National Fibromyalgia Audit 2019
Dr Sharon Cowley Dr Sekharipuram Ramakrishnan
Regional Department of Rheumatology, Navan Hospital
Fibromyalgia is a common condition with an estimated prevalence of 2% of the general population. The prevalence of fibromyalgia is further increased in patients with chronic inflammatory arthritis and systemic autoimmune rheumatic diseases. However diagnosis and management of this condition remain a challenge.
This audit set out to evaluate the current diagnostic methods, patient education techniques, therapeutic interventions and follow up given to patients with fibromyalgia all over the Republic of Ireland. We also aimed to assess any unmet needs in the provision of care.
A questionnaire was issued to all permanent public Rheumatology Consultants practising in the Republic of Ireland. 37 were identified and 29 responded to our request. Questions were formulated to assess compliance with the EULAR 2016 working group recommendations for fibromyalgia care and also to identify areas where these recommendations are unable to be implemented due to lack of resources. Consultants were also specifically asked to specify areas they deemed in need of provision in order to attain recommended interventions.
31% (9) of consultants diagnose fibromyalgia with the 1990 criteria while 38% (11) diagnose fibromyalgia with the ACR 2010 criteria and 31% (9) use alternative means for diagnosis. 10.3% (3) use the Fibromyalgia Impact Questionnaire to measure physical functioning, work status, depression, anxiety, morning tiredness, pain, stiffness, fatigue, and well-being at diagnosis. 89.7% (26) do not routinely use this measurement at diagnosis. 13.8% (4) of consultants use the Functional Pain Scale at diagnosis, while 86.2% (25) do not. A minority, 27.6% (8) of respondents document a pain score at diagnosis while 72.4% (21) do not. 51.7% (15) of consultants issue patients with a written information sheet at diagnosis while 48.3% (14) do not do this routinely. 17.2% (5) of patients are referred for consultation with the Specialist Rheumatology Nurse on diagnosis while 82.8% (24) are not. 24.1% (7) of patients are referred to an internet education tool, with the most common responses being either the Arthritis Ireland online resources or Fibro-Ireland resources. 75.9% (22) are not recommended online resources.
44.8% (13) of patients are offered education classes run by their diagnosing rheumatology department, while 55.2% (16) do not have access to department run education classes. Of the 44.8% of patients who have access to educational classes 38.5% (5) are a full day class, 46.2% (6) are half day classes and 15.9% (2) did not indicate if the classes were a full-day or half-day programme. Classes are run by a variety of health care professionals. 30.8% (4) are run by physiotherapist, 30.8% (4) are run by physiotherapist and occupational therapist, 30.8% (4) are run by specialist nurse, physiotherapist and occupational therapist and 7.6% (1) are run by physiotherapist and psychologist. 13.8% (4) of rheumatology departments run specific exercise classes as is one of the recommendations of the EULAR 2016 working group, while 86.2% (25) do not.
In terms of treatment, 55.2% (16) of consultant rheumatologists report that they base their treatment on the EULAR 2016 guidelines, while 44.8% (13) do not. 51.7% (15) start simple analgesia at diagnosis, 34.5% (10) do not routinely and 13.8% (4) did not answer this question. 65.5% (19) consultants start some form of pharmacotherapy at diagnosis, while 10.3% (3) commence pharmacotherapy after education and 6.9% (2) start pharmacotherapy at both diagnosis and after education depending on the clinical circumstances. 17.2% (5) did not answer this question. 68.9% (20) respondents limit pharmacotherapy to amitriptyline/duloxetine/pregabalin/tramadol as per EULAR 2016 guidelines. 20.9% (6) don’t strictly adhere to these guidelines and 10.3% (3) did not indicate a response. When asked if opiates other than tramadol are routinely prescribed 10.3% (3) prescribe other opiates while 89.7% (26) do not.
79.3% (23) recommend mindfulness classes to their patients while 20.7% (6) do not. 96.6% (28) recommend aerobic and strengthening programmes to their patients as diagnosis, while 3.4% (1) do not. Regarding acupuncture, 31% (9) recommend acupuncture to their patients, 65.5% (19) do not recommend acupuncture routinely and 3.5% (1) did not respond to this question.
96.6% of consultants recommend aerobic and strengthening exercise to their patients while 3.4% do not. 69% (20) recommend hydrotherapy to their patients while 31% (9) do not. 41.4% (12) consultants have access to hydrotherapy for their patients. This access is available in the greater Dublin area, North West and Cork and Limerick, while 58.6% (17) do not have access to this resource.
24.1% (7) of consultants admit patients for multidisciplinary assessment, while 75.9% do not routinely. Of those who do not routinely admit their patients, 10.3% (3) indicated it was due to lack of access, 58.6% (17) felt it was not necessary and 31.1% (9) did not reply to this question. Admission for MDT assessment occurs in the greater Dublin area, West and North-West.
41.4% (12) of consultants have had patients discuss use of cannabis with them, 37.9% (11) have not had this discussion and 20.7% (6) did not respond to this question. 17.2% (5) of consultants use trigger point injections for pain relief while 82.8% do not routinely.
55.2% (16) of consultants refer their patients for cognitive behavioural therapy (CBT), one of the 100% consensus recommendations by the EULAR 2016 Fibromyalgia working group. Only 6.9% (2) consultants have direct access to CBT, with 93.1% with no direct access. One hospital in the South East was the only site with direct access. Only 6.9% of consultants have access to CBT via primary care, with 86.2% (25) with no access, even via primary care and 6.9% (2) unsure about access. There was 100% lack of direct access to counselling services nationwide. No respondents were aware of the Counselling in Primary Care (CIPC) programme where they can access counselling services via the primary care practitioner.
This audit shows there is varied clinical practice in treating patients with fibromyalgia with regard diagnostic criteria, pharmacotherapy, education, MDT input and follow up. There is geographical variance in access to admission for MDT assessment, with this only available in the greater Dublin area, West and North-West. Hydrotherapy also lacks nationwide availability, currently available Cork, Leitrim and Dublin. Only one centre in the South East has direct access to cognitive behavioural therapy (CBT) sessions delivered by a Psychotherapist. Supportive measures in the form of counselling may be offered for chronic disease management as the next best alternative to CBT. However there was widespread lack of awareness of the Counselling in Primary Care (CIPC) programme, offered via primary care referral and available to medical card patients.