Fibromyalgia and Disability Evaluation

[Fibromyalgia: how to appreciate work capacity?]
Perdrix J.
Rev Med Suisse. 2007 Jun 20;3(116):1585-7.
[Article in French]
Centre d'expertises médicale,s PMU, 1011 Lausanne. jean.perdrix@hospvd.ch
Fibromyalgia is a chronic pain syndrome of which there remains difficult to evaluate the functional repercussion. As in other affections without, or with weak shown organic substrate, the evaluation of the work capacity requires a rigorous approach, which adopts an integrative bio-psycho-social model. Diagnostic classification poses problems insofar as the same syndromic association can result in different diagnoses. The object of this article is to highlight some difficulties related to the coexistence of medical and legal logics which can sometimes be divergent. Generalization, on the legal and administrative side, of simple dichotomic rules, must in no manner lead the physician to make the saving of taking into account the complexity.

[Re: M. Späth, G. Neeck "The expert assessment of fibromyalgia" (Zeitschrift für Rheumatologie 61:661-666 (2002))]
Geissler N.
Z Rheumatol. 2003 Jun;62(3):299; author reply 300.
[Article in German]
Comment on:
Z Rheumatol. 2002 Dec;61(6):661-6. PMID: 12491129.

Fibromyalgia and the conundrum of disability determination.
Hadler NM, Ehrlich GE.
J Occup Environ Med. 2003 Oct;45(10):1030-3.

[Re: M. Späth, G. Neeck "The expert assessment of fibromyalgia" (Zeitschrift für Rheumatologie 61:661-666 (2002))]
Geissler N.
Z Rheumatol. 2003 Jun;62(3):299; author reply 300.
[Article in German]
Comment on:
Z Rheumatol. 2002 Dec;61(6):661-6. PMID: 12491129.

[The expert assessment of fibromyalgia]
Spath M, Neeck G, Späth M.
Z Rheumatol. 2002 Dec;61(6):661-6.
[Article in German]
Comment in:
Z Rheumatol. 2003 Jun;62(3):299; author reply 300. PMID: 12931687.
Friedrich-Baur-Institut, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstr. 1a 80336, Munich, Germany.
Research on fibromyalgia over the last ten years has focused on the broad variety of pathogenetic aspects of a pain amplification syndrome. This emphasizes pain as the leading symptom. The sociomedical implications are obvious and considerable, and therefore fibromyalgia has increasingly become the subject of expert assessments. The expert assessment should not discuss the existence or non-existence of fibromyalgia, but evaluate the individual impairments, disabilities and handicaps which may lead to an individual degree of dysfunctioning.

Fibromyalgia and the conundrum of disability determination.
Hadler NM, Ehrlich GE.
J Occup Environ Med. 2003 Oct;45(10):1030-3.

[The expert assessment of fibromyalgia]
Spath M, Neeck G, Späth M.
Z Rheumatol. 2002 Dec;61(6):661-6.
[Article in German]
Comment in:
Z Rheumatol. 2003 Jun;62(3):299; author reply 300. PMID: 12931687.
Friedrich-Baur-Institut, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstr. 1a 80336, Munich, Germany.
Research on fibromyalgia over the last ten years has focused on the broad variety of pathogenetic aspects of a pain amplification syndrome. This emphasizes pain as the leading symptom. The sociomedical implications are obvious and considerable, and therefore fibromyalgia has increasingly become the subject of expert assessments. The expert assessment should not discuss the existence or non-existence of fibromyalgia, but evaluate the individual impairments, disabilities and handicaps which may lead to an individual degree of dysfunctioning.

Factors of importance for work disability in women with fibromyalgia: an interview study.
Liedberg GM, Henriksson CM.
Arthritis Rheum. 2002 Jun 15;47(3):266-74.
Linköping University and University Hospital, Linköping, Sweden. gunilla.liedberg@hul.liu.se
OBJECTIVE: Fibromyalgia symptoms such as continuous pain, tiredness, hyperalgesia, and allodynia limit gainful employment. The present study examines which factors influence the decision to remain in a work role for women with fibromyalgia. This information is important for the individual and for public finances.METHODS: Qualitative interviews were performed with 39 women, 19 of whom were gainfully employed and 20 who had stopped working. The transcribed interviews were analyzed and divided into categories and subcategories.RESULTS: Four categories appear, at societal and individual levels, that were regarded as important by the women for remaining in a work role. CONCLUSIONS: The ability to remain at work depends not only on limitations in work capacity, but also on the capacity of society to adjust work environments and work tasks. More individual solutions are needed to allow women with fibromyalgia to maintain work roles.

Tender point scores and their relations to signs of mobility, symptoms, and disability in female home care personnel and the prevalence of fibromyalgia syndrome.
Lundberg G, Gerdle B.
J Rheumatol. 2002 Mar;29(3):603-13.
Department of Rehabilitation Medicine, INR, Faculty of Health Sciences, Linköping, Sweden.
OBJECTIVE: In this study of female home care personnel employed in a municipality (n = 643; participation rate 94%) we investigated (1) the prevalence of tender points and fibromyalgia (FM); (2) the relationships between tender point score and other signs and symptoms; (3) if subgroups based on the tender point score differed with respect to signs, symptoms, disability, and health related quality of life; and (4) signs that showed the strongest intercorrelations with disability and health. METHODS: The following variables were registered: (1) Signs: joint mobility, spinal posture and mobility, tender points, and segmental mobility and pain provocation at L4-S1 levels of the low back. (2) Symptoms: pain and pain intensity and other symptoms. (3) Disability (i.e., self-rated reduced capacity for everyday activities and employment) and health: 3 indices and sick leave. RESULTS: The tender point score correlated with the number of pain regions and the pain intensities, and the amount of other symptoms, sick leave, and disability. Tender point score was the strongest regressor of the investigated signs in regression of the 2 disability indices. Segmental pain showed the strongest correlation with tender point score. Three subgroups identified by tender point score showed significant differences in segmental pain, prevalence and intensity of different symptoms, disability, and health related quality of life. The prevalence of FM was 2.0%. CONCLUSION: Tender point score together with different symptoms showed relatively strong correlations with disability. A relatively high prevalence of FM was found in occupationally active female home care personnel.

Assessing impairment and disability for syndromes presenting with chronic fatigue.
Coetzer P, Lockyer I, Schorn D, Boshoff L.
J Insur Med. 2001;33(2):170-82.
Sanlam, Bellville, Republic of South Africa.
Many disability claims are based on the subjective symptom of fatigue, which can be caused by a wide spectrum of diagnoses including fibromyalgia, chronic fatigue syndrome and cardiopulmonary diseases. Chronic pain is very often a compounding problem. It is vital for every insurer to have fair and objective criteria to distinguish between invalid claims and those with merit. This review article proposes objective tools and parameters to achieve this goal.

Effort testing in patients with fibromyalgia and disability incentives.
Gervais RO, Russell AS, Green P, Allen LM 3rd, Ferrari R, Pieschl SD.
J Rheumatol. 2001 Aug;28(8):1892-9.
Department of Rheumatic Diseases, University of Alberta, Canada. rgervais@powersurfr.com
OBJECTIVE: To examine whether symptom exaggeration is a factor in complaints of cognitive dysfunction using 2 new validated instruments in patients with fibromyalgia (FM). METHODS: Ninety-six patients with FM and 16 patients with rheumatoid arthritis (RA) were administered 2 effort or symptom validity tests designed to detect exaggerated memory complaints as part of a battery of psychological tests and self-report questionnaires. RESULTS: A large percentage of patients with FM who were on or seeking disability benefits failed the effort tests. Only 2 patients with FM who were working and/or not claiming disability benefits and no patient with RA scored below the cutoffs for exaggeration of memory difficulties. CONCLUSION: This study illustrates the importance of assessing for exaggeration of cognitive symptoms and biased responding in patients with FM presenting for disability related evaluations.

Disability evaluation of fibromyalgia.
Wolfe CV.
Phys Med Rehabil Clin N Am. 2001 Aug;12(3):709-18.
Ohio State University and Mt. Carmel Medical Center, Columbus, Ohio, USA.
These cases represent individuals who feel they have a severe impairment and are "disabled." They have been labeled with fibromyalgia. They are truly distressed. Their symptoms, their courses, are more chronic and refractory than those of medically ill patients, and they are high users of medical services, laboratory investigations, and surgical procedures. These patients see multiple providers simultaneously and frequently switch physicians. They are difficult to care for, and they reject psychosocial factors as an influence on their symptoms. Such persons "see themselves as victims worthy of a star appearance on the Oprah Winfrey show. A sense of bitterness emerges...." Shorter, a historian, believes that fibromyalgia is "heaven-sent to doctors as a diagnostic label for pain patients who display an important neurotic component in their illness. Our culture increasingly encourages patients to conceive vague and nonspecific symptoms as evidence of real disease and to seek specialist help for them; and the rising ascendancy of the media and the breakdown of the family encourage patients to acquire the fixed belief that they have a given illness...." Regarding the finding of "disability," this is a social construct, and many authors believe it is society and the judicial system who must decide who can work. To remain objective, the physician should report the objective clinical information. Physicians need not and should not sit in judgment of the veracity of another human being.

Quality-of-life, legal-financial, and disability issues in fibromyalgia.
Wallace DJ, Hallegua DS.
Curr Pain Headache Rep. 2001 Aug;5(4):313-9.
Department of Medicine/Division of Rheumatology, Cedars-Sinai Medical Center/UCLA School of Medicine, 8737 Beverly Building, Los Angeles, CA 90048, USA. dwallace@ucla.edu
Patients with fibromyalgia have an altered quality of life that is hard to quantitate using existing indices. The principal legal issues associated with the syndrome are: Does fibromyalgia exist? Can it be caused by or flared by stress or trauma? Does disability apply to fibromyalgia and if so, how? These issues are critically reviewed.

Unscrupulous get fat on yuppie flu.
Bateman C.
S Afr Med J. 2001 Jan;91(1):24-5.

Quantitative disability evaluation of syndromes presenting with chronic fatigue.
Coetzer P, Lockyer I, Schorn D, Boshoff L.
S Afr Med J. 2000 Oct;90(10 Pt 2):1034-52.

The assessment of functional impairment in fibromyalgia (FM): Rasch analyses of 5 functional scales and the development of the FM Health Assessment Questionnaire.
Wolfe F, Hawley DJ, Goldenberg DL, Russell IJ, Buskila D, Neumann L.
J Rheumatol. 2000 Aug;27(8):1989-99.
University of Kansas School of Medicine, Wichita, USA.
OBJECTIVE: Functional assessment by self-report questionnaire plays an important role in most rheumatic conditions, but psychometric properties of questionnaires have not been studied in fibromyalgia (FM), particularly by Rasch analysis, which allows for examining adequacy of the questionnaire scale. To assess currently used instruments, we examined the Fibromyalgia Impact Scale (FIQ), 4 versions of the Health Assessment Questionnaire (HAQ), and the Medical Outcome Survey Short Form (SF-36). METHODS: More than 2,500 patients from 4 sites (3 US, 1 Israel) completed the FIQ. The HAQ questionnaires were completed by 1438 patients participating in the US National Data Bank for Rheumatic Diseases. Seven hundred sixty patients from Wichita, Kansas, completed the SF-36. Rasch analysis was applied separately to each of these data sets. RESULTS: The FIQ systematically underestimated functional impairment by its handling of activities not usually performed. All questionnaires had problems with non-unidimensionality and ambiguous items when applied to patients with FM. In addition, scales were found to be non-linear. Because of these findings we used the 20 item HAQ questionnaire as an item bank to develop a new questionnaire more suitable for use in FM, the fibromyalgia HAQ (FHAQ). This questionnaire fits the Rasch model well, is relevant, is linear, and has a long, well spaced scale. CONCLUSION: No available functional assessment questionnaire works well in FM. A new questionnaire, the FHAQ, was developed. It has appropriate metric properties and should function well in this condition. Since the FHAQ is a subset of the larger HAQ questionnaire, a new questionnaire is not required; only a different method of scoring is needed. Additional studies regarding sensitivity to change are required to fully validate the FHAQ.

Validation of a German version of the Fibromyalgia Impact Questionnaire (FIQ-G).
Offenbaecher M, Waltz M, Schoeps P.
J Rheumatol. 2000 Aug;27(8):1984-8.
Department of Physical Medicine and Rehabilitation, University of Munich, Germany. Offenbaecher@phys.med.uni-muenchen.de
OBJECTIVE: To translate the Fibromyalgia Impact Questionnaire (FIQ) into German and to evaluate its reliability and validity for the use of German speaking patients with fibromyalgia (FM). METHODS: We administered the FIQ to 55 patients with FM (15 patients filled out the questionnaire 10 days later) together with German versions of the Stanford Health Assessment Questionnaire (HAQ), the Medical Outcomes Survey Short Form-36 (SF-36), and a tender point count (TPC). All patients were asked about the severity of pain today (10 cm visual analog scale) and the duration of symptoms. Tenderness thresholds were assessed by dolorimetry at all tender points with a Fisher dolorimeter and laboratory tests were obtained. Test-retest reliability was assessed using Spearman correlations. Internal consistency was evaluated with Cronbach's alpha of reliability. Construct validity of the FIQ was evaluated by correlating the HAQ and subscales of the SF-36 as well as the TPC and the tenderness thresholds. RESULTS: Mean age of participants was 54.3 years and mean duration of symptoms 9.5 years. Test-retest reliability was between 0.62 and 1 for the physical functioning as well as for the total FIQ and other components. Internal consistency was 0.92 for the overall FIQ. Significant correlations were obtained between the FIQ items, the HAQ, and the SF-36. CONCLUSION: The German FIQ is a reliable and valid instrument for measuring functional disability and health status in German patients with FM.

Factors of importance for work disability in women with fibromyalgia.
Henriksson C, Liedberg G.
J Rheumatol. 2000 May;27(5):1271-6.
Department of Neuroscience and Locomotion, Faculty of Health Sciences, Linköping University, Sweden.
OBJECTIVE: To identify factors of importance for women with fibromyalgia (FM) to continue working despite the limitations imposed by the symptoms. METHODS: A mail questionnaire with questions regarding social background, symptoms, sickness benefits, work situation, work conditions and adjustments, opinions regarding own work ability, and satisfaction with the situation was sent to 218 consecutive women seen at a university pain or rheumatology clinic. Answers were obtained from 176 women. RESULTS: Pain, poor quality sleep, abnormal tiredness, muscle stiffness, and increased pain after muscle exertion were frequently reported symptoms. Fifty percent of the women were employed, 15% full-time. Twenty-three percent reported FM as the reason for not working. The work situation had been changed for 58% of the working women, and 80% counted on being able to continue working. CONCLUSION: Work disability is a serious concern in FM, and the majority of women with FM have limitations in their ability to work. Our results indicate that individual adjustments in the work situation need to be made and that women who have found a level matching their ability may continue to work and find it satisfactory. Early intervention in the work situation is recommended.

Chronic widespread pain as a medico-legal issue.
Gordon DA.
Baillieres Best Pract Res Clin Rheumatol. 1999 Sep;13(3):531-43.
University of Toronto, Ontario, Canada.
A systematic approach to the determination of disability in persons with chronic widespread pain is based on a careful history, examination for tender points, and special investigations to establish a firm diagnosis. Further assessment requires determination of subjective and objective measures of impairment. The causes of fibromyalgia are multifactorial and understanding them requires an appreciation of the role of physical or psychological trauma, and associated medical and psychosocial factors. Despite the presence of disability risk factors, most patients with fibromyalgia maintain a good range of normal daily activities and continue working.

[Fibromyalgia (generalized tendomyopathy) in expert assessment. Analysis of 158 cases]
Kissel W, Mahnig P.
Schweiz Rundsch Med Prax. 1998 Apr 15;87(16):538-45.
[Article in German]
Comment in:
Schweiz Rundsch Med Prax. 1998 Jun 10;87(24):856. PMID: 9658972.
MEDAS Zentralschweiz, Luzern.

Work and disability status of persons with fibromyalgia.
Wolfe F, Anderson J, Harkness D, Bennett RM, Caro XJ, Goldenberg DL, Russell IJ, Yunus MB.
J Rheumatol. 1997 Jun;24(6):1171-8.
Arthritis Research Center, Wichita, KS 67214, USA. fwolfe@southwind.net
OBJECTIVE: To determine the prevalence and determinants of self-reported work disability in persons with fibromyalgia (FM). METHODS: A longitudinal, multicenter survey of 1604 patients with FM from 6 centers with diverse socioeconomic characteristics was begun in 1988. Assessments were by self-report questionnaire and telephone contact, and included work and disability events that occurred before and after 1988. Comparative analyses were performed on the entire data set and, separately, on the Wichita data set. RESULTS: More than 16% of patients reported receiving US Social Security disability (SSD) payments (highest center rate 35.7%; lowest center rate 6.3%) compared to 2.2% of the US population (US Social Security Administration data) and 28.9% of patients with rheumatoid arthritis seen at the Wichita outpatient rheumatology clinic. Overall, 26.5% reported receiving at least one form of disability payment when SSD and other sources of disability payments were considered. In Wichita, less than 25% of SSD awards were made specifically for FM, but after 1988 that figure increased to 46.4%. Work disability was greatest at the San Antonio and Los Angeles centers. Multivariate predictors (correlates) included pain, Health Assessment Questionnaire disability, and unmarried status. In addition, more than 70% of patients reporting being disabled did receive disability payments. On the other hand, 64% reported being able to work all or most days, and more than 70% were employed or were homemakers. CONCLUSION: Although most patients (64%) report being able to work, we found high rates of self-reported work disability awards among persons with FM followed in 6 rheumatology centers. But we also found great variability among centers as to awards and as to self-reported work ability. Center differences in work disability might reflect clinic referral patterns, physician beliefs, or socioeconomic status.

Which physicians are qualified to evaluate disability in fibromyalgia? Comment on the article by Bennett.
Kovarsky J.
Arthritis Rheum. 1997 Jun;40(6):1184-5.
Comment on:
Arthritis Rheum. 1996 Oct;39(10):1627-34. PMID: 8843852.

Primary juvenile fibromyalgia: psychological adjustment, family functioning, coping, and functional disability.
Reid GJ, Lang BA, McGrath PJ.
Arthritis Rheum. 1997 Apr;40(4):752-60.
The Toronto Hospital, General Division, Psychology, Ontario, Canada.
OBJECTIVES: 1) To determine the importance of psychological adjustment and family functioning in primary juvenile fibromyalgia by assessing these factors in children with fibromyalgia and in their parents, compared with children with juvenile rheumatoid arthritis (JRA) and with pain-free control children and their parents. 2) To examine which of these factors predict functional disability. METHODS: Fifteen children in each of the 3 study groups, and their parents, completed self-report questionnaires and pain diaries. A medical evaluation of each child was performed, including assessment of tender points by palpation and by dolorimetry. RESULTS: All children in the fibromyalgia group met the Yunus and Masi criteria for fibromyalgia, and 11 met the American College of Rheumatology criteria. There were almost no significant group differences in the children's or parents' psychological adjustment, ratings of family functioning, or coping strategies. Significant group differences in functional disability, pain, fatigue, tender point threshold, and control point tolerance were found. A number of the psychological adjustment, pain, fatigue, and coping variables were significantly associated with functional disability. CONCLUSION: The notion that fibromyalgia is a psychogenic condition is not supported by these results. Fibromyalgia is associated with disability of a magnitude comparable to that of other chronic pain conditions. Disability among children with fibromyalgia or JRA is a function of the children's psychological adjustment and physical state, and of the parents' physical state and method of coping with pain.

Assessment of functional limitation and disability in patients with fibromyalgia.
Mannerkorpi K, Ekdahl C.
Scand J Rheumatol. 1997;26(1):4-13.
Department of Physical Therapy, Sahlgren University Hospital, Göteborg, Sweden.
Fibromyalgia syndrome (FMS) is characterized by diffuse widespread musculoskeletal pain. The aims of this literature study were to review measures and instruments used to assess functional limitations and disability in patients with FMS. A 10-year search was done on Medline, CATS, and CINAHL. Of the 73 articles found, only standardized instruments and tests permitting quantification were included. Reviews, trials of medication therapy, epidemiological studies, and measures of the psychological and impairment level were excluded. The articles were divided into cross-sectional and longitudinal studies. No studies evaluating the reliability, validity or sensitivity of the functional tests applied to the FMS were found. Of the disability instruments reviewed, only the Arthritis Impact Measurement Scales and Fibromyalgia Impact Questionnaire were evaluated for reliability and validity for the FMS population. The Arthritis Self-Efficacy Scales and Quality of Life Scale proved their sensitivity, detecting change in a controlled longitudinal study.

Fibromyalgia and disability.
Smith MD.
J Rheumatol. 1997 Jan;24(1):229; author reply 230-1.
Comment on:
J Rheumatol. 1996 Mar;23(3):534-9. PMID: 8832998

Coping strategies predict disability in patients with primary fibromyalgia.
Martin MY, Bradley LA, Alexander RW, Alarcón GS, Triana-Alexander M, Aaron LA, Alberts KR.
Pain. 1996 Nov;68(1):45-53.
University of Alabama School of Medicine, Department of Medicine, Birmingham 35294-0006, USA.
We administered the Coping Strategies Questionnaire (CSQ) to 80 patients with fibromyalgia (FM) to determine the relationship between coping strategies and functional disability. A principal components factor analysis revealed two dimensions of patients' CSQ responses: Coping Attempts and Catastrophizing. Coping Attempts consists of five scales: Reinterpreting Pain, Ignoring Pain Sensations, Diverting Attention, Coping Self-Statements and Increasing Activity Level. Catastrophizing is comprised solely of the CSQ Catastrophizing scale. Both coping strategy dimensions were significantly related to patients' disability scores on the Sickness Impact Profile even after controlling for demographic and clinical variables as well as neuroticism. Coping Attempts was associated with higher levels of Physical (P < 0.05) and Total Disability (P < 0.01), and lower levels of Psychosocial Disability (P < 0.05). Catastrophizing was associated with higher levels of Total Disability (P < 0.01). These relationships suggest that investigators should attempt to identify Coping Attempts strategies that best reduce patients' psychological distress in the laboratory. It then may be possible to teach patients to use these strategies to reduce distress in their home and work environments.

Fibromyalgia and the disability dilemma. A new era in understanding a complex, multidimensional pain syndrome.
Bennett RM.
Arthritis Rheum. 1996 Oct;39(10):1627-34.
Comment in:
Arthritis Rheum. 1997 Jun;40(6):1184-5. PMID: 9182936.
Department of Medicine, Oregon Health Sciences University, Portland 97201, USA.

Fibromyalgia outcome: the predictive values of symptom duration, physical activity, disability pension, and critical life events--a 4.5 year prospective study.
Wigers SH.
J Psychosom Res. 1996 Sep;41(3):235-43.
Department of Physical Medicine and Rehabilitation, University Hospital of Trondheim, Norway.
Forty-four fibromyalgia patients were followed through 4.5 years to assess the extent to which symptom duration, physical activity level, disability pensions, and the occurrence of critical life events would predict long-term outcome. Outcome measures included pressure tenderness (dolorimeter score), work capacity (ergometer cycle test), global subjective improvement (verbal rating scale), and visual analogue scale ratings of pain, disturbed sleep, lack of energy, and depression. Significant outcome predictors were identified by means of separate multiple regression analyses on each outcome measure at follow-up, using symptom duration, physical activity level, disability pension status, and occurrence of critical life events as independent variables, together with baseline symptom intensity and age, which were adjusted for. An adequate physical activity level and increasing age predicted a positive outcome, while receiving a permanent disability pension or having experienced an excess of major negative life events predicted a negative outcome. Symptom duration did not affect outcome.

Pain, disability, and physical functioning in subgroups of patients with fibromyalgia.
Turk DC, Okifuji A, Sinclair JD, Starz TW.
J Rheumatol. 1996 Jul;23(7):1255-62.
Pain Evaluation and Treatment Institute, University of Pittsburgh School of Medicine, Pennsylvania 15213, USA.
OBJECTIVE: To investigate (1) whether patients with fibromyalgia (FM) could be subgrouped on the basis of psychosocial and behavioral responses to pain, and (2) the relationships among pain severity, perceived disability, and observed physical functioning, as measured by cervical spinal mobility. METHODS: 117 patients with FM received a comprehensive examination, underwent physical performance tasks during the evaluation, and completed self-report inventories. RESULTS: About 87% of the patients could be classified into the Multidimensional Pain Inventory clustering groups identified and validated in patients with a range of chronic pain problems (Dysfunctional, Interpersonally Distressed, and Adaptive Copers). Although the 3 groups exhibited comparable levels of physical functioning, the Dysfunctional and Interpersonally Distressed patients reported higher levels of pain, disability, and depression. Interpersonally Distressed patients also reported significantly lower levels of marital satisfaction than the other 2 subgroups. There were significant associations between pain severity and perceived disability, and pain severity and physical functioning, defined by spinal mobility tests. The relationship between disability and physical functioning did not reach statistical significance. Correlational analyses by subgroups revealed a significant association between patient perceived disability and physical functioning in the Adaptive Copers, but not the Dysfunctional or Interpersonally Distressed patients. CONCLUSIONS: Patients with FM can be classified into 3 subgroups based on psychosocial and behavioral characteristics. These subgroups show substantial differences in clinical presentation of their symptoms. Although the results should be considered preliminary due to the narrow range of physical functioning, the differential relationships between perceived disability and physical functioning across cluster groups suggest the importance of FM syndrome as a heterogeneous disorder. Treating patients with FM as a homogeneous group may compromise research results, impede understanding of the mechanisms underlying this condition, and deter development of effective treatment.

Assessing functional disability and health status of women with fibromyalgia: validation of a Hebrew version of the Fibromyalgia Impact Questionnaire.
Buskila D, Neumann L.
J Rheumatol. 1996 May;23(5):903-6.
Rheumatic Disease Unit, Ben-Gurion University of the Negev, Beer Sheva, Israel.
OBJECTIVE. To validate a translated version of the Fibromyalgia Impact Questionnaire (FIQ) to be used by Hebrew speaking populations. METHODS. We administered the FIQ to 100 women with fibromyalgia (FM). The FIQ measures physical functioning, work status, depression, anxiety, sleep, pain, stiffness, fatigue, and well being. All patients were asked about the presence and severity (assessed by visual analog scale) of relevant FM symptoms (pain, fatigue, anxiety, etc.); a count of 18 tender points was conducted by thumb palpation, and tenderness thresholds were assessed by dolorimetry. Test-retest reliability was assessed using Spearman correlations. Internal consistency was evaluated with Cronbach's alpha coefficient of reliability. To assess content validity a cutoff criterion of > or = 25% impairment responses was set to indicate a valid item. Construct validity of the FIQ was evaluated by correlating the physical functioning score as well as the separate items with measures of symptom severity, count of tender points, and tenderness thresholds. RESULTS. Test-retest reliability was r = 0.96 for physical functioning, and 0.80-0.96 for other items of FIQ. Internal consistency was alpha = 0.93 at Time 1 and 0.86 at Time 2. Seventeen of 19 items of the FIQ met the > or = 25% criterion. Significant moderate to high correlations were obtained between the FIQ items and severity symptoms, point count, and tenderness threshold. CONCLUSION. The FIQ is a reliable and valid instrument for measuring functional disability and health status in Israeli women with FM.

A prospective long-term study of fibromyalgia syndrome.
Kennedy M, Felson DT.
Arthritis Rheum. 1996 Apr;39(4):682-5.
Boston University Arthritis Center, Massachusetts, USA.
OBJECTIVE: To ascertain the long-term natural history of fibromyalgia syndrome (FMS). METHODS: Patients with a history of FMS, seen in an academic rheumatology referral practice, were originally surveyed soon after onset of symptoms, and then were reinterviewed 10 years later in a prospective followup cohort study. A validated telephone survey was administered that inquired into current symptoms, medical care and treatments used, and work disability. The results were compared with the prior surveys. RESULTS: Of the original 39 patients, there were 4 deaths. Of the remaining 35 patients, 29 (83%) were reinterviewed. Mean age at current survey was 55 years, and mean duration of symptoms was 15.8 years. All patients had persistence of some fibromyalgia symptoms, although almost half (48%) had not seen a doctor for them in the last year. Moderate to severe pain or stiffness was reported in 55% of patients; moderate to a lot of sleep difficulty was noted in 48%; and moderate to extreme fatigue was noted in 59%. These symptoms showed little change from earlier surveys. In 79% of patients, medications were still being taken to control FMS symptoms. Despite continuing symptoms, 66% of patients reported that FMS symptoms were a little or a lot better than when first diagnosed. Fifty-five percent of patients said they felt well or very well in terms of FMS symptoms, and only 7% felt they were doing poorly. With the exception of sleep trouble, which was persistent, baseline survey symptoms correlated poorly with symptoms at the 10-year followup. CONCLUSION: FMS symptoms last, on average, at least 15 years after illness onset. However, most patients experience some improvement in symptoms after FMS onset.

The fibromyalgia syndrome: a consensus report on fibromyalgia and disability.
Wolfe F.
J Rheumatol. 1996 Mar;23(3):534-9.
Comment in:
J Rheumatol. 1997 Jan;24(1):229-30; author reply 230-1. PMID: 9002051.
J Rheumatol. 1997 Jan;24(1):229; author reply 230-1. PMID: 9002049.
J Rheumatol. 1997 Jan;24(1):229; author reply 230-1. PMID: 9002050.
J Rheumatol. 2001 Mar;28(3):676-7; author reply 677-8. PMID: 11296983.
University of Kansas School of Medicine, Wichita 67214, USA.

Work disability evaluation and the fibromyalgia syndrome.
White KP, Harth M, Teasell RW.
Semin Arthritis Rheum. 1995 Jun;24(6):371-81.
Department of Medicine, University Hospital, University of Western Ontario, Canada.
Fibromyalgia syndrome (FMS) is a common and costly cause of work disability. Patients with FMS, nevertheless, encounter considerable difficulties in their assessment of claims for disability payments. Factors that contribute to FMS as an important cause of disability are its high prevalence, the patients' perception of severe discomfort, and poor function. Disability evaluation in FMS is controversial for several reasons including lack of acceptance of the diagnosis, concurrent psychological abnormalities, difficulties in objectifying disability, deficiencies in instruments of evaluation, the uncertain efficacy of treatment, and physician attitudes. Third parties appear to have inappropriate expectations of the physician's role in determining disability. We suggest that the process of disability evaluation be improved by more objective assessments and by the inclusion of other health professionals in assessing disability and necessary retraining. Further research is needed to develop better instruments for measuring disability, to assess the long-term effects of various treatments, and to clarify the contributions of the work place and of compensation in causing or aggravating FMS.

[Guidelines for social medicine assessment and evaluation of primary fibromyalgia]
Raspe H, Cellarius J, Mau W, Wasmus A, von Gierke S.
Gesundheitswesen. 1994 Nov;56(11):596-8.
[Article in German]
Institut für Sozialmedizin, Lübeck.
Primary fibromyalgia belongs to the spectrum of rheumatic soft tissue disorders. It is characterized by wide-spread chronic pain and a low pain threshold. The etiology of the disorders is still unknown. Clinical diagnosis requires examination by a rheumatologically trained physician pathognomonic findings are largely lacking. Classification criteria have been published by Wolfe et al. on behalf of the American College of Rheumatology (ACR). The prognosis of FMA is unfavourable and does hardly, respond to therapy. FMA patients' work capacity cannot be established by mere diagnosis; individual impairments have to be taken into account: Clinical, psychosocial and behavioural dimensions have to be considered. Neither inpatient rehabilitation nor early retirement seem to significantly influence the course of FMA. The patient can usually work fulltime in jobs requiring light activities.

Comparison between self-report measures and clinical observations of functional disability in ankylosing spondylitis, rheumatoid arthritis and fibromyalgia.
Hidding A, van Santen M, De Klerk E, Gielen X, Boers M, Geenen R, Vlaeyen J, Kester A, van der Linden S.
J Rheumatol. 1994 May;21(5):818-23.
Department of Internal Medicine, University Hospital, Maastricht, The Netherlands.
OBJECTIVE. To study concordance between self-report measures and clinical observations of functional disability in ankylosing spondylitis (AS), rheumatoid arthritis (RA), and fibromyalgia (FM). METHODS. 35 patients with AS completed 9 selected items of the Functional Index questionnaire, whereas 12 patients with RA and 13 with FM completed 7 selected items of the Arthritis Impact Measurement Scales. Five days later, all 60 patients and 4 controls actually performed the selected activities, which were recorded on video. The tapes were assessed in random order by 12 observers (6 occupational therapists and 6 physicians). Both patients and observers indicated functional disability on a 10 cm visual analog scale (VAS). RESULTS. Interobserver agreement was high (Cronbach's alpha 0.98). All observers scored the 4 healthy controls as having no disability at all. Mean discordance scores (VAS patients minus VAS observers) for the selected items were negligible in AS [-0.17 cm (p = 0.30)], moderate in RA [+1.10 cm (p = 0.06)] and high in FM [+2.44 cm (p < 0.01)]. CONCLUSION. Discordance between self-report questionnaires and observed functional disability is a feature most striking in FM. In validation of self-report questionnaires of functional disability the appropriate spectrum of rheumatological diagnoses should be considered.

Fibromyalgia--a new cause for disability pension.
Bruusgaard D, Evensen AR, Bjerkedal T.
Scand J Soc Med. 1993 Jun;21(2):116-9.
Department of Community Medicine, University of Oslo, Norway.
Fibromyalgia is a condition under dispute. Accepted by some as a major step forward in understanding some of the patients with widespread muscular pain, looked upon as a confusing side step by others. In 1988 fibromyalgia was by far the most frequent single diagnosis as a reason for disability pension in Norway. Disability statistics however show big differences between counties. Two neighbouring counties had among the lowest and the highest incidence of disability pensioners with the diagnosis fibromyalgia. New pensioners with fibromyalgia and some closely related diagnoses have been studied during the year 1988 by means of reading the insurance records. It became apparent that the difference between the two counties with respect to the incidence of fibromyalgia as a cause of disability pension could be explained by differences in diagnostic setting by the doctors and difference in the assessment from the insurance system, rather than real differences in morbidity pattern. Complaints from the musculoskeletal system is frequent and increasing in the population both as a reason for sick leave and disability pension. Whether this complicated and challenging situation is made more easy to handle by defining a subgroup of those persons as having "fibromyalgia" is questioned.

Fibromuscular pain disorders in the injured worker: accurate examination is the key to diagnosis.
Harrington JT.
Wis Med J. 1992 Oct;91(10):585-7.

[Soft tissue pain and psychiatric evaluation]
Marelli R.
Z Unfallchir Versicherungsmed. 1991;84(1):34-42.
[Article in German]
Zentrum für Medizinische Begutachtungen, Basel.
Attention is drawn to the special position of the psychiatric assessor. In his evaluation, the assessor takes into consideration psychic and somatic findings and also social factors. Precisely in connection with the assessment of soft-tissue pain there is a growing recognition that the Ancient Greek dualism of "psyche and soma" is already obsolete. Psychic and somatic factors are mutually dependent, and psychosomatic illness has a multifactorial origin involving predisposition, the development of the personality in early childhood and later, and finally the development of environmental influences in the individual sphere and in the social sphere in general. A subject of special discussion are personality factors which are correlated with a developmental impairment of aggressive motivation. The inhibition of aggression seems to play a decisive role in determining the symptoms. The loss of constructive aggressivity is presented as a trigger for soft-tissue pain.

Illness worry and disability in fibromyalgia syndrome.
Robbins JM, Kirmayer LJ, Kapusta MA.
Int J Psychiatry Med. 1990;20(1):49-63.
Sir Mortimer B. Davis-Jewish General Hospital.
Fibromyalgia (FM) is a common syndrome of functional somatic symptoms. This article examines whether an amplifying somatic style (increased body awareness and illness worry) might explain the distress and disability expressed by FM patients. Twenty FM patients were compared to twenty-three rheumatoid arthritis (RA) patients on measures of depressive and somatic symptomatology, pain, disability, and amplifying somatic style. FM patients reported greater somatic symptomatology, equivalent levels of pain, and less physical disability than did RA patients. No differences were observed between groups on body awareness or illness worry. Illness worry correlated highly with symptomatology for both groups but with physical disability only among FM patients. Results suggest that disability in functional somatic syndromes may be determined by patients' worry about having a serious disease. Feelings of vulnerability and apprehension about having an illness of unknown origin may contribute to FM sufferers' activity limitations, inability to sustain a work effort, and varied somatic distress.

[Expert assessment of psychosomatic disorders in rheumatology]
Mathies H, Abbach B.
Versicherungsmedizin. 1989 Jul 1;41(4):139-40.
[Article in German]
There are often big problems regarding expert evidences of psychosomatic clinical pictures, because, contrary to the complaints expressed and perceived by the patient, somatic findings are not evident to justify a permanent disablement. Nearly without exception it is a question of chronified cases of psychosomatic complaints up to real psychoneuroses. The diagnosis and delimination from a simulation is difficult and is frequently failed. Without doubt there are cases, in which only the psychic component determines the vocational disablement.

Cost/benefit medicine, red flags, and fibrositic workscales.
Roth SH.
Arch Intern Med. 1989 Mar;149(3):721.
Comment in:
Arch Intern Med. 1990 Feb;150(2):460. PMID: 2302023.

Pain, functional disability, and psychological status: a 12-month study of severity in fibromyalgia.
Hawley DJ, Wolfe F, Cathey MA.
J Rheumatol. 1988 Oct;15(10):1551-6.
Arthritis Center, University of Kansas School of Medicine, Wichita.
We mailed monthly questionnaires regarding fibromyalgia symptoms to 75 patients during a one-year period. Fibromyalgia symptoms in individual patients were generally stable over time as assessed by repeated measures and slope analyses, but patients clearly differed from one another in symptom severity. Pain, psychological status, and functional disability, but not sleep disturbance or morning stiffness, were the independent explanatory factors for disease severity in regression models. Functional disability has not been recognized previously as an important factor in fibromyalgia severity, but our data suggest that it should be assessed as a process and outcome measure in future fibromyalgia studies.

[Rheumatism of soft tissues as a cause of temporary incapacitation (according to observations in a metallurgic plant).]
KAWENOKI-MINC E.
Reumatologia. 1960;3:25-38.
[Article in Polish]