The new Canadian guidelines mentioned above confirm the clear message that fibromyalgia is a condition that should be diagnosed and treated in primary care. Only the most difficult cases should be referred to Rheumatology, say the rheumatologists.
With no reliable physical signs or lab tests, the diagnosis is based on the history. Greater awareness of fibromyalgia as a complex, multifaceted syndrome with chronic widespread pain, fatigue, poor-quality sleep, mood disorder and cognitive changes is advised. Investigations should be limited to FBC, ESR, CRP, CK and thyroid function. Patients should receive the clear message that there is, as yet, no cure for fibromyalgia. Symptoms fluctuate but rarely completely resolve. There is no single, uniformly and enduringly effective treatment. Management (not cure) should be multimodal and rehabilitative – targeting improved function. This might include medication, CBT and exercise therapy. Curiously there is a warning that ‘fibromyalgia can be faked’, especially in the presence of ‘perverse incentives’ such as welfare and insurance claims. Finally there is a warning that clinicians should avoid attributing fibromyalgia to any particular cause – injury, insult or illness – as this may have adverse consequences with respect to rehabilitation. 1,2