Canadian Guidelines for Fibromyalgia Recognize the Need for Easier Path to Diagnosis and Management

July 29, 2013  |  Fibromyalgia Defined, Treatment  |  Share
Canadian Guidelines for Fibromyalgia Recognize the Need for Easier Path to Diagnosis and Management

Our friends from McGill University came out with a whole new plan for managing fibromyalgia recently in their 2012 Canadian Guidelines for Fibromyalgia. The content is nothing earth shattering or particularly new, really, they discuss the usual diagnostic issues and the typical treatment strategies, and they’re not even particularly succinct at fully 46 recommendations. So why are these guidelines so intriguing?

Because they are simple. Forehead smackingly obvious. Diagnosis by listening to the patient’s complaint of symptoms? Scandalous! Physicians employing the art of medicine? Blasphemy! Emphasis on primary care over rheumatologic specialists for most cases? Say it ain’t so!

I say, where have you been all of our lives, Canadian Guidelines?!

The Canadian Guidelines Defined

Forty-six recommendations may seem overwhelming, yes, but the Canadian guidelines are evidence-based, drawing from decades of scientific exploration as well as the American College of Rheumatology’s 2010 guidelines for fibromyalgia. They are also well organized, divided into manageable sections for diagnosis, management, and outcomes making them easier to digest. Here is a brief peek:

Diagnosis:

  • Out with the tried and not-so-true tender point exam and the diagnosis of exclusions with a multitude of unnecessary, often invasive tests to no end, and a long line of specialists, and in with primary care docs ordering simple blood tests to assess for obvious illnesses that can masquerade as fibromyalgia, like hypothyroidism, MS, myopathy, early inflammatory arthritis, etc. Anything more invasive or detrimental to well-being should be done on an individual basis only if indicated or suspected, like lime disease, cancer, infection, etc.
  • Evidence for a neurological basis for fibromyalgia should reassure doctors of the validity of the illness. Good that guidelines point this out, but the fact that they feel the need to is somewhat telling (we’ll get to this in a sec).
  • A link to genetics should discourage reliance on a triggering event as the cause of symptom development.

Management:

  • In general, non-pharmacological treatments get a lot of attention. Specifically, self-management treatments that involve active participation, like education, coping skills, and graduated exercise of your choosing, are emphasized to encourage as normal a lifestyle as possible.
  • Treatments that improve psychological wellness, like managing depression, reducing catastrophizing, improving coping, etc. are aimed at reducing fear of pain, fear of movement/activity, and improving self-efficacy (belief in your ability to do stuff successfully).
  • Doctors should educate patients about alternative therapies, recognizing their notable lack of scientific evidence, advising patients to be safe in practicing such therapies, and encouraging patients to disclose their use of such therapies (and to be tolerant of their use – again, we’ll get to this).
  • There is extensive information on drug therapies of all types – analgesics, opioids, cannabinoids, and antidepressants and anticonvulsants with pain relieving properties, and other commonly prescribed drugs – with recognition that polypharmacy is often the key and that drugs should be chosen to target the most prominent symptoms. Patients should be monitored for use habits.

Outcome:

  • Many things such as reason of onset, confirmation of diagnosis, excessive testing, excessive use of drug treatments, coping skills, locus of control, mood disorders, even the doctor-patient relationship will influence outcomes.
  • Recognizing that symptoms wax and wane over time will help patients and physicians manage treatments and not go to extremes unnecessarily.
  • Physicians should use good clinical judgment during initial treatment, stabilization of treatment, and when changing treatments with an eye toward improvement or degradations in function or symptoms, side effects, or patient motivation.
  • Physicians should also encourage patients to remain in the workforce or, if on sick leave, to participate actively in exercise, psychological therapy and development of coping skills like activity pacing to facilitate the ability to continue working.
  • The healthcare cost burden can be managed with better treatment plans and management of comorbid conditions like depression and by avoiding excessive testing and pharmacotherapies.

The complete guidelines (I’ve just summed them up here) are logical, reasonable, thoughtful, and comprehensive. They are also pragmatic in recognizing that a multidisciplinary team approach, while dreamy, is not always accessible, practical or feasible for patients.

Educating Doctors About Patients

There is an interesting and somewhat striking emphasis on educating physicians about fibromyalgia patients. It’s almost like the guidelines are telling physicians (the ones who need to be told, that is, because many don’t), get over yourselves, fibro is real and here are your patients, pay attention. Nicely, of course.

And before I get any nastygrams from physicians, it is likely the case (at least it was a few years ago from my esteemed personal sources) that fibromyalgia doesn’t get much attention in med school or training. Sometimes it’s not until a patient is sitting there, years later, that a physician actually encounters an honest-to-goodness case of fibromyalgia. From that perspective, these guidelines are a great resource.

No matter how you look at it, the Canadian guidelines are a huge step in the right direction and could be just the sort of manual for fibro that’s been missing all these years.

What do you think about the omission of tenderpoint exams? Do you think these guidelines will be helpful or too cumbersome for doctors? What’s your favorite place in Canada? Mine’s the North Channel – absolutely gorgeous sailing waters in northern Lake Huron.

[photo: flickr]

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