. New York, NY: Pfizer Pharmaceuticals, 2013.

  50. Cymbalta (duloxetine delayed-release capsules) for oral use [package insert]. Indianapolis, IN: Lilly USA, LLC, 2012.

  51. Savella (milnacipran HCl) tablets [package insert]. St. Louis, MO: Forest Laboratories, Inc., 2013.

  52. Traynor LM, Thiessen CN, Traynor AP. Pharmacotherapy of fibromyalgia. Am J Health Syst Pharm 2011; 68: 1307–19.

  53. Smith HS, Bracken D, Smith JM. Pharmacotherapy for fibromyalgia. Frontiers Pharmacol 2011; 2: 17.

  54. Arnold LM. Biology and therapy of fibromyalgia. New therapies in fibromyalgia. Arthritis Res Ther 2006; 8: 212.

  55. Martin SA, Coon CD, McLeod LD, Chandran A, Arnold LM. Evaluation of the fibromyalgia diagnostic screen in clinical practice. J Eval Clin Pract 2014; 20: 158–65.

  56. Masters ET, Mardekian J, Emir B et al. Electronic medical record data to identify variables associated with a fibromyalgia diagnosis: importance of health care resource utilization. J Pain Res 2015; 8: 131–8.

  57. California Heathcare Foundation. Chronic Disease Registries: A Product Review. Oakland, CA, Sacramento, CA: California Healthcare Foundation, 2015.

  58. American College of Physicians. Joint Principles of the Patient Centered Medical Home. Philadelphia, PA: American College of Physicians, 2007.

  59. National Committee for Quality Assurance website. The future of patient-centered medical homes: foundation for a better health care system. www.ncqa.org/Portals/0/Public Policy/2014 Comment Letters/The_-Future_of_PCMH.pdf (accessed September 22, 2015).

  60. Faber M, Voerman G, Erler A et al. Survey of 5 European countries suggests that more elements of patient-centered medical homes could improve primary care. Health Aff (Millwood) 2013; 32: 797–806.

  61. Nielson M, Gibson A, Buelt L, Grundy P, Grumbach K. The Patient-Centered Medical Home's Impact on Cost and Quality. Annual Review of Evidence 2013–2014. Washington, DC: Patient-Centered Primary Care Collaborative, 2015.

  62. Tirodkar MA, Morton S, Whiting T et al. There's more than one way to build a medical home. Am J Manag Care 2014; 20: e582–9.

  63. Jackson GL, Powers BJ, Chatterjee R et al. Improving patient care. The patient centered medical home. A systematic review. Ann Intern Med 2013; 158: 169–78.

  64. National Committee for Quality Assurance. NCQA Patient Centered Medical Home. Washington, DC: National Committee for Quality Assurance, 2015.

  65. Bojadzievski T, Gabbay RA. Patient-centered medical home and diabetes. Diabetes Care 2011; 34: 1047–53.

  66. Wang QC, Chawla R, Colombo CM, Snyder RL, Nigam S. Patient-centered medical home impact on health plan members with diabetes. J Public Health Manag Pract 2014; 20: E12–20.

  67. Ackroyd SA, Wexler DJ. Effectiveness of diabetes interventions in the patient-centered medical home. Curr Diabetes Rep 2014; 14: 471.

  68. Taliani CA, Bricker PL, Adelman AM, Cronholm PF, Gabbay RA. Implementing effective care management in the patient-centered medical home. Am J Manag Care 2013; 19: 957–64.

  69. Randall I, Mohr DC, Maynard C. VHA patient-centered medical home associated with lower rate of hospitalizations and specialty care among veterans with posttraumatic stress disorder. J Healthc Qual 2014. doi:10.1111/jhq.12092. [Epub ahead of print]

  70. Amiel JM, Pincus HA. The medical home model: new opportunities for psychiatric services in the United States. Curr Opin Psychiatry 2011; 24: 562–8.

  71. Evans L, Whitham JA, Trotter DR, Filtz KR. An evaluation of family medicine residents' attitudes before and after a PCMH innovation for patients with chronic pain. Fam Med 2011; 43: 702–11.

  72. Porter ME, Pabo EA, Lee TH. Redesigning primary care: a strategic vision to improve value by organizing around patients' needs. Health Aff (Millwood) 2013; 32: 516–25.

  73. Peikes DN, Reid RJ, Day TJ et al. Staffing patterns of primary care practices in the comprehensive primary care initiative. Ann Fam Med 2014; 12: 142–9.

  74. Hsu C, Coleman K, Ross TR et al. Spreading a patient-centered medical home redesign: a case study. J Ambul Care Manag 2012; 35: 99–108.

  75. Patel MS, Arron MJ, Sinsky TA et al. Estimating the staffing infrastructure for a patient-centered medical home. Am J Manag Care 2013; 19: 509–16.

  76. O'Malley AS, Gourevitch R, Draper K, Bond A, Tirodkar MA. Overcoming challenges to teamwork in patient-centered medical homes: a qualitative study. J Gen Intern Med 2015; 30: 183–92.

  77. Moran KJ, Burson R. Understanding the patient-centered medical home. Home Healthc Nurse 2014; 32: 476–81.

  78. Henderson S, Princell CO, Martin SD. The patient-centered medical home: this primary care model offers RNs new practice-and reimbursement-opportunities. Am J Nurs 2012; 112: 54–9.

  79. Berenson RA, Devers KJ, Burton RA. Will the Patient-Centered Medical Home Transform the Delivery of Health Care? Washington, DC: Urban Institute, 2011.

  80. Schram AP. The patient-centered medical home: transforming primary care. Nurse Pract 2012; 37: 33–9.

  81. Willard R, Bodenheimer T. The Building Blocks of High-Performing Primary Care. Oakland, CA: California Healthcare Foundation, 2012.

  82. Cronholm PF, Shea JA, Werner RM et al. The patient centered medical home: mental models and practice culture driving the transformation process. J Gen Intern Med 2013; 28: 1195–201.

  83. Scholle SH, Asche SE, Morton S et al. Support and strategies for change among small patient-centered medical home practices. Ann Family Med 2013; 11 (Suppl. 1): S6–13.

  84. Arnold LM, Stanford SB, Welge JA, Crofford LJ. Development and testing of the fibromyalgia diagnostic screen for primary care. J Womens Health (Larchmt) 2012; 21: 231–9.

  85. Baron R, Perrot S, Guillemin I et al. Improving the primary care physicians' decision making for fibromyalgia in clinical practice: development and validation of the Fibromyalgia Detection (FibroDetect®) screening tool. Health Qual Life Outcomes 2014; 12: 128.

  86. Fox BP. A PCMH model that works. Reflections on the PBS Special. http://www.medscape.com/viewarticle/841916 (accessed June 4, 2015).

  87. Serio CD, Hessing J, Reed B, Hess C, Reis J. The effect of online chronic disease personas on activation: within-subjects and between-groups analyses. JMIR Res Protoc 2015; 4: e20.

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: lesley.arnold@uc.edu

Disclosures
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

Diagnosis

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

Management

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

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