Over the last several months, we have received a number of inquiries from our Executive Members requesting information about the evaluation of the disease state known as Fibromyalgia. This report will attempt to give you additional insights into this disorder. We will also discuss how this disorder should be approached when applying for disability benefits.

Fibromyalgia belongs to a group of common nonarticular rheumatic disorders characterized by pain, tenderness and stiffness of muscles, tendon insertions and adjacent soft-tissue structures. The condition can present itself as a primary (affecting a specific muscle or tendon site) or generalized (affecting multiple sites). This condition can also present itself in a concomitant fashion, associated with other underlying disorders such as osteoarthritis. Fibromyalgia is often related to overuse or microtrauma to a particular muscular group.

Fibromyalgia is often referred to with a number of differing terms such as Fibromyositis or Myofascial Pain Syndrome. The term myalgia indicates muscular pain. In contrast, myositis is due to inflammation of muscular tissue and is an inappropriate term for fibromyalgia when such inflammation is absent. Fibromyalgia indicates pain in fibrous tissue, muscles, tendons, ligaments and other "white" connective tissues.

Various combinations of these conditions may occur together as muscular rheumatism. Any of the fibromuscular tissues may be involved. The most commonly affected areas are the occiput (area to the back of the head and neck), shoulders, chest, low back and thighs.

Etiology

The etiology or origin of Fibromyalgia is obscure. The condition occurs mainly in females and may be induced or intensified by physical or mental stress. These stresses include, but are not limited to, environmental stresses, poor sleep, trauma or exposure to cold. The condition may also be triggered or intensified by another underlying disorder such as a rheumatic disorder. A viral or other systemic (system wide) infection may also precipitate this syndrome.

PFS or Primary Fibromyalgia Syndrome is particularly likely to occur in otherwise healthy young women who tend to be stressed, tense, depressed, anxious or striving. It also occurs in older women associated with unrelated minor changes of vertebral osteoarthritis.

Men appear to be more likely to develop localized fibromyalgia in association with a particular occupational or recreational strain. However, a smaller number of males do show symptoms associated with significant psychogenic manifestations. As in females, environmental stresses, including a treatment source's lack of credence in the disorder can exacerbate symptoms.

Signs & Symptoms

Fibromyalgia usually presents with the onset of gradual stiffness and pain. The pain might be diffuse and achy as in Primary Fibromyalgia or localized as is seen with trauma or overuse scenarios. There may be tenderness or muscle spasms, usually localized to specific small zones or trigger points. Inflammation is not characteristic of fibromyalgias and only occurs if there is an underlying systemic condition.

The diagnosis of fibromyalgia is recognized by the typical pattern of diffuse fibromyalgic pain with no evidence of another underlying condition. In other words, the diagnosis is made primarily by ruling out other disorders such as osteoarthritis, rheumatoid arthritis, polymyositis or connective tissue disease. Most difficult of all is the exclusion of psychogenic (mentally induced) muscular pain and spasms. It is this possible mental connection that also makes using fibromyalgic disorders so difficult to prove when attempting to acquire disability benefits.

Fibromyalgia may also remit spontaneously which also works against it as a primary diagnosis when attempting to acquire benefits. As you know, in order to receive disability benefits, the condition must last or be expected to last for twelve continuous months or be expected to result in death. Most disorders including fibromyalgia, with a history of spontaneous remissions, do not fit this definition!

Representation of Fibromyalgia .

When representing a claimant with a primary diagnosis of fibromyalgia, you must take extraordinary steps to prove it as a total disability. The following approach will help you to establish this disorder as meriting Social Security disability:

Start by doing a careful assessment of the case! That is, when you interview a claimant who is alleging fibromyalgia, look for evidence of a long-standing disorder. If the claimant has not suffered from the disorder for a period of at least the past six months without remission, do not take the case. If the claimant has had the disorder for the past six months or more, question him about treatment. What you are looking for is consistency in treatment.

Fibromyalgia of a level that would cause a disability is painful. Therefore, look for consistent medical contacts for the treatment of pain. Note the claimant's current medications. Has there been any physical therapy or other treatments for the disorder?

You must also inquire whether or not the claimant has any other underlying physical disorders that might be responsible or contributing to his muscular pain. The fact is that a fairly serious additional diagnosis such as osteroarthritis or diabetes may help the claimant's case.

To win a case such as this, you will also need the cooperation of the claimant's attending physician. Attempt to acquire a letter from the claimant's doctor that specifically describes the claimant's condition since the onset of the disorder. What is the physician's opinion of the claimant's disorder? Does the attending physician feel that the claimant is totally disabled? If he does, solicit his opinion in writing.

Does the claimant have significant limitations in his/her ability to perform normal daily activities? If so, you will need to document the restrictions by acquiring ADLs (activities of daily living) reports from multiple sources. These sources include the claimant's physician, family members and the claimant himself. Make sure that the alleged restrictive activities are consistent.

Does the claimant have an underlying mental disorder? Recall that fibromyalgia does have a strong psychogenetic component. If there is a mental disorder, this condition will need to be carefully evaluated and documented. In many cases, the mental disorder ends up being the primary diagnosis. Therefore, careful documentation may lead to an allowance based on a mental disorder with fibromyalgia becoming the secondary diagnosis. This approach should be taken regardless of the gender of the claimant.

If there is no history of a mental disorder, it may be wise to ask SSA for a psychological evaluation to rule out a possible underlying mental problem. If you take the case, it does not hurt to look under every possible rock in these types of cases. A serious additional may be just what it takes to win!

If the claimant refuses to allow for a psychological evaluation, you may want to drop the case. The chances of winning Social Security disability based on fibromyalgia alone are not good unless consistent severity can be established.

Summation

If you encounter a claimant who is alleging disability due to fibromyalgia, take the following steps before accepting the case:

1) Carefully interview the claimant.

2) Establish that the disorder has been present in a restrictive way for at least the past six months.

3) Establish that the claimant has been treated by a physician for the disorder over the past six months or more.

4) Note the claimant's current medications. Is he/she taking prescribed pain medication? Are there any secondary symptoms suffered by the claimant as a result of the prescribed medications?

5) Solicit the attending physician's opinion of the claimant's disorder.

6) Establish the existence of any other physical disorders.

7) Establish the existence of a possible mental disorder.

8) Acquire detailed ADLs from the claimant, his/her family members and the attending physician.

All of the above steps can be done prior to taking the case with the claimant's or his/her family's help. If the claimant is unwilling to help you take these important steps, you may wish to decline the case.