The challenge of diagnosis and the management of fibromyalgia in Primary care

Problem

Fibromyalgia Syndrome (FMS) is a complex condition where patients can present with multiple symptoms, such as chronic widespread pain, fatigue, non-refreshed sleep, mood disturbance and cognitive impairment. FMS affects 2% of the population but management of the condition is dependent on a diagnosis which can be challenging in primary care. Once diagnosis is confirmed optimal management requires education and effective self-management of function and psychosocial aspects of pain. GPs are often the first point of contact for patients, but they may not feel confident in the diagnosis and management of fibromyalgia. This study investigated current practice to identify how best to support early diagnosis and enhance engagement of FMS self-management in primary care.

Approach

Interviews were conducted with 17 GPs and 8 secondary care practitioners including rheumatologists, pain consultants, clinical psychologists and physiotherapists, across Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group (BNSSG CCG).Thematic analysis was used to analyse the data with the support of NVivo 11.

Findings

GPs reported a range of experience in patients with FMS and subsequently differing levels of confidence in diagnosis. Some were aware of diagnostic tools but not all found them useful. Some used them as guiding principles but more often it was a diagnosis of exclusion. Identification of FMS was challenging to GPs within a consultation time frame and secondary care practitioners sympathised. GPs reported delays in diagnosis through excluding other possible conditions and patients sometimes found accepting a FMS diagnosis difficult because of no ‘cure’. These factors often resulted in multiple consultations.GPs also reported difficulty in referring patients, because of uncertainty of who, where or when to refer and GPs were under the impression that referrals to secondary care were discouraged. Secondary care practitioners acknowledged that referrals for FMS was increasing substantially and this had put increasing demand on their service, however, they still encouraged referrals when necessary.The management of FMS in primary care was challenging and was often approached by managing the symptoms presented at each consultation. Although self-management was acknowledged to be the best approach, GPs would often provide written guidance to patients but had insufficient time to support the process. Many felt that this support was best placed in NHS provided courses or peer-support groups.GPs had access to a range of resources designed to support and guide diagnosis and management, but they reported varying degrees of usefulness and awareness of what was available.

Consequences

Early diagnosis and management of FMS is the recommended approach for patient satisfaction and for reduction in demand for secondary care services. However, this is dependent on adequate training and support for, and co-designed by, primary care practitioners and should always be guided by patient needs.