Fibromyalgia Protocol — Executive Summary

Protocol Steps

MDT Specialties

Week Program

ACR 2016

Diagnostic Standard

EULAR 2017

Management Guideline

1 Diagnosis

Diagnostic Standard

ACR 2016 criteria — WPI + Symptom Severity Scale + generalised pain in ≥4/5 regions + ≥3 months duration. No biomarker or imaging required — clinical diagnosis.

Screening Tool

FiRST (Fibromyalgia Rapid Screening Tool) — Score ≥5/6 triggers full assessment. Apply routinely in RA, SLE, and axSpA clinics to detect secondary FM overlay.

⚠️

Key Principle — Secondary FM FM coexists with RA, SLE, axSpA, OA, Sjögren's. Misattributing FM symptoms to a disease flare and escalating immunosuppression is the most common consequential error in this population.

MDT Composition

Rheumatology — diagnostic lead, pharmacology
Physiotherapy — functional assessment, exercise program
Psychology/CBT — mandatory for all patients
Dietitian — nutritional screening & education
Orthopedics — structural clearance pre-program

Mandatory Baseline Measures

FIQ-R · NRS · CSI · PHQ-9 · GAD-7 · PCS · PSQI · 6MWT. Repeated at Week 4 and Week 8.

2 Pharmacological Management

Guiding Principle

Pharmacotherapy is adjunctive — never primary. Non-pharmacological treatment starts simultaneously. Medications are moderately effective in ~50% of cases.

Tier	Agent	Best For
1st Line	Amitriptyline	Sleep + fatigue + diffuse pain
1st Line	Duloxetine	Pain + depression/anxiety
1st Line	Pregabalin	Pain + sleep + neuropathic features
2nd Line	Cyclobenzaprine / Gabapentin	Sleep / neuropathic overlay
Caution	Tramadol (short course only)	Severe acute flare — never with SNRIs

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Never use in FM: Strong opioids · NSAIDs as FM therapy · Benzodiazepines · Corticosteroids for FM symptoms · Zolpidem

3 8-Week Rehabilitation Program

Core Evidence Base

Core — Strong Aerobic exercise · Pain Neuroscience Education · CBT · Sleep hygiene
Core — Conditional Resistance training · Mind-body exercise · Mindfulness
Adjunctive Hydrotherapy · TENS · Massage · Heat therapy

Exercise Target

Optimal aerobic dose: ~470 METs-min/week. Program progresses from 75 METs-min (Week 1) to 470 METs-min (Week 8). Hybrid format: 3 clinic sessions/week + daily home program.

Wk 1–2 Foundation

ExerciseWalking 10–15 min, RPE 2–3, stretching

PsychologyIndividual assessment + Pain Neuroscience Education

GoalBuild confidence, establish baseline

Wk 3–4 Building

Exercise20–25 min aerobic + resistance (BW, 40–50% 1RM)

PsychologyPacing + Cognitive restructuring

ReviewMDT + medication review Week 4

Wk 5–6 Progressive

Exercise30 min aerobic + resistance (50–60% 1RM) + aquatic

PsychologyBehavioural activation + CBT-I (sleep)

AddMindfulness + dietitian group session

Wk 7–8 Consolidation

Exercise35–40 min aerobic + full circuit (60–70% 1RM) + Tai chi

PsychologyRelapse prevention + Graduation

FinalFull outcome reassessment + discharge plan

Psychology Program (Group — 6–10 patients)

8 structured sessions: Pain Neuroscience Education → Pacing → Cognitive Restructuring → Behavioural Activation → CBT-I → Relapse Prevention → Graduation. All group-format except Week 1 (individual).

Post-Program Pathways

Response	Definition	Next Step
Good	≥30% FIQ-R improvement	Monthly physio × 3 months, then quarterly
Partial	10–29% improvement	Extended 4-week program or psychology referral
Non-response	<10% improvement	Intensive pain program + medication review

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Bottom Line for Partners This is a structured, outcome-monitored, evidence-based MDT program. Pharmacotherapy is adjunctive. The 8-week rehabilitation program is the intervention. Full protocol documentation is available on request.

Fibromyalgia Management Protocol