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msk.fibromyalgia.core.v1PRODUCTION
msk.fibromyalgia.core.v1

Fibromyalgia (ACR 2016 WPI/SSS; central sensitisation)

rheumatologychronicadult
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Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Adult chronic widespread pain. FM is a POSITIVE construct valid regardless of coexisting disease (Wolfe 2016 PMID 27916278 removed exclusion language); central-sensitisation / nociplastic phenotype (AAPT 2019 Arnold PMID 30453109)

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FM framed as a positive criterion-based diagnosis, with a PARALLEL (not gating) mimic/comorbidity screen

Patient inputs (18)

Age ≥50 with new girdle stiffness + raised ESR pivots toward PMR/GCA; late-onset FM under-recognised under ACR 2016 (Wolfe 2016)

ME/CFS, IBS, chronic migraine, depression/anxiety, TMD overlap is the rule, not exception — drives symptom-domain treatment (AAPT 2019)

Opioids are ineffective and harmful in FM (EULAR 2017 — avoid) → deprescribing pathway is mandatory if present

Triptan / tramadol / MAOI / other serotonergic agents + planned SNRI or TCA → serotonin-syndrome guard

WPI 0-19: number of painful body areas — core ACR 2016 diagnostic input feeding calc.acr_fibromyalgia_2016

SSS 0-12 (fatigue, waking unrefreshed, cognitive symptoms + somatic burden) — core ACR 2016 diagnostic input feeding calc.acr_fibromyalgia_2016

Symptoms present at a similar level ≥3 months — ACR 2016 mandatory duration criterion

Pain in ≥4 of 5 regions (generalised-pain criterion added in 2016 to eliminate regional-pain misclassification) (Wolfe 2016)

Hypothyroidism is the cardinal endocrine mimic — TSH is the decisive pivot vs FM

Normal inflammatory markers support FM; raised → pursue PMR / inflammatory-arthritis workup (the inflammatory pivot)

New objective synovitis, weight loss + raised ESR in ≥50 yr (PMR/GCA), proximal weakness + raised CK (myopathy) — gate the mimic workup, not the FM diagnosis

eGFR caps pregabalin / gabapentin dose (renally cleared α2δ ligands)

F:M ratio markedly narrower under ACR 2016 vs 1990 tender-point criteria — sex is a weak discriminator; do not under-diagnose male/late-onset FM (Wolfe 2016)

Statin myopathy is a treatable mimic of FM proximal pain — check CK; do not attribute statin myalgia to FM

Creatine kinase — raised CK points to inflammatory/statin myopathy, not FM (the muscle pivot)

Hypercalcaemia is a reversible cause of diffuse pain/fatigue; CMP also screens hepatic/renal

Vitamin D deficiency causes diffuse musculoskeletal pain that mimics/aggravates FM

Duloxetine contraindicated in hepatic impairment / significant alcohol use

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationallife_threateningserotonergic_polypharmacy_or_new_suicidality
    SNRI/TCA combined with triptan/tramadol/MAOI/linezolid (serotonin-syndrome risk) OR new suicidality on an antidepressant-class FM drug
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepmr_gca_pivot_age50_girdle_stiffness_raised_esr
    Age ≥50 + new shoulder/hip-girdle pain & morning stiffness + raised ESR/CRP — the PMR/GCA pivot vs FM
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremyopathy_pivot_proximal_weakness_raised_ck
    Objective proximal weakness + raised creatine kinase — the muscle pivot (statin-induced [drug-induced modifier] / inflammatory myopathy), not FM
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateinflammatory_pivot_objective_synovitis_or_raised_markers
    Objective synovitis OR persistently raised ESR/CRP — the inflammatory pivot. Raises prior for inflammatory arthritis/SLE/PMR; does NOT exclude concurrent FM (Wolfe 2016 — conditional independence)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehypothyroid_pivot_abnormal_tsh
    Abnormal TSH — the endocrine pivot; hypothyroidism mimics and aggravates FM (fatigue, diffuse pain, cognitive slowing). Abnormal TSH (not isolated antithyroid antibodies — present in 37.9% of clinically-defined FM without dysfunction, Nishioka 2016 PMID 27905199) gates the route
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecentralised_pain_overlap_with_structural_oa_or_axial_lbp
    Widespread pain + high central-sensitisation (CSI) DISPROPORTIONATE to radiographic OA or to axial low-back structural disease — the centralised-pain-overlap pivot (shared central-aspects-of-pain construct across OA/back-pain/FM — McWilliams 2024 PMID 38889286)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateopioid_on_board_for_fm
    Patient maintained on opioids for fibromyalgia pain
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesevere_disability_refractory_to_multimodal_care
    Severe functional disability persisting despite education + exercise + symptom-domain pharmacotherapy
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Non-pharmacological core — FIRST-LINE (EULAR 2017: exercise the only "strong for"; Macfarlane PMID 27377815)
axis: fm_nonpharmacological_core
Selected axis "Non-pharmacological core — FIRST-LINE (EULAR 2017: exercise the only "strong for"; Macfarlane PMID 27377815)" by default fallback (first axis)
  • patient education + self-management
    first line
    education
    triggers: fm_diagnosis_confirmed
    EULAR 2017 Macfarlane — initial management is education + non-pharm; explain nociplastic/central mechanism to legitimise and de-medicalise
  • graded aerobic exercise
    first line
    exercise_therapy
    physical • progressive, most days
    triggers: fm_diagnosis_confirmed
    EULAR 2017 ONLY "strong for"; Bidonde 2017 Cochrane CD012700 PMID 28636204 — HRQoL MD -7.89 (95% CI -13.23 to -2.55), pain MD -11.06 (-18.34 to -3.77); well tolerated
  • progressive resistance exercise
    first line
    exercise_therapy
    physical • 2-3x/week, progressive
    triggers: fm_diagnosis_confirmed, deconditioning
    Busch 2013 Cochrane CD010884 PMID 24362925 — FIQ multidimensional function MD -16.75 (95% CI -23.31 to -10.19), pain MD -3.3/10, leg-extension strength +27.32 kg; safe at moderate-high intensity
  • cognitive behavioural therapy
    first line
    psychological_therapy
    triggers: unhelpful_coping, comorbid_mood, high_disability
    Bernardy 2013 Cochrane CD009796 PMID 24018611 — pain SMD -0.29 (end), -0.40 (6 mo); mood SMD -0.33; disability SMD -0.30; durable, no excess dropout
  • sleep optimisation / CBT-I
    first line
    sleep_intervention
    triggers: unrefreshing_sleep, high_SSS_sleep_domain
    Sleep is a core SSS domain; non-pharm sleep management before sedative drugs (EULAR 2017)
  • multimodal / multidisciplinary rehabilitation
    add on
    multimodal_program
    triggers: severe_disability, failure_of_single_modality
    EULAR 2017 Macfarlane — multimodal rehab for severe disability; 2024 physiotherapy umbrella review reaffirms (Carrasco-Vega PMID 38966940)

outpatient playbook — drug actions (6)

  1. 1. education + graded aerobic + resistance exercise + CBT/sleep
    progressive; aerobic most days, resistance 2-3x/wk • non-drug • ongoing
    trigger: FM confirmed by ACR 2016
    EULAR 2017 first-line; exercise the only "strong for" (Bidonde 2017 HRQoL MD -7.89; Busch 2013 FIQ MD -16.75; Bernardy 2013 CBT pain SMD -0.29)
  2. 2. duloxetine
    30 mg → 60 mg PO daily • PO • once daily
    trigger: Pain-dominant ± comorbid depression/anxiety, non-pharm insufficient, no hepatic impairment
    Lunn 2014 NNTB 8; network MA best for pain & depression (Farag 2022)
  3. 3. pregabalin (or gabapentin)
    Pregabalin 75 mg qHS → 150-225 mg BID (gabapentin 300 mg qHS → 1200-2400 mg/d) • PO • BID / TID
    trigger: Sleep-disturbance/pain-dominant; SNRI insufficient/intolerant; eGFR-adjusted
    Derry 2016 pregabalin RR 1.8; Arnold 2007 gabapentin ≥30% 51% vs 31%
  4. 4. amitriptyline (low-dose bedtime)
    5-10 mg → 25-50 mg PO qHS • PO • once daily at bedtime
    trigger: Sleep/fatigue/QoL-dominant; not elderly with anticholinergic/cardiac risk
    Network MA best for sleep SMD -0.97, fatigue SMD -0.64, QoL SMD -0.80, best acceptability (Farag 2022 PMID 35587348)
  5. 5. cyclobenzaprine (low-dose bedtime, alternative to TCA)
    5-10 mg PO qHS • PO • once daily at bedtime
    trigger: Sleep-dominant + muscle tension; TCA not tolerated
    Tofferi 2004 global OR 3.0, NNT 4.8, sleep benefit (PMID 14872449)
  6. 6. structured opioid taper
    individualised slow taper • non-drug • ongoing
    trigger: Patient on opioid for FM
    EULAR 2017 — opioids ineffective/harmful in FM; never abrupt stop

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Chronic widespread pain ≥3 months in ≥4 of 5 body regions (ACR 2016 Wolfe generalised-pain criterion); Multisite pain + fatigue + unrefreshing sleep + cognitive "fibro-fog" (AAPT 2019 Arnold); Referral for diffuse pain with unremarkable inflammatory / metabolic labs (EULAR 2017 Macfarlane).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Fibromyalgia (ACR 2016 WPI/SSS; central sensitisation)** (msk.fibromyalgia.core.v1).
Phenotype framing: FM vs PMR vs early inflammatory arthritis/SLE vs hypothyroidism vs ME/CFS vs somatic-symptom/depression. MECE pivots: inflammatory markers, objective synovitis, TSH/FT4, CK, age + girdle stiffness, post-exertional malaise. FM is conditionally INDEPENDENT of a coexisting inflammatory/endocrine disease — a positive mimic does NOT exclude concurrent FM (Wolfe 2016)
Scope: Adult chronic widespread pain. FM is a POSITIVE construct valid regardless of coexisting disease (Wolfe 2016 PMID 27916278 removed exclusion language); central-sensitisation / nociplastic phenotype (AAPT 2019 Arnold PMID 30453109)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Non-pharmacological core — FIRST-LINE (EULAR 2017: exercise the only "strong for"; Macfarlane PMID 27377815)**.
1. patient education + self-management (education, first line) — EULAR 2017 Macfarlane — initial management is education + non-pharm; explain nociplastic/central mechanism to legitimise and de-medicalise
2. graded aerobic exercise physical progressive, most days (exercise_therapy, first line) — EULAR 2017 ONLY "strong for"; Bidonde 2017 Cochrane CD012700 PMID 28636204 — HRQoL MD -7.89 (95% CI -13.23 to -2.55), pain MD -11.06 (-18.34 to -3.77); well tolerated
3. progressive resistance exercise physical 2-3x/week, progressive (exercise_therapy, first line) — Busch 2013 Cochrane CD010884 PMID 24362925 — FIQ multidimensional function MD -16.75 (95% CI -23.31 to -10.19), pain MD -3.3/10, leg-extension strength +27.32 kg; safe at moderate-high intensity
4. cognitive behavioural therapy (psychological_therapy, first line) — Bernardy 2013 Cochrane CD009796 PMID 24018611 — pain SMD -0.29 (end), -0.40 (6 mo); mood SMD -0.33; disability SMD -0.30; durable, no excess dropout
5. sleep optimisation / CBT-I (sleep_intervention, first line) — Sleep is a core SSS domain; non-pharm sleep management before sedative drugs (EULAR 2017)
6. multimodal / multidisciplinary rehabilitation (multimodal_program, add on) — EULAR 2017 Macfarlane — multimodal rehab for severe disability; 2024 physiotherapy umbrella review reaffirms (Carrasco-Vega PMID 38966940)

Setting playbook (outpatient) — Confirm FM by ACR 2016 WPI/SSS, run a parallel focused mimic/comorbidity screen, start education + exercise + non-pharm FIRST, add symptom-domain pharmacotherapy only as second-line, deprescribe opioids (EULAR 2017 Macfarlane PMID 27377815; Wolfe 2016 PMID 27916278)
7. education + graded aerobic + resistance exercise + CBT/sleep progressive; aerobic most days, resistance 2-3x/wk non-drug ongoing — FM confirmed by ACR 2016 (EULAR 2017 first-line; exercise the only "strong for" (Bidonde 2017 HRQoL MD -7.89; Busch 2013 FIQ MD -16.75; Bernardy 2013 CBT pain SMD -0.29))
8. duloxetine 30 mg → 60 mg PO daily PO once daily — Pain-dominant ± comorbid depression/anxiety, non-pharm insufficient, no hepatic impairment (Lunn 2014 NNTB 8; network MA best for pain & depression (Farag 2022))
9. pregabalin (or gabapentin) Pregabalin 75 mg qHS → 150-225 mg BID (gabapentin 300 mg qHS → 1200-2400 mg/d) PO BID / TID — Sleep-disturbance/pain-dominant; SNRI insufficient/intolerant; eGFR-adjusted (Derry 2016 pregabalin RR 1.8; Arnold 2007 gabapentin ≥30% 51% vs 31%)
10. amitriptyline (low-dose bedtime) 5-10 mg → 25-50 mg PO qHS PO once daily at bedtime — Sleep/fatigue/QoL-dominant; not elderly with anticholinergic/cardiac risk (Network MA best for sleep SMD -0.97, fatigue SMD -0.64, QoL SMD -0.80, best acceptability (Farag 2022 PMID 35587348))
11. cyclobenzaprine (low-dose bedtime, alternative to TCA) 5-10 mg PO qHS PO once daily at bedtime — Sleep-dominant + muscle tension; TCA not tolerated (Tofferi 2004 global OR 3.0, NNT 4.8, sleep benefit (PMID 14872449))
12. structured opioid taper individualised slow taper non-drug ongoing — Patient on opioid for FM (EULAR 2017 — opioids ineffective/harmful in FM; never abrupt stop)

Non-pharmacologic actions:
- Validate the diagnosis; explain nociplastic/central-sensitisation mechanism (EULAR 2017)
- Graded aerobic + resistance exercise prescription with low-start titration (Bidonde 2017; Busch 2013)
- CBT / pain-coping skills referral (Bernardy 2013)
- Sleep hygiene / CBT-I (EULAR 2017)
- Multidisciplinary pain-rehab referral if severe disability (Macfarlane 2017; Carrasco-Vega 2024)
- Deprescribe opioids, benzodiazepines; stop strong-NSAID monotherapy for FM (EULAR 2017)

AVOID / contraindication checks:
- Start exercise low and go slow to avoid post exertional symptom flare (EULAR 2017 Macfarlane)
- Screen for untreated mimic before attributing all pain to FM (Wolfe 2016)

Monitoring

Regimen monitoring:
- exercise adherence and tolerance each visit (EULAR 2017)
- symptom domain rescore revised FIQ or WPI SSS (Wolfe 2016)

Setting (outpatient) monitoring:
- Re-score WPI+SSS / revised FIQ at 4-12 wk and periodically (Wolfe 2016)
- Drug tolerability + DDI review each change (EULAR 2017)
- Mood/suicidality on SNRI/TCA; sedation/weight/oedema on α2δ (drug-class)
- Exercise adherence; opioid-taper progress (EULAR 2017)
- Periodic re-screen for emergent mimic (TSH, ESR/CRP, CK as indicated) (Wolfe 2016)

Follow-up plan: Long-term self-management; relapse/flare plan; reinforce sustained exercise and sleep; periodic re-screen for new mimic/comorbidity (TSH, ESR/CRP, CK as indicated); de-prescribe ineffective agents; reassess opioid taper completion (EULAR 2017 Macfarlane; 2024 reaffirming reviews PMID 38855963, 38966940)
- Close-out criterion: Long-term self-management + relapse plan + de-prescribing plan in place

Monitoring phase: Re-score symptom domains (revised FIQ / WPI+SSS) at intervals; drug tolerability + DDIs (SNRI/TCA serotonergic, α2δ sedation/oedema/weight, amitriptyline anticholinergic); exercise adherence; opioid-taper progress; mood/suicidality screen on antidepressant-class drugs; periodic re-screen for emergent mimic/comorbidity (EULAR 2017 Macfarlane)

Disposition

Current setting: outpatient — Confirm FM by ACR 2016 WPI/SSS, run a parallel focused mimic/comorbidity screen, start education + exercise + non-pharm FIRST, add symptom-domain pharmacotherapy only as second-line, deprescribe opioids (EULAR 2017 Macfarlane PMID 27377815; Wolfe 2016 PMID 27916278)

Disposition criteria:
- Continue primary-care/outpatient management if responding to multimodal plan (EULAR 2017)
- Refer rheumatology only for diagnostic uncertainty or inflammatory overlap (Wolfe 2016 — FM itself does not need a specialist)
- Refer multidisciplinary pain-rehab for severe disability (Macfarlane 2017)

Escalation triggers (move to higher acuity):
- New objective synovitis / persistently raised ESR-CRP → rheumatology + inflammatory-arthritis or PMR workup (rheum.rheumatoid-arthritis.core.v1 / rheum.gca.chronic.v1)
- Abnormal TSH → treat hypothyroidism first (endo.hypothyroidism.core.v1) then re-evaluate residual FM
- Proximal weakness + raised CK → myopathy workup (statin/inflammatory) before attributing to FM
- Severe refractory disability despite multimodal care → multidisciplinary pain program
- New suicidality on antidepressant-class drug → urgent psychiatric escalation

Patient Action Plan

**Fibromyalgia self-management plan**
Personalised values: dominant_symptom_domain, current_FM_drug_and_dose, exercise_prescription, opioid_taper_plan, WPI_SSS_baseline.

**Stable — managing symptoms, exercising** (green):
Triggers:
- Pain/fatigue at usual manageable baseline
- Keeping up graded exercise most weeks
- Sleep at personal baseline
Actions:
- Keep up your aerobic + strengthening exercise — this is the single most effective treatment (EULAR 2017 strong recommendation)
- Maintain regular sleep routine and pacing
- Continue any prescribed symptom medication as directed; do not add extra pain pills
- Use your coping/relaxation skills proactively, not only in a flare

**Flare — symptoms worse than usual** (yellow):
Triggers:
- Pain, fatigue or "fibro-fog" clearly worse than baseline for several days
- Sleep markedly disrupted
- New life stressor / overexertion / poor sleep run
Actions:
- Do NOT stop exercising — scale back to gentle movement, then rebuild gradually (avoid the rest-deconditioning cycle)
- Return to sleep and pacing basics; use CBT/relaxation skills
- Do NOT escalate to opioids or add benzodiazepines — these worsen FM long-term (EULAR 2017)
- Contact your provider if the flare persists beyond ~2 weeks or function drops
Contact provider when:
- Flare not settling after ~2 weeks of self-management
- New medication side effects (mood change, marked drowsiness, swelling)

**New feature that is NOT typical fibromyalgia** (red):
Triggers:
- New joint swelling/redness, fever, or unexplained weight loss
- New muscle weakness (trouble standing from a chair, climbing stairs)
- New severe headache / jaw or scalp pain / visual change in age ≥50
- New or worsening thoughts of self-harm on your medication
Actions:
- Seek prompt medical assessment — these features are NOT explained by fibromyalgia and need evaluation (mimic/coexisting disease)
- For thoughts of self-harm, seek urgent/emergency help now
- Bring your full medication list including any opioid taper plan
Contact provider when:
- Any red-zone trigger — fibromyalgia does not cause objective inflammation, weakness, fever or weight loss; a separate condition must be excluded (Wolfe 2016)
- Always seek emergency help for suicidality

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] SNRI/TCA combined with triptan/tramadol/MAOI/linezolid (serotonin-syndrome risk) OR new suicidality on an antidepressant-class FM drug
- [SEVERE] Age ≥50 + new shoulder/hip-girdle pain & morning stiffness + raised ESR/CRP — the PMR/GCA pivot vs FM
- [SEVERE] Objective proximal weakness + raised creatine kinase — the muscle pivot (statin-induced [drug-induced modifier] / inflammatory myopathy), not FM

Citations

- ACR 2016 revised fibromyalgia criteria (Wolfe, Semin Arthritis Rheum 2016) + EULAR 2017 revised management recommendations (Macfarlane, Ann Rheum Dis) + AAPT 2019 (Arnold, J Pain). No superseding FM society guideline at the 2026 floor (verified 2026-05-16; depth-pass-2 evidence reconciled 2026-05-17; evidence-gap noted in notes). [PMID:27916278](https://pubmed.ncbi.nlm.nih.gov/27916278/)
- Cited evidence (PMID 27377815) [PMID:27377815](https://pubmed.ncbi.nlm.nih.gov/27377815/)
- Cited evidence (PMID 30453109) [PMID:30453109](https://pubmed.ncbi.nlm.nih.gov/30453109/)
- Cited evidence (PMID 24385423) [PMID:24385423](https://pubmed.ncbi.nlm.nih.gov/24385423/)
- Cited evidence (PMID 29489029) [PMID:29489029](https://pubmed.ncbi.nlm.nih.gov/29489029/)

Last reconciled with current guidelines: 2026-05-22.
References
  • ACR 2016 revised fibromyalgia criteria (Wolfe, Semin Arthritis Rheum 2016) + EULAR 2017 revised management recommendations (Macfarlane, Ann Rheum Dis) + AAPT 2019 (Arnold, J Pain). No superseding FM society guideline at the 2026 floor (verified 2026-05-16; depth-pass-2 evidence reconciled 2026-05-17; evidence-gap noted in notes). — PMID:27916278
  • Cited evidence (PMID 27377815) — PMID:27377815
  • Cited evidence (PMID 30453109) — PMID:30453109
  • Cited evidence (PMID 24385423) — PMID:24385423
  • Cited evidence (PMID 29489029) — PMID:29489029