2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome
Mary-Ann Fitzcharles1,2, Peter A. Ste-Marie2,3, Don L. Goldenberg4, John X. Pereira5, Susan Abbey6, Manon Choinière7, Gordon Ko8, Dwight Moulin9, Pantelis Panopalis1, Johanne Proulx10, Yoram Shir2
Background/Purpose: The healthcare community remains challenged regarding the care of fibromyalgia (FM) patients. Previous guidelines have mostly addressed treatment options rather than provide an overall approach to FM care. With new evidence concerning pathogenesis and more diverse treatment strategies, updated direction for global care in FM is needed. These evidence-based guidelines for the diagnosis, management, and patient trajectory of persons with FM were developed taking into account these new advances and new American College of Rheumatology 2010 diagnostic criteria.
Methods: A needs assessment by structured consultation with 139 healthcare professionals from relevant disciplines across Canada generated 18 key questions. Questions drove a literature search to identify evidence, which was graded according to the classification system of the Oxford Centre for Evidence Based Medicine, and supporting recommendations were drafted. Recommendations were edited and appraised by an advisory panel to reflect meaningful clinical practice. The whole document was reviewed by an international expert.
Results: Forty six recommendations pertaining to the identification, evaluation, and management of persons with FM, incorporating new clinical concepts are presented. The essence of the recommendations is as follows: FM represents a composite of symptoms, with body pain present as the pivotal symptom. There is a spectrum of severity which associates with functional outcome, with fluctuating symptoms over time. The diagnosis of FM is clinical, not one of exclusion, not needing specialist confirmation, and requires only limited laboratory testing. A physical examination is required to exclude other conditions presenting with body pain, but tender point examination is not required to confirm the diagnosis. There is no confirmatory laboratory test and excessive testing is strongly discouraged. Ideal care for most patients is in the primary care setting. Treatments should be multimodal, incorporating non-pharmacologic and pharmacologic strategies, with focus towards reduction of symptoms and improvement of function. Patients must be active participants in their healthcare and non-pharmacologic strategies are imperative. Patient-tailored management that is symptom-based is recommended. In the absence of an ideal pharmacologic treatment, an agent impacting multiple symptoms is desirable. Doses of medications lower than those used in clinical trials and combination of medications may facilitate adherence. Emphasis on healthy lifestyle practices, maintenance of function including retention in the workforce, periodic assessment for the need for continued medication, and evaluation of efficacy/side effects of ongoing treatments is recommended. New symptoms should be evaluated according to good clinical practice to exclude another illness without summarily attributing symptoms to FM.
Conclusion: These new Canadian guidelines for the care of patients with FM should provide the health community with confidence in the global care of these patients and thereby improve patient outcome.
1 Division of Rheumatology, McGill University, Montreal, Quebec, Canada
2Alan Edwards Pain Management Unit, McGill University Health Center, Montreal, Quebec, Canada
3Faculty of Law, Université de Montréal, Montreal, Quebec, Canada
4Division of Rheumatology, Tufts University School of Medicine, Boston, Massachusetts, USA
5Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
6Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
7Centre de la recherche du Centre hospitalier de l’Université de Montréal; Department of Anesthesiology, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
8Division of Physiatry, University of Toronto, Toronto, Ontario, Canada
9Departments of Clinical Neurological Sciences and Oncology, University of Western Ontario, London, Ontario, Canada