Chapter 49 Fibromyalgia

Question 1

Fibromyalgia (FM)

Answer 1

a medical condition that appears to
involve disordered afferent processing and which may be associated with multiple symptoms including: chronic widespread pain, fatigue, sleep disturbances, cognitive alterations, mood disturbances, dysesthesias, stiffness, poor balance, oral and ocular symptoms (e.g., keratoconjunctivitis sicca), headaches, sexual dysfunction, impaired physical function, and
psychological distress

Question 2

The core symptoms seen

in FM and many other “central” pain syndromes are

Answer 2

multifocal pain, fatigue, insomnia, cognitive or memory problems, and, in many cases, psychological distress.

Question 3

Common disorders that may coexist with fibromyalgia

include

Answer 3

regional musculoskeletal pain syndromes (e.g., low back pain, temporomandibular joint disorder [TMD]), chronic fatigue syndrome, irritable bowel syndrome (IBS), irritable bladder syndrome or interstitial cystitis, headaches, vulvodynia, and pelvic pain (often attributed to endometriosis).

Question 4

when individuals have multifocal pain combined with other somatic symptoms

Answer 4

in clinical practice, it is useful to consider a fibromyalgia-like
or central sensitivity syndrome

Question 5

the most reproducible pathogenic features of Fibromylagia

Answer 5

Evidence of augmented pain and sensory processing

Question 6

PATHOPHYSIOLOGY

OF FIBROMYALGIA

Answer 6

Once a diagnosis of fibromyalgia is established, the

most consistently detected objective abnormalities involve pain and sensory processing systems.

Question 7

One of the earliest findings

Answer 7

is that tenderness in FM is not confined to tender points, but extends throughout the entire body.

Question 8

Theoretically, such diffuse tenderness could be due to

Answer 8

psychological (e.g., hypervigilance) or neurobiological factors (i.e., factors that can lead to temporary or permanent amplification of sensory input)

Question 9

FM patients display a decreased threshold

to

Answer 9

heat, cold, and electrical stimuli

Question 10

There are two different specific pathogenic mechanisms
in FM that have been identified using experimental pain
testing:

Answer 10

(1) decreased descending analgesic activity, and

(2) increased wind-up or temporal summation

Question 11

diffuse noxious inhibitory controls (DNIC)

Answer 11

application of
analgesic effect produced by an intense painful stimulus for 2 to 5 min produces generalized
whole-body analgesia

Question 12

The DNIC response is thought to be partly mediated

by

Answer 12

descending opioidergic and serotonergic-noradrenergic

pathways.

Question 13

The biochemical and imaging

findings suggesting increased activity of endogenous opioidergic systems are consistent with

Answer 13

the anecdotal experience
that opioids are generally ineffective in FM and
related conditions

Question 14

efficacious in treating FM and related conditions

Answer 14

any type of compound that simultaneously raises both serotonin and norepinephrine
(tricyclics, duloxetine, milnacipran, tramadol)

Question 15

individuals

with FM may have evidence of wind-up, indicative of

Answer 15

central sensitization

Question 16

patients with

FM have approximately threefold higher concentrations of

Answer 16

substance P in CSF compared with normal controls

Question 17

Another neurotransmitter in pain processing that likely

plays some role in FM is

Answer 17

the excitatory neurotransmitter

glutamate. CSF levels of glutamate are twice as high in FM patients than controls

Question 18

a strong genetic and

familial component to the development of fibromyalgia

Answer 18

First-degree relatives of individuals with fibromyalgia display
an eightfold greater risk of developing fibromyalgia
than those in the general population

Question 19

affective spectrum disorder, and more recently central sensitivity syndromes and chronic multi-symptom illnesses.

Answer 19

familial and personal coaggregation of functional pain syndromes was originally

Question 20

Neural Influences on Pain and Sensory Processing

Facilitation

Answer 20

Increase Substance P, Glutamate and EAA, Serotonin (5HT2a, 3a), Nerve Growth Factor, CCK

Question 21

Neural Influences on Pain and Sensory Processing

Inhibition

Answer 21

• Descending anti nociceptive pathways (Decrease NE, Serotonin, Dopamine)
  Increase Opioids, GABA, Cannabanoids, Adenosine

Question 22

DIAGNOSIS AND ASSESSMENT

OF FIBROMYALGIA

Answer 22

The ACR research criteria for FM require that an individual
have both a history of chronic widespread pain and
over 11 of a possible 18 tender points on examination

Question 23

optimal treatment of fibromyalgia supports a

Answer 23

multifaceted program comprising pharmacologic therapy and nonpharmacologic therapy (education, exercise, and cognitive behavioral therapy).

Question 24

Pregabalin

Answer 24

an alpha-2-delta ligand
and antiepileptic drug. is a g-aminobutyric acid (GABA) analog antiepileptic drug that binds to the a-2-d subunit of calcium channels.

Question 25

duloxetine

milnacipran

Answer 25

a selective serotoninnorepinephrine
reuptake inhibitor (SNRI),

Question 26

Antidepressants.

Answer 26

amitriptyline

Question 27

Tricyclic Antidepressants (TCAs)

Answer 27

The effectiveness of
TCAs, especially amitriptyline and cyclobenzaprine, in
treating the symptoms of pain, poor sleep, and fatigue
associated with fibromyalgia

Question 28

Cyclobenzaprine

Answer 28

centrally acting muscle relaxant structurally similar to amitriptyline, has been used to
treat the musculoskeletal pain and sleep disturbances
associated with FM.

Question 29

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Answer 29

SNRIs tend to be better tolerated than older TCAs. Venlafaxine tends to have clinically significant effects on norepinephrine reuptake only at higher doses and thus may be beneficial in FM when used at these higher
doses

Question 30

Milnacipran also demonstrated benefit in FM

Answer 30

including
improvements in fatigue, physical functioning, and
discomfort

Question 31

Centrally Acting Agents. g-Hydroxybutyrate,

Answer 31

a GABA precursor with strong sedative qualities, has been

shown to be beneficial in FM

Question 32

Pramipexole

Answer 32

a dopamine agonist used for Parkinson’s
disease and restless leg syndrome that has been shown in
one controlled study to improve pain and sleep in FM
patients treated with concomitant analgesics

Question 33

pure opioids

Answer 33

anecdotal experience has not found this
class of analgesics to be effective.

Question 34

Tramadol

Answer 34

a compound that exerts weak analgesic effects by binding to the m-opioid receptor, but the majority of its analgesic effects likely stem from serotonin/norepineprhine
reuptake inhibition. Tramadol appears to possess some beneficial effects in the management of FM both alone and as a fixed-dose combination with acetaminophen.

Question 35

exercise is beneficial in FM for both

Answer 35

physical symptoms and functional capacity.

Question 36

crucial for optimal

adherence to regimens

Answer 36

The use of low-intensity, low-impact programs and the

ability to individualize the protocol

Question 37

Catastrophizing,

Answer 37

or the belief that the worst possible outcome is going to occur, has been associated with pain severity, decreased functioning, and affective distress in FM

Question 38

Relaxation techniques

Answer 38

commonly part of cognitive behavioral therapy (CBT) for FM. progressive muscle
relaxation (PMR), autogenic training, guided imagery, and
meditation.

Question 39

multicomponent treatment reduces

Answer 39

pain, fatigue, and depressive symptoms, and improves

quality of life and physical fitness post-treatment