Concerns with fibromyalgia guidelines

We thank Stein1 for her interest in our CMAJ article,2 which reflects concepts addressed by the 2012 Canadian fibromyalgia guidelines.3

We agree with Stein that major depression and fibromyalgia are distinct disorders, however there is considerable overlap. Evaluating patients with fibromyalgia for mood disorders, including depression, is imperative and not doing so could compromise optimal patient care. The effects of an antidepressant on pain have been shown to be independent of effects on mood for a single agent only.3 Nevertheless, the choice of an agent that may address more than 1 symptom should be considered beneficial. In the guidelines,3 recommendations pertaining to antidepressant use in fibromyalgia state that “all categories of antidepressant medications including TCAs, SSRIs and SNRIs may be used for treatment of pain and other symptoms in patients with fibromyalgia,” and that physicians should explain the pain-modulating effects of antidepressants to patients.3

With regard to exercise, we have difficulty accepting a report of disablement to be so severe as to preclude any form of health-related physical activity. Regular physical activity is recommended for all persons, irrespective of health status.3 The guidelines focus on the importance of a patient-tailored exercise approach for the management of fibromyalgia.

Because most patients are given the definitive diagnosis of fibromyalgia an average of 7 years after onset of symptoms, many become deconditioned and experience kinesiophobia. Introduction of health-related physical activity should be graduated and increased to reach optimum recommendations. Exercise may contribute to a good internal locus of control, whereby a patient considers he or she can positively influence their health status. Additionally, since the publication of the guidelines, studies of tai chi, qigong, and yoga speak to the benefits of exercise that incorporates a mind component.4

Finally, we agree that physicians must remain empathetic. However, subjective complaints can be used dishonestly, especially when disablement is claimed and the physician–patient trust may be abused. Gervais and colleagues have shown that 35% of patients with fibromyalgia who were on or seeking disability benefits failed a memory effort test compared with 4% of patients who were not on or seeking disability benefits.5 This contributes to skepticism regarding the disabling nature of fibromyalgia, and puts into question the high rate of disablement.

We emphasize that a diagnosis of fibromyalgia does not automatically equate with disablement. Each disability application must be evaluated according to merit, with attention to sound medical evidence. Because the optimal treatment goal for fibromyalgia is improved function, the health care community should encourage working-aged patients to reintegrate or remain in the workforce, rather than succumb to a passive disabled status.