Take this quiz on one of the most controversial diagnoses in pain management.
Fibromyalgia is one of the most controversial diagnoses in the field of pain management.
Some health care professionals believe that the symptoms of this disorder are primarily due to mental disorders, while others believe that it is a physical disorder and that any signs of mental disorders are secondary to the pain and other physical symptoms. It is clear that many symptoms of fibromyalgia can also be symptoms of mental disorders, and it can be difficult to differentiate between them.
1. The most current research indicates that fibromyalgia is a musculoskeletal disorder.
2. Which diagnostic screening instruments are considered to be the most useful for diagnosing fibromyalgia?
A. Widespread Pain Index
B. McGill Pain Questionnaire
C. Symptom Severity Scale
D. A and C
E. All of the above
3. Chronic widespread pain is sufficient to make the diagnosis of fibromyalgia.
4. The diagnosis of fibromyalgia should be made only after other possible etiologies for widespread pain are excluded.
5. Current research indicates that mental disorders may be frequently misdiagnosed as fibromyalgia.
6. What form of therapy has been found to be most efficacious for the management of fibromyalgia?
A. Cognitive behavioral therapy
7. What form of exercise appears to be most effective for the management of fibromyalgia?
C. The most effective form of exercise has yet to be determined
8. Opioids are the most effective analgesics for the management of fibromyalgia.
9. In addition to tramadol, which other medications have been found to be effective for the management of fibromyalgia?
B. Milnacipran and duloxetine
E. A, B, and C
F. All of the above
10. What form of psychotherapy appears to be most effective for the management of fibromyalgia?
A. Cognitive behavioral therapy
11. As of yet, there are no good predictive factors to determine which of the recommended therapies is most likely to benefit the individual patient with fibromyalgia.
For answers to this quiz, please see next page.
1. Answer: B. False
Although the etiology of fibromyalgia is still unclear, at the present time it is primarily viewed as a neurologic disorder.1
2. Answer: D. A and C
Widespread Pain Index and Symptom Severity Scale. These instruments incorporate the American College of Rheumatology diagnostic criteria for fibromyalgia, which are the most widely used criteria.2,3
3. Answer: B. False
Although pain in multiple parts of the body is the primary symptom of fibromyalgia, the diagnosis also requires multiple somatic symptoms, including fatigue, unrefreshing sleep, and cognitive impairment.2,3
4. Answer: A. True
Because there are no diagnostic tests for fibromyalgia, the clinical diagnosis is based primarily on history and self-report of symptoms. Many other disorders, both physical and mental, can present with the same symptoms of fibromyalgia; it is therefore imperative to rule these out before making the diagnosis of fibromyalgia.4
5. Answer: A. True
It can be difficult to differentiate depressive and anxiety disorders from fibromyalgia. They can present with symptoms similar to those of fibromyalgia, including widespread pain, and there are no diagnostic tests for them.
In my experience, many patients who actually have a primary mental disorder are given the diagnosis of fibromyalgia, although they do not fulfill the diagnostic criteria for it. There is still a widespread belief that if pain is secondary to a mental disorder, it is consequently not “real.” The outcome is that patients may interpret this as indicating that health care providers may not be taking their pain seriously.5
6. Answer: C. Exercise
Although all of these therapies have been found to be beneficial for fibromyalgia, the strongest evidence supports the use of exercise.6
7. Answer: C. The most effective form of exercise has yet to be determined
As of yet, the most effective type of exercise for the management of fibromyalgia is still unclear.6
8. Answer: B. False
In general, the opioids appear to be ineffective for the treatment of pain associated with fibromyalgia. The only opioid-containing drug that has been found to be effective for fibromyalgia is tramadol, which contains both an opioid and an SNRI. Studies show that most of the analgesic effect is attributable to the SNRI.6
9. Answer: E. A, B, and C
The SNRIs amitriptyline, milnacipran, and duloxetine and the anticonvulsant pregabalin have been found to be most efficacious for the management of fibromyalgia. However, it is uncertain whether these SNRIs are really more effective than other SNRIs, or whether pregabalin is more effective than other anticonvulsants, including gabapentin-or if it is just that they have been studied more than other medications in the same class.
In general, the SSRIs have been found to be far less effective than the SNRIs for any form of pain.6
10. Answer: A. Cognitive behavioral therapy
Biofeedback and hypnotherapy have not been found to be especially efficacious for the management of fibromyalgia.6
11. Answer: A. True
As with most forms of chronic pain, there is very little information as to which treatment is likely to be most effective for an individual patient.6
1. Clauw DJ, Hiroshi U. Summary of the Fibromyalgia Research Symposium 2016 in Nagasaki. PAIN Reports. 2017. http://journals.lww.com/painrpts/Fulltext/2017/02000/Summary_of_the_Fibromyalgia_Research_Symposium.2.aspx. Accessed November 15, 2017.
2. Wolfe F, Clauw DJ, Fitzcharles MA, et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol. 2011;38:1113-1122.
3. Wolfe F, Clauw DJ, Fitzcharles MA, et al. 2016 revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum. 2016;46:319-329.
4. Hauser W, Perrot S, Sommer C, et al. Diagnostic confounders of chronic widespread pain: not always fibromyalgia. PAIN Reports. 2017. http://journals.lww.com/painrpts/Abstract/2017/06000/Diagnostic_confounders_of_chronic_widespread_pain_.2.aspx. Accessed November 15, 2017.
5. Gittins R, Howard M, Ghodke A, et al. The accuracy of a fibromyalgia diagnosis in general practice. Pain Med. July 2017; Epub ahead of print.
6. Macfarlane GJ, Kronisch C, Dean LE, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 2017;76:318-328.