A comparison of the fibromyalgia (FMS) pathway provided in Tallaght University Hospital (TUH) against recommendations for the non-pharmacological management of fibromyalgia as outlined in the EULAR guidelines 2016.
Sarah O Driscoll, Maria McGrath, Carol Rafferty, Elaine Hughes, Professor David Kane, Dr Ronan Mullan.
Tallaght University Hospital
Management of fibromyalgia should aim at improving health-related quality of life balancing benefit and risk of treatment that often requires a multidisciplinary approach with a combination of non-pharmacological and pharmacological treatment modalities tailored according to pain intensity, function, associated features (such as depression), fatigue, sleep disturbance and patient preferences and comorbidities; by shared decision-making with the patient. Initial management should focus on non-pharmacological therapies (McFarlane GJ et al, 2017).
The FMS pathway in (TUH) provides 4 group based exercise and education sessions for patients referred from Rheumatology and Rheumatology MSK Triage with FMS.
to audit the FMS pathway in TUH against the revised EULAR guidelines 2016 for the non-pharmacological management of FMS.
The recommendations for the non-pharmacological management of FMS 2016 were used to compare the practise in the FMS pathway. Each chart was reviewed to determine the input from PT and OT and whether each of the guidelines was met, as part of the pathway.
19 patient charts of those who attended the pathway in 2017 were audited. There were recommendations for and against certain interventions. These were categorised in terms of level of evidence, grade of evidence, strength of recommendation and % agreement among clinical experts.
Data was input to an excel spread sheet and scored for whether or not the recommendation was met for each chart audited.
There was strong evidence for the use of exercise which was provided to 100% of people attending the pathway.
Heated pool therapy with or without exercise is recommended and group based exercise was performed in the aquatic therapy pool in 100% of cases.
Individualised exercise programs were provided in 46.5% of cases either before or after the pathway as 1:1 sessions in PT.
There was weak evidence for acupuncture, CBT (particularly where other interventions have failed), meditative movement, mindfulness and mind body therapy which we do not offer in the pathway.
There was weak evidence for a multi-modal approach to management. The pathway is run by PT and OT providing a partly multi-disciplinary approach.
The FMS pathway in TUH provides a multimodal aquatic exercise and education based format which is supported by the EULAR 2016 guidelines. There are a number of interventions that we do not offer. These include; acupuncture, CBT, meditative movement therapies, mindfulness and mind-body therapy.
There are a number of research questions proposed in the guidelines which when answered may influence practise in the future. These include:
Which type of exercise is most effective: strength and/or aerobic training?
Are combined pharmacological and non-pharmacological approaches to management more effective than single-modality management?
Are there characteristics of patients with fibromyalgia that predict response to specific therapies?
How should fibromyalgia be managed when it occurs as a comorbidity to inflammatory arthritis?
What aspects of a healthcare system optimise outcome for patients (who is best for the management of FM patients)?
1. EULAR revised recommendations for the management of fibromyalgia. G J Macfarlane, C Kronisch, L E Dean, F Atzeni, W Häuser, E Fluß, E Choy, E Kosek, K Amris, J Branco, F Dincer, P Leino-Arjas, K Longley, G M McCarthy, S Makri, S Perrot, P Sarzi-Puttini, A Taylor, and G T Jones. Ann Rheum Dis 2017;36:318-328