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Training and Development

Fibromyalgia Guidelines for the Disability Analyst

MED/S2/CMEP~0035

Version 8 Final

Module: 14

ATOS HEALTHCARE

PROVIDED ON BEHALF OF THE DEPARTMENT FOR WORK AND PENSIONS

Atos Healthcare

Fibromyalgia – Guidelines for the Disability Analyst 8 Final MED/S2/CMEP~0035

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Foreword

This training has been produced as part of a training programme for Health Care Professionals approved by the Department for Work and Pensions Chief Medical Adviser to carry out benefit assessment work.

All Health Care Professionals undertaking assessments must be registered practitioners who in addition, have undergone training in disability assessment medicine and specific training in the relevant benefit areas. The training includes theory training in a classroom setting, supervised practical training, and a demonstration of understanding as assessed by quality audit.

This training must be read with the understanding that, as experienced practitioners, the Health Care Professionals will have detailed knowledge of the principles and practice of relevant diagnostic techniques, and therefore such information is not contained in this training module.

In addition, the training module is not a stand-alone document, and forms only a part of the training and written documentation that the Health Care Professional receives. As disability assessment is a practical occupation, much of the guidance also involves verbal information and coaching.

Thus, although the training module may be of interest to non-medical readers, it must be remembered that some of the information may not be readily understood without background medical knowledge and an awareness of the other training given to Health Care Professionals.

Office of the Chief Medical Adviser

October 2014

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Document control

Superseded documents

Version history

Version Date Comments

8 Final 06th October 2014 Signed off by HWD and CMMS

8c draft 25th August 2014 External QA comments incorporated

8b draft 13th May 2014 Peer review comments incorporated

8a draft 12th December 2013 Schedule 28 review SE

7 Final 20th December 2012 Signed off by HWD and CMMS

7a Draft 19th December 2012 Update to clarify MCQs

6 Final 23rd August 2012 Signed off by HWD and CMMS

Changes since last version

Foreword updated

Document rewritten using current research information

Section 3 Most questions changed

Section 4 Case study and questions rewritten

Section 5 Overview rewritten

Section 6 updated with current disability analysis information

Section 7 rewritten with current Revised WCA information and new case study added

Section 8 rewritten and new case study added

Section 9 added (guidance for case studies)

References updated

All MCQ questions changed

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Outstanding issues and omissions

Issue control

Author: Medical Training & Development

Owner and approver: Clinical Director

Signature: Date:

Distribution:

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Contents Page

Section Page

1. Aims and Objectives 7

2. Introduction 8

3. Current Knowledge of Fibromyalgia Syndrome (FMS) 9

4. Fibromyalgia Case Example 10

5. Overview of Fibromyalgia 12

5.1 Epidemiology 12

5.2 Aetiology 12

5.3 Diagnosis 12

5.4 Clinical features 17

5.5 Management 18

5.6 Prognosis 19

6. Face-to-Face Assessment in the Disability Analysis Setting 20

6.1 Before the Assessment 20

6.2 Setting the Scene at the Beginning of the Assessment 20

6.3 History 21

6.4 Examination 22

6.5 Observed Behaviour 23

6.6 Logical Reasoning and Justification of Advice 23

7. Fibromyalgia and the Revised Work Capability Assessment 25

7.1 Revised Work Capability Assessment Case Study 26

8. Fibromyalgia and Disability Living Allowance 32

8.1 Higher Rate Mobility Component 32

8.2 Care Component 33

8.3 Disability Living Allowance Case Study 34

9. Self Assessment and Case Study Guidance 38

9.1 Knowledge Self Assessment Quiz 38

9.2 Revised WCA Case Study Suggested Guidance 39

9.3 DLA Case Study Suggested Guidance 40

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10. Summary 42

11. Further Reading 43

12. Evaluation 44

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1. Aims and Objectives

Aim

The aim of this module is to present to Healthcare Professionals (HCPs) an overview of fibromyalgia syndrome which will enable them to approach claimants with the condition in a structured and consistent way.

Objectives

By the end of the module the HCP will have considered:

An overview of fibromyalgia including aetiology, diagnosis, management and prognosis

The assessment of fibromyalgia in disability analysis, developing a consistent and focused approach

The assessment of fibromyalgia in Revised WCA and DLA cases

.

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2. Introduction

These guidelines form part of Atos Healthcare’s programme for continuing medical education for Health Care Professionals (HCPs). They are designed to encourage consistency in our approach to complex conditions; provoke reflection on our own perceptions with regard to them; and foster awareness of current medical thinking.

This document aims to refresh your awareness of fibromyalgia and examines the implications of the condition in the disability analysis setting.

The purpose of this module is to encourage HCPs working in disability analysis to adopt a common approach to this at times difficult and complex condition.

The disability analyst’s particular focus in fibromyalgia is the assessment and measurement of overall functional disablement. It is hoped that this training module will encourage HCPs to approach these cases in a way that is objective, thoughtful and structured.

2.1 How to use these Guidelines

After the introduction, there is a short questionnaire to complete. This is followed by a short case study to help HCPs to begin to think about some of the principles of assessment of claimants with fibromyalgia.

The document contains an overview of the condition including diagnosis, management and prognosis. This is followed by a review of the principles of disability analysis when assessing claimants with fibromyalgia, with specific sections about Revised Work Capability assessments and Disability Living Allowance assessments (with case studies to complete). HCPs should read the whole document, however they need only complete the case studies for the relevant benefit strand for which they are trained.

There is a reading list with further sources of information about fibromyalgia, if HCPs wish to undertake further self directed learning.

At the end of the document there is a MCQ to be completed and returned to the local training support manager.

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3. Current Knowledge of Fibromyalgia Syndrome (FMS)

Before proceeding with the rest of the module, it would be helpful to complete the following short exercise. First read the question, and then tick the most appropriate box.

Yes No

Don’t

Know

Fibromyalgia is entirely psychological in origin

Fibromyalgia is wholly physical in origin

Fibromyalgia can be associated with significant levels of functional impairment

Fibromyalgia is common with a prevalence of around 10% worldwide

Depression is associated with fibromyalgia

There is often overlap in the symptoms experienced in fibromyalgia with the condition of CFS/ME

The condition occurs equally in men and women

Fibromyalgia can be diagnosed with a biochemical marker

Sleep problems are commonly reported in Fibromyalgia

The aetiology of fibromyalgia has been clearly established

Fibromyalgia is usually triggered by a viral infection

Antidepressant medication is used in the treatment of fibromyalgia

Fatigue is not present in fibromyalgia

The prognosis is usually good in fibromyalgia

Paraesthesiae, muscle spasms and migraine are symptoms of fibromyalgia

Analgesic medication is very effective in treating the pain of fibromyalgia

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4. Fibromyalgia Case Example

Read the following case study information. Try to decide how to approach the face-to-face assessment of this claimant and the task of providing the Decision Maker (DM) with advice.

Mrs F is a 56 year old woman who provides the following history in her claim form:

She was diagnosed with fibromyalgia 18 months ago. She also lists irritable bowel syndrome, high blood pressure and hypothyroidism on her claim form.

The symptoms began with all over body pain and within a month or so she had developed significant fatigue. Both the pain and fatigue have been very difficult to control. Currently she indicates that she has widespread muscle pain and periods of severe fatigue. She also describes problems with headaches, dizziness and poor concentration. She is taking medication but does not find it very helpful. She also describes problems with her bowels, with frequent abdominal pain, loose motions and urgency.

She was working as a receptionist at a doctor’s surgery, but had to stop work 16 months ago because of the fibromyalgia (pain, fatigue and difficulties with concentration).

She sees her GP regularly and has not been referred for specialist review.

A report from her GP attached to the claim form states” Fibromyalgia 18 months, IBS 3 years, hypertension 3 years - stable, hypothyroidism 6 months – on thyroxine, stable now.

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Thinking about the information provided:

Are there special considerations that may guide a HCP’s initial approach to assessing claimants with fibromyalgia?

What areas of the history should HCPs concentrate on, and why?

If performing a physical examination, what areas of the physical examination should the HCP concentrate on, and why? Are there any special considerations that need to be taken into account during an examination?

Should a mental state assessment be performed, and if so, what areas should be focused on?

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5. Overview of Fibromyalgia

Fibromyalgia is described as a syndrome of symptoms, including: chronic widespread pain, un-refreshing sleep, fatigue, depression and cognitive dysfunction.

The diagnosis, however, remains controversial with ongoing, sometimes fierce, debate between medical professionals, people with a diagnosis of fibromyalgia, professional organisations, patient support groups, pharmaceutical companies and governmental organisations.1

It is often considered to be part of a continuum of medically unexplained symptoms of polysymptomatic distress that include chronic fatigue syndrome, irritable bowel syndrome and chemical sensitivities.

5.1 Epidemiology

The prevalence is thought to be around 2-3% worldwide. It affects women more commonly than men.

The prevalence of fibromyalgia increases with age, with it occurring most in those over 60 years old.

5.2 Aetiology

The cause of fibromyalgia remains obscure, although it is likely to be multi-factorial in nature. It is not associated with any structural or functional abnormalities in the joints, muscle or connective tissue.

Fibromyalgia is a syndrome characterised by dysfunctional pain processing in the central nervous system, in genetically susceptible individuals. An individual’s experience of pain is influenced by physical, psychological and social factors, which can improve or worsen the pain.

5.3 Diagnosis

Fibromyalgia is a clinical diagnosis, made on the basis of clinical history and examination findings. It is not a diagnosis of exclusion and it can occur with other conditions such as: degenerative or inflammatory rheumatic disorders, rheumatoid arthritis, SLE and osteoarthritis. One study found that 17% of those with osteoarthritis, 21% with rheumatoid arthritis and 37% of those with SLE would fulfil the 2010 American College of Rheumatology criteria for fibromyalgia.2

1 Wolfe F. Fibromyalgia wars. J Rheumatol 2009;36:671-8.

2 Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Hauser W, Katz RS, et al. Fibromyalgia criteria and severity

scales for clinical and epidemiological studies: a modification of the ACR preliminary diagnostic criteria for fibromyalgia. J Rheumatol2011;38:1113-22

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There is no diagnostic test for fibromyalgia, but investigations may be undertaken to rule out other conditions.

In 1990 the American College of Rheumatology developed criteria for the diagnosis of fibromyalgia for use in clinical and epidemiological research. However, these criteria have been also used by clinicians as an aid for diagnosis. These criteria were subsequently revised in 2010 (see page 16), but have been included here for completeness.

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The American College of Rheumatology Criteria for the Classification of Fibromyalgia (1990)3

1. History of widespread pain for more than three months

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

Pain below the waist

In addition, axial skeleton pain (cervical spine, anterior chest, 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 considered lower segment pain.

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

Definition

Pain, on digital palpation*, must be present in at least 11 of the following 18 tender point sites:

Occiput: Bilateral, at the suboccipital muscle insertions.

Low cervical: Bilateral, at the anterior aspects of the intertransverse spaces at C1-C7.

Trapezius: Bilateral, at the midpoint of the upper border.

Supraspinatus: Bilateral, at its origins, above the scapular spine near the medial border.

Second rib: Bilateral, at the second costochondral junctions, just lateral to the junctions on upper surfaces.

Lateral epicondyle: Bilateral, 2cm distal to the epicondyles.

Gluteal: Bilateral, in upper outer quadrants of buttock 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 is performed with an approximate force of 4kg (not appropriate in disability analysis setting). For a tender point to be considered positive, the subject must state that the palpation was painful. ‘Tender’ is not to be considered painful.

3 Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of

Rheumatology 1990 criteria for the classification of fibromyalgia: report of the multicenter criteria committee. Arthritis Rheum 1990;33:160---72.

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Figure 1 - Tender point sites of fibromyalgia syndrome

However, problems with these criteria have been described such as the tender point test being hard to standardise. Some people with fibromyalgia do not have the tender points, and some healthy people do have them. Also, the criteria do not take into account symptoms such as sleep problems and fatigue.

In 2010, the American College of Rheumatology revised the criteria, eliminating the tender points and focussing more on symptoms of widespread pain and neuropsychological symptoms (fatigue, un-refreshing sleep, cognitive dysfunction, anxiety and depression). These 2010 criteria are currently being evaluated for clinical accuracy.

The American College of Rheumatology Diagnostic Criteria for Fibromyalgia (2010)4

Criteria A patient satisfies diagnostic criteria for fibromyalgia if the following 3 conditions are met:

1) Widespread pain index (WPI) of ≥7, and symptom severity (SS) scale score of ≥5 or WPI 3–6 and SS scale score of ≥9.

2) Symptoms have been present at a similar level for at least 3 months.

3) The patient does not have a disorder that would otherwise explain the pain.

Ascertainment

1) WPI: note the number areas in which the patient has had pain over the last week. In how many areas has the patient had pain? Score will be between 0 and 19.

4 Wolfe F, Clauw DJ, Fitzcharles M, Goldenberg DL et al. The American College of Rheumatology Preliminary

Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity, Arthritis Care & Research

2010:62(5): 600–610

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Shoulder girdle left, shoulder girdle right, upper arm left, upper arm right. lower arm left, lower arm right

Hip (buttock, trochanter) left, hip (buttock, trochanter) right, upper leg left, upper leg right

Lower leg left, lower leg right

Jaw left, jaw right, chest, abdomen

Upper back, lower back, neck

2) SS scale score:

Fatigue

Waking un-refreshed

Cognitive symptoms

For the each of the 3 symptoms above, indicate the level of severity over the past week using the following scale:

0 = no problem

1 = slight or mild problems, generally mild or intermittent

2 = moderate, considerable problems, often present and/or at a moderate level

3 = severe: pervasive, continuous, life-disturbing problems

Considering somatic symptoms in general, indicate whether the patient has:*

0 = no symptoms

1 = few symptoms

2 = a moderate number of symptoms

3 = a great deal of symptoms

The SS scale score is the sum of the severity of the 3 symptoms (fatigue, waking unrefreshed, cognitive symptoms) plus the extent (severity) of somatic symptoms in general. The final score is between 0 and 12.

* Somatic symptoms that might be considered: muscle pain, irritable bowel syndrome, fatigue/tiredness, thinking or remembering problem, muscle weakness, headache, pain/cramps in the abdomen, numbness/tingling, dizziness, insomnia, depression, constipation, pain in the upper abdomen, nausea, nervousness, chest pain, blurred vision, fever, diarrhoea, dry mouth, itching, wheezing, Raynaud’s

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phenomenon, hives/welts, ringing in ears, vomiting, heartburn, oral ulcers, loss of/change in taste, seizures, dry eyes, shortness of breath, loss of appetite, rash, sun sensitivity, hearing difficulties, easy bruising, hair loss, frequent urination, painful urination, and bladder spasms.

It should be noted that there is ongoing debate as to whether fibromyalgia is a helpful diagnosis and whether it should be specifically diagnosed. Some feel it is helpful in that a “diagnosis generates comfort, relief, acceptance, credibility and legitimacy”.5 However, others feel that a diagnosis of fibromyalgia is unhelpful. Wolfe in his article ‘Fibromyalgia Wars’ concludes that a fibromyalgia “diagnosis offers short-term legitimacy and social benefit to patients, but at the cost of creating and expanding illness.”

5.4 Clinical features

People with fibromyalgia generally complain of widespread pain often with fatigue, sleep disturbance and cognitive dysfunction. Presentations will vary from individual to individual and the symptoms are not all present in every patient or at all times. Other symptoms that may be present include:

Irritable bladder

Irritable bowel

Migraine

Muscle spasm

Dizziness

Perception of swelling of limbs

Paraesthesiae

Sensitivity to temperature changes

Anxiety

Depression

Irritability

Memory lapses

Reduced concentration

5 Huibers MJ, Wessely S. The act of diagnosis: pros and cons of labelling chronic fatigue syndrome. Psychol Med

2006;36:895-900.

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5.5 Management

There is no cure for fibromyalgia and the focus of management is on improving symptoms to improve quality of life, rather than the elimination of pain. Management of the condition is often complex and challenging.

Education about fibromyalgia by explaining the nature of the condition, including underlying theories about the pain mechanisms, can be helpful. Specific education about managing certain symptoms such as sleep routines may also be useful.

Physical therapies can include active and passive therapies. A Cochrane systematic review found that regular aerobic exercise improves wellbeing, aerobic capacity, tenderness and pain. Other therapies that may help include: strength training, balneotherapy (heated pool treatment), manipulation, massage, electrotherapy and ultrasound. Studies have found no evidence that acupuncture is helpful in the improvement of the symptoms of fibromyalgia in the long term.

Psychological therapies that may be used include cognitive behavioural therapy, self-management and pain management programs. Cognitive behavioural therapy helps address links between pain, mood and behaviour and assists manage negative coping strategies. Self-management and pain management programs may also help.

Medications used in the treatment of fibromyalgia include analgesics, anti-depressants and anticonvulsants. Analgesics that are used include paracetamol, weak opioids and NSAIDs, although evidence supporting their use is limited. There is evidence that tramadol is effective in the management of pain in fibromyalgia, however there is no place for the use of strong opioids. Antidepressant medications used include: tricyclic antidepressants (especially amitriptyline), selective serotonin reuptake inhibitors (such as fluoxetine and paroxetine) and serotonin noradrenaline reuptake inhibitors (such as duloxetine and milnacipran), with trials suggesting antidepressants are useful in reducing pain, fatigue and depression. Second generation anticonvulsants (such as gabapentin or pregabalin) are also used and may help with pain, fatigue and sleep problems.

A meta-analysis study has recently concluded that the medications used in fibromyalgia are not generally associated with a significant clinical benefit and the benefits of non-pharmacological treatment are limited.6 The authors of the study recommend a combination approach to therapy consisting of aerobic exercise, CBT and drug therapy.

The European League against Rheumatism (EULAR) issued evidence based guidelines for the management of fibromyalgia in 2007. They recommended the following:

Comprehensive assessment of pain, function, and psychosocial context.

A multidisciplinary approach with a combination of non-pharmacological and

6 Nuesch E, Hauser W, Bernardy K, Barth J, Juni P. Comparative efficacy of pharmacological and non-

pharmacological interventions in fibromyalgia syndrome: network meta-analysis. Ann Rheum Dis2013;72:955-62.

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pharmacological treatment modalities tailored according to pain intensity, function and associated features (such as depression, fatigue and sleep disturbance) in discussion with the patient:

o Heated pool treatment with or without exercise

o Individually tailored exercise programmes including aerobic exercise and strength training

o Cognitive behavioural therapy

o Other therapies such as relaxation, rehabilitation, physiotherapy and psychological support

Medications:

o Tramadol is recommended for the management of pain in fibromyalgia. Simple analgesics such as paracetamol and other weak opioids can also be considered in the treatment of fibromyalgia. Corticosteroids and strong opioids are not recommended

o Antidepressants: amitriptyline, fluoxetine, duloxetine, milnacipran, moclobemide and pirlindole reduce pain and often improve function therefore they should be considered for the treatment of fibromyalgia

o Tropisetron, pramipexole and pregabalin reduce pain and should be considered for the treatment of fibromyalgia

5.6 Prognosis

Prognosis can be variable and difficult to predict due to the complex nature of the condition. It depends on where a person fits on the continuum of symptoms. Those seen in primary care have a better prognosis than those under specialist care.

Studies from the 1990s indicated that fibromyalgia was associated with significant rates of disability with associated significant occupational impact. Nowadays there is a better understanding of the condition and more treatment options, but it is difficult to find studies with recent prognosis data.

While recent prognosis data is not available, it is clear that some people with fibromyalgia are able to continue working whilst others have significant functional impairment, which impacts on their ability to work.

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6. Face-to-Face Assessment in the Disability Analysis Setting

Questions that need to be considered when completing assessments in the disability analysis setting include:

To what extent is the person functionally impaired (taking into account any variability)?

Consistency - is the claimed degree of disability in keeping with the history, clinical findings and natural history of the disorder?

What is the prognosis?

In order to provide advice on these matters, a clear, focused and personalised assessment must be performed.

6.1 Before the Assessment

As with any face-to-face assessment, the information available on MSRS (for Revised WCA cases) or in the file should be carefully reviewed. This may consist of claim forms completed by the claimant (or their carer), letters from their GP or hospital specialists, factual reports as well as previous reports (such as an ESA 85 or and IB 85).

In Revised WCA cases particular attention must be paid to the current claimant questionnaire (ESA50) and all areas where the claimant indicates that there may be a problem must be fully explored. At times the claimant may also bring additional evidence to the assessment. Any evidence brought by the claimant must be read and the report should make reference to the evidence that has been considered. Full justification should be provided if there is a conflict between the opinion of the HCP and the medical evidence.

In DLA claims the HCP will need to read the information provided by the DM on the DLA request form (DBD313A) and ensure the report addresses all the queries raised by the DM.

6.2 Setting the Scene at the Beginning of the Assessment

In order to ensure that the assessment yields the maximum amount of information, HCPs should invest time in creating a good rapport with the claimant. Because of the nature of the condition and the differing perceptions surrounding it, some individuals may adopt a defensive attitude, assuming that the HCP will approach the proceedings with in-built disbelief. HCPS should make it clear that their mind is open, that they are prepared to listen, and that their report will be fair and objective.

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6.3 History

6.3.1 Condition History

Symptoms should be carefully elicited. Widespread pain, fatigue, poor concentration and cognitive difficulties, sometimes described as ‘fibrofog’, and disturbed sleep are commonly reported, but be sure to enquire about any other related symptoms.

Any concomitant condition must be identified and individually recorded, as it may be contributing to any functional impairment present.

Information about any treatment received, including medication or specialist treatment, must be recorded along with its impact on the symptoms/function.

6.3.2 Typical Day History

An account of the activities of a typical day should be taken in keeping with the general guidelines (see Revised WCA Handbook or Guidance for Health Care Professionals undertaking Disability Living Allowance/Attendance Allowance Assessments Handbook). The HCP should explore all of life’s key activities in the process, such as feeding, cooking, keeping the house clean, shopping, gardening, social life and so on. This should include clarifying details such as how often the task is performed, is it repeatable and whether there are after effects. Evidence of consistency should be sought in how each of these activities is managed. This in turn should be confirmed by informal observation where possible.

It should be noted in interpreting this evidence that one of the common complaints of claimants with fibromyalgia is that although tasks can often be accomplished they cannot be sustained, or reliably performed again, without significant detriment (e.g. exhaustion to the extent of being unable to continue with any other activities for the rest of the day/ next few days). Ensure this is probed and explored within the typical day history.

6.3.3 Variability

In addition, careful account must be taken of variability; since fibromyalgia, like most other chronic conditions, encompasses a spectrum of capabilities. Information on variability, indicating to the DM ‘where’ the claimant sits on the severity spectrum, is an important contributor to the HCP’s advice. It is not sufficient to simply make the general comment that the symptoms “vary from day to day”, or between one part of the day and the next. The DM requires information on the actual duration of disabling problems; the frequency of days when severe pain or fatigue is experienced; the average proportion of “bad” days to “good”, and a description of what the person says he/she can and cannot do on the “good” days and the “bad” days.

In Revised Work Capability assessments remember to look for added clues about the extent of variability, and other ways fibromyalgia impacts on a claimant’s life, by scrutinising information, which may be contained under the section headed ‘About your illnesses or disabilities’ (page 3, of ESA 50 version 01/13). Here, claimants

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have an added opportunity to describe in their own words the way in which they feel their condition(s) affect(s) them. It allows them to expand on their personal experiences of living with fibromyalgia. This is especially important if they feel that subsequent parts of the form (detailing the functional ‘Activity’ areas) are not applicable/ “don’t fit” their view of the difficulties they have.

6.4 Examination

6.4.1 Physical Examination

It goes without saying that any physical examination performed must be carried out with particular care and consideration. HCPs should seek and document the claimant's express permission to carry out any physical examination. Consent must be requested verbally and then formally documented within the report. HCPs should also ensure the claimant is happy to proceed at each stage of the physical examination. HCPs should be mindful of the basic principles of examination etiquette (current guidance is contained within the benefit specific handbooks and in the Learning Set, “General Principles of Examination (MED-CMEP~115)” which is available on Sharepoint). The range of joint movements must be assessed through active movements and the use of passive movements to assess these movements would not be considered appropriate. If the claimant indicates a movement is causing discomfort or pain then the examination of that movement should stop.

In essence, there should be a functional need for any physical examination and HCPs should be able to justify this. HCPs may be criticised for ‘over-examining’ if it results in unnecessary discomfort to the claimant, when there was little justification to do so. In a similar vein, they should be able to defend their reasoning for not undertaking a particular examination if it would have yielded useful evidence: e.g. checking for signs of muscle-wasting. Whilst HCPs may feel that a physical examination is important in order to provide the DM with the most comprehensive evidence on which to base their decision, they should respect the wishes of claimants who are reluctant to participate in / attempt an activity. Claimants should certainly never be pushed to complete an activity in the face of obvious pain. HCPs are reminded that if they are unable to perform a formal examination due to pain or fatigue, they can still record formal observations for the exam (as opposed to general observations) such as any obvious joint deformities in the hands, any generalised muscle wasting or intrinsic muscle wasting in the hands etc

It is important to remember that the person may well be examined by another disability analyst at some time in the future in order to determine progress, and the methods and style of recording clinical findings must be in accord with Atos Healthcare’s standards and recommendations.

HCPs are reminded it should possible to carry out the MSO while the claimant is wearing loose indoor clothing. If an abnormality is suspected, and therefore a regional inspection and examination are required, it would be usual to ask the claimant to remove the relevant items of outer clothing in order to complete this task. Further explanations and consent to proceed are essential at this stage. HCPs are also reminded to consider whether the presence of an attendant, a relative or a friend should be offered. If an attendant, relative or friend is present, the HCP should

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record the fact on the report form, making a note of the person’s identity. If the claimant does not want an attendant, the HCP should record that the offer was made and declined.

Characteristically the physical examination rarely reveals definitive positive clinical findings, but particular features, such as muscle wasting, should be positively sought; recorded; and explained to the DM.

When a particular functional deficit is claimed, for example mobilising or manual handling, the associated muscle groups and joints should receive particular attention and muscle power carefully assessed and recorded – again, bearing in mind the general principles of examination as discussed above.

6.4.2 Mental State Examination

Because of the possible effects of fibromyalgia on mental functioning, it will almost always be appropriate to assess the claimant’s mental state in the form of a mental state examination.

Fibromyalgia can affect concentration, memory, cognition and mood. Therefore a mental state examination should clearly document associated findings including cognitive function. Like the physical examination findings, the contribution of the mental state examination findings to the advice given must be clearly explained to the DM.

In Revised WCA cases if the claimant indicates any problems with mood, concentration or ‘fibrofog’ then a MSE must always be documented. If a mental health/function assessment is not carried out, then the reasons for not doing so should be fully justified. In DLA reports, a MSE should always be documented.

6.5 Observed Behaviour

This should be carefully noted, assessed and recorded. As usual, the observations recorded must be focused, relevant and in accordance with Atos Healthcare’s guidance in relation to personal descriptions. Remember however that the claimant will almost certainly complain of variability and a “snapshot” account may be challenged on this basis. In addition it is a frequent complaint that a high level of activity on one day may well be achieved but will not result in incapacitating malaise until the next day.

6.6 Logical Reasoning and Justification of Advice

An important step in disability analysis is to logically reason all the available evidence in order to formulate the advice. Remember evidence is not just that available from the face-to-face assessment. Sources such as the ESA 50 (in Revised WCA cases), hospital/specialist letters as well as information from carers if available must be considered. In fibromyalgia, where there are few if any overt clinical findings, it is

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particularly important to carefully evaluate whether the person’s description of their disability is consistent with their daily activities and lifestyle.

Take careful account of the effects of pain and fatigue, of variability of symptoms, and of the ability to reasonably sustain any given activity, not just the ability to perform it once. Ensure the advice given is not formed from a "snapshot" of the claimant on the day of assessment, but reflects their functional ability over a period of time. Taking all of this into account, if a claimant cannot repeat an activity with a reasonable degree of regularity, and certainly if they can perform the activity only once, then they should be considered unable to perform that activity.

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7. Fibromyalgia and the Revised Work Capability Assessment

HCPs will recall the main aims of the ESA Work Capability Assessment are to provide a fair, accurate and robust assessment of the level of a person’s functional ability in relation to capability for work in the modern workplace, as well as to ensure that those who currently have limited capability for work and work related activity are identified.

The Work Capability Assessment has been reviewed regularly since its inception to ensure the aims are fulfilled. These reviews have resulted in revision of the regulations on two occasions (2011 and 2012) so that the process is now known as the Revised Work Capability Assessment.

Thinking about the current Revised WCA activity groups along with the LCW and LCWRA descriptors (HCPs may wish to refer to the Revised WCA Handbook), what descriptors might be relevant to consider when assessing people with fibromyalgia?

A review of symptoms associated with fibromyalgia reveals great heterogeneity and therefore it is likely that multiple activity areas and descriptors may need to be considered.

Symptoms such as widespread pain and fatigue may affect lower limb and upper limb activities; mobilising, sitting and standing, reaching, picking up and moving and manual dexterity.

Fibromyalgia is not usually associated with significant sensory loss (resulting in

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visual, hearing or speech impairment). It is also not usually associated with loss of consciousness or incontinence. Therefore sensory, consciousness and continence functional impairment is unlikely unless other conditions affecting these modalities are present.

Symptoms of fibromyalgia such as cognitive difficulties and profound pain and fatigue may impact on mental functioning, especially within the understanding and focus group of activities. If the symptoms are significant they may affect the ability to complete personal action and if severe, hazard awareness may be affected. Unless there are other co-morbid mental illness conditions (such as depression or anxiety) present, it is unlikely there will be functional impairment of the adapting to change or social interaction activities. The scope of these activity groups shows the focus of these activities is intended for conditions such as psychosis, autism, severe anxiety and depression.

For the purposes of Revised WCA, skill is required to assess the degree to which the stated difficulty in persisting with tasks is due to the physical component of the illness, and which is due to psychological factors – and there may be a risk of double application of physical and mental function descriptors. The ability to perform activities reliably and repeatedly is integral to the activity descriptors in Revised Work Capability Assessment (Amended 2012 Regulations) and to the advice given to the DM in any of the benefit assessments.

HCPs may wish to reinforce their knowledge by re-reading the scope of each of the Revised WCA descriptors in the Revised WCA handbook.

7.1 Revised Work Capability Assessment Case Study

Review the information in the following case scenario, think about which descriptors may be appropriate and write a justification of your advice.

Ms AM

Age: 38 years old

Med 3: fibromyalgia

Referral type: Initial ESA referral

ESA 50 information: Diagnosed with fibromyalgia 3 months ago. She indicates problems with pain and fatigue affecting ability to mobilise, reach and pick up and move objects. She also describes problems with her sleep.

History

She developed generalised pain about 6 months ago. Was mild at first but over a few months it worsened. She also noticed she was feeling exhausted at times even though she wasn’t doing that much. Her GP diagnosed fibromyalgia about 3 months ago. It was a relief to get a diagnosis, although she worries about whether she will see any improvement in her condition. She has not been referred to a specialist.

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She was commenced on amitriptyline, with some improvement in her sleep but with no noticeable effect on her pain or fatigue. She takes paracetamol and NSAIDS for the pain, which help but do not take the pain away completely. Her GP has advised her to use online individual CBT resources and she is awaiting an appointment for group CBT (has been told there is a waiting list of several months). The pain is present all the time and is improved slightly after taking the painkillers. Nothing specific makes it worse that she has identified. Sleep has improved since beginning amitriptyline.

The fatigue is difficult to manage as it can vary from day to day. It is difficult for her to identify factors, which make the fatigue better or worse. The educational material provided by the GP indicates that small amounts of regular exercise are beneficial and so she has tried to follow a plan where she does 20 minutes of exercise (walking) every second day (she walks around the local park). She is unsure whether this improves the fatigue, but she does not think it makes it worse. She suffers with tiredness every day, but the severity varies. At the moment she feels she has 1-2 bad days a week with fatigue and 5-6 days when it is not so bad. On her bad days she paces her activities and will have a rest (not sleep) in the afternoon. On the good days, although the fatigue is there, she can manage most of her activities and does not need a rest.

She denies any mental health problems or cognitive problems.

Medications: amitriptyline 25mg nightly, paracetamol as required (2-4 tablets taken most days), ibuprofen as required (taken a few times a week)

Lives alone in one bed flat on first floor. Drove to MEC (parked 300m away from centre and walked from car park to MEC). Stopped work 3 months ago because of problems with pain and fatigue. Was working as a gardener, but found the work was just too physical for her to cope with.

Currently mostly able to get to sleep within an hour of going to bed and only occasionally wakes during the night. She has days when she wakes feeling un-refreshed (about half of the time). This has improved as she used to wake feeling un-refreshed all of the time. Usually wakes around 7-8am. Will get up and make a cup of tea before returning to bed for a couple of hours. She may watch some breakfast TV or read the newspaper (which is delivered) during this time. Mid-morning she will get up and get washed and dressed. Although it can be painful she generally gets washed and dressed every day, because if she doesn’t it makes her feel worse. She normally has a bath as she finds that the warm water helps with the pain.

She tends to pace her activities during the day to try to manage her fatigue. On her good days she will get up and dressed, make some breakfast (toast), do a small amount of housework (she like to do a small amount each day, to keep on top of it), spends the morning reading or using the computer. Makes herself a sandwich or soup for lunch. Each day she tries to walk to local shops (about 300m away) in the afternoon. Sits and has a coffee at the café before walking back home.

Does her main grocery shopping online. Is able to go to the supermarket if she has to, but finds it easier to do it online and get the groceries delivered fortnightly. She is able to put the groceries away. She makes her own meal in the evening, nothing

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complicated but she likes to eat healthily.

Goes to the main library in the centre of the town every week or so. Catches the bus, as it is easier than driving in the heavy traffic and trying to find parking. The bus stops are close to her flat and the library. Usually takes out 3-4 books at a time and is able to carry them home in a bag. Often will visit the charity shops as well when she is town, as she can usually find good reasonably priced books and clothes there.

Uses a computer most days. No specific problems using a computer. Able to use a Smartphone without any difficulty. Looks after her cat without any difficulty.

Family and friends have offered to help but she wants to try to remain as independent as she can. She wants to return to work, as she loved her job as a gardener, but does not feel physically able to at present.

Examination

Lower Limb: hips, knees and ankles - full range of movement bilaterally (movements performed slowly), normal power. Able to bend forward to reach knees, Declined to squat (as she was concerned it would cause pain). No evidence of generalised muscle wasting present. Calluses were present on soles of feet.

Upper Limb: shoulders, elbows and wrists - full range of movements bilaterally (movements performed slowly), normal power, normal finger movements, normal grip and pinch power bilaterally.

Mental State Examination: well kempt, normal build, appears tired, normal rapport, normal eye contact, normal behaviour, speech normal, concentration adequate, cognition normal, normal insight

Observed behaviour

Rose slowly from sitting 3 times without assistance, walked slowly 15m to assessment room, normal gait. Slowly got on and off couch but did not need assistance, slowly able to remove/put on jacket unaided, able to manage buttons, medication and papers without assistance.

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Advice

Thinking about the information above, what advice would you give the DM?

What pieces of evidence are you using to support your advice?

Write a comprehensive justification for your advice. Remember to address any variability or inconsistency within the evidence.

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What prognosis advice would you give and why?

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8. Fibromyalgia and Disability Living Allowance

Disability Living Allowance consists of 2 components:

Care - payable to those who need help with personal care or who have difficulty planning and preparing a main meal.

Mobility - payable to those with mobility problems due to a physical difficulty with walking, or with a need for guidance or supervision when walking in unfamiliar places out of doors due to physical or mental health problems.

8.1 Higher Rate Mobility Component

This is payable to claimants who are:

Unable to walk due to physical disability

Virtually unable to walk without severe discomfort due to physical disability (and some other deemed conditions including prescribed categories of severely sight impaired people)

8.1.1 Forming a Mobility Opinion

DLA legislation requires the claimant to have a physical disability in order to be entitled to the higher rate mobility component. Where a person has a condition with both physical and mental elements (such as fibromyalgia), providing the physical problem is contributing to walking difficulties, Upper Tribunal Judges have ruled that all the walking problems should be considered ‘physical’ in this context.

8.1.1.1 The Limb Function Table

An area of evidence within the DLA report is the limb function table. HCP’s opinions here need to be consistent with their mobility opinion. There are four levels of function referred to in this table. It allows the conversion of medical findings in the limbs into levels of function for the DM.

These levels of function broadly correlate with the levels of disability:

Full function and slight impairment (1 & 2) correlate with significant disability unlikely

Substantial impairment (3) correlates broadly with significant disability likely

Nil function (4) correlates broadly with severe disability likely

Some HCPs struggle when completing this table for claimants with fibromyalgia. Remember it is reflecting the HCP’s opinion on limb function, not just clinical examination findings. Therefore ensure the effects of symptoms such as limb and joint pain, and fatigue are reflected when completing this table. For example if a

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claimant has significant lower limb functional impairment due to fatigue this should be reflected with ‘3’ being documented in the appropriate boxes. If the claimant’s condition is very severe (such that they are bedbound) then it is likely ‘4’ would be appropriate. Remember any inconsistencies in the evidence must clearly be explained for the DM in the justification of the advice given.

The DM needs to understand all aspects of a claimant's mobility, not just the likely walking distance or speed and stability of gait but also if any halts are necessary or there is any variability in function.

8.2 Care Component

To qualify for the lowest rate of the care component of DLA, a person will have to be so severely disabled physically or mentally that they need attention from another person for a significant portion of the day in connection with bodily functions and/or they cannot plan and prepare a cooked meal for themselves if they have the ingredients.

To qualify for the middle rate of the care component in DLA they need frequent attention from another person throughout the day in connection with their bodily functions and/or continual supervision throughout the day by another person to avoid substantial danger to themselves or others.

To qualify for the highest rate of the care component in DLA they need frequent attention from another person throughout the day in connection with their bodily function and/or continual supervision throughout the day by another person to avoid substantial danger to themselves or others. They also need prolonged, or repeated, attention from another person during the night in connection with their bodily functions and/or need another person to be awake for a prolonged period or at frequent intervals during the night to watch over them to avoid substantial danger to themselves or others.

Remember attention is defined as helping someone in connection with his or her bodily functions. Examples of bodily functions include: breathing, hearing, seeing, communicating, eating and drinking, walking, sitting, sleeping, cleanliness and skin protection (including being turned in bed), getting into or out of bed, dressing/undressing, going to the toilet (including undressing, wiping and re-dressing). Bodily functions do not include shopping or other domestic tasks, many of which would normally be undertaken by a home carer.

The symptoms of fibromyalgia can certainly affect bodily functions, such as walking, getting in and out of bed, sleeping, going to the toilet etc, especially if severe. Remember to take a detailed typical day history that also addresses any variability present. People with significant fibromyalgia symptoms may also have difficulty planning and preparing a cooked meal for themselves.

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8.3 Disability Living Allowance Case Study

Mrs FL

Age: 56 years old

Information from the GP: Fibromyalgia diagnosed 12 months ago. Complains of severe widespread pain that affects all aspects of daily living. Has been seen in rheumatology clinic in the past and currently awaiting a pain clinic appointment.

Claim form information: Diagnosed with fibromyalgia 12 months ago, although pain has been present for much longer. Pain much worse over last 6 months. She indicates problems with walking, looking after herself and daily chores.

History

She describes problems with pain for several years but fibromyalgia was only diagnosed after she changed GPs about 12 months ago. Pain has become much worse over the last 6 months. Initially she felt she was able to manage the pain, but it has become much worse in the last 6 months and is impacting on every activity of her life. She was seen once in the rheumatology clinic about 5 months ago and they referred her to the pain clinic. But she is still awaiting an initial appointment. GP has given her some advice about exercise and self help resources, but she feels too unwell to exercise or use the computer at the moment. Her daughter has moved back home 3 months ago to help look after her. Painkillers don’t seem to help, even tramadol, which her GP recently prescribed. GP has started her on amitriptyline and pregabalin, but it has made no difference. She feels at her wits end. There is not much variability, she has severe widespread pain every day and would describe all her days being ‘bad’, with no ‘good’ days.

Medications: amitriptyline 100mg nightly, tramadol 50mg 3 times a day, pregabalin 300mg day

Lives in a 3 bedroom house with her adult daughter. Assessment performed as DV. Last worked 6 months ago as a lawyer. Stopped work because of fibromyalgia.

Sleeps poorly, wakes often during the night and feels un-refreshed in the morning. Daughter will bring her a cup of tea in bed. She will rest in bed for a few hours before getting up slowly. Sometimes her daughter helps her get out of bed, but she can manage by herself (if she has to go to the toilet overnight for example). On the days when her daughter is working she will often stay in bed until late morning or early afternoon, as there is not much to get up for. Used to have bedroom upstairs but found climbing the stairs very painful, so has converted downstairs dining room into bedroom. There is a downstairs toilet and shower. Has not been upstairs for a couple of months.

Daughter works part time shift work as a nurse. She does not feel she could manage at home by herself without her daughters help.

Daughter does the grocery shopping online and gets it delivered for convenience.

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Daughter puts the groceries away after they are delivered. Daughter also does all the cooking and housework. She used to be able to do all these things herself and finds the loss of independence makes her feel very low. She can make herself a hot drink and simple snacks like toast or porridge in the microwave. Has not cooked a meal for months. Finds it difficult to concentrate and is painful to prepare ingredients and lift pots and pans.

Spends all of her time in the house, only leaves for medical appointments. Last time she left the house was about a month ago, to visit the GP. She finds it too painful to walk any distance. Can’t even walk to the local shops 100m away currently.

Used to love going for long walks and was a member of the local ramblers group. But had to stop this about a year ago when the pain became worse. She tried to do regular small amounts of exercise (10mins a day) but in the end even this was not possible. She is able to walk the small distance around the ground floor of the house slowly

Has lost interest in reading, finds it difficult to concentrate. Finds it difficult to use the computer because of pain in upper limbs and also feels that her concentration is not up to it. Is able to manage own medications independently.

She feels very low about her current situation and often feels tearful. Finds it hard to feel positive about anything and is really worried that things will not improve.

Examination Findings

Lower Limb: hips, knees and ankles full range of movement bilaterally (movements performed slowly), normal power. Able to bend forward to reach knees, Declined to squat (as he was concerned it would cause pain). Evidence of generalised muscle wasting present. Calluses were not present on soles of feet.

Upper Limb: shoulders, elbows and wrists full range of movements bilaterally (movements performed slowly), normal power, normal finger movements, normal grip and pinch power bilaterally

Mental State Examination: well kempt, normal build, appears tired, poor rapport, poor eye contact, flat affect, did not smile during assessment, tearful at times, voice quiet, concentration adequate, cognition normal, normal insight

Observed Behaviour

Daughter opened door, claimant waiting in sitting room chair. Able to get up from chair slowly unaided. Walked very slowly with an antalgic gait to bedroom (5m) for examination. Able to get on bed unaided, daughter helped her off the bed.

Able to handle papers (appointment letters) and medications unaided. Daughter helped her remove her cardigan.

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What mobility opinion would you give?

What pieces of evidence support your mobility opinion?

What care opinion would you give?

What pieces of evidence support your care opinion?

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9. Self Assessment and Case Study Guidance

9.1 Knowledge Self Assessment Quiz

Having had some time to consider the information within this document, review the questions from the self-assessment exercise in section 2 again. Have any of your answers changed?

Yes No

Don’t

Know

Fibromyalgia is entirely psychological in origin

Fibromyalgia is wholly physical in origin

Fibromyalgia can be associated with significant levels of functional impairment

Fibromyalgia is common with a prevalence of around 10% worldwide

Depression is associated with fibromyalgia

There is often overlap in the symptoms experienced in fibromyalgia with the condition of CFS/ME

The condition occurs equally in men and women

Fibromyalgia can be diagnosed with a biochemical marker

Sleep problems are commonly reported in Fibromyalgia

The aetiology of fibromyalgia has been clearly established

Fibromyalgia is usually triggered by a viral infection

Antidepressant medication is used in the treatment of fibromyalgia

Fatigue is not present in fibromyalgia

The prognosis is usually good in fibromyalgia

Paraesthesiae, muscle spasms and migraine are symptoms of fibromyalgia

Analgesic medication is very effective in treating the pain of fibromyalgia

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9.2 Revised WCA Case Study Suggested Guidance

What advice would you give the DM?

Descriptors for lower and upper limb function: ‘none of the above apply’

What pieces of evidence are you using to support your advice?

Mobilising:

From the evidence presented it is likely the claimant would be able to mobilise at least 200m reliably and repeatedly.

Able to mobilise around house

Walks to local shops (300m away) and back 5-6 times a week

Able to walk 300m from car park to MEC on day of assessment

Able to use public transport, walk around library and around local charity shops on a weekly basis

Able to walk 20 minutes around a local park every second day

Clinical examination findings normal

Observed to walk 15m in MEC at a normal speed and with a normal gait

Reaching:

Able to get dressed unaided

Able to wash unaided

Able to wash, dry and brush hair

Able to put groceries away in overhead cupboards

Clinical examination findings normal

Observed to remove and put on hat and jacket unaided

Picking up and moving:

Able to make own meals

Able to carry library books to and from library

Able to put groceries away (into high and low cupboards and fridge)

Clinical examination findings of upper limb normal

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Observed to be carrying medium sized bag in either hand

Suggested example of justification of advice

Ms M has been diagnosed with fibromyalgia causing generalised pain and fatigue. She is being managed by her GP, uses simple analgesics and is awaiting group CBT.

Whilst she has ongoing pain and fatigue, she is able to complete daily activities (such as dressing, washing, cooking and housework) for the majority of the time. She is able to walk moderate distances regularly around the local park and town. This is consistent with the observed behaviour and normal clinical examination findings of the upper and lower limbs.

While her condition does vary from day-to-day, for the majority of the time there is unlikely to be significant functional impairment of mobilising, reaching or picking up and moving.


As under threshold, no prognosis advice is required.

9.3 DLA Case Study Suggested Guidance

What mobility opinion would you give?

Unable to walk more than 50m

What pieces of evidence support your mobility opinion?

Has significant difficulty mobilising around the house

Unable to mobilise up stairs

Has moved bedroom to ground level

Rarely leaves the house

Unable to walk to local shops 100m away

Although the range of lower limb movements are normal, they appear painful during the examination

Walked very slowly with an antalgic limping gait

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What care opinion would you give?

Likely to have some attention needs (coping with hot pans, using a traditional cooker) because of problems with significant widespread chronic pain and fatigue. From the evidence (history and observations) it appears that she would not be able to prepare a main meal for herself (equivalent to low rate care).

From the available evidence it does not appear that she requires frequent attention for bodily functions (such as washing, dressing, toileting) or constant supervision for the majority of the time (either during the day or at night).

With regards to the ‘mental health, learning disabilities and cognitive impairment’ section of the report the evidence indicates she is not neglecting her hygiene/nutrition, she is aware of common dangers, she does not wander and is not destructive to property.

What pieces of evidence support your care opinion?

Able to dress and wash herself

Able to toilet independently, no problems with incontinence

Able to manage own medications independently

Unable to prepare meals for herself currently

Able to get up from a chair unaided

Able to handle papers and medications

Normal upper limb movements (although noted to be painful)


The shorter duration of the condition and the fact that she is awaiting an appointment to be reviewed at pain clinic, where further management may be associated with some improvement in the future, would be consistent with a medium term prognosis.

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10. Summary

Fibromyalgia syndrome is common, complex and chronic in nature.

Individuals suffering from the syndrome complain of diffuse pain, fatigue and abnormal sleep pattern. They also frequently complain of impaired cognition and mental function effects.

The condition overlaps in its characteristics with a number of other conditions, including chronic fatigue syndrome and major depressive disorder.

The disability analyst’s approach should be accurate, consistent and pragmatic. It should include a clear factual description of the characteristics of the claimant’s disorder, and the way in which the condition affects the claimant’s functional abilities. Any inconsistencies that are not consistent with the characteristics of the condition should be clearly expressed.

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11. Further Reading

The American College of Rheumatology Website: http://www.rheumatology.org/Practice/Clinical/Classification/Classification_Criteria_for_Rheumatic_Diseases/

Wolfe F, Smyth HA, Yunus MB et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: the Multicenter Criteria Committee. Arthritis Rheum 1990;33:160

Wolfe F, Clauw, DJ, Fitzcharles MA et al. The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. Arthritis Care & Research. Vol. 62, No. 5, May 2010, pp 600–610

EULAR evidence based recommendations for the management of fibromyalgia syndrome http://www.enfa-europe.eu/assets/downloads/eular

Canadian Guidelines: Fitzcharles MA, Ste-Marie PA, Pereira JX; Canadian Fibromyalgia Guidelines Committee. Fibromyalgia: evolving concepts over the past 2 decades. CMAJ 2013 May 15.

Management of Fibromyalgia. Drugs and Therapeutic Bulletin. Vol 48, No 8, August 2010

Schmidt-Wicke, T & Clauw, D.J. Fibromyalgia: from pathophysiology to therapy. Nat. Rev. Rheumatol. 7, 518-527 (2011)

Clauw, D.J. Fibromyalgia: An Overview. The American Journal of Medicine, Vol122 (12A) S3-S13 (2009)

NHS Choices information on fibromyalgia: http://www.nhs.uk/conditions/Fibromyalgia/Pages/Introduction.aspx

UK fibromyalgia charities: Arthritis Research UK information on fibromyalgia http://www.arthritisresearchuk.org/arthritis-information/conditions/fibromyalgia.aspx

Fibromyalgia UK http://www.fmauk.org/index.php Fibroaction http://www.fibroaction.org/Default.aspx UK fibromyalgia http://www.ukfibromyalgia.com/index.html

http://www.rheumatology.org/Practice/Clinical/Classification/Classification_Criteria_for_Rheumatic_Diseases/

http://www.rheumatology.org/Practice/Clinical/Classification/Classification_Criteria_for_Rheumatic_Diseases/

http://www.enfa-europe.eu/assets/downloads/eular

http://www.nhs.uk/conditions/Fibromyalgia/Pages/Introduction.aspx

http://www.arthritisresearchuk.org/arthritis-information/conditions/fibromyalgia.aspx

http://www.fmauk.org/index.php

http://www.fibroaction.org/Default.aspx

http://www.ukfibromyalgia.com/index.html

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12. Evaluation

Fibromyalgia Syndrome: Guidelines for the Disability Analyst

In order to evaluate your understanding of this module, please answer the following questions, referring to the reference material when required.

If the objectives have been achieved you should have no difficulty in responding correctly.

Correct Incorrect

1. Fibromyalgia is a diagnosis of exclusion

2. Fibromyalgia has been found to be associated with dysfunctional pain processing in the central nervous system

3. Unlike CFS/ME, fibromyalgia is not associated with cognitive dysfunction

4. Tender points must be present for fibromyalgia to be diagnosed

5. Fibromyalgia can occur with other conditions such as rheumatoid arthritis or SLE

6. The focus of management of fibromyalgia is on improving symptoms to improve quality of life

7. Fibromyalgia is always associated with a poor prognosis

8. Treatment of fibromyalgia can include physical therapies, psychological therapies and medications

NAME (Print)

SIGNATURE:

DATE:

On Completion please return to your local Medical Services Centre

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Observation Form

Please photocopy this page and use it for any comments and observations on this document, its contents, or layout, or your experience of using it. If you are aware of other standards to which this document should refer, or a better standard, you are requested to indicate on the form. Your comments will be taken into account at the next scheduled review.

Name of sender: Date:

Location and telephone number:

Please return this form to: XXXXXXXXXXXXX Training and Development Co-ordinator Atos Healthcare

3300 Solihull Parkway Birmingham Business Park Birmingham B37 7YQ

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