Fibromyalgia: Fibromyalgia

Physical Mechanisms and Evaluation of Severity

Richard Podell, MD
Clinical Professor of Family Medicine UMDNJUMDNJ-Robert Wood Johnson Medical School 105 Morris Ave. Springfield, NJ 07081 53 Kossuth St., Somerset, NJ 08873 973 218 9191; www.

The ACR Criteria For Fibromyalgia Require:
1. History of widespread pain for at least 3 months in 4 quadrants of the body along with axial skeletal pain 2. Pain at 11 or more of 18 specifically designated musclemuscle-tendon sites called ³tender points´ 3. Appropriate Rule/outs Note: Tender points are sites that are normally more tender i.e. sensitive to pressure

4 cm2) .Fibromyalgia Examine using thumb with force that just makes thumbnail blanch (4 kg/1.

Individuals with less than 11 of 18 may still have severe functional limitations. the correlation is very far from perfect. But. (Chronic Pain Syndrome. Tender Point Count and Intensity Can vary from day to day The degree of tender points tends to predict functional limitation.) The cut-off between ´fibromyalgiaµ and ´chronic pain cutsyndromeµ is somewhat arbitrary   .

Neural sensitization in fibromyalgia Small stimuli are amplified and distorted by the pain signaling pathways within the CNS In a sense the volume knob for pain is turned up to ´very highµ This is fibromyalgia·s anatomical and functional ´end organµ damage    .

FMS is Multi-system³not just Multi-system³ muscles       Chronic Fatigue Syndrome NonNon-restorative Sleep Cognitive Problems (´fibro fogµ) Irritable bowel Irritable bladder Chronic headache       Vulvodynia Orthostatic Hypotension Postural Orthostatic Tachycardia (POTS) Anxiety Depression Delayed Post Exertional Flare-Up Flare- .

2002. Arthritis Rheum.46:1333-43. Functional magnetic resonance imaging evidence of augmented pain processing in fibromyalgia. al.) . et.Fibromyalgia Evidence That Fibromyalgia (FMS) is a Physical Illness Involving Increased Neural Sensitivity: Functional MRI/SPECT Studies ´« support the hypothesis that fibromyalgia is characterized by cortical or sub-cortical augmentation of pain processingµ sub(Gracely R.

FMS PATIENTS COULD ACCOMPLISH THE TASK BUT HAD TO WORK HARDER TO DO IT . This increased activation was present whether or not standard neurocognitive tests were abnormal.Lange·s fMRI Results for CFS   Individuals with severe CFS were given a cognitive task that required a rapid physical response Functional MRI showed that these individuals recruited many more areas of the brain than did controls.

µ Lange G. Our findings provide objective evidence for the subjective experience of cognitive difficulties in individuals with CFS. 26: 513-524. Cook..Lange·s Conclusion ´Individuals with CFS appear to have to exert greater effort to process auditory information as effectively as demographically similar health adults. . Steffner. D et. NeuroImage 2005. Objective evidence of cognitive complaints in Chronic Fatigue Syndrome: A BOLD fMRI study of verbal working memory. A l. J .

Symptoms FMS Patients Report     Pain Fatigue Poor Stamina Cognitive Difficulties These symptoms worsen after modest exertion³often with a delay³The Delayed exertion³ delay³ PostPost-Exertional Flare-Up Phenomenon Flare-  .

BUT symptoms of illness often flare up later The delay may be several hours or one or more days The effects of over-doing tend to be cumulative. OveroverOverdoing for several days causes a greater and longer flareflareup than overdoing for just one day .The Post-Exertional Flare-Up PostFlarePhenomenon     Characteristic of severe FMS/CFS Stamina for several hours of activity might or might not be highly limited.

e. Therefore. often with a delay.Assessing Functional Limitations  FMS and CFS patients claim that over-activity causes oversymptoms to flare. ´overIf they push through their ´limitsµ for several days. the flareflare-up will be more severe and longer than if they ´push´push-throughµ for only a single day. To Have Face Validity. Such worsening accumulates with repeated episodes of ´over-doingµ i. . Disability Assessment Methods Must Evaluate for PostPostExertional Flare-up and for the effects of repeated Flareefforts over days or weeks or months.

. lumbar disc.Current FCE Protocols Ask The Wrong Question These might have use for rheumatoid arthritis. etc. where relevant limitations should show within a few minutes or hours of effort But there is no logical or empirical basis for extrapolating just several hours of FCE results to any judgment about whether a person with FMS/CFS can sustain comparable effort over multiple days. weeks or months. . angina.

Current FCE Protocols Lack Scientific Basis for FMS/CFS   Search of PubMed data-base using keywords: dataFCE or Functional Capacity Evaluation AND Fibromyalgia or Chronic Fatigue Syndrome: Only 1 scientific paper for FCE and FMS and 5 for FCE and CFS. . None justified extrapolation from short-term FCE testing to any conclusion shortabout ability to work for 40 hours a week.

ongoing function--not just function--not performance over several hours.CONCLUSION  FCE protocols cannot be relevant until they are revised and then validated to look specifically at sustained. .

Consider two individuals with FMS/CFS³one FMS/CFS³ who can work and one who cannot. THEIR PHYSICAL EXAM FINDINGS WILL LIKELY BE IDENTICAL .Physical Exam Findings    (Except in a few special situations) no finding on standard physical examination predicts or should be expected to predict the severity of illness or the ability to work.

But their absence does not mean that illness is mild. Muscle strength.Physical Exam   If present orthostatic low BP. standard ´mental statusµ exam. postural orthostatic tachycardia and neurocognitive test abnormalities suggest severe disease. x-rays and neuro exams will xusually be normal even when FMS/CFS is severe. joint motion. .

Lab Testing  No standard lab tests adequately measure the severity of illness or degree of limitation In research studies groups of FMS and CFS patients tend to show more lab abnormalities than do groups of controls. . But the overlap is too large to apply to individuals.

.´No objective evidenceµ on Physical Exam   We should not expect any specific ´objectiveµ physical exam or lab findings to be present or absent for disabling FMS/CFS. To suggest that the absence of such ´objective findingsµ on PE or Labs rules out disability misunderstands the nature of this illness.

Diaries.What Evidence Can We Use      Medical Records³most important Records³ Consistency of patients reports with the known clinical patterns of FMS/CFS Opinions of Treating Physicians Opinions of IME Physicians Independent evidence on Credibility-.g. Affidavits .Does Credibility-patient actually live in the manner they report? e. Surveillance.

#1 almost always is the Medical Records . All have potential strengths and weaknesses. Any can be biased.Evaluating the Evidence   No Method is Perfect.

105 Morris Avenue. .DrPodell. M. 08873 973-218973-218-9191 www.     Richard Podell.D. Springfield. NJ 07081 53 Kossuth St. Somerset.