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Date: 17th November 2015

Fibromyalgia

(Module 14)

MED/S2/CMEP~0035

Fibromyalgia

MED-CMEP~0035 Page 2 of 48

Foreword

This training has been produced as part of a training programme for Healthcare Professionals (HCPs) who conduct assessments for The Centre for Health and Disability Assessments on behalf of the Department for Work and Pensions. All HCPs 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 HCPs 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 HCP 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 HCPs.

Fibromyalgia


Document control

Superseded documents

Version history

Version Date Comments

9 Final 17th November 2015 Final Document

9a Draft 15th October 2015 Review and update

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

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

Reference to Atos Healthcare updated to the Centre for Health and Disability Assessments

Reference to Disability Analyst updated to Healthcare Professional

Reference to DLA removed from module

Section 5 updated to reflect recognition of fibromyalgia as an established medical condition with information on epidemiology, aetiology, diagnosis, clinical features and management updated to be in keeping with current data

Section 6.1 amended to address information brought by claimant to the assessment (adapted from UTS 13/2014)

Section 6.3.3 – ESA50 information updated to reflect current version of form

Section 7.2 – case amended to Revised WCA case instead of DLA

Section 8 – guidance updated to reflect information in scenarios

Section 11 – Multiple choice question 3 updated

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Outstanding issues and omissions

Issue control

Author: Clinical Learning and Development

Owner and approver: Clinical Director

Signature: Date:

Distribution:

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Contents Page

1. Aims and Objectives 6

2. Introduction 7

3. Current Knowledge of Fibromyalgia Syndrome (FMS) 8

4. Fibromyalgia Case Example 9

5. Overview of Fibromyalgia 12

5.1 Epidemiology 12

5.2 Aetiology 12

5.3 Diagnosis 13

5.4 Clinical features 15

5.5 Management 15

5.6 Prognosis 16

6. Face-to-Face Assessment in the Disability Analysis Setting 18

6.1 Before the Assessment 18

6.2 Setting the Scene at the Beginning of the Assessment 18

6.3 History 19

6.4 Examination 19

6.5 Observed Behaviour 19

6.6 Logical Reasoning and Justification of Advice 19

7. Fibromyalgia and the Revised Work Capability Assessment 20

7.1 Revised Work Capability Assessment Case Study 1 21

7.2 Revised Work Capability Assessment Case Study 2 25

8. Self Assessment and Case Study Guidance 29

8.1 Knowledge Self Assessment Quiz 29

8.2 Revised WCA Case Study 1 Suggested Guidance 30

8.3 Revised WCA Case Study 2 Suggested Guidance 31

9. Summary 32

10. Further Reading 33

11. Evaluation 47

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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 cases

.

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2. Introduction

These guidelines form part of the Centre for Health and Disability Assessments’ programme for continuing medical education for Healthcare 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 Healthcare Professional’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.

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 a specific section containing case studies relating to Revised Work Capability Assessments (WCA) which should be completed by all HCPs.

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

XXXXX

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Thinking about the information provided:

XXXXX

XXXXX

Fibromyalgia


XXXXX

XXXXX

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5. Overview of Fibromyalgia

Fibromyalgia, or fibromyalgia syndrome, is characterised by chronic widespread pain and fatigue.

Although the diagnosis used to be controversial with different opinions from medical professionals, people with a diagnosis of fibromyalgia, professional organisations, patient support groups, pharmaceutical companies and governmental organisations1, there now appears to be an increased recognition of the condition.

Fibromyalgia is included in the World Health Organisation International Statistical Classification of Diseases and Related Health problems (ICD-10) under:

M79 – other soft tissue disorders, not elsewhere classified

M79.7 - fibromyalgia

5.1 Epidemiology

The prevalence is thought to be around 2- 4.7% in the United Kingdom. This means that 1.2 – 2.8 million people in the UK have fibromyalgia. It affects women more commonly than men.2 3 4

The prevalence of fibromyalgia increases with age, however it can occur at any age.

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. Research has shown a deficiency in serotonin together with an increase in the neurotransmitter Substance P within the nervous system which may result in this dysfunctional pain processing.

Studies have also shown that people with fibromyalgia do not have enough restorative deep sleep.

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

2 http://www.fibromyalgiasyndrome.co.uk/how-many-people-have-fms.html

3 http://fibroaction.org/Pages/About-Fibro.aspx

4 http://fmauk.org/general-articles-highlights-208/372-survey-of-five-european-countries-prevalence-of-

fibromyalgia

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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, systemic lupus erythematosus (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.5

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. The 1990 and 2010 diagnostic criteria have both been included here for completeness.

5 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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The American College of Rheumatology Criteria for the Classification of Fibromyalgia (1990)6

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

XXXX

6 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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XXXXX

XXXXX

5.4 Clinical features

XXXX

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. Depending on the symptoms present, an individual with fibromyalgia may be under the care of a GP, a neurologist, a rheumatologist, a psychologist, or a variety of other healthcare professionals.

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, counselling, 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, muscle relaxants 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. Muscle relaxants are used where symptoms of stiffness or muscle spasms are

Fibromyalgia


present and include tizanidine or methocardamol. Tricyclic antidepressants can also act as muscle relaxants.

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.7 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 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

7 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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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 the Medical Services Referral System (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 and/or 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. This evidence should be photocopied with the consent of the claimant and attached to the file. If the claimant refuses consent, then the HCP should explain that although the information can be summarised within the WCA report, the Decision Maker will not have a copy of the evidence to be able to give it proper consideration. All the available evidence 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.

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

XXXXX

6.3.2 Typical Day History

XXXXX

6.3.3 Variability

XXXXX

6.4 Examination

6.4.1 Physical Examination

XXXX

6.4.2 Mental State Examination

XXXXX

6.5 Observed Behaviour

XXXXX

6.6 Logical Reasoning and Justification of Advice

XXXXX

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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.

XXXXX

XXXXX

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7.1 Revised Work Capability Assessment Case Study 1

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

XXXXX

History

XXXXX

Clinical Examination

XXXXX

Observed behaviour

XXXXX

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Advice

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

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

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

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What prognosis advice or re-referral period would you give and why?

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7.2 Revised Work Capability Assessment Case Study 2

XXXX

History

XXXXX

Clinical Examination

XXXXX

Observed Behaviour

XXXXX

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Advice

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


Fibromyalgia


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

Fibromyalgia


What prognosis advice or re-referral period would you give and why?

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8. Self Assessment and Case Study Guidance

8.1 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

Fibromyalgia


8.2 Revised WCA Case Study 1 Suggested Guidance

What advice would you give the DM?

XXXXX


XXXXX

Suggested example of justification of advice

XXXXX

What prognosis or re-referral advice would you give and why?

XXXXX

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8.3 Revised WCA Case Study 2 Suggested Guidance

What advice would you give the DM?

XXXXX


XXXXX

Suggested example of justification of advice

XXXXX

What prognosis or re-referral advice would you give and why?

XXXXX

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9. 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 Healthcare Professional’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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10. 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 www.enfa-europe.eu/assets/downloads/eular.pdf

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 Action UK - http://www.fmauk.org/index.php Fibroaction - http://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.pdf

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://fibroaction.org/default.aspx

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

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11. Evaluation

Fibromyalgia Syndrome: Guidelines for the Healthcare Professional

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. 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 Assessment Service 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: Centre for Health and Disability Assessments Learning and Development

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fibromyalgia - whatdotheyknow · fibromyalgia, or fibromyalgia syndrome, is characterised by...

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