The Controversies and Points of Debate that Remain a Challenge for Fibromyalgia Care
Presenter:
Fitzcharles, Mary-Ann MB ChB, MD
Co-Authors:
Ste-Marie, Peter A. BA, LL.B.; Goldenberg, Don L. MD; Pereira, John X. MD; Abbey, Susan ; Choinière, Manon ; Ko, Gordon MD; Moulin, Dwight E. MD; Panopalis, Pantelis FRCP; Proulx, Johanne ; Shir, Yoram MD
Description:
Background/Purpose: Fibromyalgia (FM) continues to present challenges for the health care community, with perceptions of disease and attitudes of physicians being highly polarized. Neurophysiologic studies provide reassurance of validity of FM, but clinical care remains dependant on the traditional "art of medicine". In the process of formulating Canadian guidelines for care of FM patients, debate was generated on a number of highlighted clinical issues (1). This report examines these contentious issues in order to provide insight regarding challenges surrounding FM.
Methods: In developing evidence based guidelines for the clinical care of FM, 11 of 60 recommendations did not achieve 80% approval at the first round of voting by a nationwide multidisciplinary health care panel. Modifications according to panel input were made and resubmitted for a second voting, at which time all passed, and form the basis of this report.
Results: Contention was seen in the following areas. 1. Criteria for diagnosis: The healthcare community remains fixated on application of diagnostic criteria, the absence of which causes uncertainty. The tender point count (TPC) remains entrenched in clinical practice. Agreement was obtained by recommending that the 2010 ACR criteria may be used to validate a clinical diagnosis, and TPC may be done by choice, but neither is required for diagnosis. 2. Treatments: Initial recommendation todiscourage use of complementary and alternative medicine (CAM) treatments in absence of evidence for efficacy was modified to emphasize lack of evidence to support CAM use, thereby allowing for individual choice. Although antidepressants in all classes have shown some efficacy, individual bias favoured the newer serotonin norepinephrine reuptake inhibitors. Resolution was achieved by recommending that the specific choice be tailored to the patient according to physicians' knowledge and evidence for efficacy. 3. Terminology: Recommendation to change the terminology of antidepressants and anticonvulsants to pain modulators was rejected in favour of promoting their pain modulating effects rather than a nomenclature change. 4. Past/triggering events: Causation in FM is contentious with experts recommending acknowledgement of previous negative lifetime events, but without excessive emphasis on its importance. 5. Work and disability: Recommendation to remain in the workforce was softened to state that continued work is ideal, with application of a rehabilitation program to improve function and possible return to work.
Conclusion: The healthcare community must adopt a rational and unified approach to the management of FM to dispel false notions that hinder management. The abundance of anecdotal literature, strong advocacy from various groups and the subjective nature of FM symptoms may all have played a part in diagnosis and treatment uncertainty. These guidelines reflect the available evidence with clinically applicable input from health care workers from various disciplines and adhere to strict standards of development. Continued dialogue will help dispel misperceptions and facilitate optimal patient care.
Disclosure:
M. A. Fitzcharles, Purdue Pharma L.P., 5, Eli Lilly and Company, 5, Pfizer Inc, 5, Valeant, 5; P. A. Ste-Marie, None; D. L. Goldenberg, Pfizer Inc, 5; J.
Fitzcharles, Mary-Ann MB ChB, MD
Co-Authors:
Ste-Marie, Peter A. BA, LL.B.; Goldenberg, Don L. MD; Pereira, John X. MD; Abbey, Susan ; Choinière, Manon ; Ko, Gordon MD; Moulin, Dwight E. MD; Panopalis, Pantelis FRCP; Proulx, Johanne ; Shir, Yoram MD
Description:
Background/Purpose: Fibromyalgia (FM) continues to present challenges for the health care community, with perceptions of disease and attitudes of physicians being highly polarized. Neurophysiologic studies provide reassurance of validity of FM, but clinical care remains dependant on the traditional "art of medicine". In the process of formulating Canadian guidelines for care of FM patients, debate was generated on a number of highlighted clinical issues (1). This report examines these contentious issues in order to provide insight regarding challenges surrounding FM.
Methods: In developing evidence based guidelines for the clinical care of FM, 11 of 60 recommendations did not achieve 80% approval at the first round of voting by a nationwide multidisciplinary health care panel. Modifications according to panel input were made and resubmitted for a second voting, at which time all passed, and form the basis of this report.
Results: Contention was seen in the following areas. 1. Criteria for diagnosis: The healthcare community remains fixated on application of diagnostic criteria, the absence of which causes uncertainty. The tender point count (TPC) remains entrenched in clinical practice. Agreement was obtained by recommending that the 2010 ACR criteria may be used to validate a clinical diagnosis, and TPC may be done by choice, but neither is required for diagnosis. 2. Treatments: Initial recommendation todiscourage use of complementary and alternative medicine (CAM) treatments in absence of evidence for efficacy was modified to emphasize lack of evidence to support CAM use, thereby allowing for individual choice. Although antidepressants in all classes have shown some efficacy, individual bias favoured the newer serotonin norepinephrine reuptake inhibitors. Resolution was achieved by recommending that the specific choice be tailored to the patient according to physicians' knowledge and evidence for efficacy. 3. Terminology: Recommendation to change the terminology of antidepressants and anticonvulsants to pain modulators was rejected in favour of promoting their pain modulating effects rather than a nomenclature change. 4. Past/triggering events: Causation in FM is contentious with experts recommending acknowledgement of previous negative lifetime events, but without excessive emphasis on its importance. 5. Work and disability: Recommendation to remain in the workforce was softened to state that continued work is ideal, with application of a rehabilitation program to improve function and possible return to work.
Conclusion: The healthcare community must adopt a rational and unified approach to the management of FM to dispel false notions that hinder management. The abundance of anecdotal literature, strong advocacy from various groups and the subjective nature of FM symptoms may all have played a part in diagnosis and treatment uncertainty. These guidelines reflect the available evidence with clinically applicable input from health care workers from various disciplines and adhere to strict standards of development. Continued dialogue will help dispel misperceptions and facilitate optimal patient care.
Disclosure:
M. A. Fitzcharles, Purdue Pharma L.P., 5, Eli Lilly and Company, 5, Pfizer Inc, 5, Valeant, 5; P. A. Ste-Marie, None; D. L. Goldenberg, Pfizer Inc, 5; J.
