Additional Material

Pre-Test

Question 1

Which of the following is the hallmark symptom of fibromyalgia syndrome?

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Correct. Fibromyalgia syndrome classically is characterized by widespread pain in addition to a number of other symptoms that will be reviewed in this module. Answers A and B are typical of myofascial pain syndrome. Answer C describes inflammatory polyarthritis such as rheumatoid arthritis.

Question 2

Which statement is most accurate about fibromyalgia syndrome?

Correct. Fibromyalgia may exist as a comorbidity with myofascial pain and other chronic musculoskeletal pain condition. Fibromyalgia is a not uncommon disorder of the central nervous system in which there is abnormal pain processing. It can occur in isolation or as one of multiple pain contributors. Patients with fibromyalgia syndrome have diminished pain threshold and tolerance and the disorder must be treated to optimize patient outcomes. As patients with fibromyalgia often have limited exercise tolerance, an exercise program should be initiated gradually and focus on aerobic activity. There is strong efficacy evidence for aerobic exercise in the treatment of patients with fibromyalgia. Answer C is incorrect because fibromyalgia is a clinical diagnosis; there are no characteristic imaging or biomarker findings. Answer D is incorrect because there is no pathoanatomic evidence linking fibromyalgia to inflammation and/or degeneration.

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Question 3

When beginning treatment with a new fibromyalgia patient, which of the following would be the most appropriate first step?

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Correct. At the foundation of treating patients with chronic non-cancer pain in general and fibromyalgia syndrome in particular is education. Aerobic exercise has strong efficacy evidence. Often patients with fibromyalgia have comorbid myofascial pain for which stretching can be very helpful. Answer A is incorrect because while medications can be useful, they would not be the first step as they constitute a passive approach to treatment. It is very important for patients with fibromyalgia to be an active participant in their pain management. Answer B is incorrect as a first step; interdisciplinary pain management programs can be very helpful and typically are prescribed if simpler approaches to treatment are ineffective. Answer D is incorrect because fibromyalgia is a clinical diagnosis.

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Question 4

A patient with fibromyalgia is struggling with pain and fatigue. She has tried to exercise at home but is frustrated that her pain is not getting better. She states that her lower back begins to ache after she walks several blocks. What is the next most appropriate treatment step.

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Correct. Patients with fibromyalgia syndrome often experience limited exercise tolerance and they benefit from a supervised exercise program. Axial pain, such as that experienced around the neck, upper back and lower back, are another hallmark characteristic of fibromyalgia. The goal is to build exercise tolerance through gradual titration. Pain medications would not be indicated because the exercise itself has analgesic properties. Answer B is incorrect because there are no red flags that would indicate the need for spinal imaging. Patients with fibromyalgia commonly experience fatigue as well. This is not an indication for referral to a psychiatrist, thus answer D is incorrect. Answer E also is incorrect. While activity pacing is important, bed rest is counter-productive.

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Question 5

Which statement is true about stepwise fibromyalgia treatment?

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Correct. Mood disorders (e.g., depression, anxiety) co-exist commonly with fibromyalgia. As with all types of chronic non-cancer pain, mood disorders and pain disorders are mutually exacerbating, thus both must be treated to afford optimal patient outcomes. Answer A is incorrect because adjunctive techniques such as cognitive behavioral therapy can be prescribed along with any step of treatment. Answer C is incorrect because non-pharmacological strategies should be tried before prescribing medications. If there is a comorbid mood disorder, severity of symptoms and patient preferences should dictate whether pharmacological and/or non-pharmacological treatment approaches are prescribed. Answer D is incorrect because interdisciplinary treatment programs are typically prescribed as a later step in treatment if other treatments have been ineffective. Answer E is incorrect because trigger point injections are indicated in the treatment of myofascial pain, not fibromyalgia.

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Post Test

Question 1

Which of the following is true about fibromyalgia syndrome?

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Correct. While patients with fibromyalgia commonly experience fatigue, it is a non-specific symptom that should be carefully evaluated. Depression and hypothyroidism are both commonly associated with fatigue and, therefore, should be screened in the patient with fibromyalgia. A is incorrect. While pain is a part of fibromyalgia, it is not always the most troubling symptom; often patients are more disabled by fatigue than pain. C is incorrect as headaches can be part of fibromyalgia and the yield associated with brain imaging is low in the face of a completely normal neurological examination. D is incorrect, as patients with fibromyalgia not infrequently report symptoms that cannot be corroborated on exam. Weakness is more a manifestation of decreased stamina rather than decreased motor strength. Patients may also report joint swelling without any objective evidence of synovitis. E is incorrect because fibromyalgia does not cause dry mouth; this symptom is part of Sjogren’s syndrome and is a not uncommon medication side effect, particularly those that are anticholinergic.

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Question 2

A 23 year old medical student presents with headaches and fatigue. Her symptoms have been present for well over 2 years and have worsened since she started medical school a year ago. She describes her sleep as fragmented and she awakens feeling unrefreshed. She denies change in her weight, fever, chills or sweats. Physical examination reveals normal strength and reflexes of all extremities, normal funduscopic examination, and absent meningismus. She has tenderness in multiple areas with light palpation. Range of motion of all of her joints and axial skeleton is normal. Examination of the neck reveals taut bands and trigger points in her trapezii bilaterally. Compression of the trigger points causes pain that radiates to her forehead, the location of the headache. Additional evaluation prior to the initiation of any treatment should include:

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Correct. This patient presents with a symptom complex supportive of fibromyalgia syndrome, so neither a head CT scan, a lumbar puncture nor an erythrocyte sedimentation rate are indicated. Abnormal thyroid function can be associated with fatigue and should be screened.

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Question 3

The first step in treating a 30 year old patient with depression and fibromyalgia syndrome characterized by morning stiffness, generalized pain and non-restorative sleep should include each of the following EXCEPT:

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Correct. Analgesics are not indicated as first line treatment of fibromyalgia. Education lies at the foundation of treatment as does an aerobic exercise program. As the patient has depression, initiation of antidepressant pharmacotherapy is a reasonable first step, especially given her sleep disturbance.

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Question 4

A 52 year old woman presents with a diagnosis of fibromyalgia for 15 years. She had been doing well until 6 months ago when she moved to Pittsburgh to be near her daughter. She had previously lived in Tucson, Arizona. Since being in Pittsburgh she frequently babysits her grandchildren, often staying up later than usual. She used to exercise regularly, but since the move she has not been able to carve out sufficient time to do so. She reports fatigue. She has been on a stable dose of gabapentin for the past 5 years. Her creatinine clearance is normal and her gabapentin has not been maximally titrated. The next most appropriate recommendation is to:

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Correct. This patient has longstanding fibromyalgia and a significant change in her routine and environment have resulted in destabilization of her fibromyalgia. Her sleep-wake cycle is off, she is not exercising, and she is not able to sufficiently set limits to carve out time for herself. Referral to physical therapy alone would not solve all of these issues, nor would titrating her gabapentin or switching to a different medication. Interdisciplinary team treatment that involves psychology would help to comprehensively address the factors that are contributing to the patient’s fibromyalgia symptoms.

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Question 5

A 45 year old woman is not interested in taking a medication for her fibromyalgia. In addition to pain, she describes non-restorative sleep, daytime fatigue, chronic anxiety about whether she will be able to keep up her performance at work, and decreased physical stamina. She describes the problems with stamina and deconditioning as her primary problems; she can “trudge through the pain – though it is exhausting.” Using shared decision-making that is focused on the patient’s preferences to improve her functioning, each of the following is an initial treatment option EXCEPT:

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Correct. As she is deconditioned, starting with an unsupervised jogging program would likely result in worsening of her symptoms. Instead, education about activity pacing, behavioral approaches to sleep restoration and physical therapy for supervised exercise represent rational initial approaches.