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New Canadian Guidelines for Treating Fibromyalgia

  [ 7 votes ]   [ 1 Comment ] • May 16, 2013

Physicians from the McGill University Health Centre (MUHC), McGill University and the University of Calgary have published a review article in the CMAJ (Canadian Medical Association Journal) to help family doctors diagnose and treat fibromyalgia.   The article represents the first time researchers have published Canadian guidelines to help manage the condition.

[Download full text of CMAJ review article “Fibromyalgia: evolving concepts over the past 2 decades”]

Fibromyalgia is a chronic condition that affects the central nervous system causing pain throughout the body. It is often accompanied by fatigue, depression and sleep problems.   It affects mostly women and their multiple symptoms often go years without a proper diagnosis and treatment. 

"One million Canadians have fibromyalgia and the time has come to take their suffering seriously.   This is a real condition that greatly impacts patients and their families.   Finally there are national guidelines to help diagnose and treat this syndrome," says Dr. John Pereira, a study co-author from the University of Calgary’s Faculty of Medicine and a physician at the Calgary Chronic Pain Centre. 

Fibromyalgia is usually diagnosed by rheumatologists but due to the high prevalence of the disease many patients are not able to seek advice from a specialist. Therefore, primary care physicians are best positioned to take over this role, as recommended by the 2012  Canadian Fibromyalgia Guidelines.   In the review, the authors provide evidence-based tools for primary care physicians to make the diagnosis and manage the condition long-term. 

We are the first ones to develop guidelines that look at diagnosis, treatment and follow-up of fibromyalgia,” says Dr. Mary-Ann Fitzcharles, corresponding author from the Research Institute of the MUHC and MUHC’s rheumatologist. “Currently, there is no cure for fibromyalgia but the guidelines set out the most appropriate management strategy.”   

Authors recommend non-pharmaceutical interventions such as exercise, relaxation techniques, cognitive behavioral therapy as well as medications tailored to the individual patient. The main treatment goal is to improve quality of life by alleviating the most troublesome symptom(s), with pain recognized as the most common and serious. 

The authors also urge more research into the effects of early diagnosis and treatment as well as other treatment options.   For more information on the fibromyalgia guidelines, visit


2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome

By Mary-Ann Fitzcharles, et al.

Background/Purpose: The healthcare community remains challenged regarding the care of fibromyalgia (FM) patients. Previous guidelines have mostly addressed treatment options rather than provide an overall approach to FM care. With new evidence concerning pathogenesis and more diverse treatment strategies, updated direction for global care in FM is needed. These evidence-based guidelines for the diagnosis, management, and patient trajectory of persons with FM were developed taking into account these new advances and new American College of Rheumatology 2010 diagnostic criteria.

Methods: A needs assessment by structured consultation with 139 healthcare professionals from relevant disciplines across Canada generated 18 key questions. Questions drove a literature search to identify evidence, which was graded according to the classification system of the Oxford Centre for Evidence Based Medicine, and supporting recommendations were drafted. Recommendations were edited and appraised by an advisory panel to reflect meaningful clinical practice. The whole document was reviewed by an international expert.

Results: Forty six recommendations pertaining to the identification, evaluation, and management of persons with FM, incorporating new clinical concepts are presented. The essence of the recommendations is as follows:

  • FM represents a composite of symptoms, with body pain present as the pivotal symptom.

  • There is a spectrum of severity which associates with functional outcome, with fluctuating symptoms over time.

  • The diagnosis of FM is clinical, not one of exclusion, not needing specialist confirmation, and requires only limited laboratory testing.

  • A physical examination is required to exclude other conditions presenting with body pain, but tender point examination is not required to confirm the diagnosis.

  • There is no confirmatory laboratory test and excessive testing is strongly discouraged.

  • Ideal care for most patients is in the primary care setting.

  • Treatments should be multimodal, incorporating non-pharmacologic and pharmacologic strategies, with focus towards reduction of symptoms and improvement of function.

  • Patients must be active participants in their healthcare and non-pharmacologic strategies are imperative.

  • Patient-tailored management that is symptom-based is recommended.

  • In the absence of an ideal pharmacologic treatment, an agent impacting multiple symptoms is desirable.

  • Doses of medications lower than those used in clinical trials and combination of medications may facilitate adherence.

  • Emphasis on healthy lifestyle practices, maintenance of function including retention in the workforce, periodic assessment for the need for continued medication, and evaluation of efficacy/side effects of ongoing treatments is recommended.

  • New symptoms should be evaluated according to good clinical practice to exclude another illness without summarily attributing symptoms to FM.

Conclusion: These new Canadian guidelines for the care of patients with FM should provide the health community with confidence in the global care of these patients and thereby improve patient outcome.

Source: National Guidelines Website, 2013. By 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.

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Article Comments Post a Comment

Useful but lacking
Posted by: IanH
Jul 11, 2013
While I agree with the intention to diagnose FM without laboratory tests and to not regard it as a diagnosis of exclusion, these guidelines should have discussed the known immunological variables. I am not sure why they are not mentioned. There seems to be a considerable lack of either knowledge or information regarding the immune system and FM. Only elevation of substance P is mentioned but its possible effects are not. Of glaring omission are mention of IL-1, IL-6, IL-8, corticotrophic releasing factor, TNF-alpha and IFN-gamma.

While these may be a little beyond the understanding of a primary health care provider they do shed some light on the underlying biochemical abnormalities. Also the abnormal response to exercise is not adequately covered.

This guideline has not really changed since 2000.
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