New Canadian Guidelines for Treating Fibromyalgia

New Canadian Guidelines for Treating Fibromyalgia

New guidelines for the treatment of fibromyalgia in Canada were released this week in Winnipeg at the annual meeting of the Canadian Pain Society.  The Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome fall on the heels of the American Academy of Rheumatology’s preliminary diagnostic criteria for fibromyalgia, which was modified after it was criticized by some physicians.

Are the new guidelines the same, similar, or different?

And why does it matter for fibromyalgia patients? Will doctors treat you differently north and south of the border?

canada flagBoth physician groups, in Canada and the United States, acknowledge the primary symptoms of fibromyalgia; which are wide-spread pain, fatigue and cognitive changes.  Another aspect both seem to agree on is mood disturbance and other variable somatic symptoms – which are symptoms that have no medical explanation.

What I find interesting is that both groups seem to have reviewed only part of the research on fibromyalgia that’s been done over the past decade. Only one citation includes research done in 2012 and less than 1% are from 2011. They seem to pick and choose their studies, rather than a full research review.

Canada’s criteria suggest physicians do a comprehensive clinical evaluation of patients, with attention to primary symptoms and co-occurring/comorbid disorders; such as irritable bowel syndrome, migraine, bladder problems, dysmenorrhea, and myofascial pain in the face and temporomandibular joint.

That is different from the U.S. criteria, which completely omits the importance of correlating other common symptoms to comorbid disorders.

It is interesting that the Canadian criteria considers myofascial pain of the face and temporomandibular joint, but ignores the research on myofascial pain syndrome (MPS) as a peripheral pain generator to fibromyalgia.

Myofascial trigger points (MTrPs) are the diagnostic criteria for MPS. These knotted up pieces of muscle fiber can be easily felt unless they’re behind other muscle or bone, or the muscle affected is too tight. But they are not limited to the face and jaw as suggested in the Canadian criteria.

Many symptoms of nerve pain and numbness can be attributed to MPS, and since MTrPs can be felt, it provides a measurable guide to the effectiveness of certain therapies. Other comorbid disorders of fibromyalgia share this same condition.  It contributes to sexual dysfunction, impotence in men, chronic pelvic pain disorder, migraine, etc., and can be exacerbated by other conditions known to exist with fibromyalgia.

At least the Canadian guidelines take myofascial pain under consideration, which is contrary to the Americans guidelines.

The Canadian criteria specifically correlate fatigue with sleep disorders that can be evaluated and measured with a sleep study. I only wish they would have reviewed the research of Mork, et al., which was done this year. While it was a small study, it does suggest heart rate variability during sleep could contribute to fibromyalgia sleep disturbance, as well as neck and upper back pain.

I can’t say the Canadian criteria are worse. In some respects they are the same, but they do consider some comorbid conditions to fibromyalgia, which is a plus.

The American criteria focus more on what fibromyalgia is not, rather than what it is.

I found the Canadian criteria to be more complete and less confusing. They make medication suggestions that are based on patient outcome (including opioids, cannabinoids, antidepressants and anticonvulsants), but only if they are closely monitored.

Also suggested are alternative interventions such as massage, transcutaneous electrical nerve stimulation (TENS) and acupuncture. This is a huge plus for the Canadian criteria.

Fibromyalgia is usually diagnosed by rheumatologists, but many patients are not able to seek advice from a specialist. It is suggested by both the American and Canadian physician groups that general practitioners learn how to diagnose and treat fibromyalgia. This conclusion is concerning — since the criteria in the U.S. have been called vague and confusing by some rheumatologists.

Family doctors are already overwhelmed in the U.S., so I fear this suggestion will only create further problems. It seems possible that these particular Canadian and American rheumatologists would rather not treat fibromyalgia at all.

The Canadian criteria encourage patient empowerment, education, and the need to assess the psychological and social consequences of fibromyalgia. They consider adjunctive therapies, consider many medications for their tool chest, understand the necessity of a physical exam, and the presence of sensitivities; all of which focus on improving patient outcome.

For this reason, while I feel the Canadian criteria could use some more work, it is superior to what is proposed in the U.S.

Celeste Cooper, RN

Celeste Cooper, RN

Celeste Cooper is a retired RN, educator, fibromyalgia patient, and lead author of the Broken Body Wounded Spirit: Balancing the See Saw of Chronic Pain devotional series (coauthor, Jeff Miller PhD), and Integrative Therapies for Fibromyalgia, Chronic Fatigue Syndrome and Myofascial Pain: The Mind-Body Connection (coauthor, Jeff Miller PhD), and Insider Secrets for Treating Fibromyalgia.

Celeste is a fibromyalgia expert for Dr. Oz, et, al. at Sharecare and advocates for all chronic pain patients as a participant in the Pain Alliance to Implement a National Strategy (Pains Project). Her website is

The information in this column is not intended to be considered as professional medical advice, diagnosis or treatment. Only your doctor can do that!  It is for informational purposes only and represent the author’s personal experiences and opinions alone. It does not inherently or expressly reflect the views, opinions and/or positions of National Pain Report or Microcast Media.

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Fitzcharles MA,  Ste-Marie PA, Goldenberg DL, Pereira JX, Abbey S, Choinière M, Ko G, Moulin D, Panopalis P, Proulx J, and Shir Y. 2012 Canadian Guidelines for the diagnosis and  management of fibromyalgia syndrome. CMAJ cmaj.121414; published ahead of print May 6, 2013

Mork P, Nilsson J, Lorås H, Riva R, Lundberg U, Westgaard R. Heart rate variability in fibromyalgia patients and healthy controls during non-REM and REM sleep: a case-control study. Scand J Rheumatol. 2013 Feb 20. [Epub ahead of print]

Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB: Fibromyalgia Criteria and Severity Scales for Clinical and Epidemiological Studies: A Modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol 38;1113-1122, 2011.

Authored by: Celeste Cooper, RN

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Sue MacDonald

I wish to make one comment at this time although I have many. Somatic symptoms are NOT symptoms that have no medical explanation as you have incorrectly stated early in this article. Somatic refers to ‘of the body’ and such symptoms are real physical complaints and are certainly not related to somatization disorder. Please do NO more harm to the cause of educating people about Fibromyalgia.

Linda Dr Holman has a theory that there is a cervical connection in FM. Also prevalent is myofascial pain syndrome, which causes the greatest pain. My website offers a great deal of information that might help you. It is in my signature line.

Linda Mills

I have been recently diagnosed with Fibromyalgia . I was in a car accident back in 2005 . I developed sever pain in my neck shoulder area . At the time I was told it was whiplash . It has gotten so bad that I sit with my head perfectly still as im scared to turn my head it hurts so bad . I just recently had an MRI/ SCAN and it showed I had disk degenerating disease . I have had in the past to go to emergency with what I was told was muscle spasm’s in my neck . I live with so much pain and no one seems to be able to tell me exactly wjay is causing the pain or for sure what it is .