1. 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
; www. DrPodell.org

2. 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

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

4. 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

5. 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

6. FMS is Multi-system—not 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

7. 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: )

8. 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

9. 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:

10. 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

11. 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

12. 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.

13. 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.

14. 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.

15. 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.

16. 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

17. 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.

18. 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.

19. “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.

20. 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

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

22. Richard Podell, M.D.
105 Morris Avenue, Springfield, NJ 07081
53 Kossuth St. Somerset, NJ, 08873