And How to Bring These Difficult Cases to Closure
If a physician were to tell you that you have a medical condition that requires treatment, as a health care professional you would be savvy enough to ask for a diagnosis. You would ask how the diagnosis was confirmed, how you contracted the condition and what the standard course of treatment would be. No doubt, you would also want to know if the condition would worsen or improve with treatment, if there is a predictable outcome, or whether the condition might worsen. If the same physician told you there were no answers for most (if any) of those questions, you might feel you needed another opinion.
Organic pathologies have objective methods used for diagnosis. There is usually an identifiable causal relationship that is identified, whether that cause be the result of an infection, a reaction to an environmental factor, a genetic problem, a metabolic problem or an injury. There is a standard course of treatment, often complimented with the use of specific medications. Most organic pathologies will run a predictable course. The cure, progression or control of the pathology generally falls within predictable parameters. And outcomes too are generally predictable. There are answers for all of these questions for just about every condition that is encountered by the case manager, with the exception of a small handful of conditions—and fibromyalgia is one of those conditions. This article explores fibromyalgia in the context of its use in compensable injury claims.
Not a Diagnosis
Fibromyalgia (literally meaning ”fiber/muscle pain”) was first proposed as a medical term in 1990. Contrary to common belief, it is not a diagnosis. Dr. Frederick Wolfe, the chairman of the committee representing the American College of Rheumatology (ARC), stated that the criteria for identifying the condition were for the purpose of “classification rather than diagnostic criteria.” The purpose of the classification was intended for research purposes only. The ARC specifically stated that the classification was not intended to apply to insurance cases because the condition was identified by palpating 18 specific points on the body. The condition was said to be present when the patient reported pain in at least 11 locations. The ARC issued this caveat when introducing the term to the medical community:
“Within the setting of compensation, work injury, disability or litigation, however, fibromyalgia has a different meaning. For although we know something about the validity and reliability of our diagnoses in the clinic (where causation is rarely a question), almost nothing is known about diagnostic validity and reliability in the compensation setting. Although there are no research data on this point, the author [Dr. Wolfe] has seen and is convinced that both the tender point count and dolorimetry score can be manipulated by a patient.”
Since that statement in 1990, not much has changed—despite intensive investigation. Other methods of diagnosing the condition have been investigated. These include various lab tests and functional neuroimaging of various parts of the brain. Typically, the identification of the condition is a differential diagnosis. Most of the time, this brings the physician back to the ARC method, i.e., consideration of all the various subjective complaints, coupled with pain in response to palpation of the “tender points” coupled with a reported history of widespread pain lasting more than three months which affects the body above and below the waist, both anteriorly and posteriorly.
There is no single cause that has been identified as causing the condition, though several causes have been proposed. They include stress, genetic predisposition, clinical symptoms, metaboloic problems associated with cerebral spinal fluid abnormalities, and abnormalities in the hypothalamus, as well as the pituitary and adrenal glands. Other proposed causes include low levels of morning salivary cortisol, high levels of evening salivary cortisol, dopamine dysfunction, abnormal serotonin metabolism, human growth hormone deficiency, and deficient immune response to intestinal bacteria. There is no consensus on causal connection.
Multiple factors are said to aggravate the condition. Some of these include physical activity, physical inactivity, weather changes, travel by automobile, allergies, stress, lack of emotional support, chemical exposure, infections and medications. There is no consensus on aggravating factors.
Only one drug is specifically approved by the FDA for the treatment of the condition, although other medications are often prescribed “off label.” Controlled studies indicate that some medications, exercise, behavioral modification, and providing the patient information are effective in some sufferers. There is no consensus for standard treatment of fibromyalgia.
Despite the fact that the ARC specifically stated that the condition is not a diagnosis, nor is it to be applied in compensable injury cases, both precepts are commonly ignored. Specifically, with regard to the use of the term in cases involving compensation, there are several questions that are unanswered by the research and mitigate in favor of the defense against the claim that the condition is the result of an injury. Those questions are:
- Is there evidence from controlled experiments that the condition exists? Do all persons with the condition get it from accidents? Do all persons who have accidents get the condition? Do persons who do not have accidents get the condition? Is the condition reported in connection with a self-inflicted injury or an injury that occurs at home?
- Is there a temporal connection? If the connection is by self-report, how reliable is the self-report?
- Is there a dose-gradient response? Do more severe injuries in the workplace result in more serious cases of the condition? Do minor injuries result in a less serious case?
- Is the published research from one study to another consistent with a specific set of findings when investigating causal connection, diagnosis, treatment, etc.?
- Is there a recognizable biological pattern related to causal connection that can be identified and does it make sense? Is a similar condition present in animals?
- Is the origin of the condition specific, or have multiple causes been suggested?
It should come as no surprise that many persons conducting functional capacity evaluations (FCEs) have found that claimants with a fibromyalgia label are reluctant to perform, often presenting with demonstrated diminished functional capacities. A study recently accepted for publication found that persons said to have fibromyalgia, chronic pain, and similar nonspecific conditions failed to generate as much force during hand strength testing or lift as much weight as persons who had undergone upper extremity or cervical spine surgeries. Furthermore, these studies show that fibromyalgia claimants performed less consistently during repeated measures protocols in which significant distraction was employed for the purpose of analyzing reproducibility of the physical performance data.
These findings indicate that there is likely to be a substantial behavioral component. If such abnormal test behaviors are not objectively classified, physicians are reluctant to take measures which move such cases toward closure. The best way to move such cases in the direction of closure is to objectively classify validity of effort during an FCE. Unfortunately, many commonly administered tests are unrelated to function and/or poor indices of effort.
Ranges of motion, manual strength testing, job simulations, assessments of repetitive movements, and assessments of positional tolerances are inadequate to objectively classify effort and do not adequately classify effort because the claimant can easily control the outcomes—and there are virtually no methods that can objectively prove that such results are not valid. Instead of being used as supportive of a conclusion, they are often used in lieu of data which adequately assess behavior.
Various types of machine testing have been used in FCEs to classify validity of effort. However, research that will be published in 2010 will demonstrate that one type of machine testing—isometric, or static testing—neither predicts actual lifting capacity nor accurately classifies effort. Multiple literature reviews conclude that isokinetic testing does not predict function or accurately classify validity of effort, although there have been more than 2,200 published studies on isokinetic strength since 1976.
In the past 25 years, at least 20 studies indicate that the standard methods of classifying effort during hand strength testing are inaccurate—but their use persists, nevertheless. In a study published in Spine, the visual estimation of effort was found to correctly identify “maximum” lifting capacities only 5-7 percent of the time in chronic back pain patients. Furthermore, no controlled studies have been conducted that document the accuracy of this methodology without using statistical analyses which report only the results of the accuracy of classification of very broad levels of effort spanning a range of levels of exertion as opposed to “maximum voluntary effort.”
Therefore, when choosing a care provider who is assessing the fibromyalgia claimant, the case manager needs to ensure the accuracy of the classification of effort. New alternatives to the standard fare, described in the aforementioned studies which have been accepted for publication, are now on the market. Parties interested in additional information regarding FCE methodology and the defense of insurance cases involving fibromyalgia and fibromylasia can be obtained from the author.
Darrell Schapmire, MS, has developed two commercially-available sincerity of effort products. His published work focuses on improving assessments of function and validity of effort. His article here explores fibromyalgia and its relationship to compensable injury cases. (firstname.lastname@example.org)