FIBROMYALGIA Diagnosis and Navy perspective for active duty N.Erikson CAPT MC USN Rheumatology Div NMCP
FIBROMYALGIA • What is it? • What it isn’t • How is it classified? • Who “diagnoses” and treats it? • Active duty disposition
FIBROMYALGIA • What is it? • a pain syndrome which is chronic and diffuse • may accompany many disorders, but • often a “primary” condition • does not lead to tissue damage • cause is unknown • no lab abnormalities • no structural alterations or visible abnormalities to exam • poorly understood
FIBROMYALGIA • What it isn’t • not a rheumatic disease • not, as a rule, recognized as disabling by the Navy
FIBROMYALGIA • How is it diagnosed? • The American College of Rheumatology has published classification criteria • primarily to define patient populations for study • when no other evidence for systemic disease, it is considered primary fibromyalgia • IN OTHER WORDS: WHEN THE PATIENT’S PAIN CAN BE EXPLAINED BY FIBROMYALGIA THERE IS NO NEED TO INVOKE A RHEUMATIC DISEASE EXPLANATION • The classification criteria are entirely clinical and can be applied by anyone!
1990 criteria for the classification of Fibromyalgia • 1. History of widespread pain. • 2. Pain in 11 of 18 tender point sites on digital palpation. • * For classification purposes, patients will be said to have fibromyalgia if both criteria are satisfied. Widespread pain must have been present for at least 3 months. The presence of a second clinical disorder does not exclude the diagnosis of fibromyalgia
History of widespread pain • Definition. Pain is considered widespread when all of the following are present: pain in the left side of the body, pain in the right side of the body, pain above the waist, and pain below the waist. In addition, axial skeletal pain (cervical spine or anterior chest or thoracic spine or low back) must be present. In this definition, shoulder and buttock pain is considered as pain for each involved side. "Low back" pain is consideredlower segment pain.
Occiput: Bilateral, at the suboccipital muscle insertions. Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7. Trapezius: bilateral, at the midpoint of the upper border. Supraspinatus: bilateral, at origins, above the scapula spine near the medial border. Second rib: bilateral, at he second costochondral junctions, just lateral to the junctions on upper surfaces. Lateral epicondyle: bilateral, 2 cm distal to the epicondyles. Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle. Greater trochanter: bilateral, posterior to the trochanteric prominence. Knee: bilateral, at the medial fat pad proximal to the joint line.*Digital palpation should be performed with an approximate force of 4 kg.For a tender point to be considered "positive" the subject must state that the palpation was painful. "Tender is not to be considered "painful." Pain in 11 of 18 tender point* sites on digital palpation.
REMEMBER… ”fibromyalgia” • is very common • has no acknowledged pathologic etiology • by itself, does not lead to loss of joint function or structure • can be diagnosed and treated by ANY care provider - some rheumatologists have special interest in the primary disorder. None currently stationed at NMCP do.
A WORD ABOUT ACTIVE DUTY MEMBERS • Intolerance or inability to perform duty due to pain of fibromyalgia is NOT routinely considered a disability by the Navy • Medical Boards for fibromyalgia ALONE are usually returned with “fit for continued service” dispositions
A WORD ABOUT ACTIVE DUTY MEMBERS • There is NO REQUIREMENT for rheumatology to evaluate a member to diagnose or treat “fibromyalgia”….anyone can do that. • Rheumatology consultation is required for active duty members UNDERGOING REFERRAL TO THE CENTRAL PEB when a diagnosis of fibromyalgia is noted • Referral to Psychiatry is also REQUIRED • REF: SECNAVINST 1850.4E
A WORD ABOUT ACTIVE DUTY MEMBERS • My personal recommendation for active duty with “fibromyalgia” and inability or intolerance of duty, PRT, and the like… • process in accordance with MILPERSMAN 1910-120; “Separation by reason of convenience of the government - physical or mental conditions” • NOTE: the current (28 AUG 01) article does NOT require a PEB before this type of admin sep, and it may be started by the member