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Fibromyalgia

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Updated 2023 AAFP guidelines for the diagnosis and management of fibromyalgia.

Background

Overview

Definition
FM is a syndrome characterized by chronic widespread pain, fatigue, and sleep disruption.
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Pathophysiology
The exact cause of FM is unknown; however, central sensitization involving genetic, immunological, and hormonal factors have been implicated.
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Disease course
Clinical manifestations of FM include chronic widespread pain (diffuse, multifocal, deep, gnawing, burning, waxing and waning, and migratory), tender joints, fatigue, sleep disturbances, weight fluctuations, morning stiffness, irritable bowel disease, cognitive disturbance, depression, anxiety, headaches, heat and cold intolerance, irritable bladder syndrome, restless legs, and Raynaud's phenomenon.
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Prognosis and risk of recurrence
FM is not associated with increased mortality.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of fibromyalgia are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2023), the Canadian Expert Group on Cannabinoids Use in Chronic Pain (CCP-CEG 2023), the Egyptian Consensus Group on Fibromyalgia (ECG-FM 2022), the Italian Society of Rheumatology (ISR 2021), the European League Against ...
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Screening and diagnosis

Diagnostic criteria: as per ECG-FM 2022 guidelines, use the 2010 ACR diagnostic criteria for FM.
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Diagnostic investigations

Physical examination: as per EULAR 2017 guidelines, obtain a comprehensive assessment of pain, function, and psychosocial context in patients with FM.
B

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  • Laboratory and imaging tests

  • Mental health assessment

Medical management

General principles: as per ECG-FM 2022 guidelines, recognize that there is no cure for FM. Aim to reduce symptoms, advocate healthy lifestyle practices, and maintain optimal function, with patient outcome goals clearly defined at the first visit.
B
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  • Antidepressants

  • Anticonvulsants

  • Skeletal muscle relaxants

  • Non-opioid analgesics

  • Opioids

  • Cannabinoids

  • Dopamine agonists

  • Serotonin antagonists

  • Sedatives

  • Corticosteroids

Nonpharmacologic interventions

General principles: as per ECG-FM 2022 guidelines, offer non-pharmacological therapies as initial management, based on availability, cost, and patient preferences.
B

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  • Work limitations

  • Exercise

  • Psychological interventions

  • Multicomponent therapies

  • Alternative and complementary therapies

Patient education

General counseling: as per ECG-FM 2022 guidelines, offer education and active participation with reassurance regarding "no harm" caused by physical activity, especially if the patient is passive. Encourage self-efficacy and social support to facilitate the practice of health-promoting lifestyles. Use a graded incremental activity to maintain or improve function.
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Follow-up and surveillance

Indications for specialist referral: as per NFGAP 2013 guidelines, consider obtaining specialist consultation, including referral to a sleep specialist or psychologist, in selected cases. Reserve continued care by a specialist in patients failed management in primary care or having more complex comorbidities.
C

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  • Assessment of treatment response

  • Follow-up