31st January 2024

Management

Fibromyalgia

Optimal management consists of prompt diagnosis and patient information, including written information. There should be a comprehensive assessment of pain, functional status, and psychosocial well-being. A multidisciplinary approach with GPs, rheumatologists, physiotherapists, and psychologists should be used. The management is graduated, starting with exercise programmes and physiotherapy, slowly increasing the intensity of exercise. Additional therapies such as hydrotherapy or acupuncture can be helpful. Patients should be encouraged to continue working if able. Response should be reassessed, and if there is insufficient effect, additional individualised management instituted. These include psychological therapies, usually cognitive behavioural therapy for pain-related depression, anxiety or poor coping mechanisms. Pharmacotherapy can be used for severe pain or sleep disturbance. The common medications used include duloxetine, pregabalin and tramadol for severe pain. Low-dose amitriptyline, cyclobenzaprine or pregabalin at night are often used for severe sleep issues. Multimodal rehabilitation programs can be used for severe disability.

CRPS 

Prompt diagnosis and early treatment are best practice to avoid complications associated with disuse and the psychological consequences of living with undiagnosed chronic pain. Patients should receive education on the condition and be encouraged to use the limb. Patients should be informed that the pain associated with CRPS does not indicate tissue damage. Physiotherapy and occupational therapy input is considered first line treatment. Psychological therapies such as desensitisation therapy can also be used. In more complex cases, patients may be referred to rheumatology to confirm the diagnosis or to exclude the ongoing pathology, particularly after an operation. There is limited high-quality data for pharmacotherapy, and these should be started on an individual basis. Medications can include NSAIDs, neuropathic pain medications, and topical treatments such as lidocaine or capsaicin. In some cases, bisphosphonates can be used in CRPS if there is abnormal uptake on a bone scintigraphy scan. Referral to the pain team may also be beneficial. 

References

• Macfarlane, G. J., Kronisch, C., Dean, L. E. et al. EULAR revised recommendations for the management of fibromyalgia. Annals of the Rheumatic Diseases, 2017;76(2), 318. 
• Goebel A, Barker CH, Turner-Stokes L et al. Complex regional pain syndrome in adults: UK guidelines for diagnosis, referral and management in primary and secondary care. Royal College of Physicians. 2012.
• UpToDate [Internet]. Complex Regional Pain Syndrome in Adults: Treatment, Prognosis and Prevention. Uptodate.com. 2022 [cited 29 April 2022]. Available from:
• https://www.uptodate.com/contents/complex-regional-pain-syndrome-in-adults-treatment-prognosis-and-prevention?search=chronic%20regional%20pain%20syndrome&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2