Chronic Widespread Pain, Including Fibromyalgia
Chronic Widespread Pain, Including Fibromyalgia
Improved primary care management of long-term pain may involve reorganization and investment in non-specialist services to deliver improved access to psychology, physiotherapy, and other components of effective treatment. This can create a multidisciplinary approach coordinated by the primary care physician, but elements of care may be provided at different times in different places, and may not therefore be truly multidisciplinary. Although there is good evidence that the multidisciplinary approach is effective in highly focused programmes, it is unclear if this more disseminated primary care approach is equally effective.
Added to this discussion, there are features of a primary care physician-led approach that may enhance value because people with CWP and fibromyalgia will already be known to their primary care physician, and may have consulted regularly for other conditions, including regional pain syndromes, chest pain, headache, and also non-painful problems such as depression, fatigue, sleep disturbance, irritable bowel syndrome, and dizziness. Embedding primary care physician-led care for CWP may facilitate early recognition of CWP, and maintain continuity of care for this group of patients. The treatment of many of the comorbid features of CWP, such as depression, is already well established in primary care, and the primary care physician may be uniquely placed to develop a strong therapeutic relationship with patients and provide ongoing support and education to facilitate effective self-management. All these are elements of high quality care that may improve outcomes for people with CWP. By effective primary care management, expensive specialist care can be reserved for those with severe symptoms that do not respond to this approach. A recent systematic review and research suggests that the most effective interventions for those with multiple problems are those developed using guidelines and targeted interventions.
The initial assessment and further management are shown in Figures 1 and 2.
(Enlarge Image)
Figure 1.
Initial assessment.
(Enlarge Image)
Figure 2.
Further management.
Clinical pathways require a defined entry point. In this case, this should be the time that CWP or fibromyalgia is suspected. The symptoms should meet the following description:
Although some patients may present with symptoms fitting this description, others will consult to discuss a specific painful area, such as low back pain, or one of the symptoms frequently associated with CWP, such as cognitive or mood symptoms, poor sleep, sicca syndrome, paraesthesia, or gastrointestinal disturbance. Identifying patients with CWP may require clinicians to proactively enquire about pain symptoms. An enquiry about widespread pain should therefore be a routine part of history taking when seeing patients with local pain syndromes or associated symptomatology (see).
The entry point for this pathway was selected as the full spectrum of CWP, rather than fibromyalgia alone. The American College of Rheumatology classification criteria for fibromyalgia required the presence of CWP plus positive clinical examination for a tender point count. More recent diagnostic criteria, however, do not include a tender point count, but instead capture the extent of CWP plus somatic and cognitive symptoms, and also fatigue. Thus, CWP is increasingly seen as a spectrum, with fibromyalgia representing the most severe manifestation. Much of the evidence in this area is based on fibromyalgia treatment trials. Extending the principles of good practice across the clinical spectrum should maximize the benefits for patients being seen in primary care with more limited symptoms.
It can be difficult for clinicians to accept purely syndromic definitions based exclusively on the presence and distribution of symptoms without a clear defined pathological process to attribute these to. The lack of a test for CWP or fibromyalgia—or even of defined reproducible clinical signs—can frustrate both clinicians and patients. Nevertheless, our understanding of these pain syndromes is improving. Evidence of genetic susceptibility comes from twin studies, and abnormal pain processing has been implicated as a likely aetiology in fibromyalgia with changes in brain neuroreceptor binding patterns, anatomical structure, and metabolite activity seen on neuroimaging.
The section on risk factors and red flags in this pathway serves a dual purpose, both to screen for underlying pathology and to identify, from the outset, people in pain who are at risk of chronicity and poor outcomes. This allows targeting treatment most effectively, with those people most at high risk benefiting from a more specialist approach from the beginning. Both rheumatic and neurological disorders can present as CWP, and following this pathway should ensure appropriate specialist referral for those who are most likely to need it. Features in the history or clinical examination are generally more important than laboratory investigations, although a limited set is included. Much of the work on predictors of poor outcomes in chronic painful conditions has come from research into back pain, and has focused on psychological, social, and work-based risk factors. Screening for underlying pathology and poor prognostic factors appears early in the pathway, but should also be reconsidered if symptoms change or if treatment is ineffective.
Identifying patients who would benefit from early specialist referral is a core skill in primary care. As with all skills, it comes with experience and cannot be completely captured in an algorithm. Unnecessary referrals may be detrimental to both individual patients and the system as a whole. The consequences of missed underlying pathology may be devastating for a person's health and can lead to medico-legal claims. In pathways, an unavoidable risk is that the setting of objective criteria for referral may lead to unnecessary referrals. As with all guidance, the recommendations in the pathway must be used in the context of clinical experience and decision-making.
Patients have a reasonable expectation that their condition, treatment, and likely outcome will be explained to them in a clear and supportive way. People's ideas, concerns, and expectations need to be explored and addressed, and therapeutic goals agreed. This must include acknowledging that most treatments focus on restoring and maintaining quality of life, rather than removing pain itself, which may persist.
Explanation and education can easily be sidelined due to demands on clinical time, excessive focus on exclusion of underlying disorders, unfamiliarity with CWP and fibromyalgia, poor communication skills, and inexperience. However, even clinicians who are unfamiliar with these conditions will have generic skills in 'long term conditions' management that can be successfully applied here, using the pathway to identify the tools, interventions, and actions that are particular to CWP and fibromyalgia. Primary care physicians with appropriate skills can improve outcomes for patients with widespread pain using better communication.
Poor information and explanation can lead to an over reliance on pharmacological interventions of limited benefit. Instead of this negative consequence, clinicians need to be willing to enter into a longer and potentially challenging conversation about self-management techniques where the patient is being asked to change from being a passive recipient of care to taking responsibility and actively managing their pain.
The pathway provides a valuable resource to promote consistent messages about CWP from primary through to specialist care, regardless of the health professional seeing the patient. Explanations that could be interpreted as the pain being 'all in the mind' are likely to cause offence and be unhelpful.
This pathway suggests explicit acknowledgement:
Extensive links have been included to a number of national organizations based on different pain conditions and geographical location. These organizations provide written and verbal information via a range of media, and also direct support. Different approaches will suit different people, and clinicians should see it as part of their role to help people identify the resources that will support them best.
Relief from pain is one of the main reasons why people with CWP seek medical care. The pathways recommend a number of evidence-based pharmacological approaches. However, fewer than half of patients report substantial improvement in pain with neuromodulatory medication and intolerable adverse effects are remarkably common.
The pathway embeds generic principles of best practice such as regular monitoring of analgesia using the '4 As' (analgesia, adverse effects, activity, and adherence). This is important as the benefits of analgesia vary considerably between patients and over time for any given patient. Regular medication reviews are needed to balance benefits against side-effects.
Measuring clinical outcomes for people in pain relies on patient-reported outcome measures, and so can be less straightforward than for some conditions such as diabetes or hypertension where there are objective biomarkers. Precisely because of this, the pathway recommends routine use of validated patient-reported outcome measures to monitor the severity and impact of CWP and response to treatment.
The use of opioids other than tramadol is not generally advocated in this pathway, although a trial of weak opioids is suggested in primary care. Generally, evidence for benefit is lacking and using opioids liberally has led to problems at a national level for large numbers of people. The misuse of prescribed opioids in the USA has increased significantly over recent years with regular news reports of dubious marketing practices, questionable relationships between doctors, not-for-profit organizations and drug companies, and deaths associated with prescription opioids. Most deaths are due to overdose, but there are many other potential reasons for morbidity such as immunosuppression.
Commencing opioids in CWP and fibromyalgia, especially those without a clear prescribing ceiling, needs a great deal of experience and justification. Drugs that fall into this cautionary category include buprenorphine, fentanyl, methadone, morphine, oxycodone, hydrocodone, and meperidine. Starting long-term opioids is not recommended in this pathway and should be reserved for use by pain specialists to prevent the risk of inappropriate escalation. These cautionary recommendations are yet another example of the continuing concerns about the long-term use of strong opioids in chronic non-malignant pain. There are a number of internationally recognized guidelines for the use of opioids in long-term conditions.
Specialist management is shown in Figure 3.
(Enlarge Image)
Figure 3.
Specialist management.
Behavioural and cognitive therapies (CBT) are well established and effective treatments for CWP. By including them early in the pathway as part of a primary care approach for people with CWP, this pathway aims to extend access to these psychological therapies beyond the current care models with access to specialist CBT-based programmes available routinely only in secondary care.
To deliver CBT, some of the following will need to be achieved:
Best results are likely to be seen where pain specialists work with primary care in the community setting to share their expertise and support primary care physicians. There is the potential to improve outcomes through improved access and earlier intervention.
Discussion Points
Can Primary Care Pain Management Provide Good Value?
Improved primary care management of long-term pain may involve reorganization and investment in non-specialist services to deliver improved access to psychology, physiotherapy, and other components of effective treatment. This can create a multidisciplinary approach coordinated by the primary care physician, but elements of care may be provided at different times in different places, and may not therefore be truly multidisciplinary. Although there is good evidence that the multidisciplinary approach is effective in highly focused programmes, it is unclear if this more disseminated primary care approach is equally effective.
Added to this discussion, there are features of a primary care physician-led approach that may enhance value because people with CWP and fibromyalgia will already be known to their primary care physician, and may have consulted regularly for other conditions, including regional pain syndromes, chest pain, headache, and also non-painful problems such as depression, fatigue, sleep disturbance, irritable bowel syndrome, and dizziness. Embedding primary care physician-led care for CWP may facilitate early recognition of CWP, and maintain continuity of care for this group of patients. The treatment of many of the comorbid features of CWP, such as depression, is already well established in primary care, and the primary care physician may be uniquely placed to develop a strong therapeutic relationship with patients and provide ongoing support and education to facilitate effective self-management. All these are elements of high quality care that may improve outcomes for people with CWP. By effective primary care management, expensive specialist care can be reserved for those with severe symptoms that do not respond to this approach. A recent systematic review and research suggests that the most effective interventions for those with multiple problems are those developed using guidelines and targeted interventions.
The initial assessment and further management are shown in Figures 1 and 2.
(Enlarge Image)
Figure 1.
Initial assessment.
(Enlarge Image)
Figure 2.
Further management.
Entry to the Pathway
Clinical pathways require a defined entry point. In this case, this should be the time that CWP or fibromyalgia is suspected. The symptoms should meet the following description:
Pain lasting more than 3 months, affecting both sides of the body, and sites above and below the waist, plus pain in the axial skeleton.
Although some patients may present with symptoms fitting this description, others will consult to discuss a specific painful area, such as low back pain, or one of the symptoms frequently associated with CWP, such as cognitive or mood symptoms, poor sleep, sicca syndrome, paraesthesia, or gastrointestinal disturbance. Identifying patients with CWP may require clinicians to proactively enquire about pain symptoms. An enquiry about widespread pain should therefore be a routine part of history taking when seeing patients with local pain syndromes or associated symptomatology (see).
The entry point for this pathway was selected as the full spectrum of CWP, rather than fibromyalgia alone. The American College of Rheumatology classification criteria for fibromyalgia required the presence of CWP plus positive clinical examination for a tender point count. More recent diagnostic criteria, however, do not include a tender point count, but instead capture the extent of CWP plus somatic and cognitive symptoms, and also fatigue. Thus, CWP is increasingly seen as a spectrum, with fibromyalgia representing the most severe manifestation. Much of the evidence in this area is based on fibromyalgia treatment trials. Extending the principles of good practice across the clinical spectrum should maximize the benefits for patients being seen in primary care with more limited symptoms.
It can be difficult for clinicians to accept purely syndromic definitions based exclusively on the presence and distribution of symptoms without a clear defined pathological process to attribute these to. The lack of a test for CWP or fibromyalgia—or even of defined reproducible clinical signs—can frustrate both clinicians and patients. Nevertheless, our understanding of these pain syndromes is improving. Evidence of genetic susceptibility comes from twin studies, and abnormal pain processing has been implicated as a likely aetiology in fibromyalgia with changes in brain neuroreceptor binding patterns, anatomical structure, and metabolite activity seen on neuroimaging.
Risk Factors and Red Flags
The section on risk factors and red flags in this pathway serves a dual purpose, both to screen for underlying pathology and to identify, from the outset, people in pain who are at risk of chronicity and poor outcomes. This allows targeting treatment most effectively, with those people most at high risk benefiting from a more specialist approach from the beginning. Both rheumatic and neurological disorders can present as CWP, and following this pathway should ensure appropriate specialist referral for those who are most likely to need it. Features in the history or clinical examination are generally more important than laboratory investigations, although a limited set is included. Much of the work on predictors of poor outcomes in chronic painful conditions has come from research into back pain, and has focused on psychological, social, and work-based risk factors. Screening for underlying pathology and poor prognostic factors appears early in the pathway, but should also be reconsidered if symptoms change or if treatment is ineffective.
Specialist Care Referrals
Identifying patients who would benefit from early specialist referral is a core skill in primary care. As with all skills, it comes with experience and cannot be completely captured in an algorithm. Unnecessary referrals may be detrimental to both individual patients and the system as a whole. The consequences of missed underlying pathology may be devastating for a person's health and can lead to medico-legal claims. In pathways, an unavoidable risk is that the setting of objective criteria for referral may lead to unnecessary referrals. As with all guidance, the recommendations in the pathway must be used in the context of clinical experience and decision-making.
Information and Explanation
Patients have a reasonable expectation that their condition, treatment, and likely outcome will be explained to them in a clear and supportive way. People's ideas, concerns, and expectations need to be explored and addressed, and therapeutic goals agreed. This must include acknowledging that most treatments focus on restoring and maintaining quality of life, rather than removing pain itself, which may persist.
Explanation and education can easily be sidelined due to demands on clinical time, excessive focus on exclusion of underlying disorders, unfamiliarity with CWP and fibromyalgia, poor communication skills, and inexperience. However, even clinicians who are unfamiliar with these conditions will have generic skills in 'long term conditions' management that can be successfully applied here, using the pathway to identify the tools, interventions, and actions that are particular to CWP and fibromyalgia. Primary care physicians with appropriate skills can improve outcomes for patients with widespread pain using better communication.
Poor information and explanation can lead to an over reliance on pharmacological interventions of limited benefit. Instead of this negative consequence, clinicians need to be willing to enter into a longer and potentially challenging conversation about self-management techniques where the patient is being asked to change from being a passive recipient of care to taking responsibility and actively managing their pain.
The pathway provides a valuable resource to promote consistent messages about CWP from primary through to specialist care, regardless of the health professional seeing the patient. Explanations that could be interpreted as the pain being 'all in the mind' are likely to cause offence and be unhelpful.
This pathway suggests explicit acknowledgement:
that pain is real and not imagined, through explanations of the mechanisms of pain focusing on central and peripheral sensitization and the presence of pain in the absence of damage;
of the level of impact of pain on the patient.
Extensive links have been included to a number of national organizations based on different pain conditions and geographical location. These organizations provide written and verbal information via a range of media, and also direct support. Different approaches will suit different people, and clinicians should see it as part of their role to help people identify the resources that will support them best.
Analgesia
Relief from pain is one of the main reasons why people with CWP seek medical care. The pathways recommend a number of evidence-based pharmacological approaches. However, fewer than half of patients report substantial improvement in pain with neuromodulatory medication and intolerable adverse effects are remarkably common.
The pathway embeds generic principles of best practice such as regular monitoring of analgesia using the '4 As' (analgesia, adverse effects, activity, and adherence). This is important as the benefits of analgesia vary considerably between patients and over time for any given patient. Regular medication reviews are needed to balance benefits against side-effects.
Measuring clinical outcomes for people in pain relies on patient-reported outcome measures, and so can be less straightforward than for some conditions such as diabetes or hypertension where there are objective biomarkers. Precisely because of this, the pathway recommends routine use of validated patient-reported outcome measures to monitor the severity and impact of CWP and response to treatment.
Long-term Opioids
The use of opioids other than tramadol is not generally advocated in this pathway, although a trial of weak opioids is suggested in primary care. Generally, evidence for benefit is lacking and using opioids liberally has led to problems at a national level for large numbers of people. The misuse of prescribed opioids in the USA has increased significantly over recent years with regular news reports of dubious marketing practices, questionable relationships between doctors, not-for-profit organizations and drug companies, and deaths associated with prescription opioids. Most deaths are due to overdose, but there are many other potential reasons for morbidity such as immunosuppression.
Commencing opioids in CWP and fibromyalgia, especially those without a clear prescribing ceiling, needs a great deal of experience and justification. Drugs that fall into this cautionary category include buprenorphine, fentanyl, methadone, morphine, oxycodone, hydrocodone, and meperidine. Starting long-term opioids is not recommended in this pathway and should be reserved for use by pain specialists to prevent the risk of inappropriate escalation. These cautionary recommendations are yet another example of the continuing concerns about the long-term use of strong opioids in chronic non-malignant pain. There are a number of internationally recognized guidelines for the use of opioids in long-term conditions.
Specialist management is shown in Figure 3.
(Enlarge Image)
Figure 3.
Specialist management.
Cognitive Behavioural Therapy
Behavioural and cognitive therapies (CBT) are well established and effective treatments for CWP. By including them early in the pathway as part of a primary care approach for people with CWP, this pathway aims to extend access to these psychological therapies beyond the current care models with access to specialist CBT-based programmes available routinely only in secondary care.
To deliver CBT, some of the following will need to be achieved:
CWP should not be treated as a 'medically unexplained symptom' by treating therapists.
CBT for people with chronic pain should be delivered by people with appropriate skills and training, including being able to use validated outcome measure instruments.
CBT should be provided in a timely manner to minimize long-term impact of the condition.
Best results are likely to be seen where pain specialists work with primary care in the community setting to share their expertise and support primary care physicians. There is the potential to improve outcomes through improved access and earlier intervention.
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