Fibromyalgia Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • These guidelines cover the referral and management for adults with fibromyalgia.

This guidance does not cover:

  • Those aged under 18 years

Assessment

Signs and Symptoms

  • Chronic widespread pain/fibromyalgia suspected:
    • Pain in two or more sections of two contralateral limbs and in axial skeleton for at least + 3 months;
      or
    • Pain on both sides of the body, above and below the diaphragm, lasting for + 3 months.

History and Examination

  • Ask about non-pain symptoms including:
    • fatigue;
    • sleep patterns;
    • memory;
    • concentration;
    • bladder;
    • bowel pattern (including IBS);
    • sensory changes;
    • weakness;
    • muscle cramp;
    • Visual change and eye pain;
    • Joint pain and swelling;
    • Weight loss, fever, Raynaud's, dry eyes/dry mouth, rashes and psoriasis; and
    • Family history of inflammatory arthritis, psoriasis and inflammatory bowel disease.

Examination

  • Musculoskeletal examination e.g. GALS screen;
  • Neurological examination (particularly looking for weakness or upper motor neurone signs);
  • Palpate for lymphadenopathy;
  • Examine for skin rashes, psoriasis; and
  • Examine any other systems identified in history.

Red Flags

Seek immediate or urgent specialist advice/treatment if:

  • Abnormal neurological signs present (including muscle abnormalities);
  • Visual disturbances/changes;
  • Swollen joints (synovitis);
  • MTP/MCP joint tenderness (or pain on squeeze test);
  • Morning joint stiffness;
  • Unexplained rise in ESR;
  • Unexplained blood/protein on urine dipstick;
  • Weight loss;
  • Fever;
  • Lymphadenopathy;
  • Recent onset Raynaud's;
  • Skin rashes; or
  • Dry eyes and mouth.

Investigations

Undertake the following to aid diagnosis, inform management or prior to referral:

  • Blood tests:
    • FBC;
    • CRP
    • U+Es;
    • Hba1c
    • LFTs
  • Bone profile; and
    • TFTs.
    • Urine Test:
    • Dipstick; and
    • Query blood / protein / glucose.
  • Additional tests - only if clinically indicated:
    • Autoimmune;
    • Coeliac screen;
    • Bence Jones protein;
    • Lyme screen; and
    • Hepatitis screen.
    • Vitamin D Deficiency

Management

Diagnosis of CWP/FMS confirmed/anticipated – low risk

Need to asses

  • severity of pain;
  • physical function;
  • sleep;
  • psychological state (PHQ9 - GAD7 - HADS);
  • social and family function; and
  • work status / employment issues.

Make a management plan

  • Patient education
  • Encourage self-management
  • Graded exercise
  • Prescribing options - 1st line low dose Tricyclic antidepressant e.g. Amitriptyline/Nortriptyline (Steroids / strong opioids not to be prescribed);
  • Consider counselling for anxiety / depression.

Regular review of condition, at least every 6 months.

  • Continue management in primary care
  • If deterioration refer to secondary care pain management service

Referral

Referral Criteria

  • Red Flags
  • Consider early referral to secondary care pain management service if:
  • Diagnostic uncertainty
  • Anticipated high risk
  • Risk factors for poor health outcome
  • Significant depression

Referral Instructions

  • e-Consultation is not currently available for this speciality
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training refer to:
    • Pain Management - Using the eRS
      • Specialty: Chronic Pain Management
      • Clinic Type: Pain Management
    • Rheumatologist - Using the eRS
      • Specialty: Rheumatology
      • Clinic Type: Musculoskeletal

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation. Signpost patient to Decision Making aid (hyperlink tool if available) – this can be printed off for the patient

Patient Information/Public Health/Self Care

Assurance & Governance

  • This guidance was developed on: 03.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 04.2017
  • Publication Date: 05.2017
  • Review Date: 05.2019
  • Ref No: MSK8 - 03.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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