Fibromyalgia Syndrome Glos Care Pathway Overview

In the majority of cases a diagnosis of fibromyalgia can be made in primary care and usually managed using self-help and community services (see sections below). Referral to Secondary Care is only necessary where there is diagnostic uncertainty or high complexity. This pathway has been designed to provide guidance to support the early diagnosis and optimal management of fibromyalgia in adults in Gloucestershire.

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Presentation

Common features of fibromyalgia include:

  • Very widespread pain
  • Fatigue
  • Waking unrefreshed
  • Cognitive symptoms ‘brain fog’
  • Many other somatic symptoms including irritable bowel, headaches, dizziness, dyspepsia, urinary symptoms, insomnia, numbness and tingling.
Red Flags
  • Abnormal neurological signs present (including muscle weakness)
  • Painful red eyes or persistent dry eyes
  • Swollen joints (synovitis)
  • Morning joint stiffness (lasting over 30 minutes)
  • Unexplained elevated CRP or Plasma viscosity
  • Unexplained blood/protein on urine dipstick
  • Weight loss
  • Fever
  • Lymphadenopathy
  • Recent onset Raynaud’s phenomenon
  • Skin rashes
Differential Diagnosis

Consider differential diagnoses:

Assessment

Physical Assessment

Please complete the Diagnostic Criteria and Symptom Severity Score.
 

Blood Tests

Purpose of Investigations

There is no specific blood test to aid the clinical diagnosis of FM as blood investigations are normal in Fibromyalgia. Investigations are performed to exclude alternative diagnoses which have some features in common with Fibromyalgia.

Full Blood Count

Can detect anaemia, low or high white cell count or platelet count and may indicate alternative diagnoses

Plasma viscosity

Can be mildly elevated and still normal, if so then useful to repeat, mildly elevated in the obese

C-reactive protein (CRP)

Can be mildly elevated and still be normal, useful to repeat if mildly elevated, mildly elevated in the obese

Urea and Electrolytes (U+E's)

Abnormalities of electrolytes can cause some symptoms similar to those of Fibromyalgia. Significant renal impairment can also have symptoms in common with Fibromyalgia

Liver Function Tests (LFT's)

Significant deranged Liver Function Tests (LFTs) can cause some symptoms in common with Fibromyalgia

Calcium, phosphate and alkaline phosphatase

To identify metabolic bone disorders

Thyroid Function Tests (TFT's)

Either hypo or hyperthyroidism can share some of the symptoms of Fibromyalgia

Creatinine kinase

To identify inflammatory and non-inflammatory myopathies

Rheumatoid factor

Only test if there is a clinical suspicion based on multiple joint pain and swelling and early morning stiffness and joint tenderness on examination. Remember false positives occur in about 20% of the population. A positive result without symptoms or signs of rheumatoid arthritis is of no significance.

Antinuclear antibody (ANA)

If autoimmune rheumatic disorders are suspected based on systems review e.g. Systemic lupus erythematosus (SLE),  Sjogren’s  syndrome, Systemic sclerosis, myositis. Remember false positives in about 10% of the population

Vitamin D

Test only in high risk groups and at clinician’s discretion: people with pigmented skin or reduced sun exposure due to cultural dress or housebound or for dermatological conditions

Radiological investigations

Are not indicated for the diagnosis of Fibromyalgia and should only be done if other conditions are suspected e.g. osteoarthritis, inflammatory joint disease or metabolic bone disease

Initial Management - Early Action For All

Explain Fibromyalgia Syndrome (FMS) diagnosis

Advice in line with / Provide patient information leaflets and information on online resources.

Emphasise importance of exercise

  • Exercise to be advised as part of early management. Provide patient information leaflets.
    • Appropriate exercise will depend on individual assessment.
    • No clear findings from research about what is the right exercise, but resistance and/or aerobic exercise favoured.
    • People with Fibromyalgia Syndrome (FMS) who need exercise advice can be given 1:1 exercise advice and Back to Fitness in core physio, or Exercise advice within the Pain Self-Management Service as appropriate. Dry land exercises should be advised unless patient not able to manage this, then hydrotherapy may be considered after assessment in the physio department.
Core Physiotherapy Services

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