Signs and Symptoms

Patients typically present with multiple symptoms including widespread pain, post-exertional malaise and non-refreshing sleep pattern lasting for at least 3 months. Cognitive and other somatic symptoms are also evaluated in the 2010 ACR diagnostic criteria.

History and Examination

Initial assessment to exclude other infective, inflammatory, metabolic or endocrine causes.

• Ask about non-pain symptoms including:
  • fatigue;
  • sleep patterns;
  • memory;
  • concentration;
  • bladder;
  • bowel pattern (including IBS);
  • sensory changes;
  • weakness;
  • muscle cramp;
  • Visual change and eye pain;
  • Joint pain and swelling;
  • Weight loss, fever, Raynaud's, dry eyes/dry mouth, rashes and psoriasis; and
  • Family history of inflammatory arthritis, psoriasis and inflammatory bowel disease.
  • Assess psychosocial aspects incorporating patient's ideas, concerns and expectations

Examination as clinically indicated. This may include:

• Musculoskeletal examination e.g. GALS screen
• Neurological examination (particularly looking for weakness or upper motor neurone signs);
• Palpate for lymphadenopathy;
• Examine for skin rashes, psoriasis;
• Examine any other systems identified in history.

If fatigue dominates pain in clinical presentation, patient may be more suitable for community Chronic Fatigue Syndrome service (referral guidelines can be found here)

If patient is presenting with non-specific/mechanical low back pain not attributed to a serious pathology, then current local guidelines should be followed.

Differential Diagnoses

• Mental Health: Depression, Anxiety
• Neurological: Multiple sclerosis
• Endocrine: DM, T4, Addisonian
• Infective: Lyme, Hep C, HIV etc
• Metabolic: Coeliac, Primary muscle disorder, Low Fe, Vit D
• Respiratory: Sleep Apnoea
• Rheumatological: RA, SLE

• Abnormal neurological signs present (including muscle abnormalities);
• Visual disturbances/changes;
• Presence of synovitis. Synovitis = soft, rubbery joint swelling which bounces back when compressed, particularly when associated with MTPJ/MCPJ swelling/ tenderness /positive squeeze test. Rheumatology service keen on relevant referrals considering the presence or absence of synovitis;
• The S Factor (used by RCGP + NRAS)
  • Stiffness – early morning stiffness lasting more than 30 minutes
  • Swelling – persistent swelling of one joint or more, especially MCPJs
  • Squeezing - squeezing the joints is painful in inflammatory arthritis
• Unexplained blood/protein on urine dipstick;
• Weight loss;
• Fever;
• Lymphadenopathy;
• Recent onset Raynaud's;
• Skin rashes;
• New onset dry eyes and mouth – but very common in the general population, often iatrogenic or idiopathic;

Please consider the following investigations to exclude other diagnoses, for example (but not limited to):

•  Blood tests:
  • Full Blood Count (FBC)
  • Renal Function Test (RFT)
  • Liver Function Test (LFT)
  • Bone Profile
  • Thyroid Function Test (TFT)
  • C-reactive protein (CRP) or Plasma Viscosity (PV)
  • HbA1c
  • Creatine kinase (CK)

• Urine Dipstick (protein, blood and glucose)
• Additional tests - only if clinically indicated:
  • Haematinics (ferritin, B12, folate)
  • Vitamin D (if at risk of deficiency)
  • Coeliac screen
  • Serology (if risk of infection - consider: hepatitis, EBV, HIV, CMV)
  • Myeloma screen (if patient aged over 60yrs)
  • Cancer screening tests
  • Imaging
  • Autoimmune (Blood Tests for Rheumatology Conditions)
    • (N.B. In suspected cases of FMS there is no indication for auto antibody testing e.g. ANA. These tests should only be done when patient have specific CTD symptoms (e.g. Raynaud’s, sicca symptoms etc)

• Please see Investigations | Diagnosis | Chronic pain | CKS | NICE for further details.

Diagnosis of Fibromyalgia/ Central Sensitivity Syndrome confirmed/anticipated – low risk

• Need to assess
  • Severity of pain;
  • Physical function;
  • Sleep;
  • Psychological state (PHQ9 – GADS or HADS);
  • Social and family function; and
  • Work status / employment issues.
• Make a management plan
  • Patient education. Hyland model is a useful paradigm for explaining central sensitivity syndrome / fibromyalgia and helps avoid a restricted biomedical focus in clinical approach – a guide for patients has been provided in the supporting information section with a focus on lifestyle management.
  • Encourage self-management with emphasis on a lifestyle management approach. Consider advice on sleep hygiene, warm baths.
  • Graded activity consider physical therapies that engage the patient e.g. hydrotherapy, physiotherapy, exercise prescription.
  • Treat psychological symptoms if prominent. Consider counselling/CBT including referral to mental health services.
  • Prescribing options - 1st line low dose Tricyclic antidepressant e.g. Amitriptyline.
  • (Corticosteroids or strong opioids should not be prescribed);
  • Use the fit note for any necessary workplace adaptations
  • Consider patient referral to a community based central sensitivity syndrome/ fibromyalgia group programme (further information included in supporting Information)
• Regular review of condition in primary care at least every 6 months. Reappraise diagnosis if significant change in symptoms or do not fit usual pattern of symptoms
  
  • Continue management in primary care
  • If deterioration consider seeking advice or referral to secondary care.

The majority of Fibromyalgia diagnoses will be made in Primary Care.

Referral Criteria

Guidance from or referral to appropriate specialist with suitable priority (e.g. Rheumatologist, Endocrinologist, Psychiatrists) if:

• Diagnostic uncertainty exists
• Evidence of inflammatory joint problems
• Any red flags
• Significant depression

It is expected that there is closure on the need for further investigation and opinion before considering referral to the pain clinic.

Consider early referral to Plymouth Pain Management Centre if:

• Anticipated high psychosocial issues (but not significant depression where initial mental health input more appropriate
• Risk factors for poor health outcome
• Patient potentially requiring more intensive pain management strategies. These include group programmes such as: Central sensitivity syndrome / fibromyalgia specific programme, or Pain management programme)

All referrals must include:

• Details of the pain problem including longevity
• Treatment trialled including pharmacological and non-pharmacological. It would be helpful to know the outcome of previous trials of pain medication with maximum doses reached.
• Current medication
• Past medical history
• Psychosocial history including history of anxiety and depression and any treatments previously undergone for this

Referral Instructions

e-Referral Service Selection

Refer to Pain Management

• Specialty: Pain Management
• Clinic Type: Pain Management
• Service: DRSS-Western-Pain Management-Devon ICB-15N

Referral Form

DRSS Referral form

Patient Information

• Hyland Model – patient education guide
• Information leaflet from a Plymouth Fibromyalgia sufferer
• Pain toolkit booklet
• Fibromyalgia Action UK
• Versus Arthritis

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: February 2017

Updated: January 2024