Case 26.4 – Fibromyalgia [SDL]

Definition of fibromyalgia:

• Fibromyalgia is a chronic pain syndrome characterized by widespread musculoskeletal pain, fatigue, sleep disturbance, and cognitive dysfunction ("fibro fog")
• It is a clinical diagnosis - there are no specific diagnostic tests or biomarkers
• Considered a disorder of central pain processing/sensitization - the nervous system amplifies pain signals
• More common in women (female:male ratio ~9:1), typically presents age 20-50 years
• Prevalence ~2-8% in general population

Evolution of diagnostic criteria:

1990 ACR criteria (American College of Rheumatology):

• Required widespread pain (all 4 quadrants of body + axial skeleton) for ≥3 months
• Required ≥11 of 18 specified tender points on digital palpation
• Limitations: Tender point examination was subjective, time-consuming, poorly reproducible; criteria didn't capture other core symptoms (fatigue, cognitive issues, sleep problems); created perception of "tender points" being diagnostic rather than part of spectrum

2010/2011 ACR criteria (revised, still widely used):

• Removed tender point examination (recognized as unreliable)
• Introduced two key measures:
  • Widespread Pain Index (WPI): Number of painful body regions (0-19) from checklist
  • Symptom Severity Scale (SS): Rates severity (0-3) of:
    • Fatigue
    • Waking unrefreshed
    • Cognitive symptoms
    • Plus extent of somatic symptoms (headaches, IBS, numbness, etc.)
• Diagnostic criteria:
  • WPI ≥7 AND SS score ≥5, OR WPI 3-6 AND SS score ≥9
  • Symptoms present for ≥3 months
  • No other disorder that would explain the pain
• Advantages: Can be used in clinical practice and self-report; captures broader symptom profile; more objective; recognizes fibromyalgia as multi-symptom disorder, not just pain

2016 revision (fibromyalgia criteria):

• Generalized pain (defined as pain in ≥4 of 5 regions) required
• Combined and clarified the WPI and SS score requirements
• Reinforced that fibromyalgia can coexist with other conditions

Key changes in understanding:

• From peripheral to central: Shift from viewing fibromyalgia as muscle/tissue problem to recognizing it as central nervous system disorder (central sensitization, abnormal pain processing)
• From exclusion to recognition: Previously a "diagnosis of exclusion"; now recognized as distinct clinical entity that can coexist with other conditions (e.g., RA, lupus)
• Dimensional rather than binary: Fibromyalgia exists on a spectrum - "fibromyalgianess" can vary in degree
• Biopsychosocial model: Recognition that biological, psychological, and social factors all contribute to development and maintenance
• Legitimization: Increasing acceptance as "real" condition (historically dismissed as psychosomatic or malingering)

Contemporary understanding - pathophysiology:

• Central sensitization: Enhanced pain processing in CNS - "volume turned up" on pain signals
• Reduced descending pain inhibition (pain suppression systems don't work properly)
• Neurotransmitter abnormalities: low serotonin, noradrenaline, dopamine; high substance P (pain transmitter) in CSF
• Altered brain connectivity and activity on functional imaging
• Sleep architecture abnormalities (reduced deep sleep, alpha-wave intrusion into sleep)
• HPA axis dysfunction (stress response abnormalities)
• Possible genetic predisposition (family clustering, gene polymorphisms in pain pathways)

Clinical application: Diagnosis is clinical, based on characteristic symptom pattern (widespread pain, fatigue, cognitive issues, sleep disturbance) lasting ≥3 months, after excluding other causes. Modern criteria facilitate diagnosis without requiring tender point examination.

Core clinical features of fibromyalgia:

1. Widespread chronic pain (cardinal feature):

• Diffuse, aching, sometimes burning quality
• Affects multiple sites - often described as "hurting all over"
• Typically axial (neck, back) and proximal limbs (shoulders, hips)
• Worse with activity initially, but also worse with prolonged rest/inactivity
• Variable intensity - fluctuates day-to-day, can have flares
• Allodynia (pain from normally non-painful stimuli) and hyperalgesia (exaggerated pain response)

2. Fatigue (present in >90%):

• Severe, persistent, unrelieved by rest
• "Exhausted all the time"
• Not proportional to activity level
• Can be as debilitating as the pain

3. Sleep disturbance (present in ~75%):

• Non-restorative sleep - "wake up more tired than when went to bed"
• Difficulty falling asleep, frequent waking, early morning waking
• Sleep architecture abnormalities (reduced slow-wave sleep)

4. Cognitive dysfunction - "fibro fog" (present in >50%):

• Difficulty concentrating
• Memory problems (especially short-term memory)
• Slower processing speed
• Word-finding difficulties
• Feeling "mentally clouded"

Associated symptoms (very common):

• Headaches: Tension-type or migraines (in 50-70%)
• Irritable bowel syndrome: Abdominal pain, bloating, altered bowel habit (in 40-70%)
• Paraesthesias: Numbness, tingling (without objective neurological signs)
• Temporomandibular joint dysfunction (TMJ): Jaw pain, clicking
• Restless legs syndrome
• Dizziness, balance problems
• Sensory sensitivities: Light, noise, temperature, smells
• Multiple chemical sensitivity
• Bladder symptoms: Urgency, frequency (interstitial cystitis overlap)

Psychological comorbidities (very common):

• Depression (20-80%): Can be cause, consequence, or comorbid condition
• Anxiety disorders (up to 60%)
• Note: While psychological factors are important, fibromyalgia is NOT purely psychological - there are demonstrable biological abnormalities

Conditions frequently comorbid with fibromyalgia:

• Chronic fatigue syndrome (significant overlap, may be part of same spectrum)
• Autoimmune rheumatic diseases (lupus, RA, Sjögren's syndrome) - fibromyalgia can coexist
• Migraine
• IBS
• Interstitial cystitis
• PTSD, history of trauma/abuse (increased prevalence)

Investigations in suspected fibromyalgia:

Purpose of investigations:

• No test confirms fibromyalgia - diagnosis is clinical
• Investigations are done to exclude other conditions that can mimic fibromyalgia (the "fibromyalgia masqueraders")
• Reassure patient and clinician that other serious pathology is not present
• Identify comorbid conditions

Recommended baseline investigations:

• Full blood count: Exclude anaemia (fatigue), infection, haematological disorders
• Inflammatory markers (ESR, CRP): Should be normal in fibromyalgia; elevated suggests inflammatory arthritis, PMR, connective tissue disease
• Thyroid function (TSH, free T4): Hypothyroidism mimics fibromyalgia (fatigue, pain, cognitive dysfunction)
• Calcium and vitamin D: Vitamin D deficiency causes diffuse musculoskeletal pain and fatigue
• Creatine kinase (CK): Exclude myositis/myopathy (should be normal in fibromyalgia)
• Liver and kidney function: Baseline, exclude other causes of fatigue
• Glucose/HbA1c: Diabetes can cause fatigue

Additional investigations (based on clinical features):

• Rheumatoid factor, anti-CCP: If joint symptoms suggest inflammatory arthritis
• ANA (antinuclear antibodies): If features suggest SLE or other connective tissue disease
  • Caution: Low-titre ANA can be positive in healthy people and fibromyalgia patients; don't over-interpret
• Coeliac serology: If significant GI symptoms
• Ferritin: Iron deficiency causes fatigue
• B12: Deficiency causes fatigue, paraesthesias, cognitive issues
• Sleep study (polysomnography): If obstructive sleep apnoea suspected (snoring, witnessed apnoeas, severe daytime sleepiness)

Investigations NOT routinely recommended:

• Extensive autoimmune panels (unless specific clinical features)
• Lyme serology (unless epidemiological risk and appropriate symptoms)
• Imaging (X-rays, MRI) - not helpful unless specific joint/neurological concerns
• EMG/nerve conduction studies - unless true neurological deficits

Expected findings in fibromyalgia:

• All routine blood tests should be normal
• Normal inflammatory markers (CRP, ESR)
• Normal CK
• Physical examination: tenderness to palpation, but no objective joint swelling, muscle weakness, or neurological deficits

Key clinical points:

• "Red flags" requiring further investigation: Objective weakness, abnormal neurology, joint swelling, elevated inflammatory markers, unexplained weight loss, focal symptoms - these suggest alternative/additional diagnoses
• Normal investigations support the diagnosis of fibromyalgia and provide reassurance
• Avoid excessive testing: Can reinforce illness beliefs and delay acceptance/treatment
• Fibromyalgia can coexist with other conditions - finding another diagnosis doesn't exclude fibromyalgia

Overview of non-pharmacological management:

• Non-pharmacological approaches are first-line and essential in fibromyalgia management
• Generally more effective than medications for long-term outcomes
• Require active patient participation and self-management
• Multidisciplinary approach targeting different aspects of the condition

1. Patient education and validation (fundamental first step):

• Explanation of condition:
  • Fibromyalgia is a real medical condition, not "all in your head"
  • Explain central sensitization/altered pain processing in accessible terms
  • Set realistic expectations - condition is chronic but manageable; focus on improving function and quality of life, not "cure"
• Validation of symptoms: Acknowledge the reality and impact of symptoms; reduces anxiety and improves therapeutic relationship
• Avoid reinforcing illness behavior: While validating, also emphasize active self-management and gradual return to activity
• Written information/resources: Reliable patient information leaflets, support groups

2. Exercise and physical therapy (STRONG evidence - most effective intervention):

Aerobic exercise:

• Gold standard non-pharmacological treatment
• Start LOW, go SLOW - begin at very low intensity and duration, gradually increase
• Types: walking, cycling, swimming, aquatic exercise (warm water particularly beneficial)
• Goal: 20-30 minutes moderate intensity, 2-3 times/week, building up over weeks-months
• Benefits: reduces pain, fatigue, depression; improves physical function, sleep, quality of life
• Challenge: Initial increase in pain/fatigue (post-exertional malaise) - counsel patients this improves with persistence; pacing is key

Strengthening exercises:

• Resistance training 2-3x/week
• Improves muscle strength, reduces pain, improves function

Flexibility/stretching exercises:

• Gentle stretching, yoga, tai chi
• Improve flexibility, reduce stiffness, promote relaxation

Physiotherapy:

• Develop individualized exercise program
• Education on pacing, posture, body mechanics
• Hands-on treatments (massage, manual therapy) may provide temporary relief

3. Cognitive Behavioral Therapy (CBT) (STRONG evidence):

• Addresses maladaptive thoughts, behaviors, and coping strategies
• Key components:
  • Cognitive restructuring: Challenge catastrophic thinking, pain beliefs
  • Behavioral activation: Gradual increase in activities despite pain
  • Coping skills training: Develop adaptive pain management strategies
  • Relaxation techniques
• Benefits: reduces pain, disability, depression; improves coping and self-efficacy
• Can be individual or group format

4. Sleep hygiene and management:

• Regular sleep-wake schedule (same bedtime/wake time daily)
• Bedroom environment: dark, quiet, cool, comfortable
• Avoid: caffeine (especially afternoon/evening), alcohol, heavy meals before bed, screens before bed
• Wind-down routine before bed
• Limit daytime napping
• Use bed only for sleep (not TV, work)
• If can't sleep after 20 minutes, get up and do relaxing activity

5. Stress management and relaxation techniques:

• Mindfulness meditation (growing evidence for pain reduction)
• Progressive muscle relaxation
• Deep breathing exercises
• Guided imagery
• Biofeedback
• Benefits: reduce stress, muscle tension, pain; improve sleep and wellbeing

6. Pacing and activity management:

• Avoid "boom-bust" cycle (overactivity on good days → flare → prolonged rest → deconditioning)
• Break activities into manageable chunks with rest breaks
• Set realistic daily goals
• Gradual, consistent increase in activity tolerance
• Energy conservation strategies

7. Other interventions with varying evidence:

• Acupuncture: Modest evidence for short-term pain relief; may be worth trying
• Massage therapy: Temporary symptom relief, relaxation; not curative
• Heat therapy: Warm baths, heating pads - provide temporary relief, muscle relaxation
• TENS (transcutaneous electrical nerve stimulation): Mixed evidence; some patients find helpful
• Dietary modifications: Limited evidence; some patients report benefit from anti-inflammatory diets, eliminating certain foods (individualized approach)

Why multidisciplinary approach is important:

Fibromyalgia is multifaceted:

• Physical symptoms (pain, fatigue)
• Psychological factors (depression, anxiety, stress, catastrophizing)
• Sleep disturbance
• Functional impairment (work, social, daily activities)
• No single intervention addresses all aspects

Multidisciplinary team can include:

• GP/physician: Diagnosis, coordination of care, medical management
• Physiotherapist: Exercise prescription, physical rehabilitation
• Occupational therapist: Activity pacing, energy conservation, work adaptations
• Clinical psychologist: CBT, pain management programs, addressing comorbid mental health
• Pain specialist: Complex cases, refractory symptoms
• Rheumatologist: Diagnosis confirmation, exclude other conditions, complex cases
• Nurse specialist: Patient education, self-management support
• Pharmacist: Medication management, monitoring

Benefits of multidisciplinary approach:

• Addresses condition holistically (biopsychosocial model)
• Combines complementary interventions synergistically
• Provides comprehensive support and expertise
• Validates the complexity of the condition
• Better outcomes than single-modality treatment
• Empowers patient self-management

Practical delivery:

• Specialist fibromyalgia/chronic pain clinics (ideal but limited availability)
• Coordinated care in primary care with referrals to specialists as needed
• Group programs (pain management programs) - cost-effective, peer support

Key messages for patients:

• Active participation in treatment is essential - "you are your own best treatment"
• Improvement is gradual - weeks to months, not days
• Combination of approaches more effective than single treatment
• Focus on function and quality of life, not complete pain elimination
• Self-management strategies are lifelong skills

Overview of pharmacological management:

• Medications are adjuncts to non-pharmacological management, not first-line sole treatment
• Generally provide modest symptom relief (typically 30-50% pain reduction in responders)
• Only ~30-50% of patients respond to any given medication
• No single drug is effective for all symptoms or all patients
• Start low, go slow with dosing; trial for adequate duration before assessing efficacy
• Important: Traditional analgesics (paracetamol, NSAIDs, opioids) are largely ineffective in fibromyalgia

Medications with STRONG evidence (first-line pharmacological options):

1. Amitriptyline (tricyclic antidepressant):

• Dose: 10-25mg at night initially, can increase to 50-75mg (lower than antidepressant doses)
• Mechanism: Increases serotonin and noradrenaline (enhances descending pain inhibition); sedative effects improve sleep
• Evidence: Reduces pain, improves sleep, fatigue; one of the most studied medications in fibromyalgia
• Side effects: Dry mouth, constipation, drowsiness/morning hangover, weight gain, urinary retention, cardiac effects (caution in elderly/cardiac disease)
  • Often limit use due to side effects
• Advantages: Inexpensive, well-established, helps sleep
• Contraindications: Recent MI, arrhythmias, heart block, glaucoma, urinary retention

2. Duloxetine (SNRI - serotonin-noradrenaline reuptake inhibitor):

• Dose: 30mg daily initially, increase to 60mg daily after 1 week (can go up to 120mg)
• Mechanism: Enhances serotonin and noradrenaline (descending pain modulation); also treats comorbid depression/anxiety
• Evidence: FDA-approved for fibromyalgia; reduces pain, improves function; also effective for comorbid depression
• Side effects: Nausea (especially initially - take with food), dry mouth, constipation, dizziness, insomnia, sweating, sexual dysfunction
  • Withdrawal effects if stopped abruptly - taper gradually
• Advantages: Also treats depression; generally better tolerated than amitriptyline; taken during day
• Contraindications: Uncontrolled narrow-angle glaucoma; caution with liver disease

3. Pregabalin (anticonvulsant, alpha-2-delta ligand):

• Dose: 75mg twice daily initially, can increase up to 300mg twice daily (typical effective dose 300-450mg/day in divided doses)
• Mechanism: Binds to alpha-2-delta subunit of voltage-gated calcium channels; reduces excitatory neurotransmitter release; modulates pain processing
• Evidence: FDA-approved for fibromyalgia; reduces pain, improves sleep, anxiety; multiple RCTs showing efficacy
• Side effects: Dizziness, drowsiness, weight gain (common and can be significant), peripheral edema, dry mouth, blurred vision, cognitive impairment/"brain fog"
  • Weight gain limits long-term use in many patients
• Advantages: Also improves sleep and anxiety; can be effective when other options fail
• Contraindications: Caution in renal impairment (dose adjustment needed); potential for misuse (controlled drug in some countries)

4. Gabapentin (anticonvulsant, similar to pregabalin):

• Dose: Start 300mg at night, can increase to 1800-2400mg/day in divided doses
• Evidence: Some evidence for efficacy (less robust than pregabalin); often used as alternative to pregabalin
• Side effects: Similar to pregabalin (dizziness, drowsiness, weight gain, edema)
• Advantages: Cheaper than pregabalin in some settings

Medications with MODERATE evidence (second-line options):

Other antidepressants:

• Milnacipran (SNRI): FDA-approved for fibromyalgia in US; similar efficacy to duloxetine; not available in all countries
• Cyclobenzaprine (muscle relaxant, structurally similar to amitriptyline): 10-30mg at night; improves sleep and pain; very sedating
• Fluoxetine, paroxetine (SSRIs): Weaker evidence than SNRIs; may help comorbid depression but less effective for pain than SNRIs/tricyclics

Medications with LIMITED/NO evidence or NOT recommended:

• Paracetamol: No good evidence; may provide minor short-term relief; generally ineffective as monotherapy
• NSAIDs (ibuprofen, naproxen): Fibromyalgia is not inflammatory condition; NSAIDs largely ineffective; may help if comorbid inflammatory condition or short-term flare
• Opioids (codeine, tramadol, morphine, etc.):
  • NOT recommended - no evidence of efficacy in fibromyalgia
  • Risks (dependence, tolerance, hyperalgesia, constipation, cognitive effects) outweigh any potential limited benefit
  • Can worsen central sensitization
  • Avoid prescribing opioids for fibromyalgia
• Benzodiazepines: Not recommended - no evidence for pain/fibromyalgia; risk of dependence; may worsen sleep architecture; reserve only for short-term anxiety management if needed
• Corticosteroids: No role in fibromyalgia (not inflammatory)
• Cannabinoids: Insufficient evidence currently; some patients report benefit but formal trials show limited/no efficacy

Practical prescribing approach:

Step 1: Choose initial medication based on:

• Predominant symptoms:
  • Sleep problems prominent: Amitriptyline or pregabalin (nighttime dosing)
  • Comorbid depression/anxiety: Duloxetine
  • Daytime fatigue (want to avoid sedation): Duloxetine
• Comorbidities/contraindications: e.g., avoid amitriptyline in cardiac disease, elderly
• Patient preference, previous experience

Step 2: Titrate dose slowly

• Start low, increase gradually to minimize side effects
• Allow adequate trial at therapeutic dose (6-8 weeks minimum) before judging efficacy

Step 3: Assess response

• Meaningful improvement = ≥30% reduction in pain AND improvement in function/quality of life
• If effective: continue at minimum effective dose
• If ineffective or intolerable side effects: taper off and try alternative medication (different class)

Step 4: Combination therapy (if needed)

• Can combine medications from different classes (e.g., amitriptyline + duloxetine, or pregabalin + duloxetine)
• Some evidence for additive benefit, but also increased side effect risk
• Use lowest effective doses of each

Limitations and realistic expectations:

• Modest efficacy: Even in responders, typically only 30-50% symptom reduction; complete pain relief is rare
• Side effects common: May limit use or adherence; need to balance benefits vs. side effects
• Individual variation: No way to predict who will respond to which medication - trial and error approach necessary
• Not curative: Medications manage symptoms; do not address underlying condition
• Long-term use: Unclear optimal duration; many patients continue long-term, but periodic reassessment of need is appropriate
• Cost: Some medications (especially pregabalin, duloxetine) can be expensive

Key messages:

• Medications should be part of comprehensive management, not sole treatment
• Combination of medication + exercise + psychological approaches = best outcomes
• Set realistic expectations - modest improvement, not cure
• Avoid opioids and benzodiazepines
• Regular review to assess ongoing need and manage side effects

Prognosis of fibromyalgia:

Natural history:

• Chronic, fluctuating course - symptoms wax and wane over time with flares and remissions
• Spontaneous complete remission is uncommon (occurs in \<25% of patients)
• Many patients show some improvement over time, especially with appropriate management
• Severity and impact vary widely between individuals

Functional outcomes:

• Significant impact on quality of life: Pain, fatigue, and cognitive dysfunction affect daily activities, work, relationships
• Work disability: Higher rates of work disability and sick leave compared to general population; however, many patients continue working (with accommodations)
• Not progressive or degenerative: Fibromyalgia does not cause tissue damage, deformity, or organ failure (unlike RA, lupus)
• Not life-threatening: Does not shorten life expectancy

Factors associated with better prognosis:

• Younger age at diagnosis
• Higher education level
• Active coping strategies (vs. passive/catastrophizing)
• Regular exercise and physical activity
• Engagement with treatment and self-management
• Good social support
• Employment/maintaining work
• Absence of severe depression or other psychiatric comorbidity

Factors associated with poorer prognosis:

• Severe baseline symptoms
• Long duration before diagnosis
• Multiple comorbidities (especially psychiatric)
• History of trauma/abuse
• Litigation/compensation-seeking
• Passive coping, catastrophizing
• Social isolation, poor support

Realistic outcome expectations:

• Goal is symptom management and functional improvement, not "cure"
• Most patients can achieve meaningful improvement in symptoms and quality of life with appropriate multimodal treatment
• Return to pre-fibromyalgia functional level may not be possible for all, but many can work, maintain relationships, and have good quality of life
• Self-management strategies become lifelong tools

Key challenges in managing fibromyalgia patients:

1. Diagnostic challenges:

• No objective test - relies on clinical assessment
• Overlap with other conditions (chronic fatigue syndrome, depression, other pain syndromes)
• Delayed diagnosis common (average 2-7 years from symptom onset) - patients see multiple doctors, undergo extensive testing
• Persistent stigma and dismissal by some clinicians ("it's all in your head")

2. Complexity of condition:

• Multisystem symptoms - pain, fatigue, sleep, cognitive, mood, GI, etc.
• Comorbidities common - requires management of multiple conditions
• Heterogeneous presentation - "fibromyalgia" encompasses diverse patients with varying symptoms and severity

3. Treatment challenges:

• No single effective treatment - requires multimodal approach
• Modest efficacy of available treatments - many patients don't respond to first-line therapies
• Side effects limit medication use
• Non-pharmacological treatments (exercise, CBT) require active patient participation, time, and resources - not always available or acceptable to patients
• Trial-and-error approach necessary - frustrating for patients and clinicians

4. Patient factors:

• Illness beliefs and expectations: Patients seeking "cure" or explanation of exact cause (which we can't provide)
• Catastrophizing and passive coping: "Nothing will help," helplessness
• Secondary gain issues: Disability benefits, avoidance of work/responsibilities (in minority of patients)
• Multiple previous failed treatments: Leads to demoralization, skepticism about new approaches
• Doctor-shopping: Seeking the doctor who will "fix" them or provide desired diagnosis/treatment

5. Healthcare system challenges:

• Limited access to multidisciplinary services (physiotherapy, psychology, pain clinics)
• Time constraints in primary care - comprehensive fibromyalgia management is time-intensive
• Lack of specialist expertise in fibromyalgia
• Pressure for quick fixes (medication prescriptions) rather than behavioral interventions

6. Psychosocial challenges:

• Stigma - "invisible illness," others (family, employers) may not believe or understand
• Social isolation - reduced ability to participate in activities
• Relationship strain
• Financial impact - work disability, healthcare costs

Approach to frustrated patients with previous failed treatments:

1. Therapeutic alliance and validation:

• Listen and validate: "I believe your symptoms are real and I understand how difficult this has been for you"
• Acknowledge frustration with previous failed treatments
• Avoid dismissive language; show empathy and commitment to working with them
• Continuity of care: Regular appointments with same clinician builds trust

2. Review and reframe:

• Review previous treatments: What has been tried? At what doses/duration? Why discontinued?
  • Often medications were tried at inadequate doses or for insufficient duration
  • Or stopped due to side effects that might be manageable with slower titration
• Identify any partial responses: Even small improvements are worth noting and building on
• Reframe goals: Shift from seeking "cure" to improving function and quality of life
  • "We may not eliminate all your pain, but we can work on helping you do more of the things that matter to you"

3. Re-educate about condition and management:

• Explain fibromyalgia in clear, accessible terms (central sensitization, altered pain processing)
• Emphasize that fibromyalgia is not progressive or damaging - "hurt does not equal harm"
• Explain why traditional pain medications (NSAIDs, opioids) don't work for fibromyalgia
• Reinforce importance of active approaches (exercise, pacing, self-management) over passive treatments
• Set realistic expectations about treatment outcomes (modest improvement, not cure)

4. Collaborative goal-setting:

• Ask patient about their priorities: What would they most like to be able to do? (e.g., return to work, play with grandchildren, sleep better)
• Set SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound
  • E.g., "Walk for 10 minutes 3 times this week" rather than "get rid of pain"
• Focus on functional goals (activities) rather than symptom elimination
• Celebrate small achievements - reinforce progress

5. Offer fresh approach with evidence-based treatments:

• Consider medications not yet tried or re-trial with different approach:
  • If amitriptyline caused morning hangover, try earlier dosing or lower dose, or switch to duloxetine
  • If pregabalin caused weight gain, try gabapentin with dietary support
• Emphasize non-pharmacological approaches:
  • Exercise - "best evidence we have"; reassure about initial symptom increase; develop very gradual program
  • Refer to physiotherapy, psychology (CBT), pain management programs if available
• Address specific symptoms:
  • Sleep - hygiene, medications
  • Mood - treat depression/anxiety
  • IBS - dietary advice, appropriate medications

6. Address barriers to treatment engagement:

• Fear-avoidance: "Exercise will make me worse" - educate about temporary increase, long-term benefit; start very gently
• Catastrophizing: Challenge negative thoughts; consider CBT
• Practical barriers: Cost, access, time - problem-solve together (e.g., home exercise if can't attend gym)

7. Manage expectations about timeline:

• "Improvement takes time - we're looking at weeks to months, not days"
• "This is a marathon, not a sprint - we'll work on this together over time"
• Regular review appointments to monitor progress and adjust plan

8. Avoid interventions that can cause harm:

• Do NOT prescribe opioids - explain why they don't work for fibromyalgia and can make things worse
• Avoid excessive investigations - reinforces illness beliefs and fear
• Avoid unnecessary referrals to multiple specialists - maintain coordinated care

9. Provide ongoing support:

• Regular follow-up (even brief appointments) maintains therapeutic relationship
• Be accessible for flares/concerns
• Connect with patient support groups (peer support valuable)
• Provide written resources, reliable websites

Key messages for frustrated patients:

• "I believe you and I'm committed to working with you on this"
• "We have evidence-based treatments that can help, even if previous attempts haven't worked"
• "You are not alone - fibromyalgia affects millions of people and many improve with the right approach"
• "You have more control over this condition than you might think - the most powerful treatments require your active participation"
• "Improvement is possible, even if we can't cure the condition entirely"

When to refer to specialist:

• Diagnostic uncertainty
• Refractory symptoms despite appropriate trials of multiple treatments
• Complex comorbidities
• Severe functional impairment
• Access to multidisciplinary pain management program