Treating Fibromyalgia in a Primary Care Setting

In this podcast, Dana Villmore, PhD, Pa-C, discusses the diagnosis and management of fibromyalgia for primary care providers, a topic she recently presented at the 2021 American Academy of Physician Assistants Annual Conference.

Additional Resource: 

Dana Villmore, PhD, Pa-C, is an assistant clinical professor in the Physician Assistant Program at the University of New England in Portland, Maine. 



Leigh Precopio:  Hello everyone, and welcome to another installment of Podcasts360, your go‑to resource for medical news and clinical updates. I'm your moderator Leigh Precopio with Consultant360.

Patients with fibromyalgia are often managed by rheumatologists despite being seen regularly by primary care providers. However, the role of the primary care provider in the diagnosis and management of fibromyalgia is essential to providing the best care for this patient population. Therefore, it is critical that primary care providers are comfortable with the pathophysiology, symptoms and comorbidities, current diagnostic criteria, and available treatment options for fibromyalgia.

To learn more about the role of the primary care provider for patients with fibromyalgia, I am joined by Dana Villmore, PhD, Pa-C, who presented on this topic at the 2021 American Academy of Physician Assistants Annual Conference. Dr Villmore is an assistant clinical professor in the Physician Assistant Program at the University of New England in Maine.

Thank you so much for joining me today, Dr Villmore. To begin, could you give us a brief overview of your session?

Dana Villmore:  I basically went over the pathophysiology, the clinical presentation, signs and symptoms, diagnosis of fibromyalgia with the current diagnostic criteria, and its management both the pharmacological and non‑pharmacological management in more of the primary care provider setting and how you would do that.

Leigh Precopio:  Do any specific patient characteristics, such as age or comorbidities, impact how you approach the treatment and management of fibromyalgia?

Dana Villmore:  Yeah. They tend to have comorbid mood disorders especially. So anxiety, depression, things like that. If they do have those, they definitely should be treated, especially with an antidepressant, the SNRIs, the serotonin‑norepi reuptake inhibitors are the best for that because they treat both the pain and the mood symptoms. But we also like them to go to Cognitive Behavioral Therapy too. That helps a lot. The mood improvements will reduce their pain.

Then sleep disorders, some fibro patients may have restless leg syndrome or periodic limb movement disorder. If you treat those with medication and their sleep improves, their pain will also get better too. Finally, a lot of fibro patients may have inactive lifestyles and be obese. Treating those with exercise will kill two birds with one stone.

Leigh Precopio:  Diagnostic criteria for patients with fibromyalgia have changed over time. Could you discuss the currently recommended diagnostic tools you would use in a patient you suspect has fibromyalgia?

Dana Villmore:  It used to be we did tender point assessments. There were 18 tender points across the body. You would use a special instrument to see if they were tender, but that one was hard for people to do properly.

Now the criteria by the American College of Rheumatology uses a Widespread Pain Index. They use a Symptom Severity Score to characterize it. A certain threshold would mean that you have fibro, but you need at least a three‑month history of generalized pain. It also takes into account, fatigue, waking unrefreshed, cognitive symptoms, presence of headaches, lower abdominal pain and cramping, and depression.

That one is a little bit cumbersome to use because it's long to do it, but there's a newer one from the AAPT. It's the ACTTION‑APS Pain Taxonomy Group. It's a lot easier to do. This one has at least 3 months of multi‑site pain, and there's only 9 sites you would need to look at. If they have moderate or severe problems with sleep or fatigue, then they would qualify for fibro. In both of those, it doesn't matter if you have another condition, like rheumatoid arthritis or something else that could explain the pain, you can have fibro and something else. That's the newer criteria.

Leigh Precopio:  Could you discuss why it is important that primary care providers work with rheumatologists to provide a multi‑disciplinary approach to treatment?

Dana Villmore:  Primary care providers are like the boots on the ground people. They see these patients over time. They often have a lot of complaints over the years, especially fatigue, sleep, lots of workups, and they're very familiar with the patient. They can figure out, maybe this is something more, maybe this is fibro. I would say, having rheum, weigh in if you're not sure if this is something like an autoimmune disease, maybe there is joint swelling with this, then you needed to get rheum to weigh in as well. They're good in, I would say, ruling out stuff for you if you're not sure, or if you have been trying to treat fibro and you're sure that's what it is, and it does not having any success, get them to rheumatology for a consult. That would be helpful. Primary care providers are also a lot more accessible rooms hard to get in, especially in rural areas like I practiced in Bangor, Maine, super rural. Rheumatology was very hard to get into. You had to wait months to get in. This one, we can at least start the process, and then if we need rheum as a consult, we can definitely go there.

Leigh Precopio:  What are some clinical pearls that you use in your practice for the multi‑disciplinary treatment of patients with fibromyalgia?

Dana Villmore:  I would say the key with fibro is using non‑pharmacological stuff first. Exercise programs, doing cognitive behavioral therapy, working on sleep hygiene, stress reduction, is going to make a much bigger impact on their pain level than any medication does. A lot of the studies just show maybe modest improvements in pain and function with medication, so always do for non‑pharmacological stuff first. And then add your meds and adjunct. If they have a comorbid condition, definitely add those in, so that you can fix any background stuff that may be making the fibro worse.

Education is super important for these patients. Knowing why this is happening, what the treatments are, and why those work, versus why medications don't work, and then they can take ownership of their disease. Then getting them under CBT for working on coping skills, realizing that it's going to be a manageable condition and not a curable condition. Chronic pain disorders are notoriously difficult for anyone to handle, just psychologically. Getting them into someone who can talk with them about it and get them to cope better is key here.

As far as multi‑disciplinary, I like to have PT, physical therapy, involved to maybe design an exercise program for them that would work for them. Psych, obviously, would be definitely involved here as well. Then rheumatology, if you need help ruling out other things, or if they know about newer treatment options, that would be also helpful. I see it as the PCP is coordinating all of this, but there's a lot of different spokes on the wheel. You got PT, you got psyche, rheum if you need it. Maybe even sending them to massage therapy or acupuncture, things like that too. Definitely multi‑disciplinary approach is needed.

I wanted to give people hope, that yes, this is super challenging to treat, but everybody has their cocktail that you have to find. Whether it's OK, they do this certain amount of exercise per week, they go get a massage once a month, they maybe take duloxetine or something for their comorbid anxiety depression, and that works for them. But it may not necessarily work for another patient with fibro. You've got to tinker, it's definitely an art to treat this. Once you do make an impact in their life and their pain level, they're so, so thankful and it really is rewarding to treat.

Leigh Precopio:  Great, thank you for taking the time to answer all of my questions today.

Dana Villmore:  You're very welcome. It's my pleasure for being here.