Fibromyalgia Physical Mechanisms and Evaluation of Severity

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					    Fibromyalgia:
   Physical Mechanisms
 and 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
   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
            Fibromyalgia

Examine using thumb with force that just makes
       thumbnail blanch (4 kg/1.4 cm2)
    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
     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 fibromyalgia’s anatomical and functional
    “end organ” damage
    FMS is Multi-system—not just
             muscles
   Chronic Fatigue            Vulvodynia
    Syndrome                   Orthostatic
   Non-restorative Sleep       Hypotension
   Cognitive Problems         Postural Orthostatic
    (“fibro fog”)               Tachycardia (POTS)
   Irritable bowel            Anxiety
   Irritable bladder          Depression
   Chronic headache           Delayed Post
                                Exertional Flare-Up
               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. 2002;46:1333-43.)
    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, 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
             Lange’s 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.
    Symptoms FMS Patients Report
   Pain
   Fatigue
   Poor Stamina
   Cognitive Difficulties

    These symptoms worsen after modest
    exertion—often with a delay—The Delayed
    Post-Exertional Flare-Up Phenomenon
       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
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.
     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.
      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.
            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.
          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/CFS—one
    who can work and one who cannot.
   THEIR PHYSICAL EXAM FINDINGS
    WILL LIKELY BE IDENTICAL
               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.
                  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 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.
      What Evidence Can We Use
    Medical Records—most 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
        Evaluating the Evidence
    No Method is Perfect. All have potential
    strengths and weaknesses. Any can be biased.
    #1 almost always is the Medical Records
   Richard Podell, M.D.
   105 Morris Avenue, Springfield, NJ 07081
   53 Kossuth St. Somerset, NJ, 08873
   973-218-9191
   www.DrPodell.org

				
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posted:3/31/2008
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