What is the role of a primary care provider in diagnosis and management of fibromyalgia?

Allodynia = "pain due to a stimulus that does not normally provoke pain." An example would be a light feather touch (that should only produce sensation), causing pain. Allodynia is different from hyperalgesia, which is an exaggerated response from a usually painful stimulus, although both can and often do co-exist. Both are types of neuropathic pain. [1]

History

Developed in 1950s.  Smythe and Moldofsky authored diagnostic criteria in 1976. Non-pain symptoms were added back to the fibromyalgia definition and criteria in 2010. Perhaps fibromyalgia is part of a bigger picture such as “functional somatic syndrome," “bodily distress syndrome” or “central pain syndrome.” For fibromyalgia, the constituting of symptoms began in the 1930s. By a different logic, one could go back a century or forward by 30 or 40 years [4]

Symptoms

Generalized aching and stiffness is the chief diagnostic symptom. [4]

Diagnosis

Is there a lab test for fibromyalgia? FM/a test 

Fibromyalgia is often overlooked in the primary care office. Many individuals in the primary care setting who appear to satisfy fibromyalgia criteria have not received a diagnosis of fibromyalgia by clinicians. These findings have been replicated in a university rheumatology clinic. Published in 2021, using 2016 fibromyalgia diagnosis criteria, 45% of patients referred to two pain rehabilitation centers in Denmark were found to have fibromyalgia, but only 19% had been diagnosed previously. [2]

There is a lot of disagreement or confusion over criteria. For fibromyalgia, many physicians, including physician-experts, still hew to the idea of “I know it when I see it”. [4]

Is fibromyalgia real?

One report stated that “psychogenic rheumatism is encountered most frequently among middle-aged women. The typical complaint is of widespread pain and stiffness, often with report of swelling and paresthesia, but symptoms characteristically are vague”  Reynolds warned that “labelling patients [as ‘fibrositis’] whose “symptoms stem from emotional disturbance may comfort physicians or patients by creating an aura of organicity about the psychogenic disorder.” Psychogenic rheumatism rapidly disappeared from the approved lexicon, but the concerns that psychological issues were central to fibromyalgia continued [25], bolstered to some extent by self-diagnosis inherent in fibromyalgia criteria and in the high rates of psychiatric illness among those diagnosed with fibromyalgia

Treatment

Non-pharmacological

In a review of 59 studies of behavioral interventions for medically unexplained symptoms there were some benefits in pain and fatigue. There was little evidence that these interventions are effective for symptom load (somatisation). The authors concluded that general practitioner-led interventions were not shown to be effective. The relationship between patient and service provider is perceived to play a key role in facilitating a successful intervention. Future research should focus on testing the therapeutic effects of the general practitioner-patient relationship within trials of behavioural interventions. [3]

Duloxetine

Lyrica

Tramadol

Medical marijuana/ Cannaboinoid-basded medication (CBM)

Studies found improvements in pain across a study sample. In an open-label study, two thirds of study participants living with fibromyalgia responded well to sublingual THC treatment. [5]