Module 4v2

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@@.whitetext; !!!VA_Pain training_4 Welcome to the one in a series of interactive scenarios to support learning during pain training. You can find out more on using this scenario ''[[here|howtoguide]]''. ''Disclaimer: Virtual Anaesthetics is not responsible for your use of the information contained in or linked from this site. All users should act within their own competence and according to local and national guidelines and policies. All treatment information contained herein is provided as a general example only and you should always check drug doses in an appropriate formulary. Any descriptions of procedures or techniques is intended as an example only and as a supplement formal training. Individuals should only perform procedures or techniques they have been formally trained in and are competent to perform.'' @@ ''[[Next|Introduction]]'' [[I'm a clinical supervisor or trainer|trainers_area]] @@.whitetext; If you are ''not'' a health care professional please read our brief message first [[here|message]]@@ <<set $result to 0>> <<set $hot to false>> <<set $bee to false>> <<set $lake to false>> <<set $creative to false>> <<set $pandd to false>> <<set $sleep to false>> <<set $phd to false>> <<set $obs to false>> <<set $no to false>>

/* <<countdownTimer>> Widget - Start */ <<widget "countdownTimer">> <<set _seconds = $args[0]>> <<set _minutes = Math.floor(_seconds / 60)>> <<set _replacementPassage = $args[1]>> <div id="timer" class="timergreen">Time remaining _minutes:<<= (_seconds - (_minutes * 60)).toString().padStart(2, '0')>></div><<script>> if (!recall("countdown", undefined)) { setup.countdown = { startTime: new Date(), lastStr: "", passage: passage() }; memorize("countdown", setup.countdown); } else { setup.countdown = recall("countdown"); if (setup.countdown.passage !== passage()) { setup.countdown = { startTime: new Date(), lastStr: "", passage: passage() }; memorize("countdown", setup.countdown); } } setup.countdown.intervalID = setInterval(function () { if (setup.countdown.passage !== passage()) { clearInterval(setup.countdown.intervalID); forget("countdown"); setup.countdown.passage = ""; } else { var curtime = new Date(), str, seconds = State.temporary.seconds; var diff = Math.floor(seconds - ((curtime - setup.countdown.startTime) / 1000)), min = Math.floor(diff / 60); if ((diff >= 0) && (diff < seconds)) { if ($("#timer").length) { str = "Time remaining " + min + ":" + (diff - (min * 60)).toString().padStart(2, '0'); if (str != setup.countdown.lastStr) { $("#timer").empty().wiki(str); setup.countdown.lastStr = str; } if (diff <= 10) { if (!$("#timer").hasClass("timerred")) { $("#timer").removeClass("timeramber").addClass("timerred"); } } else if (diff <= 20) { if (!$("#timer").hasClass("timeramber")) { $("#timer").removeClass("timergreen").addClass("timeramber"); } } } } if (diff < 0) { clearInterval(setup.countdown.intervalID); forget("countdown"); $("#passages div.passage").empty().wiki('<<include "' + State.temporary.replacementPassage + '">>'); delete setup.countdown.passage; } } }, 200); <</script>> <</widget>> /* <<countdownTimer>> Widget - End */

@@.whitetext; !!!VA_Pain training_4: Fibromyalgia Enter your first name: <<textbox "$firstname" "">> Enter your surname: <<textbox "$surname" "">> <<set $role = ["-", "Stage 1 Anaesthetist in Training", "Stage 2 Anaesthetist in Training", "Stage 3 Anaesthetist in Training", "Consultant Anaesthetist", "Associate Specialist Anaesthetist", "Speciality Doctor Anaesthetist", "Foundation Doctor", "Doctor (Other)", "Medical Student", "Other health care professional", "Role outside healthcare"]>>''Select your professional role:'' <<listbox "$role">> <<optionsfrom $role>> <</listbox>> <<set $randomid to random(10000000,99999999)>> <<nobr>><span id="ReplaceMe"> <<link "''Next''">> <<script>> Dialog.setup("Analytics"); Dialog.wiki("Users' privacy and data protection are our priorities. Virtual Anaesthetics uses analytics and collects anonymised data to improve your service and provide academic governance including passage function, anonymised scores, playtime, and any feedback comments you provide. This anonymised data may also be used in part or in its entirety for research and publication. For more information on our privacy policy please see ''[[here|https://www.virtualanaesthetics.com/privacy-policy/]]''. Please also be aware that this information is temporarily stored in your local internet browser cache. If using a public or shared computer you can avoid this by clearing your internet history and website data on competition of the scenario."); Dialog.open(); <</script>> <<replace "#ReplaceMe">> ''[[Next|Core clinical learning objectives]]''<br> <</replace>> <</link>></span><</nobr>>

<<cacheaudio "fibrointro" "audio/fibrointro.mp3">> <<cacheaudio "creativehopelessness" "audio/creativehopelessness.mp3">> <<set $history to []>> <<set $started to 0>>

!!@@.greentext;2021 Curriculum learning syllabus@@ !!!@@.greentext;Stage 1 Pain learning outcomes@@ @@.greentext; ''//Recognises, assesses and treats acute pain independently Differentiates between acute and chronic pain//''@@ !!!@@.greentext;Key capabilities@@ * Can recognise, examine, assess and manage acute pain in the surgical and non-surgical patient * Is able to safely and appropriately prescribe medication for pain management * Demonstrates effective communication skills regarding pain management with patients, relatives and carers * Demonstrates the basic assessment and management of acute on chronic and chronic pain in adults * Describes the concept of biopsychosocial multi-disciplinary pain management * Describes the special circumstances in assessing and managing perioperative pain in specific patient groups including children, pregnancy and breast feeding, the elderly and frail, those with learning and communication difficulties, autism, dementia, renal and hepatic impairment and substance abuse * Demonstrates the safe use of equipment used in pain management !!!@@.greentext;Stage 2 learning outcome:@@ @@.greentext;''//Understands the aetiology and management of acute, acute on chronic and chronic pain//''@@ !!!@@.greentext;Key capabilities@@ * Utilises a multi-disciplinary approach to the management of complex pain within a biopsychosocial model of care * Can confidently manage acute pain in the whole perioperative pathway in a timely manner * Is able to assess patients, interpret investigations and initiate management of chronic malignant and non-malignant pain in a timely manner under distant supervision * Can assess and manage acute on chronic and chronic inpatient pain in adults and recognise when referral to specialist pain services is appropriate * Identify barriers to effective pain management including those related to patient beliefs, society, culture, and healthcare provision * Explains the risk factors for persistent post-surgical pain including measures to minimise its occurrence !!!@@.greentext;Stage 3 learning outcome:@@ @@.greentext;''//Able to initiate complex pain management for in-patients and to sign-post to appropriate pain management services//''@@ !!!@@.greentext;Key capabilities@@ * Applies knowledge and understanding of assessment and management of pain in a multiprofessional context * Demonstrates safe effective pharmacological management of acute and procedure pain in all age groups * Acts as an effective member of the inpatient pain team * Effectively engages with multi-disciplinary primary and secondary pain services and palliative care when necessary * Recognises the need for and complications of interventional pain procedures * Prescribes appropriately in the perioperative period and recognises the long term implications of not reviewing patient analgesia in the post–operative period following discharge * Plans the perioperative management of patients for surgery who are taking high dose opioids and other drugs of potential addiction [[Back|Core clinical learning objectives]]

!!!@@.greentext;Scenario learning objectives:@@ By the end of Module 4 you should be able to: * Know the commonly used diagnostic criteria for fibromyalgia (FM) * Describe the clinical presentation of fibromyalgia and its differential diagnosis * Understand the initial management of FM * Have an overview of a psychological model-based pain management programme (PMP) * Appreciate the importance of the multi-disciplinary team in the management of FM * Summarise the recommendations on the use of drugs commonly used in persistent pain in pregnancy [[Next|Start of shift]] [[Show me the curriculum for this scenario|curriculum]]

@@.whitetext;<p style="text-align:justify">''Q1 Fibromyalgia (FM):'' </p> <<radiobutton "$choice1" "1">>  ''A.'' Is more commonly diagnosed in females across all ages <<radiobutton "$choice1" "2">>  ''B.'' Has a prevalence of approximately 2-6% of the population in the developed world <<radiobutton "$choice1" "3">>  ''C.'' Is usually diagnosed between the ages of 50 and 60 <<radiobutton "$choice1" "4">>  ''D.'' Is increasing in incidence according to studies in the UK <<radiobutton "$choice1" "5">>  ''C.'' Like chronic fatigue is associated with lower socioeconomic status@@ <<timed 59s>> <<goto Q2>> <</timed>> <<countdownTimer 60 "Q2">> <<button [[Next question->Q2]]>> <</button>>

!!!@@.greentext; Scenario learning objectives:@@ By the end of scenario 4 you should be able to: * Know the commonly used diagnostic criteria for fibromyalgia (FM) * Describe the clinical presentation of fibromyalgia and its differential diagnosis * Understand the initial management of FM * Have an overview of a psychological model-based pain management programme (PMP) * Appreciate the importance of the multi-disciplinary team in the management of FM * Summarise the recommendations on the use of drugs commonly used in persistent pain in pregnancy [[Credits and certificate|credits]] <<set $historyOutput to "">> <<nobr>> <<set _last to $started>> <<for _event range $history>> <<set $historyOutput to $historyOutput + "<br>Passage: " + _event.passage + ", Seconds: " + setup.toSeconds(_last, _event.time)>> <<set _last to _event.time>> <</for>> <</nobr>> <<nobr>> <<set $passagetimes to $historyOutput>> <<set $id to "VApain4">> <<set $playtimehr to playTime('hours')>> <<set $playtimemin to playTime('minutes')>> <<set _data = {randomid: $randomid, role: $role, id: $id, playtimehr: $playtimehr, playtimemin: $playtimemin, result1: $result1, result2: $result2, passagetimes: $passagetimes }>> <<run sendData4(_data)>> <</nobr>>

@@.whitetext;<<if $choice1 eq "2">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q2 Regarding the pathology of FM:''</p> <<radiobutton "$choice2" "1">>  ''A.'' The neuroimaging of individuals with FM is indistinguishable from that of healthy controls <<radiobutton "$choice2" "2">>  ''B.'' There is conclusive evidence that alterations in peripheral pain processing are the cause of the symptoms seen in FM <<radiobutton "$choice2" "3">>  ''C.'' FM is likely to be an immune mediated disorder due to disordered cytokine production <<radiobutton "$choice2" "4">>  ''D.'' First degree relatives of people with FM are 8.5 times more likely to develop FM <<radiobutton "$choice2" "5">>  ''E.'' Autonomic dysfunction is not a feature of the condition and should alert the clinician to an alternative diagnosis @@ <<timed 59s>> <<goto Q3>> <</timed>> <<countdownTimer 60 "Q3">> <<button [[Next Question->Q3]]>> <</button>>

@@.whitetext;<<if $choice2 eq "4">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q3 In relation to the diagnosis of FM:''</p> <<radiobutton "$choice3" "1">>  ''A.'' Requires the physical finding of at least 10 out of 16 defined tender points <<radiobutton "$choice3" "2">>  ''B.'' Chronic widespread pain of at least three months duration as cardinal symptom of FM <<radiobutton "$choice3" "3">>  ''C.'' Positive antinuclear antibody or rheumatoid factor are highly likely to exclude a diagnosis of FM <<radiobutton "$choice3" "4">>  ''D.'' Vitamin D levels provide important information for diagnosis <<radiobutton "$choice3" "5">>  ''E.'' Diagnostic criteria exist for FM and should be adhered to for individual diagnosis @@ <<timed 59s>> <<goto Q4>> <</timed>> <<countdownTimer 60 "Q4">> <<button [[Next question->Q4]]>> <</button>>

@@.whitetext;<<if $choice3 eq "2">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q4 There are a number of features seen in FM including which of the following:''</p> <<radiobutton "$choice4" "1">>  ''A.'' Psychiatric disturbance, IBS, and migraine occur more commonly in people with FM than in the general population <<radiobutton "$choice4" "2">>  ''B.'' Symptoms of autonomic dysfunction including orthostatic hypotension, altered heart rate variability and Raynaud’s Phenomenon is seen in some patients <<radiobutton "$choice4" "3">> ''C.'' Patient’s frequently report paraesthesia including numbness, burning or crawling sensations <<radiobutton "$choice4" "4">>  ''D.'' Fatigue and sleep disturbance are core features of the condition <<radiobutton "$choice4" "5">>  ''E.'' All of the above @@ <<timed 59s>> <<goto Q5>> <</timed>> <<countdownTimer 60 "Q5">> <<button [[Next question->Q5]]>> <</button>>

@@.whitetext;<<if $choice4 eq "5">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q5 The differential diagnosis of FM is wide and there are no confirmatory tests to support the diagnosis. All of the following should alert the clinician to an alternative diagnosis except:'' </p> <<radiobutton "$choice5" "1">>  ''A.'' Pain in the joints associated with swelling <<radiobutton "$choice5" "2">>  ''B.'' Elevated ESR and/or CRP associated with morning stiffness <<radiobutton "$choice5" "3">>  ''C.'' Skin biopsy showing small fibre neuropathy <<radiobutton "$choice5" "4">>  ''D.'' Generalized fatigue not associated with pain <<radiobutton "$choice5" "5">>  ''E.'' Persistent depressed mood and loss of interest in things as the dominant symptom @@ <<timed 59s>> <<goto Q6>> <</timed>> <<countdownTimer 60 "Q6">> <<button [[Next question->Q6]]>> <</button>>

@@.whitetext;<<if $choice5 eq "3">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q6 The initial management of FM should include:''</p> <<radiobutton "$choice6" "1">>  ''A.'' Titrated opioids up to a maximum of 120mg/24h <<radiobutton "$choice6" "2">>  ''B.'' Referral for psychological interventions for pain management for all patients <<radiobutton "$choice6" "3">>  ''C.'' Patient education as a prominent aspect of management <<radiobutton "$choice6" "4">>  ''D''. A structured programme of cardiovascular fitness training starting at a minimum of 30 low-impact sessions a week <<radiobutton "$choice6" "5">>  ''E.'' The initiation of a tricyclic antidepressant@@ <<timed 59s>> <<goto Q7>> <</timed>> <<countdownTimer 60 "Q7">> <<button [[Next question->Q7]]>> <</button>>

@@.whitetext;<<if $choice6 eq "3">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q7 For patients not responsive to initial therapies the next step in management should be:'' </p> <<radiobutton "$choice7" "1">>  ''A.'' Withdrawal of the initial drug therapy if benefit is not seen at the maximum tolerated dose <<radiobutton "$choice7" "2">>  ''B.'' To assume that non-adherence to the agreed treatment plan is likely <<radiobutton "$choice7" "3">>  ''C.'' Referral to Rheumatology as an underlying inflammatory rheumatic disease is likely if there has been treatment failure <<radiobutton "$choice7" "4">>  ''D.'' A combination of pharmacological and nonpharmacological treatment depending on symptoms is appropriate <<radiobutton "$choice7" "5">>  ''E.'' Referral to a supervised exercise programme @@ <<timed 59s>> <<goto "Q8">> <</timed>> <<countdownTimer 60 "Q8">> <<button [[Next question->Q8]]>> <</button>>

@@.whitetext;<<if $choice7 eq "4">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q8 FM frequently affects women of childbearing age. A patient with FM who becomes pregnant should be told:'' </p> <<radiobutton "$choice8" "1">>  ''A.'' During pregnancy and the immediate postpartum period they will experience a reduction in the symptoms they associate with FM <<radiobutton "$choice8" "2">>  ''B.'' During pregnancy and the immediate postpartum period they may experience an increase in the symptoms they associate with FM but these symptoms frequently occur in pregnant women without FM <<radiobutton "$choice8" "3">>  ''C.'' During pregnancy they will experience a reduction in the symptoms they associate with FM with an increase in symptoms in the postpartum period <<radiobutton "$choice8" "4">>  ''D.'' There are no studies on the relationship between FM and pregnancy <<radiobutton "$choice8" "5">>  ''E.'' The symptoms of FM are not affected by pregnancy in the majority of women @@ <<timed 59s>> <<goto "Q9">> <</timed>> <<countdownTimer 60 "Q9">> <<button [[Next question->Q9]]>> <</button>>

@@.whitetext;<<if $choice8 eq "2">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q9 Regarding commonly used analgesic drugs in pregnancy and breastfeeding:'' </p> <<radiobutton "$choice9" "1">>  ''A.'' Women on gabapentin should take high dose folic acid during the first trimester <<radiobutton "$choice9" "2">>  ''B.'' The higher risk period for teratogenicity includes weeks 4 to 16 of pregnancy when major embryological organogenesis occurs <<radiobutton "$choice9" "3">>  ''C.'' NSAIDs should be avoided during the second trimester due to risk of neonatal pulmonary hypertension and in utero ductus arteriosus constriction <<radiobutton "$choice9" "4">>  ''D.'' During the postpartum period codeine should be used in preference to tramadol or dihydrocodeine in breastfeeding women <<radiobutton "$choice9" "5">>  ''E.'' Lower doses of several analgesic agents should be used to reduce the likelihood of foetal toxicity @@ <<timed 59s>> <<goto "Q10">> <</timed>> <<countdownTimer 60 "Q10">> <<button [[Next question->Q10]]>> <</button>>

@@.whitetext;<<if $choice9 eq "1">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q10 Psychiatric comorbidity can occur in people with persistent pain problems and may be treated with antidepressant drugs. On the use of antidepressant agents in pregnancy and during breastfeeding:'' </p> <<radiobutton "$choice10" "1">>  ''A.'' Monoamine oxidase inhibitors are considered safe in pregnancy <<radiobutton "$choice10" "2">>  ''B.'' Of the serotonin reuptake inhibitors paroxetine is the first-choice drug of its class <<radiobutton "$choice10" "3">>  ''C.'' Patients successfully treated with antidepressants prior to pregnancy should generally continue the same drug <<radiobutton "$choice10" "4">>  ''D.'' Withdrawal of antidepressants should be attempted as soon as pregnancy is confirmed <<radiobutton "$choice10" "5">>  ''E.'' Tricyclic antidepressants are associated with a high incidence of congenital birth defects @@ <<timed 59s>> <<goto "Done!">> <</timed>> <<countdownTimer 60 "Done!">> <<button [[Done!->Done!]]>> <</button>>

<<if $choice10 eq "3">><<set $result to $result + 1>> <</if>> You've scored <<print $result>> out of 10 <<set $result1 to $result>> [[Time for work]]

It's 8:28am next morning when you arrive in the department. You’ve spent the journey to work pondering what gave Alison the impression you enjoyed MCQ so that you can avoid doing that elsewhere. You find Paul arranging chairs in one of the seminar rooms. “Morning $firstname!” he says brightly. “There’s a printed programme for the day over on the side there if you wanted to take a look?” You pick up a [[programme]]

You have another session in the pain service tomorrow. It’s a change from the busy acute side of things from last week. You are flicking through the latest online edition of the BJA when the email notification pings up in the corner of the screen. [[click to open the email->email1]]

@@.typing;''From:'' James Jones (Consultant Pain Management) ''Sent:'' Today ''To:'' Dr $firstname $surname ''Subject:'' Tomorrow Hi $firstname I’m afraid I’ve managed to double book myself tomorrow so won’t be in first thing. Fortunately, Paul our other psychologist has a PMP on and he is more than happy for you to join him. It’s an excellent opportunity for you to see one way of how these can be delivered. Alison said you rather enjoyed the MCQs she sent you last time you did an acute pain round so fortunately I’ve manged to find some that are relevant to the topic! I've also attached a summary of the information on UpToDate® that you are likely to find relevant. BW James Dr James Jones, MBBS FRCA FFPMRCA Consultant in Anaesthesia and Pain Medicine, UK @@ [[www.onlinepainMCQ.ac.uk->warning]] [[UpToDate® summary]] [[I'll skip those thanks->Time for work]]

@@.whitetext;<p style="text-align:justify">''Q1 Fibromyalgia (FM):'' </p> <label><<radiobutton "$choice1" "one">>  ''A.'' Is more commonly diagnosed in females across all ages </label> <label><<radiobutton "$choice1" "two">>  ''B.'' Has a prevalence of approximately 2-6% of the population in the developed world</label> <label><<radiobutton "$choice1" "three">>  ''C.'' Is usually diagnosed between the ages of 50 and 60</label> <label><<radiobutton "$choice1" "four">>  ''D.'' Is increasing in incidence according to studies in the UK </label> <label><<radiobutton "$choice1" "five">>  ''E.'' Like chronic fatigue is associated with lower socioeconomic status </label> @@ <br> <<button [[Next question->Q2post]]>> <</button>> <<set $result to 0>>

@@.whitetext;<<if $choice1 eq "two">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 <p style="text-align:justify">''Q2 Regarding the pathology of FM:'' </p> <label><<radiobutton "$choice2" "one">>  ''A.'' The neuroimaging of individuals with FM is indistinguishable from that of healthy controls </label> <label><<radiobutton "$choice2" "two">>  ''B.'' There is conclusive evidence that alterations in peripheral pain processing are the cause of the symptoms seen in FM</label> <label><<radiobutton "$choice2" "three">>  ''C.'' FM is likely to be an immune mediated disorder due to disordered cytokine production </label> <label><<radiobutton "$choice2" "four">>  ''D.'' First degree relatives of people with FM are 8.5 times more likely to develop FM </label> <label><<radiobutton "$choice2" "five">>  ''E.'' Autonomic dysfunction is not a feature of the condition and should alert the clinician to an alternative diagnosis </label> <br> <<button [[Next Question->Q3post]]>> <</button>>

@@.whitetext;<<if $choice2 eq "four">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 <p style="text-align:justify">''Q3 In relation to the diagnosis of FM:''</p> <label><<radiobutton "$choice3" "one">>  ''A.'' Requires the physical finding of at least 10 out of 16 defined tender points </label> <label><<radiobutton "$choice3" "two">>  ''B.'' Chronic widespread pain of at least three months duration as cardinal symptom of FM </label> <label><<radiobutton "$choice3" "three">>  ''C.'' Positive antinuclear antibody or rheumatoid factor are highly likely to exclude a diagnosis of FM </label> <label><<radiobutton "$choice3" "four">>  ''D.'' Vitamin D levels provide important information for diagnosis </label> <label><<radiobutton "$choice3" "five">>  ''E.'' Diagnostic criteria exist for FM and should be adhered to for individual diagnosis </label> <br> <<button [[Next Question->Q4post]]>> <</button>>

@@.whitetext;<<if $choice3 eq "two">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 <p style="text-align:justify">''Q4 There are a number of features seen in FM including which of the following:''</p> <label><<radiobutton "$choice4" "one">>  ''A.'' Psychiatric disturbance, IBS, and migraine occur more commonly in people with FM than in the general population </label> <label><<radiobutton "$choice4" "two">>  ''B.'' Symptoms of autonomic dysfunction including orthostatic hypotension, altered heart rate variability and Raynaud’s Phenomenon is seen in some patients </label> <label><<radiobutton "$choice4" "three">>  ''C.'' Patient’s frequently report paraesthesia including numbness, burning or crawling sensations </label> <label><<radiobutton "$choice4" "four">>  ''D.'' Fatigue and sleep disturbance are core features of the condition </label> <label><<radiobutton "$choice4" "five">>  ''E.'' All of the above</label> <br> <<button [[Next Question->Q5post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q1 Fibromyalgia (FM):''</p> <label><<radiobutton "$choice1" "one" `$choice1 is "one" ? 'checked' : ''`>>  ''A.'' Is more commonly diagnosed in females across all ages </label> <label><<radiobutton "$choice1" "two" `$choice1 is "two" ? 'checked' : ''`>>  ''B.'' Has a prevalence of approximately 2-6% of the population in the developed world</label> <label><<radiobutton "$choice1" "three" `$choice1 is "three" ? 'checked' : ''`>>  ''C.'' Is usually diagnosed between the ages of 50 and 60 </label> <label><<radiobutton "$choice1" "four" `$choice1 is "four" ? 'checked' : ''`>>  ''D.'' Is increasing in incidence according to studies in the UK</label> <label><<radiobutton "$choice1" "five" `$choice1 is "five" ? 'checked' : ''`>>  ''E.'' Like chronic fatigue is associated with lower socioeconomic status</label> <br> <<if $choice1 is "two">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: B'' <p style="text-align:justify"> Estimates on the prevalence of FM vary widely however a number of large predominantly American studies have identified a figure of between 2 and 6% of the population have FM making this one of the most common chronic pain conditions. FM is more commonly diagnosed in adult females at a ratio of between 6:1 and 20:1. However during childhood males and females are equally affected. Diagnosis frequently occurs between 30 and 59 yr. In their large UK study Collin et al. found the incidence of FM in the UK has plateaued during the study period 2001-2013. They also found an association with lower socioeconomic status, but this finding was not replicated in chronic fatigue syndrome where low socioeconomic status was correlated with a lower incidence of the condition. Collin S, Bakken I, Nazareth I //et al.// Trends in the incidence of chronic fatigue syndrome and fibromyalgia in the UK, 2001-2013: a Clinical Practice Research Datalink study. //JRSM//. 2017;110:6:231-244. </p> @@ <<button [[Next question->answerQ2post]]>> <</button>>

@@.whitetext;<<if $choice4 eq "five">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 <p style="text-align:justify">''Q5 The differential diagnosis of FM is wide and there are no confirmatory tests to support the diagnosis. All of the following should alert the clinician to an alternative diagnosis except:''</p> <label><<radiobutton "$choice5" "one">>  ''A.'' Pain in the joints associated with swelling </label> <label><<radiobutton "$choice5" "two">>  ''B.'' Elevated ESR and/or CRP associated with morning stiffness </label> <label><<radiobutton "$choice5" "three">>  ''C.'' Skin biopsy showing small fibre neuropathy </label> <label><<radiobutton "$choice5" "four">>  ''D.'' Generalized fatigue not associated with pain </label> <label><<radiobutton "$choice5" "five">>  ''E.'' Persistent depressed mood and loss of interest in things as the dominant symptom </label> <br> <<button [[Next Question->Q6post]]>> <</button>>

@@.whitetext;<<if $choice5 eq "three">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 <p style="text-align:justify">''Q6 The initial management of FM should include::''</p> <label><<radiobutton "$choice6" "one">>  ''A.'' Titrated opioids up to a maximum of 120mg/24h</label> <label><<radiobutton "$choice6" "two">>  ''B.'' Referral for psychological interventions for pain management for all patients </label> <label><<radiobutton "$choice6" "three">>  ''C.'' Patient education as a prominent aspect of management </label> <label><<radiobutton "$choice6" "four">>  ''D.'' A structured programme of cardiovascular fitness training starting at a minimum of 30 low-impact sessions a week </label> <label><<radiobutton "$choice6" "five">>  ''E.'' The initiation of a tricyclic antidepressant</label> <br> <<button [[Next Question->Q7post]]>> <</button>>

@@.whitetext;<<if $choice6 eq "three">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 <p style="text-align:justify">''Q7 For patients not responsive to initial therapies the next step in management should be:''</p> <label><<radiobutton "$choice7" "one">>  ''A.'' Withdrawal of the initial drug therapy if benefit is not seen at the maximum tolerated dose</label> <label><<radiobutton "$choice7" "two">>  ''B.'' To assume that non-adherence to the agreed treatment plan is likely </label> <label><<radiobutton "$choice7" "three">>  ''C.'' Referral to Rheumatology as an underlying inflammatory rheumatic disease is likely if there has been treatment failure </label> <label><<radiobutton "$choice7" "four">>  ''D.'' A combination of pharmacological and nonpharmacological treatment depending on symptoms is appropriate </label> <label><<radiobutton "$choice7" "five">>  ''E.'' Referral to a supervised exercise programme</label> <br> <<button [[Next Question->Q8post]]>> <</button>>

@@.whitetext;<<if $choice7 eq "four">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 <p style="text-align:justify">''Q8 FM frequently affects women of childbearing age. A patient with FM who becomes pregnant should be told:''</p> <label><<radiobutton "$choice8" "one">>  ''A.'' During pregnancy and the immediate postpartum period they will experience a reduction in the symptoms they associate with FM</label> <label><<radiobutton "$choice8" "two">>  ''B.'' During pregnancy and the immediate postpartum period they may experience an increase in the symptoms they associate with FM but these symptoms frequently occur in pregnant women without FM</label> <label><<radiobutton "$choice8" "three">>  ''C.'' During pregnancy they will experience a reduction in the symptoms they associate with FM with an increase in symptoms in the postpartum period </label> <label><<radiobutton "$choice8" "four">>  ''D.'' There are no studies on the relationship between FM and pregnancy </label> <label><<radiobutton "$choice8" "five">> ''E.'' The symptoms of FM are not affected by pregnancy in the majority of women </label> <br> <<button [[Next Question->Q9post]]>> <</button>>

@@.whitetext;<<if $choice8 eq "two">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 <p style="text-align:justify">''Q9 Regarding commonly used analgesic drugs in pregnancy and breastfeeding:''</p> <label><<radiobutton "$choice9" "one">>  ''A.'' Women on gabapentin should take high dose folic acid during the first trimester</label> <label><<radiobutton "$choice9" "two">>  ''B.'' The higher risk period for teratogenicity includes weeks 4 to 16 of pregnancy when major embryological organogenesis occurs</label> <label><<radiobutton "$choice9" "three">>  ''C.'' NSAIDs should be avoided during the second trimester due to risk of neonatal pulmonary hypertension and in utero ductus arteriosus constriction </label> <label><<radiobutton "$choice9" "four">>  ''D.'' During the postpartum period codeine should be used in preference to tramadol or dihydrocodeine in breastfeeding women </label> <label><<radiobutton "$choice9" "five">>  ''E.'' Lower doses of several analgesic agents should be used to reduce the likelihood of foetal toxicity</label> <br> <<button [[Next Question->Q10post]]>> <</button>>

@@.whitetext;<<if $choice10 eq "one">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 <p style="text-align:justify">''Q10 Psychiatric comorbidity can occur in people with persistent pain problems and may be treated with antidepressant drugs. On the use of antidepressant agents in pregnancy and during breastfeeding:''</p> <label><<radiobutton "$choice10" "one">>  ''A.'' Monoamine oxidase inhibitors are considered safe in pregnancy </label> <label><<radiobutton "$choice10" "two">>  ''B.'' Of the serotonin reuptake inhibitors paroxetine is the first-choice drug of its class </label> <label><<radiobutton "$choice10" "three">>  ''C.'' Patients successfully treated with antidepressants prior to pregnancy should generally continue the same drug </label> <label><<radiobutton "$choice10" "four">>  ''D.'' Withdrawal of antidepressants should be attempted as soon as pregnancy is confirmed </label> <label><<radiobutton "$choice10" "five">>  ''E.'' Tricyclic antidepressants are associated with a high incidence of congenital birth defects </label> <br> <<button [[Submit->results2]]>> <</button>>

<<if $choice10 eq "three">><<set $result to $result + 1>> <</if>> You scored <<print $result>> out of 10! <<set $result2 to $result>> <<button [[Answers->answerQ1post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q2 Regarding the pathology of FM:''</p> <label><<radiobutton "$choice2" "one" `$choice2 is "one" ? 'checked' : ''`>>  ''A.'' The neuroimaging of individuals with FM is indistinguishable from that of healthy controls </label> <label><<radiobutton "$choice2" "two" `$choice2 is "two" ? 'checked' : ''`>>  ''B.'' There is conclusive evidence that alterations in peripheral pain processing are the cause of the symptoms seen in FM </label> <label><<radiobutton "$choice2" "three" `$choice2 is "three" ? 'checked' : ''`>>  ''C.'' FM is likely to be an immune mediated disorder due to disordered cytokine production </label> <label><<radiobutton "$choice2" "four" `$choice2 is "four" ? 'checked' : ''`>>  ''D.'' First degree relatives of people with FM are 8.5 times more likely to develop FM </label> <label><<radiobutton "$choice2" "five" `$choice2 is "five" ? 'checked' : ''`>>  ''E.'' Autonomic dysfunction is not a feature of the condition and should alert the clinician to an alternative diagnosis </label> <br> <<if $choice2 is "four">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: D'' <p style="text-align:justify">First degree relatives of people with FM are 8.5 times more likely to develop FM than first degree relatives of people with Rheumatoid arthritis are likely to acquire FM. While there are a number of peripheral factors that augment a central pain process, evidence supports the theory that alterations in central nervous system pain processing are responsible for many of the features seen in FM. Morphometric analysis of brain MRI in patients with fibromyalgia shows a significant reduction in grey matter volume compared to healthy controls. This is a finding reported in other stress and chronic pain related disorders. While a systematic review of neuroimaging in patients with FM showed moderate evidence of decreased functional connectivity in descending pain modulating systems. Functional MRI also demonstrates differences in functional connectivity of people with FM compared to healthy controls. ANS dysfunction and abnormalities of the hypothalamic-pituitary-adrenal axis have been identified in patients with FM although the significance of these changes has not been fully elucidated. </p> @@ <<button [[Next question->answerQ3post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q3 In relation to the diagnosis of FM:''</p> <label><<radiobutton "$choice3" "one" `$choice3 is "one" ? 'checked' : ''`>>  ''A.'' Requires the physical finding of at least 10 out of 16 defined tender points </label> <label><<radiobutton "$choice3" "two" `$choice3 is "two" ? 'checked' : ''`>>  ''B.'' Chronic widespread pain of at least three months duration as cardinal symptom of FM</label> <label><<radiobutton "$choice3" "three" `$choice3 is "three" ? 'checked' : ''`>>  ''C.'' Positive antinuclear antibody or rheumatoid factor are highly likely to exclude a diagnosis of FM</label> <label><<radiobutton "$choice3" "four" `$choice3 is "four" ? 'checked' : ''`>>  ''D.'' Vitamin D levels provide important information for diagnosis</label> <label><<radiobutton "$choice3" "five" `$choice3 is "five" ? 'checked' : ''`>>  ''E.'' Diagnostic criteria exist for FM and should be adhered to for individual diagnosis</label> <br> <<if $choice3 is "two">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: B'' <p style="text-align:justify">The 1990 American College of Rheumatology (ACR) classification criteria for diagnosis of FM has been used in the majority of clinical trials and includes the physical finding of 11 out 18 defined tender points. The 2010 ACR preliminary diagnostic criteria do not require a tender point examination and provides a scale for characteristic symptoms of FM. These are used to help guide clinical decision making but have not been validated for individual diagnosis. FM is a diagnosis of exclusion as multiple other conditions can have similar presentations. There are no confirmatory tests or biomarkers for the condition. Chronic widespread pain of at least three months duration without another identified cause should alert the clinician to the possibility of FM. Pain is often accompanied by persisting problems with sleep, cognition and/or fatigue. ANA and RF are often positive in healthy individuals and have a poor predictive value for systemic rheumatic disease in patients without other clinical features of these conditions. Vitamin D deficiency is common in chronic conditions and non-discriminatory. </p> @@ <<button [[Next question->answerQ4post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q4 There are a number of features seen in FM including which of the following:''</p> <label><<radiobutton "$choice4" "one" `$choice4 is "one" ? 'checked' : ''`>>  ''A.'' Psychiatric disturbance, IBS, and migraine occur more commonly in people with FM than in the general population </label> <label><<radiobutton "$choice4" "two" `$choice4 is "two" ? 'checked' : ''`>>  ''B.'' Symptoms of autonomic dysfunction including orthostatic hypotension, altered heart rate variability and Raynaud’s Phenomenon is seen in some patients </label> <label><<radiobutton "$choice4" "three" `$choice4 is "three" ? 'checked' : ''`>>  ''C.'' Patient’s frequently report paraesthesia including numbness, burning or crawling sensations </label> <label><<radiobutton "$choice4" "four" `$choice4 is "four" ? 'checked' : ''`>>  ''D.'' Fatigue and sleep disturbance are core features of the condition </label> <label><<radiobutton "$choice4" "five" `$choice4 is "five" ? 'checked' : ''`>>  ''E.'' All of the above</label> <br> <<if $choice4 is "five">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: E'' <p style="text-align:justify">Ongoing research suggests FM is a disorder of pain regulation resulting in chronic widespread musculoskeletal pain. As many as half of patients have concurrent psychiatric symptoms with depression and anxiety both prevalent in the FM population. IBS and migraine are seen more frequently than in the general population. Neurological symptoms reported by many patients with FM include paraesthesia and cognitive disturbances including problems with concentration and attention. ANS dysfunction can occur. The majority of patients report non-restorative sleep and moderate to severe chronic fatigue. </p> @@ <<button [[Next question->answerQ5post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q5 The differential diagnosis of FM is wide and there are no confirmatory tests to support the diagnosis. All of the following should alert the clinician to an alternative diagnosis except:''</p> <label><<radiobutton "$choice5" "one" `$choice5 is "one" ? 'checked' : ''`>>  ''A.'' Pain in the joints associated with swelling </label> <label><<radiobutton "$choice5" "two" `$choice5 is "two" ? 'checked' : ''`>>  ''B.'' Elevated ESR and/or CRP associated with morning stiffness </label> <label><<radiobutton "$choice5" "three" `$choice5 is "three" ? 'checked' : ''`>>  ''C.'' Skin biopsy showing small fibre neuropathy </label> <label><<radiobutton "$choice5" "four" `$choice5 is "four" ? 'checked' : ''`>>  ''D.'' Generalized fatigue not associated with pain </label> <label><<radiobutton "$choice5" "five" `$choice5 is "five" ? 'checked' : ''`>>  ''E.'' Persistent depressed mood and loss of interest in things as the dominant symptom </label> <br> <<if $choice5 is "three">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: C'' <p style="text-align:justify">Small fibre neuropathy is associated with FM and is seen in some patients. The widespread soft tissue pain described in patients with FM is not associated with evidence of tissue inflammation or specific laboratory or radiological findings and exclusion of other rheumatic and systemic disorders is key to the diagnosis. A thorough history and physical examination from an experienced clinician with limited, targeted laboratory testing confirms the absence of an alternative diagnosis in most patients. Features suggesting an alternative diagnosis include (but are not limited to): * Joint swelling, raised ESR/CRP, positive RF: Rheumatoid arthritis * Renal, cardiac, pulmonary, neurological features, facial rash, positive ANA: SLE * Onset over 60 yr, raised ESR/CRP, response to steroids: PMR * Spinal range of movement restricted, raised ESR/CRP: Spondyloarthritis * Rash, joint swelling, serological testing: Lyme disease * Pain not a prominent feature, excessive fatigue, cold: Hypothyroidism * Sensory or motor deficits, abnormal EMG: Neuropathy Note the predictive value of ANA and RF in persons not symptomatic for the condition is poor. These markers are commonly positive in healthy individuals </p> @@ <<button [[Next question->answerQ6post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q6 The initial management of FM should include:''</p> <label><<radiobutton "$choice6" "one" `$choice6 is "one" ? 'checked' : ''`>>  ''A.'' Titrated opioids up to a maximum of 120mg/24h</label> <label><<radiobutton "$choice6" "two" `$choice6 is "two" ? 'checked' : ''`>>  ''B.'' Referral for psychological interventions for pain management for all patients </label> <label><<radiobutton "$choice6" "three" `$choice6 is "three" ? 'checked' : ''`>>  ''C.'' Patient education as a prominent aspect of management </label> <label><<radiobutton "$choice6" "four" `$choice6 is "four" ? 'checked' : ''`>>  ''D.'' A structured programme of cardiovascular fitness training starting at a minimum of 30 low-impact sessions a week </label> <label><<radiobutton "$choice6" "five" `$choice6 is "five" ? 'checked' : ''`>>  ''E.'' The initiation of a tricyclic antidepressant </label> <br> <<if $choice6 is "three">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: C'' <p style="text-align:justify">Every individual with FM should have an individualized management plan based on their symptoms, co-morbidities, and preferences. Key aspects include: * Patient education * Addressing co-morbidities including mood and sleep disorders * Appropriate exercise and pacing * Drug therapy with appropriate agents when indicated Patient education is a fundamental aspect of management and should be personalised to the patient’s understanding and needs. This can include an explanation of centralised pain and reassurance of the reality if the disease. An explanation of the chronic nature of FM and the likelihood of periods where symptoms flair and then abate over a periods of days to months is important while emphasising that despite this the vast majority of people with FM lead normal active lives and that FM is not a progressive disease. Drug monotherapy may be considered for patients whose symptoms are not relieved by nonpharmacological measures. Low-dose tricyclic antidepressants is generally considered first line when drug therapy is appropriate. Other agents used include selected antidepressants such as Duloxetine (an SNRI) when mood disturbance is a prominent feature or Gabapentin/Pregabalin (alpha2/delta calcium channel modulators) especially in individuals with a significant sleep disorder. Escalating doses of opioids are not appropriate in the management of FM. </p> @@ <<button [[Next question->answerQ7post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q7 For patients not responsive to initial therapies the next step in management should be:''</p> <label><<radiobutton "$choice7" "one" `$choice7 is "one" ? 'checked' : ''`>>  ''A.'' Withdrawal of the initial drug therapy if benefit is not seen at the maximum tolerated dose</label> <label><<radiobutton "$choice7" "two" `$choice7 is "two" ? 'checked' : ''`>>  ''B.'' To assume that non-adherence to the agreed treatment plan is likely </label> <label><<radiobutton "$choice7" "three" `$choice7 is "three" ? 'checked' : ''`>>  ''C.'' Referral to Rheumatology as an underlying inflammatory rheumatic disease is likely if there has been treatment failure</label> <label><<radiobutton "$choice7" "four" `$choice7 is "four" ? 'checked' : ''`>>  ''D.'' A combination of pharmacological and nonpharmacological treatment depending on symptoms is appropriate </label> <label><<radiobutton "$choice7" "five" `$choice7 is "five" ? 'checked' : ''`>>  ''E.'' Referral to a supervised exercise programme </label> <br> <<if $choice7 is "four">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: D'' <p style="text-align:justify">Patients often experience ongoing symptoms following initial management. Combining different treatment modalities depending on which symptoms predominate, patient preferences and available resources optimises the chance of improvement. Multi-disciplinary treatment programmes including behavioural and psychological interventions combined with exercise therapy has been shown to reduce pain, fatigue, and depressive symptoms^^1^^. Combination drug therapy in patients unresponsive to monotherapy may be appropriate for some individuals. However is no evidence that opioids are effective in the long-term treatment of FM and these agents have the risk of significant side effects. 1. Hauser W, Berardy K, Arnold B, //et al.// Efficacy of multicomponent treatment in fibromyalgia syndrome: a meta-analysis of randomized controlled clinical trials. //Arthritis Rheum// 2009; 61:216. </p> @@ <<button [[Next question->answerQ8post]]>> <</button>>

@@.whitetext; <p style="text-align:justify">''Q8 FM frequently affects women of childbearing age. A patient with FM who becomes pregnant should be told:''</p> <label><<radiobutton "$choice8" "one" `$choice8 is "one" ? 'checked' : ''`>>  ''A.'' During pregnancy and the immediate postpartum period they will experience a reduction in the symptoms they associate with FM </label> <label><<radiobutton "$choice8" "two" `$choice8 is "two" ? 'checked' : ''`>>  ''B.'' During pregnancy and the immediate postpartum period they may experience an increase in the symptoms they associate with FM but these symptoms frequently occur in pregnant women without FM</label> <label><<radiobutton "$choice8" "three" `$choice8 is "three" ? 'checked' : ''`>>  ''C.'' During pregnancy they will experience a reduction in the symptoms they associate with FM with an increase in symptoms in the postpartum period </label> <label><<radiobutton "$choice8" "four" `$choice8 is "four" ? 'checked' : ''`>>  ''D.'' There are no studies on the relationship between FM and pregnancy </label> <label><<radiobutton "$choice8" "five" `$choice8 is "five" ? 'checked' : ''`>>  ''E.'' The symptoms of FM are not affected by pregnancy in the majority of women </label> <br> <<if $choice8 is "two">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> '' Correct answer: B'' <p style="text-align:justify">The relationship between FM and pregnancy has not been well established nevertheless in the studies that exist pain, fatigue, and cognitive dysfunction are more common in pregnant women with FM especially in the first and third trimesters. The withdrawal of potentially harmful medication may further exacerbate symptoms. However, less commonly, women with FM report stability or an improvement in their condition during pregnancy and the postpartum period. Supporting individuals who are pregnant or planning pregnancy to understand symptoms they associate with their condition such as fatigue, mood changes and back pain are common complaints in an otherwise normal pregnancy is a key part of management. And that this apparent exacerbation of their FM does not mean that their underlying condition has worsened. </p> @@ <<button [[Next question->answerQ9post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q9 Regarding commonly used analgesic drugs in pregnancy and breastfeeding:''</p> <label><<radiobutton "$choice9" "one" `$choice9 is "one" ? 'checked' : ''`>>  ''A.'' Women on gabapentin should take high dose folic acid during the first trimester</label> <label><<radiobutton "$choice9" "two" `$choice9 is "two" ? 'checked' : ''`>>  ''B.'' The higher risk period for teratogenicity includes weeks 4 to 16 of pregnancy when major embryological organogenesis occurs </label> <label><<radiobutton "$choice9" "three" `$choice9 is "three" ? 'checked' : ''`>>  ''C.'' NSAIDs should be avoided during the second trimester due to risk of neonatal pulmonary hypertension and in utero ductus arteriosus constriction </label> <label><<radiobutton "$choice9" "four" `$choice9 is "four" ? 'checked' : ''`>>  ''D.'' During the postpartum period codeine should be used in preference to tramadol or dihydrocodeine in breastfeeding women </label> <label><<radiobutton "$choice9" "five" `$choice9 is "five" ? 'checked' : ''`>>  ''E.'' Lower doses of several analgesic agents should be used to reduce the likelihood of foetal toxicity</label> <br> <<if $choice9 is "one">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: A'' <p style="text-align:justify">It is recommended that women taking gabapentin take high dose folic acid during the first trimester. As a rule, foetal drug exposure should be avoided where possible especially during the major period of organogenesis, weeks 4-10 of pregnancy. When making the decision to use an agent the risks and benefits need to be discussed using available evidence to choose an agent with the best safety profile. Minimizing the number of agents and the duration of exposure is also important to reduce potential harm. The RCOG //Antenatal and Postnatal Analgesia (Scientific Impact Paper No. 59)// reviews the guidance from the Medicines and Healthcare products Regulatory Agency and European Medicine Agency on the use of analgesics in pregnancy and during breastfeeding: ''Paracetamol'' is widely used to treat pain and fever throughout pregnancy and during breast feeding. It should be considered first line if non-pharmacological interventions to ameliorate pain have failed. ''NSAIDs'' risk varies with stage of pregnancy and it’s their use is generally reserved for the second trimester. There is conflicting evidence on the associated of NSAID use and first-trimester miscarriage. NSAIDs should be avoided after 30 weeks due to the risk of neonatal pulmonary hypertension and in utero ductus arteriosus constriction. Diclofenac and ibuprofen have been extensively used during breastfeeding and can be considered after paracetamol in postpartum women. ''Opioids:''There is limited data on the use of opioids during pregnancy. Their use is generally reserved for short-term treatment of moderate to severe pain. Rapid metabolism of codeine in breastfeeding women has caused fatal morphine toxicity in breastfed infants and codeine is therefore contraindicated in this group. Bisson D, Newell S, Laxton C. Antenatal and Postnatal Analgesia (Scientific Impact Paper No. 59). //BJOG// 2019;126:4:114-124 </p> @@ <<button [[Next question->answerQ10post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q10 Psychiatric comorbidity can occur in people with persistent pain problems and may be treated with antidepressant drugs. On the use of antidepressant agents in pregnancy and during breastfeeding:''</p> <label><<radiobutton "$choice10" "one" `$choice10 is "one" ? 'checked' : ''`>>  ''A.'' Monoamine oxidase inhibitors are considered safe in pregnancy </label> <label><<radiobutton "$choice10" "two" `$choice10 is "two" ? 'checked' : ''`>>  ''B.'' Of the serotonin reuptake inhibitors paroxetine is the first-choice drug of its class </label> <label><<radiobutton "$choice10" "three" `$choice10 is "three" ? 'checked' : ''`>>  ''C.'' Patients successfully treated with antidepressants prior to pregnancy should generally continue the same drug </label> <label><<radiobutton "$choice10" "four" `$choice10 is "four" ? 'checked' : ''`>>  ''D.'' Withdrawal of antidepressants should be attempted as soon as pregnancy is confirmed </label> <label><<radiobutton "$choice10" "five" `$choice10 is "five" ? 'checked' : ''`>>  ''E.'' Tricyclic antidepressants are associated with a high incidence of congenital birth defects </label> <br> <<if $choice10 is "three">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: C'' <p style="text-align:justify">There are no studies demonstrating conclusive safety of any antidepressant used during pregnancy. As with the vast majority of pharmacotherapy in pregnancy the risk of use should be weighed against the risk of deterioration without drug treatment. Non-pharmacological treatment, such as structured psychotherapy should be considered in the initial management of psychological comorbidities presenting in pregnant patients. Monoamine oxidase inhibitors (MAO) are associated with a risk of congenital abnormalities and foetal growth restriction in animal studies and have the potential for hypertensive crisis when combined with tocolytic agents in labour. Of the other antidepressants serotonin reuptake inhibitors (SSRI) including sertraline, citalopram and escitalopram have the greatest quantity of observational data suggesting little to no risk of teratogenicity. Fluoxetine has a longer half-life and there is the risk of accumulation in breastfed infants so is not considered first-line in breastfeeding women not previously on antidepressants. There is some evidence that Paroxetine is associated with a small increased risk of congenital cardiac defects. The serotonin-norepinephrine reuptake inhibitors (SNRI) are the second most prescribed antidepressant in pregnancy with Venlafaxine being the most prescribed drug of the class. There is limited data from small observational studies on the risks of atypical antidepressants including Mirtazapine in pregnancy The observational data on the use of tricyclic antidepressants (TCA) suggests low risk of teratogenicity. </p> @@ <<button [[Done!->email]]>> <</button>>

<center> @@.whitetext; ''The audio will start automatically'' @@ <<audio "fibrointro" play>> [[Transcript->transcript1]]   [[Next->audiopost]] @@.whitetext; If the audio doesn't play automatically press @@ [[PLAY|https://www.virtualanaesthetics.com/Module%204/audio/fibrointro.mp3]] @@.whitetext; (opens in a new screen).@@ <img src="images/fibrointro.jpg" style="max-width: 100%;"/> </center>

<center> @@.whitetext; ''Audio will play automatically''@@ <<audio "creativehopelessness" play>> [[Transcript->transcript2]]   [[Next->audio2post]] @@.whitetext; If the audio doesn't play automatically press @@ [[PLAY|https://www.virtualanaesthetics.com/Module%204/audio/creativehopelessness.mp3]] @@.whitetext; (opens in a new screen).@@ <img src="images/door.jpg" style="max-width: 100%;"/> </center>

@@.whitetext;Graham taps on the computer for a moment and the first session appears on the screen. Mindfulness. <center> <img src="images/lake.jpg" style="max-width: 100%;"/> </center> You watch as everyone settles down to listen.@@ [[Next->PMP4]]

<center> !!!@@.typing;Fibromyalgia (FM)@@ </center> <p style="text-align:justify">Fibromyalgia (FM) is the most common cause of widespread MSK pain and is often accompanied by fatigue, cognitive disturbance (‘fibro fog’), psychiatric and somatic symptoms.</p> <div class="notes">''Diagnosis''</div> The American College of Rheumatology (ACR) diagnostic criteria for FM replaced the <<link [[previous diagnostic criteria->UpToDate® summary]]>> <<set Dialog.setup("previous diagnostic criteria")>> <<set Dialog.wiki("American College of Rheumatology 1990 diagnostic criteria: symptoms of widespread pain occurring above and below the waist and affecting both left and right of the body + physical finding of at least 11 of 18 defined tender points")>> <<set Dialog.open ()>> <</link>> in 2010: ''A patient fulfils the diagnostic criteria for FM if:'' # They have generalized pain in 4/5 body regions # Widespread pain index (WPI) ≥7 and symptom severity (SS) scale score ≥5 or WPI 3–6 and SS scale score ≥9 # Symptoms have been present at a similar level for at least 3 months # The patient does not have a disorder that would otherwise explain the pain <center> <img src="images/painman.jpg" style="max-width: 100%;"/> </center> ''Widespread pain index (WPI): the number reported areas of pain in the last week? Score 0 to 19'' * Right upper region: jaw, shoulder girdle, upper arm, lower arm (each score 1) * Left upper region: jaw, shoulder girdle, upper arm, lower arm * Axial region: neck, upper back, lower back, chest, abdomen * Right lower region: hip/buttock, upper leg, lower leg * Left lower region: hip/buttock, upper leg, lower leg ''Symptom severity scale (SSS) plus symptoms. Score 0-12:'' * Fatigue, mild = 1, moderate = 2, severe = 3 * Waking unrefreshed, mild = 1, moderate = 2, severe = 3 * Cognitive symptoms, mild = 1, moderate = 2, severe = 3 ''Considering somatic symptoms in general during the last six months. Score 0-3:'' * Headaches, no = 0, yes = 1 * Lower abdominal pain, no = 0, yes = 1 * Depression, no = 0, yes = 1 The SS scale score is the sum of the severity of the three symptoms (fatigue, waking unrefreshed, cognitive symptoms) plus the extent (severity) of somatic symptoms in general. The final score is 0 to 12. If the WPI score is greater or equal to 7 and the SS score is greater or equal to 5 then a diagnosis of FM is likely. <div class="notes">''Epidemiology''</div> * Prevalence of moderate to severe chronic pain ~ 14% and FM ~ 5% of the UK population * Frequently diagnosed between 20-55 years of age * 9 to 1 female to male (1 to 1 ratio in paeds) <div class="notes">''Clinical presentation''</div> * Widespread MSK pain typically involving at least six body regions * Fatigue and sleep disturbance * Cognitive disturbance * Psychiatric symptoms including anxiety and depression * Headache in approx. 50% * Paraesthesia including numbness, burning or tingling, frequently symmetrical in both limbs Concurrent: * IBS * Interstitial cystitis * Dysmenorrhoea * Temporomandibular joint disorder * Endometriosis * Chronic fatigue syndrome <div class="notes">''Pathogenesis''</div> <center> !!!Genetic + environmental risk factors = altered central pain perception. </center> ''Genetics:'' * First-degree relatives are 8.5 times more likely to have FM * Polymorphisms in catechol-O-methyltransferase (COMT) genes associated with FM * Concordance in widespread pain in twins ''Functional neuroimaging:'' <p style="text-align:justify">Functional magnetic resonance imaging (fMRI) shows increase response to stimuli in the insula and anterior cingulate cortex (ACC) areas involved in processing and perception of pain signals. MRI also demonstrates a three-fold increase in age-associated grey matter loss especially in areas involved in stress, pain, and cognitive function. IL6 has been implicated and mice injected with plasma from people with FM develop a FM like disease. A subset of people with FM demonstrate small fibre neuropathy on biopsy suggesting an autoimmune element. Ultimately the pathophysiology remains an area of active research.</p> <div class="notes">''Differential''</div> <p style="text-align:justify">FM does not cause abnormalities in routine laboratory testing. Investigations are indicated where there is the suspicion of an alternative diagnosis:</p> * Systemic inflammatory arthropathies (e.g. RA) * Spondylarthropathies * Systemic autoimmune disorders (e.g. SLE) * Polymyalgia rheumatica * Osteoarthritis * Myopathies * Hypothyroidism and other endocrine disorders * Neurological disorders (e.g. peripheral neuropathies, entrapment syndromes, MS, or myasthenia gravis) * Myofascial pain syndromes (typically pain in one anatomic region) <p style="text-align:justify">Note: Approximately 10-15% people with FM and ~10% of healthy controls have positive antinuclear antibody therefore the predictive value of ANA in individuals without symptoms of systemic autoimmune disorders is poor. The same applies to Rheumatoid factor which can be positive in healthy individuals. </p> <div class="notes">''Initial management''</div> Evaluation of relative prominence of specific symptoms, past treatments and existing co-morbidities to direct management: * Patient education * Optimise management of co-morbidities * Exercise programmes * Drug monotherapy (e.g. Duloxetine an SNRI) <div class="notes">''Refractory FM''</div> * Assess for factors limiting initial treatment benefit (e.g. Is the patient remembering medication? Are they able to attend exercise sessions?) * Assess for and treat concurrent painful conditions and other co-morbidities (e.g. arthritis, OSA, psychiatric disorders) * Multidisciplinary team input * Combination drug therapy (e.g. addition of gabapentin or pregabalin) * Pain management programmes * Complementary and alternative therapies (e.g. acupuncture or meditative movement therapies) <center> ''There is little evidence that opioids are effective in the treatment of FM and side effects are common'' </center> <div class="notes">''Prognosis''</div> <p style="text-align:justify">FM is a chronic condition, and most patients seen in tertiary centres will continue to experience varying levels of pain and fatigue. Despite this, the majority remain in work and active. A better prognosis is associated with psychological factors and individual patient behaviours.</p> !!!<p style="text-align:justify"> @@.typing;The bottom line: The cardinal features of FM are chronic, widespread, MSK pain, fatigue and cognitive dysfunction. The multidisciplinary management of FM includes non-pharmacological and pharmacological treatments and identifying and treating co-morbid conditions.@@</p> [[Back->email1]] [[Show me the evidence->ref1]] <A HREF="javascript:window.print()">Click to Print This Page</A>

<p style="text-align:justify"> @@.typing;''Paul:'' Good morning everyone and welcome to the first day of the fibromyalgia pain management program. I’m Paul the clinical psychologist, I’ve got lots of experience in helping people manage fibro and you are going to be seeing a lot of me over the next eight weeks. What I’d like is if everyone in the room could introduce themselves and if you’re comfortable just tell us a little bit about how your fibro affects you and what has bought you to the PMP today? ''Helen:'' I’m Helen, I was diagnosed with fibro seven years ago but to be honest I’ve probably had it since I was a teenager. I remember always having aching legs and my parents putting it down to growing pains. As I got older I’d be so tired when I got in from work that I’d hardly be able to keep my eyes open. My GP said it was post viral fatigue but when it didn’t go away, said it might be chronic fatigue. I had a whole lot of tests and saw a rheumatologist who told me I had fibro and that I just had to learn to live with it. I feel once you’ve been labelled people assume you’re either making it up or are on the scrap heap. I’ve got so much to do that I can’t just live with it. I’ve got three kids, my husband works away, I have to do everything. Most of the time it really is all down to me. That’s why I’m here, I’m sick of a life where I feel like I’m carrying a backpack of rocks, up a mountain, in the fog. ''Sandra:'' Hi I’m Sandra, and I can really identify with some of what Helen is saying. I’m a carer for my dad and actually, I need to be well to look after him, but it feels like all the time I’m getting more and more ground down with the constant pain. Even my skin hurts sometimes and really gets me down that I’m failing in life because of having to cope with all this stuff. It took eight years of constant back and forth to the doctors to get a diagnosis. And it’s not just fibro, I suffer from migraines, dry eyes, endo, I have OA and IBS. I want to be seen as a whole person, who gets joined up care, not all these disjointed problems. I spend so much of my life sort of self-checking for how I am and whether something else has gone wrong, it’s exhausting, and I really want things to better. ''Elin:'' Hello, I’m Elin, I’ve had a similar experience to the others. I’ve had the constant stress of not having a diagnosis and being told it might be this thing or that thing. It was such a relief to have a name for all the things I was suffering. And all the time I’m trying to live with a yo-yo of symptoms, I have a good couple of weeks and then I’m on my knees. Because I look fine people assume that it’s nothing or that I’m exaggerating when I say I’m in so much pain. I have what feels like toothache but in every part of my body and on top of that there are trigger points in my neck and shoulders that send pain down my arms and back, that’s awful, but my worst things is the fibro fog, it’s so frustrating, I can’t leave the house without forgetting something. I can’t concentrate, I have to write everything down and sometimes making the simplest decision is too hard. It caused me big problems at work and that’s why I left. I want to be able to enjoy my retirement and that’s why I’m here. ''Rhiannon:'' I’m Rhiannon. My fibro is mostly pain, that, and bone crushing tiredness. It started after I gave birth five years ago. I put it down to just being normal, I’d just gone through a hellish labour and are hardly sleeping because of a new-born. But then six months in and I still wasn’t better and I knew something wasn’t right. The pain can be awful, my fingers, hands, back, neck, shoulders, legs, even my jaw feels bruised all over. I’m like Megan, my sleep is terrible. I get restless legs and that’s miserable at night when I can’t sleep. I have sciatica too and when that’s bad I know I’m in for a rough time. My GP doesn’t take me seriously, they won’t give me stronger painkillers when I need them because they say they don’t work for fibro. But I’ve got little kids and need them to be able to function. It’s so frustrating when people don’t understand. I’ve had injections in my back before which helped and I’m here because I want to try them again, and they said I had to try this first. ''Megan:'' Hi, I’m Megan. Like everyone else I was back and forth to the doctors and the hospital for countless tests and scans. Dealing with that process and living with that uncertainty for years was exhausting even before you factor in the fibro. For me, the insomnia and tiredness is horrendous. Ironically, when I’m having a flair though, I can sleep 15 hours and still wake-up tired. It’s so limiting to constantly compromise on what I can do because the energy just drains out of me. It started with pain across my back and shoulders, now I’m always in pain and that’s miserable. I turn to food for comfort and I don’t have the energy to exercise because of my fibro. I’ve also had problems with my thyroid and so I’ve pilled on the weight in the last few years. I hate it because people always put my pain down to my weight and it’s like they’re blaming me for causing this myself. I have a busy job and a long commute into work, and I feel like I’m just going through the motions in my life the whole time. ''Paul:'' Thanks everyone. I’m sure everyone can see there are some common themes that you are all talking about and it’s really helpful to bring them up at this stage so we know what’s important to you and what you want to get out of the course. This PMP is to support you in finding new ways of coping with the things you are identifying as problems. Right, now the next session is with our physio Graham on mindfulness. @@ </p> <center> [[Play audio->audio1]]    [[Next->audiopost]] </center> <<audio "fibrointro" pause>>

<p style="text-align:justify"> @@.typing;''Paul:'' Is everyone ready to start again? Yes? Great. So now we are going to have a bit of a think about what you do now to try and get on top of your condition and how that’s working for you. We briefly touched on it earlier, so can anyone expand on that and describe some of the thoughts, emotions and sensations that come with having fibro? ''Rhiannon:'' For me, the obvious one is physical pain? And being sick to death of being like this which honestly makes me feel quite hopeless. ''Paul:'' Thanks Rhiannon, so you’re talking about being in pain and how hopeless that makes you feel? ''Rhiannon:'' Yes exactly, and sad, sad that it’s like this now. ''Paul:'' What about you Sandra? ''Sandra:'' I feel anxious half the time waiting for the next problem I have to deal with. If it’s not me it’s dad or one of the kids. ''Paul:'' So you’re on high alert because you’re worried what’s going to happen and that makes you anxious? ''Sandra:'' Yes, and that I’m not going to be up to coping with the next thing, that it will be too hard. I guess I feel sort of inadequate. I live in a constant state of fear that everything is going to fall apart. It means everything in my life has narrowed down and I’ve forgotten who I am. ''Elin:'' I completely get that Sandra. After I took early retirement, I lost part of my identity and that made me feel like a failure, that I just wasn’t good enough anymore to keep everything going. ''Paul:'' So what you’re both describing is some loss of self because of your condition, and the restrictions it causes? ''Megan:'' So much of fibro is like that though. It’s like my weight gain; I can’t help it, but I feel sort of guilty and ashamed about it and I hate it went people judge me. They think I’m fat and lazy but I’m fighting the whole time to keep going. They don’t have a clue. ''Paul:'' That must be really frustrating Megan. How does it make you feel when you think people are judging you? ''Megan:'' Well…I guess…I feel angry I suppose. That they are judging me when they have no idea. ''Helen:'' I feel angry sometimes about how unfair it is that I have to deal with this. I feel angry with myself that I’m not being a good enough mum, that I’m not doing well enough at work, that I haven’t got the same perfect life that my friends do. Then I feel guilty for the kids and my husband because they have to live with the rubbish version of me. ''Paul:'' And what do you do to try and manage those feelings Helen? ''Helen:'' Well I guess I push myself even though I know I’ll pay for it later. Then it’s like a vicious circle because I’m so exhausted that I can’t do stuff with the kids or do well at work anyway and that makes me feel worse. ''Sandra:'' I’m guilty of that too. I push myself but that has the knock-on effect that I haven’t got any energy left to play with the kids or do other things I used to enjoy. ''Paul:'' So you’re sacrificing self-care to try and keep up with things? ''Sandra:'' Yes, because if I don’t do these things, I feel guilty and like a failure and that’s worse. ''Paul:'' You feel like there isn’t an alternative? ''Sandra:'' Well there isn’t really, no one else is going to look after dad and the kids. ''Paul:'' It sound like you all put a lot of energy into keeping up a front and carrying on like everything’s fine? ''Rhiannon:'' But that’s the way it is, that’s why I need the pain killers, I’m like Sandra, no one else is going to do this stuff, so I need them to keep going. ''Paul:'' And do they work for you? Do they let you keep going the way you want? ''Rhiannon:'' That’s not the point, it’s all I’ve got and they’re better that nothing. No one else has offered any real solutions. ''Paul:'' Why do you think your GP doesn’t want to give you stronger pain killers? ''Rhiannon:'' Because he doesn’t get it. He doesn’t understand how much pain I’m in. ''Paul:'' You feel misunderstood? Could there be another reason? ''Rhiannon:'' He says they’re dangerous, have side effects and don’t work in the long term. ''Paul:'' He says that? What do you think? ''Rhiannon:'' I’ve got to the point where I don’t care. I get that they have side effects, but I need them to function. I just want to feel like I’m doing something. ''Paul:'' So you feel more in control? ''Rhiannon:'' Yes! Just a tinny bit in control of this rubbish situation. ''Paul:'' And do you think that’s working? Do they give you control? ''Rhiannon:'' Well no, obviously not, that’s why I’m here, I need something else. ''Sandra:'' How are they dangerous? The drugs I mean? I thought they were safe. I’m on tramadol and amitriptyline. They wouldn’t give them too you if they weren’t safe. Surely? ''Paul:'' I think it’s dangerous in so far as all drugs come with the risk of side effects. And there’s no point in having the risk of side effects if they aren’t helping. ''Elin:'' But I was reading in the paper the other day that there’s a crisis in some countries because of these sorts of meds and loads of people have got addicted to them and can’t get off them. They’ve been dishing them out for years and now realise there’s a huge problem. ''Sandra:'' [Rushes out and slams the door] @@ </p> <center> [[Play audio->audio2]]    [[Next->audio2post]] </center> <<audio "creativehopelessness" pause>>

<center> @@.whitetext; ''With thanks to everyone who helped make this scenario happen!'' Our scenario 4 advisory support: Samantha Owen, Katie Harrop and Tim Green Our tech support: Charlie Hargood and Louis Rose Our logistical support: Patrick Wainwright Our editorial team: Sonia Pierce and Richard Wassall Our creative director and lead programmer: Kate Wainwright !!!Well done for completing VA_Pain training_4 <<nobr>><span id="ReplaceMe"> <<link "''certificate''">> <<script>> Dialog.setup("Tell us"); Dialog.wiki("<center> <h3>@@.greentext;You can make Virtual Anaesthetics better. <br><br>Tell us what you think of this scenario [[here|https://forms.gle/QjzbkPQPd5vttkBS7]]. It should take less than a minute. <br><br>Thanks!@@</h3> </center>"); Dialog.open(); <</script>> <<replace "#ReplaceMe">> ''[[certificate]]''<br> <</replace>> <</link>></span><</nobr>> @@ </center>

<center> <img src="images/timetable.jpg" style="max-width: 100%;"/> </center>[[Next->PMP1]]

<p style="text-align:justify">"I think we've got five coming today, we had one person cancel at the last minute. They’re all people with Fibromyalgia so this PMP is more tailored to that condition than the generic one we do." "What do you want me to do? I haven’t any experience of doing this sort of thing really." You ask. "No problem. Let’s play it by ear and have a look at this before people start arriving.” He hands you a patient information leaflet. “There’s so much rubbish on the internet we try and provide decent information, so they have a better idea of the condition. It’s worth you knowing what we put out there." You have a quick flick through the [[patient information leaflet->https://www.virtualanaesthetics.com/Module%204/fmpatientinfo.pdf]] </p> [[Next->PMP3]]

<p style="text-align:justify">The people gradually arrive for the PMP and take seats facing the projector screen. Everyone introduces themselves round the room and the first session begins with you sat to the side looking helpful. Graham the physio is doing the introductions and housekeeping. Everyone goes round the room [[introducing themselves->audio1]] [[Transcript->transcript1]] </p> <<audio "fibrointro" pause>>

You have a look at the eight-week programme. There are a few things that catch your eye. “Paul can you tell me…" [[what hot cross buns have got to do with pain?]] [[how FM involves beehives?]] [[what's a mindfulness lake?]] [[why we should sleep clean?]] [[how you can be creative & hopeless?]] [[what the 4 Ps & 3 Ds stand for?]]

@@.whitetext;''Hot Cross Buns aka Cross Sectional Formulations:''@@ <center> @@.whitetext; <img src="images/hotcrossbun.jpg" style="max-width: 100%;"/> Figure 1: Cross sectional formulation adapted from Padesky & Mooney^^1^^. <p style="text-align:justify">The ’hot cross bun’ formulation can be a simple and effective tool for introducing the cognitive behavioural model to patients. It supports them in developing self-awareness of how thoughts, behaviours, physical sensations, and emotions influence each other. An example in the context of persistent pain: * ''Situation:'' going for a day out with friends * ''Thoughts:'' //back is going to hurt//, won’t be able to walk far, won’t enjoy it, I’ll spoil the day for the others * ''Behaviour:'' denial or avoidance, procrastinate about plans, cancel, or shorten trip out * ''Physical sensations:'' tense, pain, faster heart rate, sweating, tiredness, lethargy * ''Emotions:'' angry, sad, anxious, frustrated, isolated, guilty This allows the individual to systematically look at their responses to a situation and then consider different, more helpful responses. Again, the same example in the context of persistent pain: * ''Situation:'' going for a day out with friends * ''Thoughts:'' //back is going to hurt//, plan a morning trip when it’s generally better, find places we can stop for coffee and sit down * ''Behaviour:'' back stretches before the trip, pacing self across the morning, planning with friends * ''Physical sensations:'' relaxed muscles, normal breathing, manageable pain * ''Emotions:'' excitement, happiness, enjoyment, confidence Note that the individual’s pain has not changed, but by changing their responses, the same situation is a much more positive event. Here’s a [[printable version->https://www.virtualanaesthetics.com/Module%204/hotcrossbun.pdf]] if you want to do one for a situation of your own. # Padesky C, Mooney K. Presenting the cognitive model to clients. //International cognitive therapy newsletter//. 1990 6;13-14 </p> @@ [[I want to know about those other things->PMP1a]] [[I want to get on with helping set up the PMP->PMP2]] </center> <<set $hot to true>>

<center>@@.whitetext; !!!Bee hives and pain <img src="images/bees.jpg" style="max-width: 100%;"/> <p style="text-align:justify"> Ever handled bees? If you annoy them on your first visit, they will be quicker to anger next time. That’s because angry bees give off bee pheromones that mean they react more strongly each time something they perceive as a threat arrives, even if you are an innocuous bee handler. Genetics are at play with some bee lines winding-up more quickly that others and you can mitigate the process by smoking them to dampen down this response from the start. The physiology of chronic pain, the principles of neuronal plasticity and the process of wind-up in humans is complex and involves interactions between the CNS, ANS, and PNS and endocrine and immune systems. There is extensive evidence that alterations in pain processing is responsible for many of the features seen in FM. ''Central sensitization'' = process whereby the CNS amplifies sensory input across many organ systems ''Wind-up'' = increase in response to a given stimulus when the stimulus is delivered repeatedly over time. In the context of pain (not bees) this relates to priming of the NMDA receptor response, and progressive increase in firing of wide-dynamic-range (WDR) second order neurons with repeated stimulation ''Long term potentiation'' = a synaptic plasticity mechanism triggered by a complex signalling cascade and expressed as a long-lasting increase in efficiency of synaptic transmission. This plays a role in learning, memory and chronic pain ''Five brain areas have been identified with functional MRI and PET scans as important central pain regions:'' ''1.'' Thalamus (somatosensory discrimination) ''2.'' Prefrontal cortex, insula and cingulate cortex (affective and motivational components of pain) ''3.'' PAG and RVM (fight or flight and stress response) ''4.'' Reticular formation (descending pathway regulation) ''5.'' Pathways to the hypothalamus and amygdala (autonomic and sensory co-ordination) ''Repetitive nociceptive stimulation and chronic inflammation leads to a number of changes in peripheral tissues and spinal cord:'' * Primary afferent pain neurons have a lower threshold * Production of substance P and calcitonin gene-related peptide (CGRP) is increased in the periphery * Changes in opioid receptor expression * Release of neurotransmitters and neuromodulators is increased including substance P, NO, CGRP, ATP, PG and glutamate * DRG and dorsal horn cell gene and protein expression is altered including an increase in voltage gated Na^^+^^ channels leading to hyperexcitability * Cell depolarisation, causing Mg^^2+^^ removal from NMDA receptors allowing their activation by glutamate. This potentiates the response of WDR second order neurons in lamina V to subsequent stimulus and an exaggerated response manifesting as allodynia. ''In the brain there is ‘central sensitization’:'' * Glial cells are activated and release IL-1, IL-6, TNF, PG, NO and excitatory amino acids * AMPA and NMDA receptors are upregulated * GABA receptors are downregulated ''How to avoid it?'' In the context of surgical insults, early recognition of risk factors, adequate multimodal analgesia, judicious use of neuraxial and regional techniques, and minimally invasive techniques to reduce tissue damage, are effective in helping prevent the phenomenon and reduce the risk of chronic pain. </p> @@ [[I want to know about those other things->PMP1a]] [[I want to get on with helping set up the PMP->PMP2]] [[Show me the evidence->ref4]] </center> <<set $bee to true>>

<center>@@.whitetext; !!!Mindfulness lakes <img src="images/water.jpg" style="max-width: 100%;"/> <p style="text-align:justify"> The mindfulness lake is one of many guided meditations available. In this instance visualization of a lake by the individual is used to bring them into the moment. The metaphor of the lake, with a sometimes-choppy surface, overlying a deeper, inner stillness, represents life events, feelings, and emotions that touch the surface of people’s lives but do not need to disturb this calm underlying acceptance from moment to moment. Mindfulness interventions vary widely, however the basic premise underlying the approach is: # Sustained attention on current physical, emotional, and thought state # Recognise these experiences as momentary and fleeting # Attenuating reactions and judgments to these experiences Mindfulness reduces: * Catastrophising^^1^^ * Anxiety^^2-5^^ * Depression^^6-7^^ * Low mood^^9^^ * Stress^^10-11^^ The most studied mindfulness treatment approach for FM is a “standard” 8-week mindfulness-based stress reduction (MBSR) program. However, mindfulness interventions focusing on principles of acceptance, non-attachment, and social engagement in addition to non-judgmental awareness are the most effective in improving FM-related outcomes including interventions delivered online^^12-14^^. Mindfulness-meditations have been demonstrated to engage multiple mechanisms to reduce pain^^15-21^^. Neuroimaging of expert mindfulness-meditators show greater activity in sensory processing regions (eg thalamus) with reduced activity in the prefrontal cortices^^20,21^^, reflecting attention on sensory processes without engaging higher-order appraisals and judgements. MBSR training is also associated with an improved immune response to vaccines^^22^^ and reduction in pro-inflammatory gene expression^^23^^. Despite evidence of the benefits, mindfulness may be difficult for some people with FM, as a cognitively demanding task requiring sustained attention, especially when concentration and cognitive difficulties feature as part of their symptoms. </p> @@ [[I want to know about those other things->PMP1a]] [[I want to get on with helping set up the PMP->PMP2]] [[Show me the evidence->ref3]] </center> <<set $lake to true>>

<center>@@.whitetext; !!!Sleep hygiene <img src="images/sleep.jpg" style="max-width: 100%;"/> <p style="text-align:justify"> ''Insomnia'' is one of the commonest problems which adults seek medical advice for, and most people will have problems sleeping at some point during their lives. ''Sleep hygiene'' is a set of behavioural and environmental recommendations intended to promote healthy sleep which were initially developed for the treatment of mild to moderate insomnia. Predisposing factors for insomnia include: *Pain conditions * OSA * SSRIs and SNRIs are associated with insomnia in approximately 20% of patients, this problem can be transient and somewhat mitigated by morning dosing * Opioids can lead to changes to sleep architecture, sleep fragmentation and nocturnal waking Perpetuating factors for insomnia include maladaptive behavioural and cognitive responses to sleeplessness: * Coffee, energy drinks and other stimulants * Day time naps * Clock watching and anxiety related to lack of sleep * Trying to sleep when not sleepy and having unrealistic expectations of total sleep time Once precipitating and perpetuating factors have been addressed, cognitive behavioural therapy for insomnia (CBT-I) either with or without adjunct pharmacotherapy, is superior efficacy in managing chronic insomnia that pharmacotherapy alone^^1-4^^. CBT-I is recommended by NICE as the first line treatment for insomnia lasting longer than three months in adults^^5^^. Cognitive aspects of CBT-I: * Addressing anxious and catastrophic thoughts relating to lack of sleep and its effects * Tackling inappropriate expectations on needed sleep duration * Relaxation including mindfulness Behavioural aspects of CBT-I and sleep hygiene measures^^5, 6^^): * Keep a regular sleep/wake schedule * Restrict bed use for sleeping and sex * Optimise the comfort of the sleep environment (eg dark, quiet, cool but not cold, supportive and comfortable bed) * Try to sleep only when sleepy, and if unable to sleep, get out of bed and do something relaxing until sleepiness occurs, avoid screens * Bedroom clocks should not be visible at night * Don’t have day-time naps or keep them less than 20 minutes in the first half of the day * Stop stimulant substances (eg coffee, energy drinks, nicotine) especially in the 8h pre-bed * Exercise is recommended, especially outside in natural light, but avoid vigorous exercise 2h before bed * Don’t go to bed hungry but avoid large or heavy meals near bedtime * Alcohol should be avoided near bedtime as it negatively impacts on sleep architecture * Electronic/screen use should be discontinued in the 1-2h before bedtime and relaxing pursuits undertaken (eg reading, warm bath, listening to relaxing music) * Electronic/screen use should be kept out of the bedroom (we know virtually everyone who owns a smart phone charges it by their bed and uses it as an alarm, but maybe try to do the rest of the list) </p> @@ [[I want to know about those other things->PMP1a]] [[I want to get on with helping set up the PMP->PMP2]] [[Show me the references->ref5]] </center> <<set $sleep to true>>

<center>@@.whitetext; !!!Creative hopelessness <img src="images/dandelion.jpg" style="max-width: 100%;"/> <p style="text-align:justify"> Creative hopelessness is an acceptance commitment therapy concept that helps individuals identify how they’ve been avoiding their pain and then evaluating what that avoidance has cost them. It ties in well with the hot-cross-bun formulation tool. !!!Step 1: What have you tried? Some examples include: ''Distraction'' eg //taking your mind off the pain with gambling, eating, or computer games// ''Avoidance'' eg //withdrawing from or avoiding life-enhancing activities or resigning from employment// ''Thinking'' eg //worrying, dwelling on the pain or impossible cures, judging or criticising self or others// ''Substances'' eg //use of prescription and non-prescription drugs, alcohol, treat foods// !!!Step2: Has this worked? At this point it is important to validate that an individual has been doing their best to get what relief they can but then guiding them to realise themselves that these methods only bring short term relief, if at all, and which can lead to overuse, over-reliance or inappropriate use of coping strategies that do not have any lasting benefit. !!!Step 3: What’s been the cost? Next sympathetically explore what the costs of these coping strategies have been. Some costs may be clear such as the loss financial renumeration of paid employment following job loss or long-term sickness absence, while the loss of social contacts, motivational aspects, daily routine and professional identity may be less immediately obvious (to name just a few). The costs of an individual’s current coping strategies can be explored in terms of health, relationships, life-satisfaction and socioeconomics and how the ‘cost’ expenditure has changed over time. The confrontation should be between the individual’s coping strategies and how that impacts on their lived experience. !!!Step 4: How is that for you? This is the point of putting 1 to 3 together and concluding that despite the effort and energy expended on the existing coping strategies in the long term they haven’t worked. This realisation may be difficult and upsetting for the individual and they may need empathetic support, but it is an important step in ‘letting go’ of unhelpful thoughts and behaviours and being open to new ways of coping. !!!Step 5: Are you open to something different? At this stage alternative ways of coping are introduced tailored to the needs of the individual. Creative hopelessness work is not about a sudden epiphany on the part of the patient. It is a process of establishing a curiosity about alternative approaches that are less about control and experiential avoidance and more about an ‘agenda of acceptance’. </p> @@ [[I want to know about those other things->PMP1a]] [[I want to get on with helping set up the PMP->PMP2]] </center> <<set $creative to true>>

<center>@@.whitetext; !!!4 Ps and 3 Ds <p style="text-align:justify"> People with persistent pain and fatigue may face a dilemma: the more they do, the worse they feel. However inactivity brings its own set of problems such as low mood and depression. Understanding that they have a limited ‘bank’ of energy that can be invested in a considered way can improve an individual’s quality of life. This is where the Ps and Ds come into play, different sources have different numbers of Ps and Ds or introduce the concept of <<link [[Spoon theory->what the 4 Ps & 3 Ds stand for?]]>> <<set Dialog.setup("Spoon Theory")>> <<set Dialog.wiki("Spoon theory can be a useful way for a person with a chronic illness or those around them to conceptualise what having limited energy reserves means and how to manage it. The individual starts their day with limited number of ‘spoons’ which represent units of energy. Once they are ‘used up’ the individual will feel fatigued or be in too much pain to continue other activities. Spoon theory allows the individual to pace themselves and expend their ‘spoons’ on what is important to them.")>> <<set Dialog.open ()>> <</link>> but the principles are consistent. For our example PMP we have 4 Ps and 3 Ds: ''Planning'' * Keeping a diary * Arranging tasks at the best time of day * Breaking larger tasks down * Scheduling enjoyable and relaxing activities as well as more mundane essential tasks * Planning rest breaks throughout the day ''Prioritisation'' * Listing what needs to be done today or this week (here the Ds come into play) * Prioritizing activities which improve quality of life, provide enjoyment or self-care ''Pacing'' * Breaking tasks up into smaller jobs or rationalising them * Resting before becoming overtired * Alternate more strenuous activities with more restful ones ''Permission'' * To allow for ‘bad days’ * To not overdo it on ‘good days’ * To be kind to yourself with self-care and self-compassion ''Dump it'' * Is this task necessary at all (eg ironing)? ''Delegate it'' * Is there someone else who can help or do this task? ''Delay it'' * Does it need to be done today? * Can it be done more efficiently with other tasks (eg avoid unnecessary trips)? * Would it be better after a break? </p> @@ [[I want to know about those other things->PMP1a]] [[I want to get on with helping set up the PMP->PMP2]] </center> <<set $pandd to true>>

"OK, can you also tell me..." <<if $hot is true>> <<elseif $hot is false>>[[what hot cross buns have got to do with pain?]] <</if>> <<if $bee is true>> <<elseif $bee is false>>[[how FM involves beehives?]] <</if>> <<if $lake is true>> <<elseif $lake is false>>[[what's a mindfulness lake?]] <</if>> <<if $sleep is true>> <<elseif $sleep is false>>[[why we should sleep clean?]] <</if>> <<if $creative is true>> <<elseif $creative is false>>[[how you can be creative & hopeless?]] <</if>> <<if $pandd is true>> <<elseif $pandd is false>>[[what the 4 Ps & 3 Ds stand for?]] <</if>> [[More about what we’re doing today?->PMP2]]

Sandra rushes out of the room slamming the door behind her. Everyone is stares at the back of the door for a long moment and there’s an awkward pause. [[Follow her]] [[Stay out of it->PMP14]] <<audio "creativehopelessness" pause>>

# Crabtree D, Ganty P. Common functional pain syndromes. //BJA Ed//. 2016;16(10):334–340 # Clauw DJ. Fibromyalgia: a clinical review. //JAMA//. 2014;311:1547. # Arnold LM, Clauw DJ. Challenges of implementing fibromyalgia treatment guidelines in current clinical practice. //Postgrad Med//. 2017;129:709 # Pomares FB, Funck T, Feier NA, //et al//. Histological underpinnings of grey matter changes in fibromyalgia investigated using multimodal brain imaging. //J Neurosci//. 2017; 37:1090 # Jones GT, Atzeni F, Beasley M, //et al//. The prevalence of fibromyalgia in the general population: a comparison of the American College of Rheumatology 1990, 2010, and modified 2010 classification criteria. //Arthritis Rheumatol//. 2015; 67:568 # Fayaz A, Croft P, Langford RM, //et al//. Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies. //BMJ Open//. 2016; 6:e010364 # Wolfe F, Clauw DJ, Fitzcharles MA, //et al//. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. //Arthritis Care Res// (Hoboken) 2010; 62:600 # Arora N, Gupta A, Reddy SB. Antinuclear antibody and subserology Testing in the Evaluation of Fibromyalgia: A Teachable Moment. //JAMA Intern Med//. 2017; 177:1369 # Wolfe F, Smythe HA, Yunus MB, //et al//. The American College of Rheumatology 1990 Criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. //Arthritis Rheum//. 1990; 33:160 # Cho SJ, Sohn JH, Bae JS, Chu MK. Fibromyalgia Among Patients With Chronic Migraine and Chronic Tension-Type Headache: A multicenter prospective cross-Sectional study. //Headache//. 2017; 57:1583 # Johnson CM, Makai GEH. Fibromyalgia and irritable bowel syndrome in female pelvic pain. //Semin Reprod Med//. 2018; 36:136 # Maixner W, Fillingim RB, Williams DA, //et al//. Overlapping chronic pain conditions: Implications for diagnosis and classification. //J Pain//. 2016; 17:T93 # Arnold LM, Hudson JI, Keck PE, //et al//. Comorbidity of fibromyalgia and psychiatric disorders. //J Clin Psychiatry//. 2006; 67:1219 # Wu YL, Chang LY, Lee HC, //et al//. Sleep disturbances in fibromyalgia: A meta-analysis of case-control studies. //J Psychosom Res//. 2017; 96:89 # Crofford LJ. Psychological aspects of chronic musculoskeletal pain. //Best Pract Res Clin Rheumatol//. 2015; 29:147 # García-Ríos MC, Navarro-Ledesma S, Tapia-Haro RM, //et al//. Effectiveness of health education in patients with fibromyalgia: a systematic review. //Eur J Phys Rehabil Med//. 2019; 55:301 # Pfeiffer A, Thompson JM, Nelson A, //et al//. Effects of a 1.5-day multidisciplinary outpatient treatment program for fibromyalgia: a pilot study. //Am J Phys Med Rehabil//. 2003; 82:186 # Luciano JV, Martínez N, Peñarrubia-María MT, //et al//. Effectiveness of a psychoeducational treatment program implemented in general practice for fibromyalgia patients: a randomized controlled trial. //Clin J Pain//. 2011; 27:383 # Bidonde J, Busch AJ, Schachter CL, //et al//. Mixed exercise training for adults with fibromyalgia. //Cochrane Database Syst Rev//. 2019; 5:CD013340 [[Back->UpToDate® summary]]

<p style="text-align:justify">There’s a coffee break after Graham's session. You grab a couple of biscuits and go and catchup with Paul. Paul smiles when he sees you. "I’m really glad to see you getting involved with this, even if it’s not a place you see yourself working in the long run there’s so much you can learn if you are open." "Everyone in the teams great and I want to get as much out of this as I can while I’m here. Do you have any advice?" you ask him. He thinks for a moment "I think carry on what you're doing, getting an idea of what the pain service does, observing the whole team not just the doctors. It’s important to try and understand the hopes and expectations of patients and how that fits with what we offer. The PMP here is based on a psychological model, which is evidence based, and it’s really important that you bare this in mind in the responses, challenges, and exchanges you have with patients. Don’t jump in and medicalise things. And don’t eat all the best biscuits." </p> [[Next->PMP5]]

After the coffee break everyone settles back down in the seminar room for the next session. [[Listen to the group->audio2]] [[Transcript->transcript2]] <<audio "creativehopelessness" pause>>

You follow her out of the room. She takes a left through the first open door into Dr Jone's vacant office. You take a seat across from her and offer her an open box of tissues that permanently resides on Dr Jone's desk. “Are you ok?” “Is what Elin said true? Are these drugs really harmful?” “That’s not a simple question. They have risks and benefits and sometimes using them is the right thing and sometimes it’s not. It depends on lots of different factors and how much benefit you get from them. There’s some really useful patient resources about pain killers on the pain medicine web site you can look at.” You write the web address down on a post-it note which Sandra folds in half and pockets. “But what if you’re pregnant?” [[Next->office]]

<p style="text-align:justify">You intently read the program and avoid making eye contact with Paul. He turns back to the group "I think we should give Sandra a minute. Shall we carry on or does anyone need a break?" The session carries on with further discussion of peoples current coping strategies. Paul expertly steers the group towards the realization that what they do now isn’t giving them what they want or need. It occurs to you this is paving the way for the next sessions and everyone is more willing to explore new alternatives.</p> [[Next->PMP14b]]

What do you tell her? [[the drug's you are on are fine, don't worry->PMP7]] [[it's all about risk benifit and we can work it out->PMP8]] [[I don't know. I'll find out and get back to you->PMP9]]

Next door everyone is leaving the seminar room. It must be the break for lunch. “Are you OK to re-join the group now?” You ask. “I think everyone’s going to lunch.” “Yes, sorry, I’m OK now.” “Don’t apologise.” After Sandra leaves you sit in the office for a minute. Dr Jones appears at the doorway [[Next->PMP11]]

<p style="text-align:justify">"Don't worry the drugs you are taking are fine in pregnancy, don't worry." Dr Jones comes into the office and takes in the scene of a tear stained Sandra and a pile of used tissues. “The PMP going well I take it?” You quickly fill him in on what’s happened. "Ah, I see. Well I think it’s a bit hasty to say those drugs are completely risk free in pregnancy." Sandra looks a bit panicked. "It’s important that we treat your pain Sandra and Paracetamol is generally the first choice of painkiller in pregnancy and considered safe.” Dr Jones continues in a reassuring tone. “Regarding the other drugs, it’s recommended you avoid them if possible, and only take them when the benefits outweigh the potential harm. However, it is important you don’t take ibuprofen after 30 weeks because that can cause problems with the baby’s circulation. We need to try non-drug treatments for your pain first and foremost, so acupuncture, tens, physiotherapy, and the things that the PMP will talk about such as mindfulness, relaxation and pacing yourself. Do you have a midwife yet?" "I’m seeing one next week." "Well I think it would be a good idea if I got in touch with the obstetricians and together we can all make a plan. How does that sound?" "Yes OK, thank you." </p> [[Next->PMP7b]]

<p style="text-align:justify">"Being pregnant doesn't change what I said about risk and benefits, it's just the risk and benefits are a bit different when you’re pregnant. We can work it out though. Why don't we book you into an urgent clinic appointment with our consultant? We can talk it through and make a plan." That seems to reassure Sandra.</p> [[Next->PMP10]]

"I'm sorry, I don't know what the risks are of those specific drugs, but I can find out for you and let you know?" "I'm so worried now." "Why don't we book you into an urgent clinic appointment with our consultant? He will be able to help." You say with conviction. That seems to reassure Sandra. [[Next->PMP10]]

Did you pick up on these features from the group? * Patients often feel dismissed or not believed * Fatigue and a range of other debilitating symptoms often accompany widespread pain * Patients frequently seek multiple health care appointments and investigations over years, often without clear diagnosis * Quality of life and a person’s ability to function are often severely affected * Sleep disruption can be a major problem If you have the opportunity you could discuss the case with your Faculty Tutor (Pain) or Clinical Supervisor? [[Next->audio1post]] <<audio "fibrointro" pause>>

"I assume from the tissues all over my desk that its going well in the PMP then?" You quickly up-date him on the morning’s events. “Ah, I see, so what do you know about the drugs we use and pregnancy?” [[My PhD was on placental transfer of drugs]] [[I know enough to give a safe anaesthetic in obs]] [[I know nothing]]

Dr Jones looks at you sceptically "That's not true is it?" "No, no it's not." You reply. "Well here's an excellent [[summary]] on the topic from the last anaesthetics CGM. So you can go and read it over lunch and I can have my office back." [[Next->PMP12]] <<set $phd to true>> <<set $obs to false>> <<set $no to false>>

"Well thats a good start, and hers an excellent [[summary]] on the topic from the last anaesthetics CGM. Now you can go and read it over lunch so I can have my office back." [[Next->PMP12]] <<set $obs to true>> <<set $phd to false>> <<set $no to false>>

"Oh, thats unfortunate. Well here's an excellent [[summary]] on the topic from the last anaesthetics CGM. So you can go and read it over lunch and I can have my office back." [[Next->PMP12]] <<set $no to true>> <<set $phd to false>> <<set $obs to false>>

<center> !!!@@.typing;Analgesics during pregnancy@@ <div class="notes">''Pregnancy is split into trimesters''</div> </center> @@.greentext;''1st trimester:''@@ 0 – 12 weeks @@.greentext;''2nd trimester:''@@ 13 – 27 weeks @@.greentext;''3rd trimester:''@@ 28 – 40 weeks <center> <div class="notes">''NSAIDs''</div> !!!@@.greentext;''Avoid unless clinically indicated. Lowest effective dose for shortest duration. May increase risk of miscarriage. Avoid after 30 weeks''@@ </center> * Used to treat mild to moderate pain * Use the minimum effective dose for the shortest duration possible in pregnancy up to 30 weeks. * Mechanism of action via inhibition of cyclo-oxygenase (COX) preventing formation of prostaglandins. <center> <img src="images/cox.jpg" style="max-width: 100%;"/> </center> * In the foetal circulation the ductus arteriosus (DA) shunts blood from the pulmonary artery to the proximal descending aorta, allowing blood ejected from the right ventricle to bypass the foetal lungs * Patency of the DA is maintained by prostaglandin E~~1~~ & E~~2~~ formed by the placenta and ductus arteriosus itself * @@.greentext;''NSAIDs after 30 weeks gestation can lead to pulmonary hypertension and premature closure of the DA''@@ leading to right ventricular dysfunction, tricuspid regurgitation, congestive cardiac failure, foetal hydrops and intrauterine death. Reduced foetal blood flow can also lead to oligohydramnios <center> <div class="notes">''Paracetamol''</div> !!!@@.greentext;''Good safety record''@@ </center> * Used to treat mild to moderate pain * Safe to use throughout pregnancy – long-proven safety record * Has analgesic and antipyretic effects although no in-vitro action on COX-1 or COX-2 but proposed COX-3 inhibitor in CNS or via action on the cannabinergic systems <center> <div class="notes">''Opioids''</div> !!!@@.greentext;''Risk vs benefit. Lowest effective dose for shortest duration''@@ </center> <p style="text-align:justify"> @@.greentext;''Codeine''@@ is used for mild to moderate pain and has a low affinity for opioid receptors. The main action is via hepatic conversion to morphine. Polymorphism within Cytochrome CYPD26 affect the rate of codeine metabolism to morphine, with individuals classed as poor, intermediate, extensive or ultrarapid metabolisers. Those with more rapid metabolism are at greater risk of side effects and toxicity, while those with poor metabolism are unlikely to gain much analgesic benefit. @@.greentext;''Dihydrocodeine''@@ has a similar affinity for opioid receptors to codeine and is used for mild to moderate pain. It is also metabolised by CYP2D6, forming @@.greentext;''dihydromorphine''@@ however even extensive metabolisers convert less than 10% of dihydrocodeine to dihydromorphine, making its behaviour in patients more reliable. @@.greentext;''Tramadol''@@ acts via opioid receptors and monoaminergic-mediated signalling. Like codeine and dihydrocodeine it is also metabolised by CYP2D6, forming the active compound O-desmethyltramadol which has been implicated in the psychiatric side-effects of tramadol use. @@.greentext;''Morphine''@@ is used for moderate to severe pain, being active in its parent form. It undergoes hepatic metabolism by the cytochrome P450 pathway, forming the active metabolite morphine-6-phosphate. @@.greentext;''Opioids''@@ are used during pregnancy for short-term treatment of moderate to severe pain if other analgesics are not sufficent. While generally considered safe, some studies have reported an increased risk of neural tube defects, cardiac anomalies and gastrochisis. Long-term opioid use in late pregnancy can lead to withdrawal symptoms in the neonate. If used around the time of delivery, opioids can produce neonatal respiratory depression. @@.greentext;''Tramadol''@@ has been assessed for teratogenicity using animal models using doses up to fifteen times the maximum human dose. At toxic levels, teratogenic effects, including decreased foetal weight, skeletal ossification and supernumerary ribs are seen. A small prospective trial in humans during early pregnancy found no increase in malformations at birth but noted a significantly higher incidence of misscarriage. Recommendations have been made to avoid the use of tramadol from pre-conception to the end of the first trimester.</p> <center> <div class="notes">''Gabapentin''</div> !!!@@.greentext;''Risk vs benefit. Give with high dose folic acid''@@ </center> <p style="text-align:justify">Gabapentin is used for treatment of neuropathic pain and in the treatment of some persistent pain syndromes. Gabapentin is a chemical analogue of the neurotransmitter gamma-aminobutyric acid (GABA). However it's action is via binding to the α~~2~~δ subunit of neuronal voltage-dependent Ca^^2+^^ channels, inhibiting influx of Ca^^2+^^. There is limited evidence on the safety of gabapentin use during pregnancy. If it is to be used during the first trimester, @@.greentext;''high dose folic acid is recommended''@@ from preconception until the end of the first trimester. After 30 weeks gestation, gabapentin use may lead to neonatal withdrawal after delivery and neonatal observation is recommended.</p> <center> <div class="notes">''Antidepressants''</div> !!!@@.greentext;''Risk vs benefit''@@ </center> <p style="text-align:justify">Antidepressant medications have been used in the management of chronic pain although the mechanism underlying their efficacy in this remains unclear. Amitriptyline, a tertiary amine tricyclic antidepressant is the most commonly used. The table below shows the common groups of antidepressant, their known mechanism of action and potential deleterious effects on the developing foetus.</p> <centre> | ''Antidepressant class'' | ''Mechanism of action'' | ''Potential foetal effects'' | | Tricyclics //e.g. amitriptyline// | inhibition of serotonin & noradrenaline reuptake, competitive antagonism of α~~1~~ & α~~2~~ adrenergic receptors, cholinergic & muscarinic ACh receptors & H~~1~~ histamine receptors | head, neck & digestive tract defects | |  SSRIs //e.g. citalopram// | inhibition of serotonin reuptake | cardiac defects, <<link [[craniosynostosis->summary]]>> <<set Dialog.setup("Craniosynostosis")>> <<set Dialog.wiki("Craniosynostosis is a condition in which one or more of the fibrous sutures of an infants scull prematurely fuse and therefore change the shape of the scull. This can be associated with speech and language delay and rarely raised ICP.")>> <<set Dialog.open ()>> <</link>>  | | SNRIs //e.g. duloxetine// | inhibition of serotonin & noradrenaline reuptake | cardiac defects, respiratory defects, craniosynostosis  | </centre> <p style="text-align:justify">Three studies published in the BJOG in 2015 showed the use of SSRIs in pregnancy to be relatively safe, with no long-term neurodevelopmental or behavioural effects on the child, although an increased risk of postpartum haemorrhage was noted. The RCOG state: @@.greentext;//''the use of antidepressant medication during pregnancy should be made on an individual patient basis, weighing the risk of harm from medication against the risk of harm of untreated depression.''//@@ There is no specific recommendation made for their use in chronic pain.</p> !!!<p style="text-align:justify">@@.typing;The bottom line: Non-pharmacological interventions should be considered first line especially during the high risk period for teratogenicity during the first trimester. Most medications do not have sufficient data available to fully establish the risk to the developing foetus and a decision to use pharmacological agents should be made weighing the benefits and the risks.@@ </p> <<if $phd is true>> [[Back->My PhD was on placental transfer of drugs]] <</if>> <<if $obs is true>> [[Back->I know enough to give a safe anaesthetic in obs]] <</if>> <<if $no is true>> [[Back->I know nothing]] <</if>> [[show me the evidence->ref2]] <A HREF="javascript:window.print()">Click to Print This Page</A>

<p style="text-align:justify">The rest of the day passes quickly. Graham the physio does an excellent talk after lunch on "What is FM pain?" and Paul rounds off the day with a talk on the hot cross bun formulation and sends everyone home with a blank copy so they can do their own as homework for the next session. You head home and after a bit of reading round the topic have another look at those impossible MCQ that Dr Jones sent.</p> [[www.onlinepainMCQ.ac.uk->Q1post]]

* Chandrasekharan NV, Dai H, Roos KL, Evanson NK, et al. COX-3, a cyclooxygenase-1 variant inhibited by acetaminophen and other analgesic/antipyretic drugs: cloning, structure, and expression. //Proc. Natl. Acad. Sci//. 2020. 99(21):13926–31 * Olley, P,. Conceani F. Prostaglandins and the Ductus Arteriosus. //Ann Rev Med//. 1981. 32(1):375–385 * Al-Hasani R, Bruchas, M. Molecular Mechanisms of Opioid Receptor-Dependent Signalling and Behavior. //Anesthesiology//. 2011. 115(6):1363–1381. * Broussard CS, Rasmussen SA, Reefhuis J, et al. Maternal treatment with opioid analgesics and risk for birth defects. Am J Obstet Gynecol 2011, 204(4) * Antenatal and postnatal analgesia (Scientific Impact Paper No. 59) Royal College of Obstetricians & Gynaecologists. * Peck TE, Hill S. Pharmacology for anaesthesia and intensive care 3rd Edition. Cambridge University press. 2008. * Bérard A, Zhao JP. Antidepressant use during pregnancy and the risk of major congenital malformations in a cohort of depressed pregnant women: an updated analysis of the Quebec Pregnancy Cohort. //BMJ Open//. 2002. 7:e013372 doi:10.1136/bmjopen-2016-013372 * Handal M, Skurtveit S, Furu K, Hernandez-Diaz S, et al. Motor development in children prenatally exposed to selective serotonin reuptake inhibitors: a large population-based pregnancy cohort study. //BJOG//. 2015. DOI: 10.1111/1471-0528.13582 * Grzeskowiak LE, Morrison JL, Henriksen TB, et al. Prenatal antidepressant exposure and child behavioural outcomes at 7-Years of Age: A study within the Danish national birth cohort. //BJOG//. 2015; DOI: 10.1111/1471-0528.13611 * Grzeskowiak LE, McBain R, Dekker GA, Cliftona VL. Antidepressant use in late gestation and risk of postpartum haemorrhage: a retrospective cohort study. //BJOG//. 2015; DOI: 10.1111/1471-0528.13612 * Bloor M, Paech MJ & Kaye R. Tramadol in pregnancy and lactation. //Anesthesia//. 2012. 21:163-167 [[Back->summary]]

@@.whitetext; ''Warning'' These are hard. Dr Jones got 6/10 on his first run. We don't know what you score so just go for it!@@ [[Next->Q1]]

The session is followed by a break for lunch. You spot Dr Jones steering Sandra out of his office. She re-joins the others on the way to the canteen. “Ah, $firstname, join me for a moment?” He gestures towards the office. [[Next->PMP14c]]

<p style="text-align:justify">Dr Jones puts an empty tissue box into his bin. "I just found Mrs East in my office, extremely distressed, and convinced that she has damaged her unborn baby. Apparently one of the group told her that her current medications are harmful?" "It wasn’t exactly that." You reply. "It was about something someone had seen in papers." "So, what do you know about these drugs in pregnancy?" </p> [[My PhD was on placental transfer of drugs]] [[I know enough to give a safe anaesthetic in obs]] [[I know nothing]]

"Ah, OK, do you know how many weeks pregnant you are?" "I think about eight weeks." "OK, and remind me what you take?" "Tramadol, Gabapentin and Amitriptyline at night from my GP and I buy paracetamol and ibuprofen from the supermarket." [[Next->PMP6]]

Next door everyone is leaving the seminar room. It must be the break for lunch. “Are you OK to re-join the group now?” You ask. “I think everyone’s going to lunch.” “Yes, sorry, I’m OK now.” “Don’t apologise.” Dr Jones replies. After Sandra leaves you both sit in the office for a minute while the corridor clears. [[Next->PMP7c]]

Dr Jones takes the chair Sandra has just vacated and seeing a valuable learning opportunity asks: “what do you know about the drugs we use and pregnancy?” [[My PhD was on placental transfer of drugs]] [[I know enough to give a safe anaesthetic in obs]] [[I know nothing]]

Almost eight months later you are sitting in the theatres staff room, waiting for the next CEPOD case to arrive, and checking the [[unread emails]] on your phone.

@@.typing;''From:'' Paul Watson (Clinical Psychologist, Pain Management) ''Sent:'' Today ''To:'' Dr $firstname $surname ''Subject:'' Good news! Hi $firstname You remember that PMP we did together a while ago? I’ve just had this from Sandra and she said she’s happy to share: <center> <img src="images/baby.jpg" style="max-width: 40%;"/> </center> She says they are both doing very well and she’s managing her FM much more successfully since the PMP with some of the strategies we covered. BW Paul Principal Clinical Psychologist, Pain Management @@ [[End]]

# Garland EL, Gaylord SA, Palsson O, //et al.// Therapeutic mechanisms of a mindfulness-based treatment for IBS: effects on visceral sensitivity, catastrophizing, and affective processing of pain sensations. //J Behav Med.// 2012;35(6):591–602. # Goldin P, Ziv M, Jazaieri H, //et al.// Randomized controlled trial of mindfulness-based stress reduction versus aerobic exercise: effects on the self-referential brain network in social anxiety disorder. //Front Hum Neurosci.// 2012;6:295. # Zeidan F, Martucci KT, Kraft RA, //et al.// Neural correlates of mindfulness meditation-related anxiety relief. //Soc Cogn Affect Neurosci//.2014;9(6):751–9. # Miller JJ, Fletcher K, Kabat-Zinn J. Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. //Gen Hosp Psychiatry.// 1995;17(3):192–200. # Goldin PR, Gross JJ. Effects of mindfulness-based stress reduction (MBSR) on emotion regulation in social anxiety disorder. //Emotion.// 2010;10(1):83–91. # Barnhofer T, Crane C, Hargus E, //et al.// Mindfulness-based cognitive therapy as a treatment for chronic depression: a preliminary study. //Behav Res Ther.// 2009;47(5):366–73. # Farb NA, Anderson AK, Mayberg H, //et al.// Minding one’s emotions: mindfulness training alters the neural expression of sadness. //Emotion//. 2010;10(1):25–33. # Paul NA, Stanton SJ, Greeson JM, //et al//. Psychological and neural mechanisms of trait mindfulness in reducing depression vulnerability. //Soc Cogn Affect Neurosci//. 2013;8(1):56–64. # Zeidan F, Johnson SK, Gordon NS, //et al//. Effects of brief and sham mindfulness meditation on mood and cardiovascular variables. //J Altern Complement Med//. 2010;16(8):867–73. # Taren AA, Gianaros PJ, Greco CM, Lindsay EK, //et al//. Mindfulness meditation training alters stress-related amygdala resting state functional connectivity: a randomized controlled trial. //Soc Cogn Affect Neurosci//. 2015;10(12):1758-68. # Creswell JD, Pacilio LE, Lindsay EK, Brown KW. Brief mindfulness meditation training alters psychological and neuroendocrine responses to social evaluative stress. //Psychoneuroendocrinology//. 2014;44():1-12. # Davis MC, Zautra AJ. An online mindfulness intervention targeting socioemotional regulation in fibromyalgia: results of a randomized controlled trial. //Annals of behavioral medicine: a publication of the Society of Behavioral Medicine//. 2013;46(3):273–84. # Amutio A, Franco C, de Perez-Fuentes MC, et al. Mindfulness training for reducing anger, anxiety, and depression in fibromyalgia patients. //Front Psychol//. 2014;5:1572 # Van Gordon W, Shonin E, Dunn TJ, //et al//. Meditation awareness training for the treatment of fibromyalgia syndrome: a randomized controlled trial. //Br J Health Psychol//. 2017;22(1):186–206 # Zeidan F, Martucci KT, Kraft RA, //et al//. Brain mechanisms supporting the modulation of pain by mindfulness meditation. //The Journal of neuroscience: the official journal of the Society for Neuroscience//. 2011;31(14):5540–8 # Zeidan F, Emerson NM, Farris SR, //et al//. Mindfulness meditation-based pain relief employs different neural mechanisms than placebo and sham mindfulness meditation-induced analgesia. //J Neurosci//. 2015;35(46):15307–25 # Brown CA, Jones AK. Meditation experience predicts less negative appraisal of pain: electrophysiological evidence for the involvement of anticipatory neural responses. //Pain//. 2010;150(3):428–38 # Lutz A, McFarlin DR, Perlman DM, //et al//. Altered anterior insula activation during anticipation and experience of painful stimuli in expert meditators. //NeuroImage//. 2013;64:538–46 # Grant JA, Rainville P. Pain sensitivity and analgesic effects of mindful states in Zen meditators: a cross-sectional study. //Psychosom Med//. 2009;71(1):106–14 # Grant JA, Courtemanche J, Rainville P. A non-elaborative mental stance and decoupling of executive and pain-related cortices predicts low pain sensitivity in Zen meditators. //Pain//. 2011;152(1):150–6 # Gard T, Holzel BK, Sack AT, //et al//. Pain attenuation through mindfulness is associated with decreased cognitive control and increased sensory processing in the brain. //Cereb Cortex//. 2012;22(11):2692–702 # Davidson RJ, Kabat-Zinn J, Schumacher J, //et al//. Alterations in brain and immune function produced by mindfulness meditation. //Psychosom Med//. 2003;65(4):564–70 # Creswell JD, Irwin MR, Burklund LJ, //et al//. Mindfulness-based stress reduction training reduces loneliness and pro-inflammatory gene expression in older adults: a small randomized controlled trial. //Brain Behav Immun//. 2012;26(7):1095–101 [[Back->what's a mindfulness lake?]]

Feizerfan A, Sheh G. Transition from acute to chronic pain. //CEACCP//. 2015;15(2):98-102 Dedhia J, Bone M. Pain and fibromyalgia. //CEACCP//. 2009;9(5):162-166. Sluka KA, Clauw DJ. Neurobiology of fibromyalgia and chronic widespread pain. //Neuroscience//. 2016; 338:114 López-Solà M, Woo CW, Pujol J, //et al//. Towards a neurophysiological signature for fibromyalgia. //Pain//. 2017; 158:34 O'Brien AT, Deitos A, Triñanes Pego Y, //et al//. Defective endogenous Pain Modulation in Fibromyalgia: A Meta-Analysis of Temporal Summation and conditioned pain modulation paradigms. //J Pain//. 2018; 19:819 Salemi S, Aeschlimann A, Wollina U, //et al//. Up-regulation of delta-opioid receptors and kappa-opioid receptors in the skin of fibromyalgia patients. //Arthritis Rheum//. 2007; 56:2464 Russell IJ, Orr MD, Littman B, //et al//. Elevated cerebrospinal fluid levels of substance P in patients with the fibromyalgia syndrome. //Arthritis Rheum//. 1994; 37:1593 Mhalla A, de Andrade DC, Baudic S, //et al//. Alteration of cortical excitability in patients with fibromyalgia. //Pain//. 2010; 149:495 Valdés M, Collado A, Bargalló N, //et al//. Increased glutamate/glutamine compounds in the brains of patients with fibromyalgia: a magnetic resonance spectroscopy study. //Arthritis Rheum//. 2010; 62:1829 Kaplan CM, Schrepf A, Vatansever D, //et al//. Functional and neurochemical disruptions of brain hub topology in chronic pain. //Pain//. 2019; 160:973 McBeth J, Lacey RJ, Wilkie R. Predictors of new-onset widespread pain in older adults: results from a population-based prospective cohort study in the UK. //Arthritis Rheumatol//. 2014; 66:757 Staud R. Peripheral pain mechanisms in chronic widespread pain. //Best Pract Res Clin Rheumatol//. 2011; 25:155 Uçeyler N, Häuser W, Sommer C. Systematic review with meta-analysis: cytokines in fibromyalgia syndrome. BMC Musculoskelet Disord 2011; 12:245 [[Back->how FM involves beehives?]]

# Morin CM, Colecchi C, Stone J, et al. Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. JAMA 1999; 281:991 # Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW. Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Arch Intern Med 2004; 164:1888 # Morin CM, Vallières A, Guay B, et al. Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial. JAMA 2009; 301:2005 # Beaulieu-Bonneau S, Ivers H, Guay B, Morin CM. Long-Term Maintenance of Therapeutic Gains Associated With Cognitive-Behavioral Therapy for Insomnia Delivered Alone or Combined With Zolpidem. Sleep 2017; 40 # NICE. Clinical knowlege summaries: Managing long-term insomnia (more than three months duration). 2020. Available at https://cks.nice.org.uk/topics/insomnia/management/managing-long-term-insomnia-greater-3-months/ # The Sleep Council. Sleep hydiene. 2020. Available at www.sleepcouncil.org.uk [[Back->why we should sleep clean?]]

<img src="images/wing.png" style="max-width: 30px" alt="small wing"/>@@.name; Scenario_4@@

<center> !!!BETA Virtual Anaesthetics_Pain training_4 <<link [[What is Beta Testing?|beta]]>> <<set Dialog.setup("What is Beta Testing?")>> <<set Dialog.wiki("@@.greentext;Beta testing is an opportunity for real users to use a product in a production environment to uncover any bugs or issues before a general release. Beta testing is the final round of testing before releasing a product to a wide audience. The objective is to uncover as many bugs or usability issues as possible in this controlled setting.@@")>> <<set Dialog.open ()>> <</link>> !!![[Start scenario|Intro 1]] </center>

Trainer guide for this scenario available ''[[here|https://www.virtualanaesthetics.com/trainerguides/module4.pdf]]'' [[Back|Introduction]]

''>'' On each page there are clickable links within the text. ''>'' Navigate using the links in the scenario or the forward and back arrows in the left menu bar NOT the forward and back arrows on your internet browser. ''>'' Each scenario should take around an hour. ''>'' Your time spent accessing the scenario is recorded on your completion certificate. ''>'' If you access the scenario several times the certificate will only show the duration of the most recent access. ''>'' For the best platform experience access from a larger screen device such as a tablet ''>'' ''Check you're not on mute''. ''>'' When printing your certificate from a mobile device turn to portrait orientation. [[Back|Intro 1]]

<<set _answer to "">> !!!@@.greentext; Welcome to the trainers area of this scenario@@ Please input the password to continue: <<textbox "_answer" "">> <<button "Check Password">> <<if _answer is "">> <<script>>UI.alert("You did not supply a password");<</script>> <<else>> <<set _answer to _answer.trim().toLowerCase()>> <<if _answer is "vatrainersarea">> <<goto "trainers_area2">> <<else>> <<script>>UI.alert("Incorrect password");<</script>> <<goto "trainers_area">> <</if>> <</if>> <</button>>

<p style="text-align:justify">We are absolutely thrilled that you have found us and shown an interest in our learning platform. We wanted to give you the heads up before you get any deeper into the scenario, that like the best medical dramas, bad things may happen. This is to support learning and clinical decision making. It is ''REALLY RARE'' for things like this to happen to otherwise well people undergoing anaesthetics. The Royal Collage of Anaesthetists has some really helpful information explaining the risks of having an anaesthetic if you want further information, available [[here|https://rcoa.ac.uk/patient-information/patient-information-resources/anaesthesia-risk]]. When you are ready, welcome to our virtual world...</p> [[Start|Introduction]]

/* Update the time of the previous history record if there is one. */ <<if $history.length gt 0>> <<set $history.last().time to Date.now()>> <<else>> /* Record the time the first passage was shown. */ <<set $started to Date.now()>> <</if>> /* Add current passage's history record to the array, unless it has a 'no-history' passage tag. */ <<if not tags().includes('no-history')>> <<set $history.push({ "passage": passage(), "time": 0 })>> <</if>>