Addressing Challenges in Fibromyalgia in Primary Care - Part II

Click here for Part IDiagnosing fibromyalgia

Pain is a two way street. When it comes to nociceptive pain, the brain has the ability to amplify or suppress through powerful anti- and pro-nocioceptive pathways. With chronic pain conditions, the cause can stem from anywhere within the unified sensory system, from the peripheral nerve to the brain, making it difficult to diagnose the exact origin of a patient's pain.

Despite these difficulties, here are a few means through which you can attempt to confirm a diagnosis of fibromyalgia.

Testing for fibromyalgia

Tender points

It is not just these tender points that are sensitive in fibromyalgia, but if a patient, demonstrates sensitivity in 9 or more out of the 18 tender points, a patient’s got fibromyalgia.

How to test: press your thumb until your nail blanches. Slowly apply pressure, and if they holler, stop.

Eliminate other possible causes

Certain conditions, such as vitamin D deficiency, could replicate the symptoms of fibromyalgia. You must make sure that there’s no other egregious cause, such as lupus, which would need to be treated differently.

Use your clinical judgment to ensure that the patient doesn’t have a somatoform disorders, or you don’t have a worked up patient on your hands who’s been reading everything under the sun on the Internet and has diagnosed themselves.

Treatment

Don’t be surprised if treatment is difficult. Studies show that you and your patient will do best using a combined cognitive behavioral pharmacological approach.

Therapy

Most patients are in denial about how much stress can affect their well being. For those in denial, work with them on implementing realistic goal setting. Patients with this disease tend to have an all or nothing mindset, and struggle with the phenomenon of trying to live a fully productive life without putting themselves out of commission. This will help to convince them that staying in therapy will reduce both their pain and anxiety.

Exercise

Exercise is another beneficial option. Patients on an exercise regimen typically don’t have as much pain or complain about pain as much, however, the all-or-nothing mentality applies here as well. With both exercise and medication administration in these populations you cannot rush.

An important component of this diagnosis is extreme sensitivity, so you must be very firm and remember to focus on grading. You cannot go too slowly in exercise and/or dosing. Remember: you are attempting to introduce curbation to psychological and physical perturbation in a system that reacts extremely to rapid change.

Someone who is very deconditioned may require six months before they can even run around the block. They need slow, chronic, gradual progression. If they overextend themselves, take it back down a step.

Pharmacological options

The first rule of psychiatry: don’t change anything that’s working.

Tricyclics

Raising the dosage of tricyclcs can become lethal, in addition to all of the major side effects associated with them. Some people are remarkably sensitive. Rule of psychiatry, don’t change anything that’s working.

Antidepressants

These may help cure some individuals, but this does not happen very often in patients with fibromyalgia or chronic fatigue syndrome. However, they don’t just treat pain and, fortunately, they have a fairly wide range of positive benefits and can help alleviate many other symptoms.

Pregabalin

Data shows that it works, and works better at a high dose. The trick is, as stated above, to start with lowest dose you can find and then don’t stop until the person is well, can’t stand it, or you’ve hit the highest dose possible.