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Q1: Definition, mechanism and classification (2 min)
- Define fibromyalgia as a chronic central sensitisation (nociplastic) pain disorder: widespread pain + fatigue + unrefreshing sleep + cognitive dysfunction ('fibro-fog') + somatic co-symptoms, with no tissue inflammation or damage.
- Describe the pathophysiology: heightened excitability of central nociceptive neurons (temporal summation/'wind-up'); neurochemical imbalance — increased substance P and glutamate, decreased serotonin, noradrenaline and dopamine; impaired descending inhibitory pathways; HPA-axis and autonomic dysfunction; and the alpha-delta sleep anomaly.
- Reproduce the ACR 2016 criteria: WPI at least 7 and SSS at least 5, OR WPI 4 to 6 and SSS at least 9; symptoms for at least 3 months; a fibromyalgia diagnosis may coexist with other conditions. Note that the old 1990 criterion of at least 11 of 18 tender points is abandoned.
Q2: Clinical features and bedside assessment (2 min)
- List the core features: widespread migrating aching pain (axial + bilateral, upper and lower), fatigue, unrefreshing sleep, fibro-fog, and somatic co-symptoms (IBS, headache, dysmenorrhoea, TMJ pain, bladder urgency, non-dermatomal paraesthesia).
- State that examination is normal apart from tenderness — no synovitis, warmth, weakness, sensory level or organomegaly; document a full joint, neurological and general examination.
- Screen for red flags demanding investigation: weight loss, fever, night pain/sweats, neurological deficit, joint swelling, markedly raised inflammatory markers.
- Use the WPI/SSS and the Fibromyalgia Impact Questionnaire; screen mood (PHQ-9, GAD-7) and sleep.
Q3: Management (3 min)
- Emphasise that non-pharmacological therapy is first-line and the most effective: patient education/validation, graded aerobic exercise, CBT, sleep hygiene, stress management and pacing; a multidisciplinary approach.
- State the pharmacological adjuncts chosen by predominant symptom: duloxetine/milnacipran (SNRI), pregabalin/gabapentin (alpha-2-delta), low-dose amitriptyline nocte; start one, titrate slowly, review at 4 to 8 weeks; treat comorbid depression/anxiety.
- State what to avoid: strong opioids (ineffective; cause hyperalgesia, dependence); corticosteroids and immunosuppressants have no role; minimise benzodiazepines.
Q4: Differential diagnosis, overlap and prognosis (3 min)
- List the key mimics to exclude: hypothyroidism (TSH), polymyalgia rheumatica (ESR/CRP, age), inflammatory arthritis (synovitis + autoantibodies), polymyositis (CK + proximal weakness), myofascial pain syndrome (localised trigger points).
- Explain the overlap with inflammatory rheumatic disease (RA, SLE, SpA in 20 to 30 percent): nociplastic pain inflates disease-activity scores (DAS28, SLEDAI, BASDAI); treat each component separately and do not escalate immunosuppression solely for central pain.
- Summarise prognosis: chronic and fluctuating but not life-shortening, not progressive, not destructive; realistic goal is improved function and quality of life; predictors of better outcome include engagement with exercise and CBT, good support, and absence of ongoing opioid use or untreated mood disorder.