Fibromyalgia

Question 1

What are common chronic pain syndromes in children and adults?

Answer 1

Kids- amplified musculoskeletal pain syndrome

Adults- fibromyalgia

Question 2

What are characteristics of chronic pain syndromes?

Answer 2

there are common characteristics among syndromes.

syndromes may move from one symptom complex to another or have characteristics of multiple syndromes

Question 3

What is cause of AMPS?

Answer 3

unknown etiology

can be related to injury, illness, or psychological distress

Question 4

What are hallmark signs of AMPS?

Answer 4

increasing pain over time, heightened pain intensity, absence of other causes

Pain may be diffuse or localized to one body part

Question 5

What patient populations get AMPS?

Answer 5

pre to adolescent girls (mean age 12-13 yrs)
higher socioeconomic status
presence of psychological distress

Question 6

What is presentation of AMPS during assessment?

Answer 6

Pain is not restricted to dermatome or peripheral nerve
can have autonomic dysfunction
multiple joints/muscles involved
multiple painful points
report numbness or weakness
normal neurological exam
normal blood work and radiographs

Question 7

What is fibromyalgia?

Answer 7

chronic musculoskeletal pain syndrome of unknown etiology

Question 8

Who gets fibromyalgia?

Answer 8

prevalence 2-10%
female to male ratio 8:1
Mean age is 30-60 years

Question 9

What are hallmark signs of fibromyalgia?

Answer 9

widespread pain over 3 months with tender points

some characteristics of associated symptoms

Question 10

Where are the tender points for fibromyalgia?

Answer 10

Lower cervical
Second rib
Occiput
Trapezius
Supraspinatus
Lateral epicondyle
Gluteal
Greater trochanter
Knee

Question 11

What are some associated symptoms of fibromyalgia?

Answer 11

fatigue, anxiety, depression, sleep, concentration, morning stiffness, headache, numbness/tingling, temperature sensitivity

Question 12

What was the old diagnostic criteria for fibromyalgia?

Answer 12

American college of rheumatology (1990)
History of widespread pain over 3 months
presence of tender points (11 out of 18)
Bilateral side pain, involving upper and lower body
No standard labs
Rule out other conditions

Question 13

What is the new diagnostic criteria for fibromyalgia?

Answer 13

Part 1: widespread pain index (WPI)

Part 2: symptom severity (SS)

Question 14

What is the WPI?

Answer 14

scored from 0-19

check each area you feel pain in over the past week

Question 15

What do SS scores mean?

Answer 15

2a: score for fatigue, waking unrefreshed and cognitive symptoms, 0-no problem, 3=severe problem
2b: other symptoms, no symptoms=0, 1-10=1, 11-24=2, >25=3

Question 16

How do you get diagnosed with FM?

Answer 16

WPI >7 and SS >5
OR
WPI 3-6 and SS >9
Presence of symptoms for 3 months
R/O other pain conditions

Question 17

What is difference between the two criteria from American college of rheumatology?

Answer 17

Tender points have been removed and replaced by a symptom checklist
inclusive of comprehensive assessment

Question 18

What is pathology behind FM?

Answer 18

Unknown etiology

Question 19

What are predisposing factors for FM?

Answer 19

rheumatic conditions
hereditary
environmental factors
traumatic events

Question 20

What is a possible pathophysiologic model of FM?

Answer 20

muscles, CNS, endocrine

Question 21

What happens with the muscles in FM?

Answer 21

Abnormalities in muscle fibers: decreased type1, atrophy in type 2, muscle tetany
Abnormalities in muscle energy metabolism: low oxidative enzymes

Question 22

What happens with the CNS in FM?

Answer 22

Altered endogenous opioid activity: decreased opioid receptors in pain inhibitory pathways

Altered neurotransmitters and neuropeptides: decreased serotonin, increased substance P and glutamate

Question 23

What happens with the endocrine system in FM?

Answer 23

Imbalance of many hormones: growth hormone cortisol, important for muscle healing

Immune system: elevated immune markers

Question 24

What occurs in neuroendocrine system with FM?

Answer 24

abnormality in hypothalamus-pituitary-adrenal gland axis (HPA)

fatigue and sleep disturbance

Question 25

What is the psychological aspect of chronic pain?

Answer 25

patient focuses on pain patient presents with emotional distress and verbalizes anxiety, depression and frustration suffering of pain is present in absence of pain severity demonstrate avoidance of physical activity due to fear of injury/harm

Question 26

What is the biopsychological model of chronic pain?

Answer 26

Dynamic interaction between physiological, psychological, and social factors that propagates clinical pain presentation

Question 27

What is part of PT eval for chronic pain?

Answer 27

Patient profile: female, middle age, recreational Body chart and location Agg/Easing factors 24 hour behavior: sleep Special questions Current and past history: trauma, psychological Family history: genetics Associated signs and symptoms: sleep issues

Question 28

What are parts of objective assessment for chronic pain?

Answer 28

Pain assessment: VAS, body posture, facial expression, motor behavior, standard pain questionnaires Joint assessment Muscle palpation Tender point assessment Neurological examination Psychological assessment: depression and anxiety questionnaire Functional tests: short form 36, fibromyalgia impact questionnaire

Question 29

What are goals for PT interventions for chronic pain?

Answer 29

Goal is to improve function Less focus on pain assessment Create patient-centered achievable functional goals Acknowledge small gains Have open discussion about discharge planning with patient Recognize need for other health care providers Be empathetic

Question 30

What treatment is best for chronic pain?

Answer 30

Interdisciplinary treatment approach is best: combination of medications, physical activity, and cognitive behavior therapy

Question 31

What is first line of treatment for medical interventions?

Answer 31

Medications: NSAIDS, antidepressants, simple analgesics Education Exercise: low impact

Question 32

What is second line of treatment for medical interventions?

Answer 32

``` Medications: Cognitive behavioral program Structured exercise program Physical medicine and rehab program Trigger point injections Pain management program acupuncture ```

Question 33

What types of exercise do chronic patients need to do?

Answer 33

Aerobic exercise: low impact, gradual increase to moderate intensity, 30 minutes Strengthening: low reps, low weight, concentric exercises Flexibility: not effective when done alone

Question 34

What are the principles behind exercise for chronic pain?

Answer 34

``` Minimize muscle microtrauma Minimize central pain Emphasize on low-moderate intensity exercise and consistency Exercise program must be individualized Encourage self-efficacy ```

Question 35

What can we educate our patients on for chronic pain?

Answer 35

``` FM condition Life-style changes Importance of exercises Pain education/neuroscience education Self-management: improve sleep, reduce pain and stress, energy consumption ```

Question 36

What are alternative therapies for chronic pain?

Answer 36

yoga, acupuncture, energy therapies, body mind relaxation, quigong movement therapy, tai chi These have mixed results

Question 37

What treatments have strong evidence for treating FM?

Answer 37

Amitriptyline, cyclobenzaprine, aerobic exercises, CBT, pt education, multidisciplinary treatment

Question 38

What treatments have moderate evidence for FM treatment?

Answer 38

tramadol, serotonin inhibitors, pregabalin, strength training, acupuncture, biofeedback

Question 39

What are weak evidences for FM?

Answer 39

growth hormone, serotonin, massage, e-stim, US

Question 40

What treatments have no evidence for treating FM?

Answer 40

opioids, corticosteroids, NSAIDs, benzodiazepine, trigger points, flexibility exercises

Question 41

What is prognosis for people with FM?

Answer 41

Negative predictors: depression, pain related anxiety, kinesiophobia or movement avoidance Positive predictors: acceptance of condition, lack of anxiety and depression

Question 42

What is a simple explanation of chronic pain you can give your patient?

Answer 42

Painful signals go from pain nerves to SC to the brain Abnormal reflex in SC to neurovascular nerves Nerves make blood vessels smaller causing lack of oxygen and build up of acid that causes intense pain Pain goes back to the SC across abnormal reflexes back to neurovascular nerves resulting in viscous cycle of pain