Study Points

Fibromyalgia

Course #94300 - $15 • 3 Hours/Credits

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  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
  1. The prevalence of fibromyalgia in women is highest in what age-group?

    EPIDEMIOLOGY

    The prevalence of fibromyalgia is 5% to 6% among patients seen in family or general medicine practice settings and among 15% to 20% of patients seen by rheumatologists [8]. As such, the syndrome is among the 100 most common diagnoses made in the family medicine setting, as well as one of the most common diagnoses in office-based rheumatology practice [8,17]. Fibromyalgia is usually diagnosed between the ages of 20 and 55 years, but the prevalence increases with age, peaking at 70 to 79 years of age (at approximately 7% for women and 1% for men) [5].

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  2. For first-degree relatives of individuals with fibromyalgia, risk of developing the disease is

    PATHOGENESIS

    Genetics is thought to be a factor in the susceptibility of fibromyalgia. Family clustering has been reported, and the risk for fibromyalgia is eight times higher for first-degree relatives of individuals with the syndrome [25]. Abnormalities in the serotonin transporter gene and the catecholamine-O-methyltransferase gene have been identified [5,9,26]. These abnormalities affect the metabolism or transport of serotonin and norepinephrine, which decrease the sensitivity of pain-processing systems through the descending central nervous system pain pathways [5].

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  3. Which of the following is most likely to be reported as an exacerbating factor for fibromyalgia symptoms?

    POTENTIAL ENVIRONMENTAL RISK FACTORS

    Psychiatric conditions have long been associated with fibromyalgia, and research suggests that such conditions may precede fibromyalgia and act as a trigger for the disease [6,8]. In one study, when individuals were asked what they perceived to be a trigger for fibromyalgia, 73% attributed the development of the disease to emotional trauma or chronic stress; 24% noted emotional/physical abuse as an adult or child as a perceived trigger [27].

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  4. The three primary manifestations of fibromyalgia are

    DIAGNOSTIC EVALUATION

    There is a wide range of symptoms and comorbidities associated with fibromyalgia, and they occur in a variety of combinations and differ in terms of severity. After the three primary manifestations (fatigue, stiffness, and sleep abnormalities), the most common symptoms are headaches (usually migraine), dry mouth, low back pain, and paresthesias (Table 1) [1,3,27,31,32,33,34]. In an online survey conducted by the National Fibromyalgia Association (NFA), 19 symptoms, affecting virtually all body systems, were noted by at least 25% of the respondents [27]. Nearly all individuals with fibromyalgia are polysymptomatic [27].

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  5. The American Pain Society recommends using what method/tool as the primary source for pain assessment in patients with fibromyalgia?

    DIAGNOSTIC EVALUATION

    Most individuals with fibromyalgia describe pain as arising from muscles and joints and also have tender skin [3]. Pain is typically axial in distribution, and pain/stiffness usually occurs in the morning and evening [3]. Patients may note a feeling of swelling in the soft tissues, primarily around the joints, but there is no objective evidence of swelling [3,28]. The American Pain Society recommends using self-reports as the primary source for pain assessment, focusing on such details as [4]:

    • Type and quality of pain

    • Source

    • Location

    • Duration

    • Time course

    • Pain affect

    • Effects on quality of life

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  6. Which of the following features distinguishes hypothyroidism from fibromyalgia?

    DIAGNOSTIC EVALUATION

    DIFFERENTIAL DIAGNOSIS OF FIBROMYALGIA

    Diagnoses to ConsiderShared ManifestationsDistinguishing Features
    Myofascial pain syndromePainful, tender areas in the muscles, commonly affecting the axial musclesPain arising from trigger points in individual muscles during examination
    Chronic fatigue syndromeChronic pain and fatigueLow-grade fever, enlargement of lymph glands, continuous subclinical inflammatory process, and acute onset of illness
    Rheumatoid arthritisJoint pain/stiffnessInvolvement of hands and feet, positive rheumatoid factor (in 80% to 90% of cases), radiographic evidence of joint erosion
    Systemic lupus erythematosusInvolvement of multiple systems, joint painMalar rash, positive antinuclear antibody test
    HypothyroidismProfound fatigue, muscle weakness, mental slowingWeight gain, hair loss, increased TSH level
    Polymyalgia rheumaticaPain/stiffness in sacrohumeral and pelvic girdleIncreased ESR (in 80% to 90% of cases), age older than 65 years, treatment with glucocorticoids resolves symptoms
    SpondyloarthropathyPain in neck, mid-thoracic, anterior chest wall, or lumbar regionsPain localized to specific spinal areas, radiographic evidence of sacroiliitis, or radiographic changes in vertebral bodies
    Polyarticular osteoarthritisPain in multiple jointsRadiographic evidence of joint degeneration
    Polymyositis or other myopathiesMuscle weaknessProximal, symmetrical muscles affected, increased serum levels of muscle enzymes, abnormal findings on EMG testing and on evaluation of biopsy samples
    Neuropathic pain syndromesTingling, numbnessBurning, shooting pain
    EMG = electromyography; ESR = erythrocyte sedimentation rate; TSH = thyroid-stimulating hormone.
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  7. According to a systematic review in which three antidepressants were evaluated for treatment of fibromyalgia, which of the following is TRUE?

    TREATMENT

    A systematic review to compare the effectiveness of the three antidepressants demonstrated several differences [81]:

    • Amitriptyline was superior to both duloxetine and milnacipran in reducing pain, sleep disturbances, fatigue, and limitations of health-related quality of life.

    • Duloxetine was superior to milnacipran in reducing pain, sleep disturbances, and limitations of health-related quality of life.

    • Milnacipran was superior to duloxetine in reducing fatigue.

    • No differences in tolerability were found among the three drugs.

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  8. Which of the following is TRUE regarding anticonvulsants for the treatment of fibromyalgia?

    TREATMENT

    The third FDA-approved drug for the treatment of fibromyalgia is pregabalin, an anticonvulsant agent. Several studies have shown pregabalin to significantly improve pain, patient global assessment, fatigue, and health-related quality of life, as well as sleep disturbances [41,72,82]. The effect of the drug has lasted for as long as six months [41]. The drug was well tolerated, with the common side effects being dizziness and sedation, which tended to resolve with time of treatment [41].

    Anticonvulsants have been evaluated in several trials, and the American Pain Society found level II evidence for this class of drug, whereas the later EULAR guidelines note level I evidence for pregabalin specifically [4,46,49]. Another anticonvulsant drug, gabapentin, has also demonstrated efficacy with respect to pain, patient global assessment, function, and sleep [41,70,72]. Gabapentin has not been approved by the FDA to treat fibromyalgia, and the drug is not specifically noted in treatment guidelines [4,46]. Approximately one-third of the respondents in the NFA survey said they had "ever used" gabapentin, and 46% who had used it considered the drug helpful [27]. The side effect profile of gabapentin is similar to that of pregabalin, but the pharmacokinetic and pharmacodynamic profile is not as favorable [41]. An overview of systematic reviews of anticonvulsants showed that both drugs had a modest effect on pain reduction, and it was not possible to conclude if one drug was better than the other [72]. The long-term safety and efficacy of both drugs is also unknown, and many patients are expected to discontinue therapy due to a high incidence of adverse effects. The overview found no evidence of clinical benefit with any other anticonvulsant, including carbamazepine [72].

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  9. For individuals with fibromyalgia, cyclobenzaprine is most effective in reducing

    TREATMENT

    Strong evidence has also been documented for cyclobenzaprine, which has both muscle relaxant and tricyclic antidepressant properties [26,58,83]. A systematic review of five randomized controlled trials showed that individuals treated with cyclobenzaprine for fibromyalgia were three times as likely to report overall improvement and to note reductions in symptoms, especially sleep disturbances, than controls [83]. Among the NFA survey respondents, 64% had ever used cyclobenzaprine and 58% of these patients considered the drug to be helpful [27].

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  10. Which of the following is NOT a recommended nonpharmacologic approach to fibromyalgia?

    FOLLOW-UP

    The authors of one review of nonpharmacologic treatment suggest that clinicians use the acronym ExPRESS to follow principles of nonpharmacologic pain management [47]:

    • Ex: Exercise

    • P: Psychiatric (i.e., addressing psychiatric comorbidities to help improve pain and disability)

    • R: Regain function (helping patients pace activities to avoid doing too much on days they feel well)

    • E: Education (referral to reliable resources)

    • S: Sleep hygiene

    • S: Stress management (such as cognitive-behavioral therapy and relaxation techniques)

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  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.