Fibromyalgia: Physical Mechanisms and Evaluation of Severity

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Fibromyalgia Physical Mechanismsand Evaluation
of Severity

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

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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 muscle-tendon sites called tender
  points
  
• 3. Appropriate Rule/outs
• Note Tender points are sites that are
  normally more tender i.e. sensitive to pressure
  

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Fibromyalgia

• Examine using thumb with force that just makes
  thumbnail blanch (4 kg/1.4 cm2)

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

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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 high
  
• This is fibromyalgias anatomical and functional
  end organ damage

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FMS is Multi-systemnot just muscles

• Chronic Fatigue Syndrome
• Non-restorative Sleep
• Cognitive Problems (fibro fog)
• Irritable bowel
• Irritable bladder
• Chronic headache

• Vulvodynia
• Orthostatic Hypotension
• Postural Orthostatic Tachycardia (POTS)
• Anxiety
• Depression
• Delayed Post Exertional Flare-Up

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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 processing
  
• (Gracely R, et. al. Functional magnetic
  resonance imaging evidence of augmented pain
  processing in fibromyalgia. Arthritis Rheum.
  2002461333-43.)

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Langes 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, This increased activation was
  present whether or not standard neurocognitive
  tests were abnormal.
• FMS PATIENTS COULD ACCOMPLISH THE TASK BUT HAD
  TO WORK HARDER TO DO IT

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Langes Conclusion

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

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Symptoms FMS Patients Report

• Pain
• Fatigue
• Poor Stamina
• Cognitive Difficulties
• These symptoms worsen after modest
  exertionoften with a delayThe Delayed
  Post-Exertional Flare-Up Phenomenon

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The Post-Exertional Flare-Up Phenomenon

• Characteristic of severe FMS/CFS
• Stamina for several hours of activity might or
  might not be highly limited. 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.
  Over-doing for several days causes a greater and
  longer flare-up than overdoing for just one day
  

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Assessing Functional Limitations

• FMS and CFS patients claim that over-activity
  causes symptoms to flare, often with a delay.
  Such worsening accumulates with repeated
  episodes of over-doing i.e. If they push
  through their limits for several days, the
  flare-up will be more severe and longer than if
  they push-through for only a single day.
• Therefore, To Have Face Validity, Disability
  Assessment Methods Must Evaluate for
  Post-Exertional Flare-up and for the effects of
  repeated efforts over days or weeks or months.

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Current FCE Protocols Ask The Wrong Question

• These might have use for rheumatoid arthritis,
  lumbar disc, angina, 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.

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Current FCE Protocols Lack Scientific Basis for
FMS/CFS

• Search of PubMed data-base using keywords FCE
  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
  about ability to work for 40 hours a week.

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CONCLUSION

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

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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.
• Consider two individuals with FMS/CFSone who can
  work and one who cannot.
  
• THEIR PHYSICAL EXAM FINDINGS WILL LIKELY BE
  IDENTICAL

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Physical Exam

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

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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.

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No objective evidence on Physical Exam

• We should not expect any specific objective
  physical exam or lab findings to be present or
  absent for disabling FMS/CFS.
  
• To suggest that the absence of such objective
  findings on PE or Labs rules out disability
  misunderstands the nature of this illness.

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What Evidence Can We Use

• Medical Recordsmost important
• Consistency of patients reports with the known
  clinical patterns of FMS/CFS
  
• Opinions of Treating Physicians
• Opinions of IME Physicians
• Independent evidence on Credibility-- Does
  patient actually live in the manner they report?
  e.g. Surveillance, Diaries, Affidavits

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Evaluating the Evidence

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

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