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Fibromyalgia syndrome - F2.1

Definition of condition: Fibromyalgia Syndrome is characterized by widespread musculoskeletal pain and stiffness of unknown etiology.  Multiple tender points are essential to the diagnosis and features include sleep disturbance, fatigue and stiffness.

Issue statement: There is no consensus in the literature on a causal relationship between work activities or trauma and Fibromyalgia.  Often the diagnosis is  overused, and is one of exclusion, not based on acceptable clinical criteria.

WCB-Alberta position

Work relationship criteria

Current evidence is insufficient to establish a causal relationship between trauma and Fibromyalgia.  The cause of Fibromyalgia is multifactorial with individual susceptibilities which are as yet unknown. The interplay of the workplace and such personal characteristics are virtually impossible to assess at this time.

Without further scientific evidence, Medical Services will not consider the cause of Fibromyalgia Syndrome to be work or trauma related, either on a direct or aggravational basis.

Clinical criteria

Although Fibromyalgia Syndrome is not considered to be caused by work or trauma, for appropriate medical management of an injured worker, it is important to establish that the diagnosis is indeed correct.

The consensus criteria published by the American College of Rheumatology will be utilized at WCB to confirm the diagnosis of Fibromyalgia.  These criteria include:

1. A history of widespread pain (for at least 3 month) with all of the following being present:

• pain in the left and right side of the body
• pain below and above the waist
• axial skeletal pain

2. Pain in 11 of 18 tender point sites on palpation.

Associated symptoms include sleep disturbance, fatigue, muscle stiffness, anxiety, irritable bowel syndrome, headaches, paresthesias.  Other physical signs include skin fold tenderness, cutaneous hyperemia, reticular skin discoloration and diffuse finger puffiness (rare).

Note: The clinical diagnosis of tender points is very subjective with a great deal of inter-examiner and inter-exam variability.

Diagnosis for WCB purposes must be confirmed by a specialist in Physiatry, Rheumatology or Neurology.

Diagnostic criteria

There are no diagnostic tests that confirm the diagnosis of Fibromyalgia.

Fitness to work criteria

For individuals with a compensable injury and a diagnosis of Fibromyalgia Syndrome, duration guidelines for the compensable injury should be observed. Additional consideration  may be given to the following:

• A functional capacity evaluation may be helpful in determining work restrictions and  capabilities and to tailor work conditioning and/or work hardening programs.
  Note : the efficacy of work conditioning and work hardening programs has not been determined in patients with Fibromyalgia.
• an in-depth job and work site analysis may be required to assure successful return to work

Permanent clinical impairment criteria

• Not Applicable

Addendum to fibromyalgia syndrome guideline

In liaising with external caregivers and/or stakeholders the following general information and summary of current education and treatment strategies may be valuable.

General information

The literature does report some patients who develop acute localized musculoskeletal pain (e.g. in the neck region) following trauma ( e.g. from a motor vehicle accident), develop more widespread pain with multiple tender points at a later time.  The same phenomenon has been observed in repetitive occupational activities.  These reports, however, are anecdotal or based on case studies.

Another hypothesis proposed in medical literature is that acute trauma may trigger neuroendocrine aberrations in a genetically predisposed individual.

Additional information: education and treatment strategies

Strategies for the management of Fibromyalgia Syndrome focus on minimal investigation, clinical observation, patient education and reassurance.

Education

• of physicians and patients to recognize that symptoms are not necessarily due to a disease process
• of patients that there is often no physical cause for pain
• active participation of patient in treatment is essential
• patients can function and continue to work and are not totally disabled in most cases
• focus on wellness rather than illness emphasizing that work will not increase disability
• set goals relating to personal and vocational life

Physical methods of treatment

• aerobic, flexibility and strengthening exercises under supervision of a therapist who understands Fibromyalgia with the goal of establishing a self administered home exercise program
• exercise programs should be tailored to individual patients tolerance and capability
• active patient participation is essential
• electrical modalities and manual techniques are not effective

Medical  treatment

Drugs

• low dose tricyclic antidepressants e.g. amitryptline will improve sleep and reduce severity of pain in many patients
• non-narcotic analgesics may be helpful e.g. acetaminophen
• anti-inflammatory agents are usually ineffective
• narcotic analgesics should not be used
• anxiolytic agent can be used on a short term basis to reduce stress but long term use is not recommended

Others

• multidisciplinary treatment programs may be helpful in selected cases with the use of exercise, cognitive therapy, education, medication and stress management
• psychological assessment to identify psychological factors that may play a role in Fibromyalgia (depression, anxiety, poor concentration) to allow for effective treatmen

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