May 2018 network news

Top tips on fibromyalgia

Fibromyalgia syndrome (FMS) is a common chronic musculoskeletal pain syndrome. Reported prevalence rates vary depending on the classification criteria used; in the UK the prevalence is estimated to be 5.4%, with women more commonly affected than men.

1.What are the symptoms of Fibromyalgia?

Typically, patients have widespread pain for more than three months which is often accompanied by fatigue, sleeplessness and cognitive symptoms.

People with FMS also commonly report an array of associated somatic symptoms e.g. irritable bowel syndrome, headache, pain/cramps in the abdomen, numbness/tingling, dizziness etc.

The extent of somatic symptoms is factored in to the classification criteria. Mood disturbance such as depression, distress and anxiety are also often a feature of FMS.

2. Do you have any diagnostic/assessment techniques?

Diagnosis of FMS is by clinical assessment and there is some evidence that patients benefit from receiving a diagnosis.

The American College of Rheumatology 2010 classification criteria state that a patient can be classified with FMS if they satisfy the points below:

  1. Widespread pain index (WPI) ≥7 and symptom severity (SS) scale score ≥5 or WPI 3–6 and SS scale score ≥9.
  2. Symptoms have been present at a similar level for at least three months.
  3. The patient does not have a disorder that would otherwise explain the pain.

The SS scale score is the sum of the severity of the three symptoms (fatigue, waking unrefreshed, cognitive symptoms) plus the extent (severity) of somatic symptoms in general. The final score is between 0 and 12 (Wolfe et al 2010).

Note that tender point count no longer forms part of the diagnostic criteria for FMS.

There are a number of conditions that can mimic FMS and of course it is essential that these conditions are excluded. Rheumatological conditions that should be factored in to the differential diagnosis include: mild systemic lupus erythematosus, polyarticular osteoarthritis, rheumatoid arthritis, polymyalgia rheumatica, hypermobility syndromes, inflammatory muscle disease, hypercalcaemia and osteomalacia. Non-rheumatological diseases that can mimic FMS include: thyroid dysfunction, neoplastic disease and neurological diseases such as multiple sclerosis.

3. Do you have any self-management advice for patients?

The foundation of FMS management is non-pharmacological interventions, education and physical activity. Where appropriate, psychological therapies such as cognitive behavioural therapy or acceptance and commitment therapy have a role in the management of FMS.

While exercise and physical activity interventions are recommended, many patients find exercise interventions extremely challenging. Patients will benefit from advice and education prior to embarking on any physical activity intervention.

An understanding of the nature of chronic pain, delivered within a biopsychosocial context is essential for patients with FMS. Advice about activity pacing is useful and can help patients avoid the ‘boom and bust’ cycle so commonly seen in FMS. There is some evidence that patients with FMS are more satisfied with their treatment where their health care provider has a good understanding of the condition.

Low back pain: A major global challenge

Lower back pain is the leading cause of years lived with disability worldwide and in the UK. In order to highlight this condition, the Lancet has recently published a review series on low back pain: a major global challenge, including the three following papers:

  • What low back pain is and why we need to pay attention.
  • Prevention and treatment of low back pain: evidence, challenges, and promising directions.
  • Low back pain: a call for action.

Some of our funded researchers, including from the Arthritis Research UK Primary Care Centre have been involved in this work.

Here we speak to one of the lead authors in the series, NIHR Professor Nadine Foster to try and understand what this means for health care professionals and what they can do to make a change.

Key messages from the series

The first paper in the series ‘What low back pain is and why we need to pay attention’ looks at what low back pain is and highlights the prevalence of the condition. Low back pain is now the number one cause of disability globally and is still increasing despite efforts to make a change. With an ageing population it’s almost inevitable that a person will get low back pain.

The second paper in the series ‘Prevention and treatment of low back pain: evidence, challenges, and promising directions’ draws attention to the mismatch between the guidelines and the care that is given, globally. It highlights that for most people back pain is a symptom and not a disease, so a purely biomedical model is not appropriate.

Current care all around the world relies too heavily on pharmacological therapy, interventional therapies and surgery instead of the treatments with the strongest evidence base. The emphasis needs to be on function and living a full life despite back pain, supported by the most effective non-pharmacological treatments.

This paper considers how to implement best practice and how this can be made easier for clinicians. The paper highlights examples of effective, promising, or emerging solutions, by solution target.

The third paper in the series ‘Low back pain: a call to action’ summarises the health care challenges associated with low back pain and identifies actions to meet them. It suggests using the notion of positive health in the management of non-specific low back pain, the ability to adapt and to self-manage in the face of social, physical and emotional challenges.

It addresses widespread misconceptions in the population and among health care professionals about the causes, prognosis, and effectiveness of different treatments for low back pain. It also highlights the key challenges for policy, public health and health care. Action is urgently needed as doing more of the same isn’t going to reverse the increasing global disability due to low back pain.

What can health care professionals do?

Health care professionals need to give the right evidence-based care early on. Focusing on key principles, such as the need to support people with back pain to be active and stay at work, and to reform unhelpful patient clinical pathways and health care reimbursement models can guide next steps.

What can you do:

  • Consider the overview of interventions endorsed for non-specific low back pain in evidence based clinical practice guidelines (Paper 2, table 2). This highlights recommendations for acute low back pain and persistent low back pain and the differences between these.
  • Read ‘The National Low Back Pain and Radicular Pain Pathway’ (PDF 2.5MB). This UK pathway is now being implemented nationally – see if you can get engaged with this in your area.
  • Reflect on the challenges highlighted in the third paper and think about where you can make a difference.

STarT Back as an example of a good clinical pathway

Stratified primary care for low back pain based on prognosis (STarT Back) is an example of a new way of delivering health care. Current UK (NICE) clinical guidance now recommends risk stratification. The Keele STarT Back tool identifies patients at low risk of persistent disabling pain who can be supported to self-manage, whilst also identifying patients who are at medium or high risk for whom further health care is needed, such as a course of physiotherapy. The tool helps us to identify patients with different prognoses and to use this information systematically in making decisions about health care. Stratified care based on using the STarT Back tool and then matching patients to different treatments has been developed and tested in the UK primary care setting, and has been shown to bring benefits for patients and for the NHS (it is cost effective).

The STarT Back tool is used by a range of clinicians such as GPs, physiotherapists, osteopaths, and chiropractors. You can find out further details about the tool and matched treatments here.

What next?

The series is written from the point of view of the desire to want things to change. A policy briefing is currently being produced summarising all the key actions. The question is who will take an interest in ensuring things change? There needs to be a collaborative effort between policy makers, clinicians, researchers and research funders to develop, test and implement effective solutions or disability rates and expenditure for low back pain will continue to rise.

MSK now a PHE priority

We know that arthritis can affect every aspect of a person’s life, but many people are never given information on what activities could prevent them developing arthritis, or how to reduce the pain it can cause once they have it and only discover more once they’re in pain and going through the process of being diagnosed. We want more people to understand the contributing factors, but to make this a reality we knew we needed to get Public Health England (PHE) on board.

How have we worked with Public Health England?

Versus Arthritis and Public Health England have worked together on several different projects over the last five years:

As a result of all this work, we’re delighted that PHE has now prioritised MSK as a public health priority. We will continue to work in partnership with PHE to ensure that people understand the impact of arthritis and the benefits of lifelong good MSK health.

Services: Our helpline turns one

What an amazing year it has been! When we launched our dedicated helpline to provide individual advice, support and guidance to people affected by arthritis, we really didn’t know what a success it was going to be. We’re so pleased we’ve been able to support over 10,000 people with arthritis with our brilliant service.

The helpline is here to help you, to support your patients

On 13th March our marketing campaign to advertise our helpline went live. Since the campaign started, we’ve had an increase in contacts via telephone, email, social media and letters. In fact, on the third day of the campaign, we got more social media enquiries to our helpline in one day than we did for the whole of February!

We have also seen that we’re in high demand; our total number of enquires received in the first year was 15,183. We have been able to answer 80% of our calls but we know there are still many more people who need support out there.

The top three enquiry topics are:

  1. Treatment and therapies
  2. Conditions
  3. Drugs and medication

The top three conditions we hear about are:

  1. Osteoarthritis
  2. Rheumatoid arthritis
  3. Fibromyalgia

In November 2017, when Arthritis Research UK and Arthritis Care merged, work started to integrate the two individual helplines.

By the summer, we will be operating and answering the phones as one single helpline on freephone 0800 520 0520.

Watch this space for the new referral pads with the helpline number.

Our listening panel

It’s important for us to put people with arthritis at the heart of everything we do. To do this we need to listen to what people with arthritis are telling us, and ensure we build this into the way we respond as a charity. For the past year we’ve been working with a panel of 45 people with arthritis to better understand what it’s like to live with. We are using this knowledge to inform and shape our work.

Our panel has been taking ‘selfie’ videos in their own homes to share how their condition impacts on their daily life. We’ve recently asked the panel to share their experiences of interactions with health care professionals, good and bad.

There is a real difference in the panel’s expectations of healthcare professionals, between those that are effectively managing their condition and those who are struggling.

Those who are managing their condition are only looking for support in their treatments and maintaining their condition, whereas those who are struggling might expect more emotional support and are really looking for their GP to ‘heal’ them.

There is a significant need for practical encouragement, targeted knowledge and signposting to relevant services. We understand how difficult it can be to meet these varied needs especially under limited time constraints and resources. We are working on how we can support you and people with arthritis to facilitate more effective consultations.

If you would like more information, please get in touch.

Want to make a difference to your local health system

We’re delighted to announce the launch of the MSK Champions programme; a prestigious leadership development opportunity, building a community of MSK Champions.

Together with Ashridge Executive Education, we’ll support you through a unique development programme to become a champion of musculoskeletal care.

We are looking for individuals who are involved in the design, commissioning or delivery of musculoskeletal care, including front line clinicians, public health practitioners, commissioners and service managers.

Applications are open now- so don’t miss out on this fantastic opportunity to make a difference to your local health system!