evidence & practice / CPD / musculoskeletal disorders

CHRONIC CONDITIONS

Fibromyalgia: clinical features,

diagnosis and management
NS863 Walker J (2016) Fibromyalgia: clinical features, diagnosis and management. Nursing Standard. 31, 5, 51-60.
Date of submission: 28 April 2016; date of acceptance: 6 June 2016. doi: 10.7748/ns.2016.e10550

Jennie Walker Abstract

Clinical educator, Surgical
Division, Nottingham
University Hospitals
NHS Trust, Nottingham,
England
Correspondence
Jennie.walker@nuh.nhs.uk
Twitter: @JennieW14
Patients with fibromyalgia experience chronic widespread pain, with associated symptoms
of fatigue, sleep disturbance and memory problems. There are many therapies which
may be helpful in managing the symptoms of fibromyalgia; however, these often require
a process of trial and error to establish optimum management using a combination of
pharmacological and non-pharmacological approaches. Nurses can support patients with
fibromyalgia using a biopsychosocial approach to symptom management. Understanding
the nature of fibromyalgia and management options will enable nurses to deliver holistic
patient-centred care.

Conflict of interest Keywords

None declared
Review
All articles are subject
to external double-blind
peer review and checked
for plagiarism using
automated software
Revalidation
Prepare for revalidation:
read this CPD article,
answer the questionnaire
and write a reflective
account: nursingstandard.
com/revalidation
Online
For related articles visit
the archive and search
using the keywords
To write a CPD article
Please email gwen.
clarke@rcni.com.
Guidelines on writing for
publication are available
at: journals.rcni.com/r/
author-guidelines
central nervous system, chronic conditions, chronic pain, fatigue, fibromyalgia, pain,
musculoskeletal disorders
Aims and intended learning
outcomes
This article aims to familiarise readers
with the nature of fibromyalgia and
different management strategies that may
help to alleviate symptoms. After reading
this article and completing the time out
activities you should be able to:
»» Describe the common signs and
symptoms of fibromyalgia.
»» Outline different pharmacological
treatments that can be used in patients
with fibromyalgia.
»» Discuss different non-pharmacological
management strategies.
»» Explain the physical, psychological and
social effects of fibromyalgia for patients
with the condition.
Introduction
Fibromyalgia is a musculoskeletal disorder
that is characterised by widespread chronic
pain and several co-morbidities such as
fatigue, sleep disturbance, headaches and
mood disorders (Deare et al 2013), which
occur in the absence of demonstrable
pathology (Glennon 2010). In addition
to pain, the patient may experience other
physical sensations such as tender skin,
swelling, numbness and sensitivity to cold
(Juuso et al 2011).
Fibromyalgia is a medical diagnosis
that is included in the International
Statistical Classification of Diseases and
Related Health Problems 10th Revision
(World Health Organization 2016).
Fibromyalgia differs from the concept
of chronic widespread pain, because
fibromyalgia includes non-pain symptoms
such as fatigue, non-restorative sleep,
cognitive problems and somatic symptoms
(Wolfe et al 2013). Therefore, fibromyalgia
may be considered a spectrum disorder
rather than a distinct disease, since it is a
group of symptoms that can range from
mild to severe. Fibromyalgia can occur in
isolation, although it may also occur in
patients with other disorders, in particular
rheumatoid arthritis and systemic lupus
erythematosus (Glennon 2010).
Fibromyalgia can affect a patient’s
activities of daily living significantly and

nursingstandard.com
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 04, 2016. For volume
personal31 number
use 5 /other
only. No 28 September
uses without2016 / 51
permission.
Copyright © 2016 RCNi Ltd. All rights reserved.
evidence & practice / CPD / musculoskeletal disorders
KEY POINT
‘The cause of fibromyalgia
remains unclear, although
it has been suggested
that fibromyalgia is a
disorder of central pain
processing that results
in a maladaptive pain
response (Glennon 2010).
Altered pain processing
leads to an increased pain
response to non-painful
stimuli (allodynia) and pain
at lower levels of stimulation
(hyperalgesia)’
52 Downloaded
/ 28 September
from2016 / volume
RCNi.com
by ${individualUser.displayName}
have a considerable effect on family life,
social activities, ability to work and quality
of life. Juuso et al (2011) conducted
narrative interviews with 15 women with
fibromyalgia. The women described their
experience of pain as something that
invaded their whole body and was always
present, although unpredictable and
fluctuating in nature. They reported that
pain dominated their daily life and made
carrying out everyday tasks demanding.
Juuso et al (2011) also reported that the
women interviewed had experienced
feelings of being met with disbelief
and not being taken seriously by others.
A crucial challenge for nurses is to be able
to understand and respond to patients’
needs and concerns along with any issues
that are important to the individual
(Eide et al 2011).
Epidemiology
Fibromyalgia occurs worldwide across
all ethnic and socioeconomic groups.
The typical age of onset is between 20
and 60 years, with an average age of 35
years (British Medical Journal (BMJ)
2015). Fibromyalgia has a strong female
prevalence, with a female to male incidence
of approximately 10:1 (Ralston and
McInnes 2014). Prevalence increases with
age and is highest in patients aged over 50
years (Lawrence et al 2008), with up to 8%
of women affected by the syndrome by the
age of 70 years (Glennon 2010).
Fibromyalgia is not thought to be
triggered by a single cause. Arnold et al
(2004) reported strong familial and genetic
factors, with first-degree relatives of people
with fibromyalgia increasingly likely to
have the condition. They found that the
odds ratio of fibromyalgia in a relative of
a person with fibromyalgia versus the odds
of fibromyalgia in a relative of a person
with rheumatoid arthritis was P = 0.0002
(Arnold et al 2004). Several risk factors
have been identified that may predispose a
person to developing fibromyalgia. These
include previous traumatic experiences,
such as motor vehicle trauma, regional
pain syndromes and post-traumatic stress
disorder, or emotional trauma such as
abuse, personality type, lifestyle choices
31 number 5
on Oct 04, 2016. For personal use only. No other uses without permission.
Copyright © 2016 RCNi Ltd. All rights reserved.
and previous episodes of depression
(Firestone et al 2012, Wierwille 2012).
Pathophysiology
The cause of fibromyalgia remains unclear,
although it has been suggested that
fibromyalgia is a disorder of central pain
processing that results in a maladaptive
pain response (Glennon 2010). Altered
pain processing leads to an increased
pain response to non-painful stimuli
(allodynia) and pain at lower levels of
stimulation (hyperalgesia) (Firestone et al
2012). It is suggested that the central
nervous system-derived pain amplification
syndrome is caused by imbalances of the
neurotransmitters that affect pain and
sensory transmission (BMJ 2015). This
includes increased levels of glutamate (an
excitatory neurotransmitter) and substance
P (a nociceptive neurotransmitter)
(Harris et al 2008, Firestone et al 2012).
It is thought that this may also cause other
common co-morbidities such as fatigue,
memory problems, sleep disturbance and
mood disorders (BMJ 2015). It is suggested
that in fibromyalgia there are reduced
pain inhibitory mechanisms, which cause
the already amplified pain sensation to
continue indefinitely (Clauw et al 2011,
Wierwille 2012).
Symptoms
The main presenting features of fibromyalgia
are chronic widespread pain, fatigue,
non-restorative sleep and variable somatic
features. People with fibromyalgia may
experience sensitivity to sensory stimuli
such as bright lights, odours or to wearing
tight clothing (BMJ 2015). Cognitive
symptoms of fibromyalgia may include
‘fibro fog’; a phenomena of forgetfulness,
short-term memory loss, decreased mental
alertness, concentration difficulties, and
difficulty in multitasking under distraction
(Firestone et al 2012). The incidence of
anxiety and depression is also higher in
patients with fibromyalgia than those
without the disorder (BMJ 2015). Therefore,
careful assessment and monitoring is
required throughout diagnosis and
treatment, and referral to mental health
services if necessary. The symptoms of
nursingstandard.com
 For related CPD articles visit
evidenceandpractice.nursingstandard.com

fibromyalgia are summarised in Box 1. characteristic of inflammatory rheumatic KEY POINT

People with fibromyalgia often report that diseases (Wierwille 2012). Differential ‘Fibromyalgia is clinically
they experience exacerbated symptoms diagnosis should consider polymyalgia diagnosed through taking
following changes in weather, sleep rheumatica, hypothyroidism, osteoarthritis the patient’s history and
deprivation, strenuous or increased levels and connective tissue disease. Additional physical examination. There
of activity, and stress (Firestone et al 2012). causes of widespread musculoskeletal pain is currently no diagnostic
There is a substantial overlap of are summarised in Box 2. It is important assessment available to
symptom clusters between fibromyalgia, that ‘red flags’ for serious pathology are diagnose fibromyalgia.
irritable bowel syndrome, premenstrual carefully investigated, such as unintentional Other than the restriction
syndrome, and chronic fatigue syndrome of activities as a result of
(Glennon 2010), which requires careful pain and multiple tender
BOX 1. Symptoms of fibromyalgia
consideration during assessment and points, physical examination
diagnosis. Common symptoms of fibromyalgia is often unremarkable
»» Anxiety and blood tests, X-rays
TIME OUT 1 »» Chronic widespread joint and muscle pain and scans typically give
Consider the various symptoms that may occur in »» Cognitive impairment (low concentration and negative results’
patient’s with fibromyalgia. Write brief notes on how forgetfulness)
these symptoms could effect your life and your ability »» Depression
to carry out daily activities?
»» Diffuse tenderness to palpation
»» Fatigue unrelieved by rest
»» Sleep disturbance and non-restorative sleep
Diagnosis
Fibromyalgia is clinically diagnosed Variable locomotor symptoms
through taking the patient’s history and »» Muscle weakness
physical examination. There is currently no »» Paraesthesia (non-dermatomal numbness or tingling
sensations)
diagnostic assessment available to diagnose
»» Raynaud’s phenomenon
fibromyalgia. Other than the restriction of »» Restless legs syndrome
activities as a result of pain and multiple »» Stiffness
tender points, physical examination is
often unremarkable and blood tests, X-rays Variable non-locomotor symptoms
and scans typically give negative results. »» Dizziness
It is important to exclude other pathology »» Fluid retention
that may be causing musculoskeletal pain »» Headaches
»» Overactive bladder (frequent urination, bladder
and fatigue to ensure that the patient spasms)
is treated appropriately. For example, »» Irritable bowel syndrome (abdominal cramps,
symptoms of hypothyroidism are similar constipation, diarrhoea)
to fibromyalgia, with fatigue, disrupted (Glennon 2010, Firestone et al 2012, Ralston and McInnes 2014,
low quality sleep, and generalised muscular British Medical Journal 2015)
pain (Wierwille 2012). However, treatment
for hypothyroidism is different to that
recommended for fibromyalgia. BOX 2. Causes of widespread
musculoskeletal pain
TIME OUT 2
»» Chronic fatigue syndrome
List five conditions that have similar signs and symptoms »» Hypermobility syndromes
to fibromyalgia. Compare your answers with those listed »» Hypothyroidism
in Box 2. »» Inflammatory arthritis
»» Neuropathies
Rheumatoid arthritis and other »» Osteomalacia
inflammatory rheumatic diseases can »» Polymyalgia rheumatica
cause widespread musculoskeletal pain »» Polymyositis and dermatomyositis
»» Statins
and stiffness similar to fibromyalgia. »» Systemic lupus erythematosus
However, fibromyalgia is not associated »» Vasculitides
with joint inflammation, localised (Glennon 2010)
oedema or a vascular rash, which can be

nursingstandard.com
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 04, 2016. Forvolume
personal31use
number 5 /other
only. No 28 September 2016
uses without / 53
permission.
Copyright © 2016 RCNi Ltd. All rights reserved.
evidence & practice / CPD / musculoskeletal disorders
TABLE 1. Investigations for fibromyalgia
Test
Full blood count
Erythrocyte sedimentation rate
C-reactive protein
Vitamin D
Thyroid-stimulating hormone
Antinuclear antibodies
Rheumatoid factor
Calcium
Alkaline phosphatase
(Ralston and McInnes 2014, British Medical Journal 2015)
54 Downloaded
/ 28 September
from2016 / volume
RCNi.com
by ${individualUser.displayName}
weight loss in addition to fatigue, previous
history of cancer, or recent infection.
Blood tests can be used to exclude
pathology and should include: a full
blood count to eliminate anaemia as a
cause of muscle pain and fatigue; thyroid
function tests to exclude hypothyroidism
or hyperparathyroidism; inflammatory
markers erythrocyte sedimentation rate and
C-reactive protein to exclude inflammatory
disease; and vitamin D levels to discount
osteomalacia (Ralston and McInnes 2014).
Screening of antinuclear antibodies and
rheumatoid factor can be undertaken to
exclude systemic lupus erythematosus and
rheumatoid arthritis respectively; however,
caution is required since there is potential
for false-positive results. Investigations for
fibromyalgia are summarised in Table 1.
TIME OUT 3
Consider how it would feel to have fibromyalgia and have
to undergo numerous tests which exclude pathology,
but none that confirm your diagnosis. If possible,
speak to someone who has fibromyalgia and ask about
their experiences. If you do not know someone with
fibromyalgia you may wish to read Lempp et al (2009).
Patients undergoing numerous tests
may feel anxious about the procedures
and possible diagnoses that are being
considered. It is important for the
nurse to listen to and acknowledge the
patient’s concerns and offer reassurance
Condition screened
Anaemia
Inflammatory disease
Osteomalacia
Hypothyroidism
Systemic lupus erythematosus
Rheumatoid arthritis
Hyperparathyroidism
31 number 5
on Oct 04, 2016. For personal use only. No other uses without permission.
Copyright © 2016 RCNi Ltd. All rights reserved.
as appropriate, so that the patient feels
supported through the diagnostic period.
The American College of
Rheumatology’s seminal paper (Wolfe et al
1990) outlined diagnostic criteria for
fibromyalgia that required the presence
of chronic widespread pain in all four
quadrants of the body (right upper, right
lower, left upper and left lower), with at
least 11 of 18 tender points identified.
These sites included the trapezius, lateral
epicondyles, knees, supraspinatus, second
rib and greater trochanters. Each site
was palpated to identify if it was painful
when pressed to obtain a diagnosis of
fibromyalgia. Despite the clear description
of tender points and criteria required for
diagnosis, these criteria did not consider
the ‘non-pain’ symptoms that may be
present in people with fibromyalgia.
The American College of Rheumatology
have since revised the diagnostic criteria
(Wolfe et al 2010) and no longer rely
on a tender point count. The criteria
determine the number of painful sites
using the widespread pain index (WPI),
and assesses the presence and severity of
other symptoms such as sleep disturbance,
fatigue or memory problems by obtaining
a symptom severity (SS) scale score. The
criteria acknowledge the individual’s
experience and provide a longitudinal
scoring system to assist diagnosis. The
American College of Rheumatology’s
diagnostic criteria (Wolfe et al 2010) is
outlined in Table 2. The diagnostic criteria
for fibromyalgia is either WPI ≥7 and SS
≥5, or WPI 3-6 and SS ≥9.
Kroese et al (2011) performed a cost-
consequence analysis (where outcomes
were reported separately to costs) of
specialised rheumatology nurses and
rheumatologists in the diagnosis of
fibromyalgia. Patients in the nurse-led
group were significantly more satisfied than
patients in the rheumatologist-led group,
as measured using questions derived from
the Quality of Care Through the Patient’s
Eyes rheumatic patients instrument, and no
differential changes in health status were
observed between the two groups during
9 months of follow-up. The total costs
for healthcare (consultation, medication,
nursingstandard.com
 For related CPD articles visit
evidenceandpractice.nursingstandard.com

home care) and patient and family costs
(home help, informal care, medical aids,
productivity costs) were also significantly
lower in the nurse-led group. Since the
analysis only covered a period of 9 months,
Kroese et al (2011) recommend a longer
follow-up to confirm these effects.
TIME OUT 4
Consider the advantages and disadvantages of the old
and new diagnostic criteria for fibromyalgia produced by
the American College of Rheumatology (Wolfe et al 1990,
2010). Discuss your thoughts with colleagues or different
members of the multidisciplinary team, and see how
their views differ.
fibromyalgia vary considerably from person
to person, it is essential that interventions
are individually tailored in a holistic manner.
Furthermore, each patient with fibromyalgia
requires individualised emotional support,
TABLE 2. The American College of Rheumatology’s diagnostic
criteria for fibromyalgia
Criteria
A patient meets the diagnostic criteria for fibromyalgia if the following three conditions are met:
1. Widespread pain index (WPI) ≥7 and symptom severity (SS) scale score ≥5, or WPI 3-6
and SS scale score ≥9
2. Symptoms have been present at a similar level for 3 months
3. The patient does not have a disorder that would otherwise explain the pain

Treatment and management Ascertainment

It may take several visits to various
1. WPI: note the number of areas in which the patient has had pain over the past week. In how
healthcare professionals before a diagnosis
many areas has the patient had pain? Score will be between 0 and 19.
of fibromyalgia is made and a management
plan is implemented. Patients may Shoulder girdle, left Hip (buttock, trochanter), left Jaw, left Upper back
experience dissatisfaction because they Shoulder girdle, right Hip (buttock, trochanter), right Jaw, right Lower back
have previously been misunderstood, not Upper arm, left Upper leg, left Chest Neck
believed, or provided with little or no Upper arm, right Upper leg, right Abdomen
support (Eide et al 2011). Prompt diagnosis Lower arm, left Lower leg, left
Lower arm, right Lower leg, right
and intervention can provide reassurance
for patients and reduce or prevent disability, 2. SS scale score:
which in turn will reduce the personal and Fatigue
social effects of fibromyalgia (Kroese et al Waking unrefreshed
2011). Symptoms of fibromyalgia can be Cognitive symptoms
managed, although at present the disorder For each of the three symptoms above, indicate the level of severity over the past week using
the following scale:
cannot be cured; therefore, the aim of
0 = no problem
healthcare interventions is to reduce 1 = slight or mild problems
debilitation and improve quality of life. 2 = moderate, considerable problems, often present and/or at a moderate level
Management of fibromyalgia symptoms 3 = severe: pervasive, continuous, life disturbing
requires a comprehensive biopsychosocial
approach. Effective management often Considering somatic symptoms in general, indicate whether the patient has:*
involves trial and error of different 0 = no symptoms
1 = few symptoms
strategies to find a combination of
2 = a moderate number of symptoms
interventions that alleviate symptoms and 3 = a great deal of symptoms
achieve optimal functional health status
(Firestone et al 2012). Treatment typically The SS scale score is the sum of the severity of the three symptoms (fatigue, waking
involves a combination of pharmacological unrefreshed, cognitive symptoms) plus the extent (severity) of somatic symptoms in general.
and non-pharmacological approaches, which The final score is between 0 and 12.
aim to reduce pain and increase function.
*Somatic symptoms that might be considered include: muscle pain, irritable bowel syndrome,
Nurses can encourage patients with
fatigue/tiredness, thinking or remembering problem, muscle weakness, headache, pain/
fibromyalgia to actively participate in self- cramps in the abdomen, numbness/tingling, dizziness, insomnia, depression, constipation,
care, offering treatment and management pain in the upper abdomen, nausea, nervousness, chest pain, blurred vision, fever, diarrhoea,
strategies that could enhance patients’ well- dry mouth, itching, wheezing, Raynaud’s phenomenon, hives/welts, ringing in the ears,
being (Onieva-Zafra et al 2015). vomiting, heartburn, oral ulcers, loss of/change in taste, seizures, dry eye, shortness of breath,
Perceptions of quality of life are unique loss of appetite, rash, sun sensitivity, hearing difficulties, easy bruising, hair loss, frequent
and dynamic for each person (Cranford urination, and bladder spasms.
and King 2011). Since the symptoms of (Wolfe et al 2010)

nursingstandard.com
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 04, 2016. Forvolume
personal31use
number 5 /other
only. No 28 September 2016
uses without / 55
permission.
Copyright © 2016 RCNi Ltd. All rights reserved.
evidence & practice / CPD / musculoskeletal disorders
KEY POINT education and active involvement in clinical
‘Setting objective decision-making about the treatment and
measureable goals for management of their condition (Onieva-
treatment can help to Zafra et al 2015). It is important that each
monitor symptoms of patient is educated about their condition
fibromyalgia and evaluate at the time of diagnosis and the concept of
the effectiveness of optimal management explained, taking into
management strategies. account the patient’s ideas, concerns and
It is important to assess expectations. Patient perceptions of their
baseline measurements illness will influence their coping response
for each goal or and their expectations of the healthcare
symptom targeted before team to manage the effects of fibromyalgia.
commencing or changing The patient’s perceptions and beliefs will
management strategies, also influence their experience of living with
so that an objective fibromyalgia and their willingness to actively
assessment of disease engage with interventions to improve quality
progression or symptom of life (Stuifbergen et al 2006).
improvements can be made’
TIME OUT 5
Find out what services are available in your local area
for people with fibromyalgia, and how you would make
a referral to these services.
Setting objective measureable goals for
treatment can help to monitor symptoms of
fibromyalgia and evaluate the effectiveness
of management strategies. It is important
to assess baseline measurements for
each goal or symptom targeted before
commencing or changing management
strategies, so that an objective assessment
of disease progression or symptom
improvements can be made. The use of
tools such as the Fibromyalgia Impact
Questionnaire (Burckhardt et al 1991) or
the Symptom Impact Questionnaire (Friend
and Bennett 2011) can be valuable in the
objective assessment of functional abilities.
Further information about these tools
is available at: http://fiqrinfo.ipage.com/
index.html. It is also important to evaluate
the patient’s knowledge of fibromyalgia
and its treatment as part of ongoing
assessment. The Fibromyalgia Knowledge
Questionnaire is a valid, reliable tool
designed to evaluate disease-specific
knowledge in patients with fibromyalgia
(Suda et al 2012). Quality of life, patient
satisfaction, and adherence to interventions
can also be used as a subtle indicators
of treatment value, and may be a useful
outcome indicator for treatment success
(Cranford and King 2011).
56 Downloaded
/ 28 September
from2016 / volume
RCNi.com 31 number 5
by ${individualUser.displayName}
on Oct 04, 2016. For personal use only. No other uses without permission.
Copyright © 2016 RCNi Ltd. All rights reserved.
Since patients with fibromyalgia may
experience postural instability, dizziness,
balance problems and paraesthesia
or weakness in lower extremities, it
may beneficial to undertake a falls
risk assessment as part of the nursing
assessment process, and reflect on the
causes of previous falls where applicable
(Rutledge et al 2013). Identification of falls
risks should lead to further assessment of
other medical conditions, muscle strength,
balance and gait to determine appropriate
multifactorial fall-prevention strategies.
Pharmacological treatments
Pharmacological agents can be tailored
according to pain, fatigue, sleep
disturbances and the presence of co-
morbidities such as anxiety or rheumatic
disease (Arnold et al 2016). Simple
analgesics such as paracetamol can be
used as part of pain management (Arthritis
Research UK 2011). While non-steroidal
anti-inflammatory drugs are effective
for treating acute and nociceptive pain,
they are not recommended for long-term
management of pain associated with
fibromyalgia because of established side
effects such as gastrointestinal and renal
complications. Opioids such as tramadol
may be considered in patients with
moderate to severe pain that is unresponsive
to other treatment modalities, although
the use of strong opioids is discouraged
(Fitzcharles et al 2013, Macfarlane et al
2016). Corticosteroids have not shown
therapeutic benefit in the treatment of
fibromyalgia and are not recommended as
part of pain management (Firestone et al
2012, Macfarlane et al 2016).
Antidepressants and anticonvulsants
can be used to treat pain, address the
common co-morbidities of anxiety and
depression, and help to improve sleep
quality. However, it is important that the
pain-modulating effects of antidepressants
are clearly explained to patients to dispel
the misconception that fibromyalgia is a
psychological condition (Fitzcharles et al
2013). No significant differences were
found in Nüesch et al’s (2013) meta-
analysis of tricyclic antidepressants,
selective serotonin re-uptake inhibitors
nursingstandard.com

(SSRIs), serotonin and noradrenaline
re-uptake inhibitors (SNRIs) and
anticonvulsants in reducing pain and
improving disease-related quality of
life. Medications such as amitriptyline,
cyclobenzaprine (not available in the
UK), gabapentin and fluoxetine have
demonstrated efficacy in randomised
controlled trials for pain associated with
fibromyalgia and other symptoms, and are
commonly used to manage pain in patients
with fibromyalgia (Arnold et al 2016).
Walitt et al (2015) reported that
the SSRIs citalopram, fluoxetine and
paroxetine may have a small benefit
over placebo for the relief of pain and
depression, but not for managing fatigue
or sleep problems. Milnacipran, an SNRI,
has also been shown to provide effective
pain relief in patients with fibromyalgia;
however, is not licensed to treat the
condition in many countries, including
the UK (Cording et al 2015). Häuser et al
(2012) found that only a small number
of patients obtain substantial symptom
relief with antidepressants; however, it is
important to note that pharmacological
treatment should be used in combination
with non-pharmacological strategies to
achieve optimal symptom management.
Anticonvulsant therapy should commence
with the lowest possible dose and titrate
accordingly, paying careful attention to
adverse events (Fitzcharles et al 2013). If no
benefit is seen after a trial of 6 weeks, the
medication should be stopped (BMJ 2015)
and alternatives considered. Üçeyler et al
(2013) identified insufficient high quality
evidence to draw definite conclusions
regarding the efficacy of lacosamide and
levetiracetam in fibromyalgia symptom
management, although pregabalin and
gabapentin can improve pain severity
and sleep functionality in patients with
fibromyalgia (Firestone et al 2012,
Macfarlane et al 2016).
Medications should be reviewed
regularly to monitor efficacy and any side
effects the patient experiences. Patients
may find it helpful to keep a diary to
record how their pain and symptoms
change in response to a new medication.
It is important that patients are informed
nursingstandard.com
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 04, 2016. For volume
Copyright © 2016 RCNi Ltd. All rights reserved.
For related CPD articles visit
evidenceandpractice.nursingstandard.com
about the potential adverse effects of new KEY POINT
medications. It may be particularly helpful ‘Fibromyalgia is a chronic
to provide advice to patients about which illness, so it is important
side effects may resolve in time to improve that the patient is aware
adherence to medication regimens. they are likely to experience
exacerbations of their
Non-pharmacological treatments symptoms, and that they
Fibromyalgia is a chronic illness, so it is are equipped with
important that the patient is aware they ways to manage these
are likely to experience exacerbations exacerbations. Nurses can
of their symptoms, and that they are deliver effective education
equipped with ways to manage these through activities planned
exacerbations. Nurses can deliver effective and designed to improve
education through activities planned and patients’ behaviour in
designed to improve patients’ behaviour in relation to their health’
relation to their health (Suda et al 2012).
Supporting patients to prioritise, plan, and
pace activities can significantly improve
the amount patients with fibromyalgia
can achieve, particularly when they
are experiencing pain, fatigue or low
quality sleep. Nurses should encourage
interventions that improve self-efficacy and
help patients to consider the modification
of aggravating factors in their physical or
social environment, taking care to avoid
social withdrawal or fear of activity. A
patient-centred approach to symptoms is
required with close monitoring and regular
follow-up, particularly in the early stages
of management (Fitzcharles et al 2013).
Exercise is recommended as the first
step of a multimodal treatment strategy
in managing fibromyalgia, and has
positive effects on global well-being,
physical function and pain. Patients with
fibromyalgia should be encouraged to
choose a type of exercise that reflects their
interests and physical goals, which can be
incorporated into their daily routine easily
(Fitzcharles et al 2013). Initially this may
be a simple activity, for example gardening
or walking. It is important to encourage
consistent exercising practices, aiming
for exercising every day, with gradually
increasing duration (Arthritis Research UK
2011). Symptoms may be exacerbated if
the exercise programme is developed too
rapidly. Therefore, initial increases may be
as little as 1 minute per day to gradually
improve fitness and prevent the patient
becoming discouraged from participating in
the programme.
personal31use
number 5 /other
only. No 28 September
uses without2016 / 57
permission.
evidence & practice / CPD / musculoskeletal disorders
KEY POINT Patients with higher levels of fitness
‘Cognitive behavioural may benefit from aquatic training or
therapy (CBT) focuses on aerobic exercise to improve fitness and
how a person’s thoughts, symptoms of fibromyalgia (Bidonde et al
beliefs and attitudes can 2014), or resistance training to improve
affect their feelings and multidimensional function, pain and
behaviours, and can be muscle strength (Busch et al 2013). Some
used to develop coping individuals may benefit from a combination
strategies to manage of exercise, relaxation and activities,
difficult situations. CBT for example yoga or t’ai chi, to improve
can be used to help with physical function, quality of life, and reduce
anxiety and depression, as symptoms of pain and depression.
well as assisting patients Sleep hygiene is an important aspect of
to understand their pain, care to improve sleep quality, and should
reducing fear of pain or be discussed as part of nursing assessment
activity and helping and evaluation. Many simple changes can
to develop positive be incorporated into the patient’s daily
coping strategies’ routine, such as establishing consistent
sleep times and avoiding daytime
naps. Other advice includes avoiding
caffeinated drinks in the evening and at
night, excessive alcohol intake, or eating
immediately before bedtime. It is also
advisable to avoid exercising or vigorous
activity immediately before bedtime.
Allocating time to unwind before bedtime
or participating in a relaxing activity,
for example reading a book or listening
to music, may help to improve quality
of sleep. It may also help to consider
the patient’s surroundings to optimise
their sleep environment, for example by
ensuring the bedroom is dark, quiet and at
a comfortable temperature.
Cognitive behavioural therapy (CBT)
focuses on how a person’s thoughts, beliefs
and attitudes can affect their feelings and
behaviours, and can be used to develop
coping strategies to manage difficult
situations. CBT can be used to help with
anxiety and depression, as well as assisting
patients to understand their pain, reducing
fear of pain or activity and helping
to develop positive coping strategies
(Fitzcharles et al 2013). CBT can provide
sustained improvements in the symptoms
of fibromyalgia (Bernardy et al 2013), and
reduce depressed mood and healthcare-
seeking behaviour (Bernardy et al 2010).
Guided imagery can be used as an adjunct
to achieve a ‘sense of mastery’ over general
symptoms. Similar approaches may include
relaxation training and biofeedback
58 Downloaded
/ 28 September
from2016 / volume
RCNi.com 31 number 5
by ${individualUser.displayName}
on Oct 04, 2016. For personal use only. No other uses without permission.
Copyright © 2016 RCNi Ltd. All rights reserved.
(Jahan et al 2012). Biofeedback is a
technique which increases awareness of
physiological responses, using electrodes
attached to the skin. The electrodes
transmit signals to a monitor that shows
readings such as blood pressure, heart rate
and muscle tension. Different relaxation
techniques can then be used to manage
these functions and the effects can be
visualised on the screen. Psychological
therapies may improve physical
functioning, pain and mood, although
Theadom et al (2015) emphasised the
lack of high quality research to support
these approaches.
Complementary and alternative medicine
might also be considered for symptoms
of fibromyalgia; however, there are few
randomised controlled trials of these
treatments (Lauche et al 2015, Arnold et al
2016). There is low to moderate-level
evidence that acupuncture improves
pain, fatigue and function, with electro-
acupuncture appearing more effective than
manual acupuncture in reducing pain and
stiffness and improving sleep and fatigue
(Deare et al 2013). These effects may last
for up to 1 month, but are not maintained
at 6 months (Deare et al 2013). Other
treatment modalities for fibromyalgia may
include heated pool therapy, massage,
relaxation techniques, t’ai chi or yoga
(Wierwille 2012, Arnold et al 2016). Music
therapy may also be effective in reducing
pain intensity and improving symptoms of
depression in patients with fibromyalgia
(Onieva-Zafra et al 2013).
TIME OUT 6
Read the Arthritis Research UK ‘Keep moving’
patient information booklet, available at: www.
arthritisresearchuk.org/shop/products/publications/
patient-information/living-with-arthritis/keep-moving.
aspx. Consider how you could use this information
to help a patient with fibromyalgia to start to exercise.
Some specialised complementary and
alternative approaches for managing
fibromyalgia may not be available in
some areas, and can be costly if not
accessible as part of the NHS. Peer support
groups can offer additional information,
experience, emotional support or practical
nursingstandard.com
 For related CPD articles visit
evidenceandpractice.nursingstandard.com

advice from others who are experiencing Conclusion

similar problems, and therefore should be Fibromyalgia is a common, chronic,
recommended as an adjunct to treatment. disabling and challenging condition which
Patients would like to be listened to effects a patient’s health and well-being.
and responded to with empathy when Treatment for the condition requires an
discussing fibromyalgia with healthcare individualised holistic approach that aims
professionals (Cranford and King 2011). to reduce symptoms and improve activities
Clinical follow-up should be guided by of daily living, function and quality of life.
how well patients are coping and how Supporting patients to prioritise, plan, and
well symptoms are managed. More pace their activities can have a significant
frequent appointments with healthcare effect on the amount they can achieve,
professionals are likely during the initial overall function and quality of life. This
phase of management or until symptoms can be enhanced using a combination of
improve or are managed effectively pharmacological and non-pharmacological
(Fitzcharles 2013). It is important to interventions such as relaxation, aerobic
discuss new symptoms as part of ongoing exercise and CBT. Understanding the
assessment and evaluation to ensure nature of fibromyalgia and different
that they are not caused by identifiable management strategies available will
pathology. Nurses should remain vigilant enhance nurses’ ability to support patients
for increased anxiety levels because this in different healthcare settings.
may affect the patient’s perception and
interpretation of difficulties, and effective TIME OUT 7
and empathic communication skills are Now that you have completed the article, you might like
required to discuss this. to write a reflective account as part of your revalidation.

References

Arnold LM, Gebke KB, Choy EH (2016)
Fibromyalgia: management strategies for
primary care providers. International Journal
of Clinical Practice. 70, 2, 99-112.
Arnold LM, Hudson JI, Hess EV et al (2004)
Family study of fibromyalgia. Arthritis and
Rheumatism. 50, 3, 944-952.
Arthritis Research UK (2011) Fibromyalgia.
www.arthritisresearchuk.org/arthritis-
information/conditions/fibromyalgia.aspx
(Last accessed: 9 September 2016.)
Bernardy K, Füber N, Köllner V et al (2010)
Efficacy of cognitive-behavioural therapies in
fibromyalgia syndrome - a systematic review
and metaanalysis of randomized controlled
trials. The Journal of Rheumatology. 37, 10,
1991-2005.
Bernardy K, Klose P, Busch AJ et al (2013)
Cognitive behavioural therapies for
fibromyalgia. Cochrane Database of
Systematic Reviews. Issue 9. CD009796.
Bidonde J, Busch AJ, Webber SC et al (2014)
Aquatic exercise training for fibromyalgia.
Cochrane Database of Systematic Reviews.
Issue 10. CD011336.
British Medical Journal (2015) BMJ Best
Practice: Fibromyalgia. bestpractice.bmj.
com/best-practice/monograph/187.html
(Last accessed: 9 September 2016.)
Burckhardt CS, Clark SR, Bennett RM (1991)
The fibromyalgia impact questionnaire:
development and validation. The Journal
of Rheumatology. 18, 5, 728-733.
Busch AJ, Webber SC, Richards RS et al (2013)
Resistance exercise training for fibromyalgia.
Cochrane Database of Systematic Reviews.
Issue 12. CD010884.
Clauw DJ, Arnold LM, McCarberg BH (2011)
The science of fibromyalgia. Mayo Clinic
Proceedings. 86, 9, 907-911.
Cording M, Derry S, Phillips T et al (2015)
Milnacipran for pain in fibromyalgia in adults.
Cochrane Database of Systematic Reviews.
Issue 10. CD008244.
Cranford C, King CR (2011) Nurse practitioner
students’ perceptions of fibromyalgia pain
and quality of life. Medsurg Nursing. 20, 4,
169-177.
Deare JC, Zheng Z, Xue CC et al (2013)
Acupuncture for treating fibromyalgia.
Cochrane Database of Systematic Reviews.
Issue 5. CD007070.
Eide H, Sibbern T, Johannessen T (2011)
Empathic accuracy of nurses’ immediate
responses to fibromyalgia patients’
expressions of negative emotions: an
evaluation using interaction analysis.
Journal of Advanced Nursing. 67, 6,
1242-1253.
Firestone KA, Holton KF, Mist SD et al (2012)
Optimizing fibromyalgia management. The
Nurse Practitioner. 37, 4, 12-21.
Fitzcharles MA, Ste-Marie PA, Goldenberg
DL et al (2013) 2012 Canadian guidelines
for the diagnosis and management of
fibromyalgia syndrome: executive summary.
Pain Research and Management. 18, 3, 119-126.
Friend R, Bennett RM (2011) Distinguishing
fibromyalgia from rheumatoid arthritis and
systemic lupus in clinical questionnaires:
an analysis of the revised Fibromyalgia
Impact Questionnaire (FIQR) and its variant,
the Symptom Impact Questionnaire (SIQR),
along with pain locations. Arthritis Research
and Therapy. 13, 2, R58.
Glennon P (2010) Fibromyalgia syndrome:
management in primary care. Arthritis
Research UK: Hands On. 6, 7, 1-6.
Harris RE, Sundgren PC, Pang Y et al (2008)
Dynamic levels of glutamate within the
insula are associated with improvements
in multiple pain domains in fibromyalgia.
Arthritis and Rheumatism. 58, 3, 903-907.
Häuser W, Wolfe F, Tölle T et al (2012) The role
of antidepressants in the management of
fibromyalgia syndrome: a systematic review
and meta-analysis. CNS Drugs. 26, 4, 297-307.
Jahan F, Nanji K, Qidwai W et al (2012)
Fibromyalgia syndrome: an overview of
pathophysiology, diagnosis and management.
Oman Medical Journal. 27, 3, 192-195.
Juuso P, Skär L, Olsson M et al (2011) Living
with a double burden: meanings of pain
for women with fibromyalgia. International
Journal of Qualitative Studies on Health and
Well-being. 6, 3, 1-9.
Kroese ME, Severens JL, Schulpen
GJ et al (2011) Specialized rheumatology
nurse substitutes for rheumatologists in the
diagnostic process of fibromyalgia: a cost-
consequence analysis and a randomized

nursingstandard.com
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 04, 2016. Forvolume
personal31use
number 5 /other
only. No 28 September 2016
uses without / 59
permission.
Copyright © 2016 RCNi Ltd. All rights reserved.
evidence & practice / CPD / musculoskeletal disorders

controlled trial. The Journal of Rheumatology.
38, 7, 1413-1422.
Lauche R, Cramer H, Häuser W et al (2015)
A systematic overview of reviews for
complementary and alternative therapies in
the treatment of the fibromyalgia syndrome.
Evidence-based Complementary and
Alternative Medicine. doi:10.1155/2015/610615.
Lawrence RC, Felson DT, Helmick CG et al
(2008) Estimates of the prevalence of arthritis
and other rheumatic conditions in the United
States. Part II. Arthritis and Rheumatism.
58, 1, 26-35.
Lempp HK, Hatch SL, Carville SF et al
(2009) Patients’ experiences of living with
and receiving treatment for fibromyalgia
syndrome: a qualitative study. BMC
Musculoskeletal Disorders. 10, 124. doi:
10.1186/1471-2474-10-124.
Macfarlane GJ, Kronisch C, Dean LE et al
(2016) EULAR revised recommendations for
the management of fibromyalgia. Annals
of the Rheumatic Diseases. doi: 10.1136/
annrheumdis-2016-209724.
Nüesch E, Häuser W, Bernardy K et al (2013)
Comparative efficacy of pharmacological
and non-pharmacological interventions
in fibromyalgia syndrome: network meta-
analysis. Annals of the Rheumatic Diseases.
72, 6, 955-962.
Onieva-Zafra MD, García LH, Del Valle MG
(2015) Effectiveness of guided imagery
relaxation on levels of pain and depression in
patients diagnosed with fibromyalgia. Holistic
Nursing Practice. 29, 1, 13-21.
Onieva-Zafra MD, Castro-Sánchez AM,
Matarán-Peñarrocha GA et al (2013) Effect
of music as nursing intervention for
people diagnosed with fibromyalgia. Pain
Management Nursing. 14, 2, e39-e46.
Ralston SH, McInnes IB (2014) Rheumatology
and Bone Disease. In Walker BR, Colledge NR,
Ralston SH et al (Eds). Davidson’s Principles and
Practice of Medicine. 22nd edition. Churchill
Livingstone Elsevier, London, 1057-1135.
Rutledge DN, Martinez A, Traska
TK et al (2013) Fall experiences of persons
with fibromyalgia over 6 months. Journal of
Advanced Nursing. 69, 2, 435-448.
Stuifbergen AK, Phillips L, Voelmeck
W et al (2006) Illness perceptions and related
outcomes among women with fibromyalgia
syndrome. Women’s Health Issues. 16, 6,
353-360.
Suda AL, Jennings F, Bueno VC et al (2012)
Development and validation of Fibromyalgia
Knowledge Questionnaire: FKQ.
Rheumatology International. 32, 3, 655-662.
Theadom A, Cropley M, Smith HE et al (2015)
Mind and body therapy for fibromyalgia.
Cochrane Database of Systematic Reviews.
Issue 4. CD001980.
Üçeyler N, Sommer C, Walitt B et al (2013)
Anticonvulsants for fibromyalgia. Cochrane
Database of Systematic Reviews. Issue 10.
CD010782.
Walitt B, Urrútia G, Nishishinya
MB et al (2015) Selective serotonin
reuptake inhibitors for fibromyalgia
syndrome. Cochrane Database of
Systematic Reviews. Issue 6. CD011735.
Wierwille L (2012) Fibromyalgia: diagnosing
and managing a complex syndrome.
Journal of the American Academy of Nurse
Practitioners. 24, 4, 184-192.
Wolfe F, Smythe HA, Yunus MB et al (1990)
The American College of Rheumatology 1990
criteria for the classification of fibromyalgia.
Report of the Multicenter Criteria Committee.
Arthritis and Rheumatism. 33, 2, 160-172.
Wolfe F, Clauw DJ, Fitzcharles MA et al (2010)
The American College of Rheumatology
preliminary diagnostic criteria for fibromyalgia
and measurement of symptom severity.
Arthritis Care and Research. 62, 5, 600-610.
Wolfe F, Brähler E, Hinz A et al (2013)
Fibromyalgia prevalence, somatic symptom
reporting, and the dimensionality of
polysymptomatic distress: results from a
survey of the general population. Arthritis
Care and Research. 65, 5, 777-785.
World Health Organization (2016)
International Statistical Classification of
Diseases and Related Health Problems 10th
Revision - WHO Version for 2016. apps.who.
int/classifications/icd10/browse/2016/en
(Last accessed: 9 September 2016.)

Call for papers

Nursing Standard is welcoming CPD article
submissions from experienced or new authors
on a variety of subjects, including:
w Continence w Communication
w Infection control w IV therapy
w Leadership w Wound care

Contact the Evidence & Practice editor

Gwen Clarke at gwen.clarke@rcni.com

60 Downloaded
/ 28 September
from2016 / volume
RCNi.com 31 number 5
by ${individualUser.displayName}
nursingstandard.com
on Oct 04, 2016. For personal use only. No other uses without permission.
Copyright © 2016 RCNi Ltd. All rights reserved.
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 04, 2016. For personal use only. No other uses without permission.
Copyright © 2016 RCNi Ltd. All rights reserved.
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 04, 2016. For personal use only. No other uses without permission.
Copyright © 2016 RCNi Ltd. All rights reserved.
evidence & practice / self-assessment questionnaire

Fibromyalgia
TEST YOUR KNOWLEDGE BY COMPLETING SELF-ASSESSMENT QUESTIONNAIRE 863

 1. Fibromyalgia is:
 a) A musculoskeletal disorder c
 b) Characterised by localised pain c
 c) More common in men c
 d) An acute condition  b) WPI ≥7 and SS ≥5, or WPI 3-6 and SS ≥9 c
c to test your knowledge.
 2. What is the typical age of onset for fibromyalgia?
 a) 10 to 30 years old c
 b) 20 to 60 years old  9. Management of fibromyalgia:
c page 51. There is one correct
 c) 50 to 70 years old c
 d) 60 to 80 years old c
 3. Which of the following is a variable locomotor
symptom of fibromyalgia?
 a) Anxiety c
 b) Cognitive impairment c
 c) Muscle weakness c
 d) Overactive bladder c
 4. A risk factor that may predispose a person to
developing fibromyalgia is:
 a) A regional pain syndrome c
 b) Post-traumatic stress disorder c
 c) Depression c
 d) All of the above c
 5. Which of the following may be associated both
with inflammatory rheumatic diseases and
fibromyalgia?
 a) Localised oedema c
 b) Vascular rash c
 c) Widespread musculoskeletal pain and stiffness c
 d) Joint inflammation c
 6. ‘Fibro fog’ is a cognitive symptom of
fibromyalgia that involves:
 a) Increased mental alertness c
 b) Improved concentration c
 c) Short-term memory loss c
 d) Improved sleep c
 7. Symptoms of fibromyalgia may be exacerbated by:
 a) Changes in the weather c
 b) Decreased levels of stress c
 c) Decreased levels of activity c
 d) High quality sleep c
 8. Which widespread pain index (WPI) and How to complete
symptom severity (SS) scale scores are this assessment
required for a diagnosis of fibromyalgia?
 a) WPI ≥3 and SS ≥2, or WPI 2-4 and SS ≥4 c This self-assessment
questionnaire will help you
 c) WPI ≥11 and SS ≥8, or WPI 9-12 and SS ≥12 c
It comprises ten multiple choice
 d) WPI ≥18 and SS ≥15, or WPI 13-16 and SS ≥19 c questions that are broadly
linked to the article starting on
 a) Should involve only pharmacological approaches c answer to each question.
 b) Should involve only non-pharmacological »» You can test your subject
approaches c knowledge by attempting
 c) Often involves trial and error of different strategies c the questions before reading
the article, and then go
 d) Will cure the condition c
back over them to see if you
 10. Nurses can support patients with fibromyalgia to: would answer any differently.
 a) Prioritise, plan and pace activities c »» You might like to read the
 b) Develop a gradually increasing exercise article before trying the
questions. The correct
programme c
answers will be published
 c) Optimise their sleep environment c
in Nursing Standard on
 d) All of the above c
12 October.
Subscribers making use
of their RCNi Portfolio can
complete this and other
questionnaires online and save
the result automatically.
Alternatively, you can cut
out this page and add it to your
professional portfolio. Don't
forget to record the amount
of time taken to complete it.
You may want to write
a reflective account based
on what you have learned.
Visit journals.rcni.com/r/
reflective-account
This self-assessment questionnaire was compiled by 
Alex Bainbridge
The answers to this questionnaire will be published on 12 October
Answers to SAQ 861 on Implementing change, which appeared in
the 14 September issue, are:
1. d 2. b 3. c 4. b 5. c 6. b 7. a 8. a 9. b 10. c

nursingstandard.com
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 04, 2016. Forvolume
personal31use
number 5 /other
only. No 28 September 2016
uses without / 63
permission.
Copyright © 2016 RCNi Ltd. All rights reserved.