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Case 1: Fibromyalgia

A 35 year old married female comes to see the clinician because of a 2 year history of progressively worsening generalized aches and pains in her muscles, and endorses concurrent depression and anxiety. She reports reading an article on fibromyalgia and identifies a great deal of her difficulties in the description she read. She is asking for your opinion and requesting help.

Question 1: The following best explains the relationship between fibromyalgia and depression (select all that apply)

1. Depression occurs only as a result of the psychological stress of being in pain

2. Depression and fibromyalgia are uncommon co-morbid conditions

3. According to ACR criteria, presence of depression automatically disqualifies a diagnosis of fibromyalgia

4. Depression and fibromyalgia appear to share several neurotransmitters as part of their pathophysiology

5. Because depression is often accompanied by somatic symptoms, fibromyalgia is thought to be a more severe subtype of depression

Question 2: The American College of Rheumatology (ACR) Criteria for the diagnosis of fibromyalgia include: (select all that apply)

1. A negative full Rheumatology connective disorder workup

2. A minimum Fourteen out of 18 tender points are positive

3. A minimum 12 month duration of symptoms is required

4. Presence of depression automatically negates a diagnosis of fibromyalgia

5. Pain should be present in all four quadrants of the body

Question 3: Common symptoms accompanying fibromyalgia include: (select all that apply)

Question 4: Cognitive behavioral therapy (CBT) is often recommended for fibromyalgia. Which of the following is/ are true? (select all that apply)

1. CBT is a second line intervention, reserved for patients not responding to pharmacotherapy due to the expense

2. CBT is effective in treating fibromyalgia pain and helps with stress management

3. CBT is most effective in patients not currently on pharmacotherapy

Question 5: This patient mentions physical exercise, and asks if it will help or harm her pain. Which of the following do you think is/are the best advice to give her? (select all that apply)

1. Exercise is helpful to patients with fibromyalgia with high quality evidence supporting its use

2. Exercise is a good idea, but there is no evidence it helps with pain

3. Exercise usually worsens pain of fibromyalgia so avoiding it until the pain improves is advisable

4. Exercise further inflames muscles and treatment guidelines suggest limiting exercising for a year after diagnosis

Question 6: Which of the following statements regarding pharmacotherapy of fibromyalgia is/are correct? (select all that apply)

1. Amitriptyline and gabapentin are FDA approved for the treatment of fibromyalgia and are first line treatment options

2. Patients with fibromyalgia are often susceptible to medication side-effects, hence slow titration is often appropriate

3. Serotonin-norepinephrine reuptake inhibitors are helpful as they modulate the descending pain pathway

4. Alpha-2 delta, calcium modulating medications (gabapentin and pregabalin) are helpful as they are thought to modulate the ascending pain pathway

Question 7: Which best represents your thoughts regarding the use of opiates in patients with fibromyalgia (select all that apply)

1. If an opiate has to be used, the recommendation is to use high potency opiates

2. Opiates are a second line option, after mono-therapy with one medication has failed

3. Opiates while potentially addicting, are thought to have a favorable risk/benefit ratio in most fibromyalgia patients

4. Opiate receptor density has been shown to be abnormal in the brains of patients with fibromyalgia

Question 8: Based on your experience dealing with other patients with Fibromyalgia, how do you feel about her long term prognosis for recovery (pick one response) -

Case 2: Lower Back Pain

A 55 year old, married male comes to clinic for yearly follow up of his long-standing diabetes and hypertension. He is doing well with both. He adds that his lower back has been hurting for 6 months and now its’ affecting his sleep and his functioning as an accountant. He asks for your thoughts and recommendations.

Question 1: Which of the following would be part of a basic exam for a patient presenting with a low back pain? (select all that apply)

1. Collect a thorough history of back pain (duration, location, nature, what makes it worse, what makes it better, etc)

2. Immediately obtain an x-ray and/or MRI, even prior to first appointment if possible

3. Assess for psycho-social stressors, and presence of depression and/or anxiety

4. Obtain a history of any trauma to low back

5. Conduct a physical examination of the back (to include visual examination, range of motion, palpation, SI joint assessment, etc)

6. Ensure evaluation includes assessment to exclude neurological deficits, cauda equine syndrome, metastatic disease to lumbar spine, etc.