Fibromyalgia (FM)  was recognized as a true syndrome with the publication of the American College of Rheumatology (ACR)  classification criteria in 1990,  which were updated in 2010. Taking into account neurophysiologic evidence of pain dysregulation as well as newer treatment options, these guidelines provide direction for optimal patient care and align with best clinical practice. Clinical challenge persists as symptoms are subjective, assessment is dependent entirely on patient report, no objective or laboratory test exists to confirm the diagnosis,  and there is an absence of a gold standard of treatment. 

With the pivot symptom of pain, the syndrome of FM includes fatigue,  nonrestorative sleep, cognitive dysfunction, mood disorder, as well as variable somatic symptoms.

Canadian prevalence rates are in the order of 2% - 3%, with females affected between 6 to 9 times more commonly than males.  Although seen most commonly in middle-aged women, FM can also affect children, teenagers, and the elderly.

Patients with FM commonly experience symptoms for a number of years prior to diagnosis. Repeated investigations, referral to various specialists, and frequent healthcare visits all contribute to considerable cost associated with this condition.  Direct healthcare costs attributed to patient care are over $4000 Canadian per year, an amount 30% higher than non-FM patients in a Quebec healthcare database. Although a reduction in healthcare utilization occurred immediately following a diagnosis of FM, this was not sustained in subsequent years.

While there is currently no cure for FM, ideal management will address pain as well as the composite of symptoms that comprise this syndrome. Treatment must incorporate non-pharmacologic strategies and may also include drug therapy,  in a patient-tailored approach.  Healthcare professionals must understand the interplay of neurophysiologic and psychological mechanisms operative in FM and appreciate that a spectrum of symptoms exists.

These guidelines are presented as recommendations pertinent to patient care in Canada, graded according to the level of supporting evidence,  and accompanied by a brief explanation to clarify their context and facilitate clinical care. They should be viewed as an aid in the care of patients with FM,  taking into account the unique needs of an individual patient, and should not be interpreted as the rule by which each patient should be managed.

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Mary-Ann Fitzcharles
Peter A. Ste-Marie
Don L.  Goldenberg
John X. Pereira
Susan Abbey
Manon Choinière
Gordon Ko
Dwight Moulin
Pantelis Panopalis
Johanne Proulx
Yoram Shir

Division of Rheumatology, McGill University, Montreal, Quebec, Canada
Alan Edwards Pain Management Unit,  McGill University Health Center,  Montreal, Quebec, Canada
Faculty of Law, Université de Montréal, Montreal, Quebec, Canada
Division of Rheumatology,  Tufts University School of Medicine,  Boston, Massachusetts, USA
Faculty of Medicine, University of Calgary, Alberta, Canada
Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
Centre de la recherche du Centre hospitalier de l’Université de Montréal; Department of Anesthesiology, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
Division of Physiatry, University of Toronto, Toronto, Ontario, Canada
Departments of Clinical Neurological Sciences and Oncology,  University of Western Ontario, London, Ontario, Canada

Biology and Therapy of Fibromyalgia. New Therapies in Fibromyalgia
The rapid growth of trials in fibromyalgia in recent years has resulted in new, evidence-based approaches to treatment. The American Pain Society (APS) developed guidelines for the optimal treatment of fibromyalgia, a summary of which was published in 2004. With the subsequent publication of new treatment data reviewed above, some updates to these guidelines may be necessary. The first recommended steps of the APS guidelines, which included confirmation of the diagnosis, education about fibromyalgia, and evaluation and treatment of comorbid disorders, such as mood and sleep disturbances, are still appropriate. However, the subsequent steps do not take the presence of comorbidity into account when recommending treatment for fibromyalgia. Recent evidence suggests that comorbidity and the presence and severity of symptom domains should be an important consideration when selecting initial treatments for fibromyalgia. In the APS guidelines, the first recommended pharmacological treatment is a trial of low dose tricyclic antidepressants or cyclobenzaprine. However, these medications are often poorly tolerated and, at low doses, are not effective for the treatment of mood or anxiety disorders, two common comorbid conditions. An alternative approach would be to recommend one of the new selective SNRIs as a first line treatment for pain in patients with or without depression or anxiety.

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Lesley M Arnold