This is an HTML version of an attachment to the Freedom of Information request 'Training, briefing and knowledge-base materials for WCA assessors regarding certain conditions'.

MEDICAL SERVICES 
PROVIDED ON BEHALF OF THE DEPARTMENT FOR WORK AND PENSIONS 
 
 
 
 
 
 
Training and Development 
 
Continuing Medical Education 
Programme 
 
Fibromyalgia - Guidelines for the Disability 
Analyst 
 
MED/S2/CMEP~0035 
Version 5 Final 
 
Module: 14 

 

 
Medical Services 
 
Foreword  
 
 
This document has been produced as part of the medical education programme for 
Health Care Professionals training for approval by the Department for Work and 
Pensions Chief Medical Adviser to carry out medical assessments. 
All Health Care Professionals undertaking medical assessments must be registered 
medical or nursing practitioners who in addition, have undergone training in disability 
assessment medicine. The training includes theory training in a classroom setting, 
supervised practical training, and a demonstration of understanding as assessed by 
quality audit. 
This guidance must be read with the understanding that, as experienced medical or 
nursing 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 module. 
In addition, the guidance is not a stand-alone document, and forms only a part of the 
training and written documentation that a 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 
 
   July 2011
Fibromyalgia – Guidelines for the Disability Analyst 
5 Final 
MED/S2/CMEP~0035 
 
Page  2 
 

 
 
 

 
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Document control 
Superseded documents  
Version history 
Version Date 
Comments 
 
 
 
5 Final 
2nd July 2011 
Signed off by CMMS 
5 a Draft  23rd 
June 
2011 
Updated by Dr Amina Hussain, following 
Schedule 28 review 

Final  16 
July 
2009 
Signed off by Medical Services Contract 
Management Team 
4a Draft  3 July 2009 
Updated by Dr P Ellis following Schedule 28 
review 
Changes since last version 
Updated to reflect withdrawal of IB PCA: so reference to Mental Health Test (PCA) 
on p. 29 removed 
Outstanding issues and omissions 
Issue control 
Author: 
Original version by Dr Tony Fisher 
 
Owner and approver:  The Medical Director  
 
Signature: 
Date: 
 
Distribution: 
 
 
 
 
 
 
 
 
Fibromyalgia – Guidelines for the Disability Analyst 
5 Final 
MED/S2/CMEP~0035 
 
Page  3 
 

 
 
 

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 Contents 
Page 
Section Page 
1. 
 
Aims and Objectives
6 
1.1 
Aim 

1.2 
Objectives 

2. 
 
Introduction
7 
3. 
Fibromyalgia sy
 
ndrome (FMS)
8 
4. 
 10
Case example
 
5. 
Overview 14 
5.1 
Clinical char
 14
acteristics
 
5.2 
 14
Work implications
 
5.3 
 15
Aetiology
 
5.4 
 15
Prognosis
 
6. 
Backgrou
 16
nd
 
6.1 
 16
18th century
 
6.2 
19
 16
 century
th
 
6.3 
 16
1900’s
 
6.4 
1950 - 80 16 
6.5 
 17
1980’s
 
6.6 
 17
1990s
 
7. 
 20
Pain and stress
 
7.1 
Pain 20 
7.2 
 20
Stressors
 
8. 
Links wi
 22
th other conditions
 
8.1 
Chronic fatigue syndrome 22 
8.2 
Major depressive disorder 23 
8.3 
Other medically unexplained syndromes 24 
8.4 
The biopsychosocial model 24 
8.5 
What’s in a name? 26 
9. 
The role of the disability analyst in
 28
 FMS
 
Fibromyalgia – Guidelines for the Disability Analyst 
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9.1 
The clinical 
 28
setting
 
9.2 
The disability
 28
 analysis setting
 
9.3 
 28
Proposed approach
 
9.4 
Our role 28 
9.5 
Scope of the examination 29 
9.6 
Disparity between findings and claimed disability 29 
9.7 
The disability
 30
 analyst’s task
 
9.8 
Other sources 30 
10. 
 31
Summary
 
11. 
References 32 
12. 
 33
Evaluation
 
  
 
 
 
Fibromyalgia – Guidelines for the Disability Analyst 
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1. 
Aims and Objectives 
1.1 
Aim 
The aim of this module is to present to Health Care Professionals an overview of 
fibromyalgia syndrome which will enable them to approach claimants with the illness 
in a structured and consistent way. 
1.2 
Objectives 
By the end of the module the reader will be able to: 
  List the characteristics of fibromyalgia syndrome, 
  List the areas where it overlaps with other, similar disorders, 
  Describe an approach to the provision of medical advice which is pragmatic, 
medically logical and in keeping with the current consensus of medical opinion. 
 
 
Fibromyalgia – Guidelines for the Disability Analyst 
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2. 
Introduction 
 
This short overview aims to refresh your awareness of fibromyalgia syndrome (FMS) 
and examines its implications in the disability analysis setting. 
From your own study of the literature, you may hold different views on some facets 
of this condition to those expressed here. However, when advising the decision 
maker it would be preferable if we adopt a common approach to the uncertainties 
and conflicts inherent in the condition and as far as possible align our methods of 
evaluation and reporting. 
The first part of the module invites you to explore your current view of the condition. 
The second presents a composite case which may help to refresh your recollection 
of its many facets. 
A brief overview follows, and finally our proposals for a consistent approach to the 
disability assessment and the formulation of advice. 
A short selection of the many references consulted is given at the end and we hope 
that the module will be informative and useful.  
Fibromyalgia – Guidelines for the Disability Analyst 
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3. 
Fibromyalgia syndrome (FMS) 
 
Consider the following questions: 
1.  What are your current views on FMS? 
2.  Complete the table: 
 
 
DON’T 
YES NO 
KNOW
FMS is entirely psychological in origin 
 
 
 
FMS is wholly physical in origin 
 
 
 
FMS is partly physical, and partly psychological in origin
 
 
 
There is always some evidence of a precipitating injury 
 
 
 
Most cases of FMS are attributable to abnormal illness   
 
 
behaviour 
Unlike CFS aerobic exercise has no beneficial effect in   
 
 
FMS 
As regards the outlook, each case is different: there are   
 
 
no clear prognostic indicators 
3.  What are the characteristics of FMS? Write them down in the space below. 
 
CHARACTERISTIC FEATURES OF FIBROMYALGIA SYNDROME 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fibromyalgia – Guidelines for the Disability Analyst 
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TRY TO RECALL WHEN YOU LAST SAW A CASE OF FMS 
 
1.  Who made the initial diagnosis: 
 A 
colleague? 
 You? 
 The 
patient? 
2.  What was the history, and what were the symptoms? 
3.  Was the assessment in connection with a disability examination?  
4.  If the person was seen in a clinical setting do you think the encounter 
would have been easier in the disability analysis context? 
5. Give reasons. 
6.  What was the outcome of your examination? 
 
 
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4. 
Case example 
Please read the following case example. It is based on an actual case but has 
been considerably amplified and altered to illustrate certain points and to 
encourage reflection. 

Mrs C. 
Mrs C is a lady of 36 years. Symptoms began some 4 years ago. At that time she 
was employed as a sales manager in a small but thriving and growing company – a 
job which she describes as very responsible, hectically busy and challenging. She 
enjoyed the job, but had difficulties with her manager who she thought disapproved 
of a woman holding such a central position in the company. 
She married at the age of 28 but her husband lost his job a few years later and he 
shouldered the household responsibilities while Mrs C became the sole 
breadwinner. They have one (disabled) boy of 6, and a daughter of 7. 
In January 1999 she contracted a mild flu-like illness but did not stop work because 
of it. While driving in the city at this time her car was struck from behind by another 
vehicle. There was an altercation between herself and the other driver. She was 
upset and shaken and had sustained a few scratches from flying glass, but was 
otherwise unharmed. She attended the local A & E department, where she was 
“checked over” and given the all clear.  
The (company) car was a write-off and relationships between her and her manager 
deteriorated further. Meanwhile her flu-like symptoms persisted and she began to 
experience pain in her lower cervical area. She thought it might be fibrositis or 
muscular rheumatism. Instead of improving,  it became steadily worse, the pain 
extending over the left suprascapular area, then the right. Whiplash injury was 
retrospectively diagnosed by her GP, 5 months after the car accident. 
Eventually she had to give up driving as she could not get in and out of the car 
without a great deal of pain, and reversing and parking were almost impossible.  
Latterly the pain extended down to her waistline and her right leg was becoming 
involved. Her employer made it clear that she would have to be replaced as they 
were highly dependent on an efficient and committed sales manager, but offered her 
a desk job. This was quite a junior post and her salary was to be just over half of 
what it was as sales manager. She refused, and her employment was terminated. 
She is suing the owner of the vehicle involved in the accident for her injuries and her 
former employers for wrongful dismissal. 
Mrs C. is in bed when you arrive to assess her for Disability Living Allowance (DLA). 
She looks quite well physically, with no signs of weight loss or muscle wasting. 
However she appears rather depressed and becomes quite emotional when 
describing her family problems and again later when explaining how she feels she 
was badly treated by her employer. 
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All four limbs are generally painful; in fact she feels that most of her body is now 
affected by the pain. Her neck discomfort is still troublesome and she experiences 
tingling in both arms. She is quite dependent on her husband for help with a variety 
of self-care tasks, like hair-washing, dressing (some days), and getting in and out of 
bed. To make matters worse she has developed a bowel problem and this has 
added to her difficulties. She experiences diarrhoea at times, with cramping pain; at 
other times she has constipation accompanied by uncomfortable fullness and lower 
left-sided abdominal discomfort. This has been (negatively) investigated in hospital. 
She sleeps poorly and in the morning is unrefreshed. Her back, shoulders and legs 
are particularly painful about this time and this adds to her feeling of lethargy and 
tiredness. Her joints, especially the wrists and elbows feel swollen, although there’s 
nothing much to be seen, she says. To make things worse, she says she keeps 
getting (she thinks) bladder infections, and although specimens have been sent to 
the laboratory on repeated occasions they have failed to identify a cause. She says 
that she keeps having to pass urine, and it feels uncomfortable. 
She has had acupuncture, aromatherapy etc. to no avail.  
Her GP referred her to an orthopaedic consultant whom she saw privately in 1999, 
about three months after the accident. He confirmed the diagnosis of whiplash injury 
and since then she has seen a number of specialists of various kinds, including a 
psychologist.  
She apologises for being in bed on the occasion of your visit explaining that she has 
a headache, which is a not infrequent event these days. A packet of paracetamol 
and a container of nasal decongestant drops sit on the bedside table. There is also a 
bottle containing amitriptyline tablets, 25mg.  
She blames her condition partly on the virus she “caught” around the time of her 
accident and which she feels is still active, and on the whiplash injury she sustained. 
She describes a fairly restricted lifestyle; she no longer reads books, although she 
used to, because she often finds she has to read and re-read the pages and she 
cannot be bothered trying to follow the plot of films on the television.  
Her mother arrives during the later stages of the assessment and she supplements 
her daughter’s history. It emerges that Mrs C is one of a family of three girls. The 
youngest suffers from chronic fatigue syndrome. Her mother says that she helps Mrs 
C as much as she can but suffers a lot from fibrositis herself. Her husband, Mrs C’s 
father, died 5 years ago; she explains that he was alcoholic and suffered from 
depression, and caused the family a great deal of worry and unhappiness. 
Your examination is unremarkable, although on palpation a number of anatomically 
disparate areas are tender. On palpation of these she reacts by expressions of pain, 
with sighing, groaning, withdrawal and facial grimacing. You are extremely careful to 
explain that you are anxious to cause her the minimum of discomfort and will desist 
from further examination if she wishes. You find no muscle wasting.   
Having taken her statement, completed the examination and made outline notes you 
leave, wondering how best to represent and explain the case to the decision maker. 
 
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PLEASE ANSWER THE FOLLOWING QUESTIONS: 
 
1. What is the differential diagnosis in this case? Give the likely 
diagnosis/diagnoses. 
2.  Are there features you would not expect to encounter in a case of FMS? 
3.  If so, what are they? 
4.  What difficulties would you encounter in describing her likely self-care 
problems to a decision maker? 
 
SUGGESTED RESPONSE TO QUESTIONS IN PRECEDING TABLE 
1.  Other diagnostic possibilities include: 
  Chronic fatigue syndrome 
 Rheumatoid 
arthritis 
 Ankylosing 
spondylitis 
 Other 
arthritides 
  Diffuse connective tissue diseases (e.g. SLE) 
  Diabetes mellitus and thyroid disorders may present in this way 
  Metabolic bone disease (other than osteoporosis). 
 Soft-tissue 
rheumatic 
disorders 
 
2. & 3. See the table overleaf 
 
4. This is one of the disability analyst’s central problems in assessing 
claimants suffering from this group of illnesses. We suggest that the 
disparity between observed clinical findings and claimed functional 
impairment is one of the defining characteristics of these syndromes. The 
point is discussed later. 
 
Please complete the table overleaf. 
Fibromyalgia – Guidelines for the Disability Analyst 
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Table 1. 
 

 
TRUE FALSE 
1. 
FMS may present with generalised muscle pains 
 
 
2. 
FMS may arise following trauma; often called 
“reactive fibromyalgia” 
 
 
3. 
Patients with reactive fibromyalgia have more 
perceived disability, self-reported pain and affective 
 
 
distress  than those with idiopathic onset 
4. 
FMS may arise following a viral infection, e.g. 
 
 
influenza, coxsackie virus 
5. 
Patients with FMS often score highly on measures 
 
 
of anxiety and depression 
6. 
Most patients with FMS are female 
 
 
7. 
Aerobic exercise reduces pain and the number of 
 
 
tender points in fibromyalgia 
8. 
A family history of depression and alcoholism is 
 
 
more common in fibromyalgia 
Patients with FMS not uncommonly also suffer from the following: 
9. 
Irritable bowel syndrome 
 
 
10.  Irritable bladder syndrome 
 
 
11.  Migraine  
 
12.  Rhinitis  
 
13.  Sleep disorder 
 
 
14.  Morning stiffness 
 
 
15.  Impaired memory 
 
 
16.  Impaired concentration 
 
 
17.  Subjective sense of joint swelling 
 
 
18.  Paraesthesiae  
 
19.  Reduced aerobic fitness 
 
 
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5. 
Overview 
All parameters in the table in the preceding section are True.  
5.1 
Clinical characteristics 
Fibromyalgia syndrome is a common condition. It is one of the most frequently seen 
disorders in rheumatology outpatient clinics, and in most studies it accounts for 
about 2% of patients seen in a general practice setting and 5% of those attending a 
general medical outpatient clinic.  
It is a chronic but non progressive disorder, characterised by a decreased ability to 
sustain repetitive activity or other forms of sustained work load as a result of pain, 
fatigue, global debility, and poor aerobic fitness, and an associated loss of 
concentration and attention span. 
Patients with FMS report problems with the activities of daily living (ADLs) that are 
as severe as those described by patients with rheumatoid arthritis (RA) and greater 
than individuals with osteoarthritis (OA). In addition they have rated their quality of 
life inferior to patients with either of these diseases, insulin dependent diabetes, 
COPD and colostomy.  In a large survey of patients with RA, OA, systemic lupus 
erythematosus (SLE), scleroderma and FMS the latter reported the poorest global 
self-assessment of functional status, the highest visual analogue pain scale and the 
lowest global assessment of health status.  
The typical patient is female, aged between 18 and 55, who complains of diffuse and 
chronic musculoskeletal pain which is aching, constant and concentrated in the axial 
regions of the body. Pain is often worse in the morning and exacerbated by changes 
in the weather, humidity, cold, stress and sleeplessness. 
Physical findings are normal except for multiple, sometimes  reproducible points of 
exaggerated tenderness to palpation.  
A wide variety of somatic complaints may accompany these signs and symptoms. 
5.2 
Work implications 
The disability which these patients exhibit is often considered sufficiently severe to 
prevent a significant proportion of them from seeking, continuing or resuming gainful 
employment and a US survey of 620 patients revealed that 15% were receiving 
disability payments. A British study of 72 patients over a mean interval of 4 years, 
found that 50% had stopped work as a result of their illness. 
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5.3 
Aetiology 
The aetiology is obscure, but the general theory is widely held that it is a disorder 
occurring in a genetically predisposed individual, triggered by environmental 
stressors. 
Individuals developing the illness in mid life often have a history of antecedent injury, 
usually to the neck area or one side of the shoulder girdle; the symptoms are 
unrelieved by conventional treatment. Typically in these cases pain spreads to the 
contralateral side, then to one lower limb, followed by all four limbs, and finally the 
axial skeleton is involved. Such patients are usually more disabled by their FMS and 
have a worse prognosis. 
Other patients describe an influenza-like illness which precedes the onset of fatigue 
and muscle pains.  
There is general acceptance that patients who attribute their FMS to trauma are 
more disabled than those with “primary” FMS and have more perceived disability, 
self-reported pain, and interference with day to day living than those with a non-
traumatic onset.  
5.4 
Prognosis 
The prognosis for fibromyalgia is poor. In one UK study less than 1 in 10 patients 
diagnosed in hospital became symptom-free over five years. Identified risk factors 
for a poor prognosis include the duration of the illness at the time of presentation 
and the presence of a comorbid psychiatric disorder. The fixed belief that the illness 
is due solely to a physical cause e.g. a “chronic” viral infection, makes the prognosis 
much more uncertain. 
Conversely, patients who take a broader perspective of their condition 
acknowledging that a combination of psychological and physical conditions have 
contributed to their illness have in general a much more favourable prognosis. 
Despite the uncertain long-term outlook, a significant proportion of people with FMS 
continue to work even if experiencing symptoms.  A number change their occupation 
to one that is less demanding. 
 
Fibromyalgia – Guidelines for the Disability Analyst 
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6. 
Background 
6.1 
18th century 
The condition now known as fibromyalgia has a long and distinguished pedigree. As 
long ago as 1750, Sir Richard Manningham described an illness with striking 
similarities to FMS, characterised by persistent fatigue and non-specific somatic 
symptoms. He called the condition febricula, or little fever, and noted that patients 
complained of profound “listlessness, with great lassitude and weariness all over the 
body…(and) little flying pains.” Interestingly, he noted an association between this 
condition and periods of emotional stress. 
6.2 
19th century 
In the 1820’s Balfour had remarked on the presence of tender points in some 
patients with rheumatic disease, and in 1841 Valliex observed that in many 
instances the tender points could only be elicited by means of palpation, the patients 
themselves often being unaware of the focal character of these locations. 
6.3 
1900s 
The term “fibrositis” is attributed to Gowers in 1904 and he theorized that there was 
an underlying inflammatory process at work, localised to the “fibrous tissues of the 
muscles”. Other synonyms arose later in the century, such as tension rheumatism, 
muscular rheumatism and the like. However in the background was the constant 
suspicion that some other, psychogenic factor was at work.  
6.4 
1950 - 80 
Graham, a Canadian rheumatologist, proposed in 1953 that fibrositis should be 
regarded not as a specific clinical entity but as a clinical syndrome of unexplained 
muscle pain. Many doctors were ill at ease with this concept. However in the 1970s 
Moldofsky in Canada found EEG abnormalities during sleep in patients with 
fibrositis. He attributed these to what he named `alpha EEG NREM sleep 
abnormality’ and formed the hypothesis that this phenomenon produced the pain 
and fatigue of these individuals. 
Fibromyalgia – Guidelines for the Disability Analyst 
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6.5 
1980s 
In the 1980s the term was gradually supplanted by fibromyalgia, or fibromyalgia 
syndrome. Although by now many professionals endorsed the condition the idea 
was rendered more palatable when Smyth, (also a Canadian rheumatologist) 
pointed out that there were indeed specific clinical markers for the disease in the 
form of discrete, reproducible tender points. In due course the “dolorimeter” was 
developed, a device which could deliver measured degrees of pressure over a 
specified area and this “objective” measurement overcame the reluctance of many 
to make the diagnosis. 
6.6 
1990s 
In 1990 the American College of Rheumatology (ACR) attempted to define the 
condition in light of the apparently reproducible nature of the tender points found on 
clinical examination (Table 2. overleaf). While the definition was appealing and 
appeared to introduce a degree of objectivity into the debate it is still viewed with a 
degree of scepticism. In 1995 the “Copenhagen Declaration” recognised the 
existence of the syndrome and so ensured that the condition is now established as a 
distinct clinical entity.  
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Table 2 
From: 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. 
 
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, and  
  Pain below the waist.  
In addition, axial skeleton pain (cervical spine or anterior chest or thoracic 
spine or low back) must be present. In this definition, shoulder and 
buttock pain is considered as pain for each involved side. Low back pain 
is 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 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”. 
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Figure 1 - Tender point sites of fibromyalgia syndrome 
 
 
The intention was not to employ these criteria as strict requirements for diagnosis, 
and many patients who could undoubtedly be regarded as suffering from FMS fail to 
meet them fully. 
It is widely felt that this classification, although initially useful, is an over-
simplification of a condition which is complex, multifactorial and not in the 
strict sense a discrete entity. 

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7. 
Pain and stress 
The aetiology is unclear. The various components of the syndrome have been 
considered in detail but no unifying common cause for the condition has been found. 
7.1 
Pain 
Pain in FMS can be regarded as attributable partly to a generalised decrease in the 
pain perception threshold i.e. the ability to discriminate between nociceptive and 
non-nociceptive (i.e. warmth, cold, touch) quality. It is also partly due to diminished 
pain tolerance (reflecting an unwillingness to receive more intense stimulation).  
In the 1990’s particularly, much research focused on the pain elicited by pressure 
algometry (dolorimetry) in which incremental pressure is applied to the “classical” 
tender points as defined by the ACR, or control sites, and the degree of reported 
pain documented. Unfortunately of course this process relies heavily on subjective 
communication between subject and examiner, and in addition it is not clear whether 
perception or tolerance levels are being assessed. 
Nevertheless there is a significant amount of evidence that patients with FMS have 
reduced thresholds for the perception and tolerance of pressure both at tender 
points and in other areas of the body.  
Pain research in animals has suggested a variety of mechanisms for central 
sensitisation to pain, including activation of certain neurons which react both to 
nociceptive and nonnociceptive stimuli, and the effects of cytokines. These 
mechanisms are theoretically possible but their relevance to FMS must remain 
purely conjectural.   
Some investigators propose a “hypervigilance” model of pain; that is a heightened 
sensitivity to pain due to a maladaptive increased attentiveness to external stimuli 
and an increased preoccupation with sensations of pain. Sufferers from FMS are 
said to have an intrinsic perceptual style of amplification of pain. 
7.2 
Stressors  
In addition there is evidence that psychological distress is central to the pain 
experience and overall morbidity of fibromyalgia, and patients with the condition 
report more stress in their lives than do healthy control subjects or sufferers from, for 
example, rheumatoid arthritis. 
Like many illnesses, fibromyalgia may be the result of one or more stressors acting 
on a person who is genetically predisposed, triggering the expression of symptoms. 
Examples of such stressors include trauma, infections (e.g. parvovirus, coxsackie, 
influenza virus) acute or longstanding emotional distress, and immune challenge 
such as occurs in certain autoimmune diseases and other situations. 
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In a similar way, a proportion of the population at large are ill-equipped to cope with 
the day to day stressors of life. With a background of negative experiences in 
childhood and poorly developed cognitive, emotional and behavioural skills as adults 
they display maladaptive coping strategies when faced with the inevitable 
challenges of their environment.  If exposed to certain stressors, whether chemical, 
physical, emotional or infective they may develop a spectrum of symptoms, both 
somatic and psychological. 
 
 
 
 
 
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8. 
Links with other conditions 
Medically unexplained physical symptoms represent by far the most frequent cause 
of referral to specialist outpatient clinics, and it is not surprising that each specialty 
has its own compartment in which such patients can comfortably be accommodated. 
Rheumatologists have their fibromyalgia, cardiologists their non-cardiac chest pain 
and gastroenterologists, irritable bowel syndrome. 
It is not surprising therefore that FMS shares common features with a number of 
other conditions.  
8.1 
Chronic fatigue syndrome 
The clearest overlap is with chronic fatigue syndrome (CFS). Some of the shared 
characteristics are illustrated below. 
 
Pain 
About 70% of subjects with CFS also experience persistent diffuse muscle pain 
Fatigue 
85% to 95% of patients diagnosed with fibromyalgia also complain of general fatigue
Myalgia* 
“Myalgia” is enshrined in the term myalgic encephalomyelitis  
Tender points 
Tender points are commonly encountered in CFS 
Sleep disorder 
Sleep disorder is common to both 
Infectious links 
These are also found in fibromyalgia, and in one series 55% of fibromyalgia patients 
volunteered that their illness had started with a viral illness 
Prevalence 
As in CFS most fibromyalgia sufferers are female and between the ages of 18 and 
55; depression is common and in general the prognosis is poor. 
*Myalgia.  The complaint of painful muscles is a common one and it has been 
pointed out that the sensation of painful weariness is one expression of fatigue. It is 
not surprising therefore that it can also be also an indicator of general distress. 
Indeed it has been said that the tender point count is a `sedimentation rate’ (ESR) 
for distress. 
A number of studies confirm the overlap between FMS and CFS and in one, 42% of 
patients with primary fibromyalgia met the full criteria for CFS and 27% were only 
one item short. 
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8.2 
Major depressive disorder 
Large number of studies have assessed the possible association between FMS and 
major depressive disorder [as defined in the Diagnostic and Statistical manual of 
Mental Disorders 4th ed. (DSM IV)
]. 
In one study1 where the authors attempt to identify and clarify any association 
between fibromyalgia and major depressive disorder they make the following points: 
 
Shared features 
High rates of symptoms of major depressive disorder are reported in fibromyalgia; 
high rates of myalgia, musculoskeletal pain and other symptoms of fibromyalgia are 
reported in major depressive disorder. 
Psychological tests and rating scales 
High rates of psychiatric symptomatology similar to that found in major depressive 
disorder are reported in fibromyalgia 
Lifetime prevalence of major depressive disorder 
High rates of major depressive disorder are found in individuals with fibromyalgia in 
a majority of studies, though not in all. 
Patterns of comorbidity 
High lifetime rates of migraine, irritable bowel syndrome, chronic fatigue syndrome 
and atypical facial pain are found in patients with fibromyalgia; high rates of major 
depressive disorder are found in patients with migraine, irritable bowel syndrome, 
chronic fatigue syndrome and atypical facial pain. 
Family history 
High rates of major depressive disorder are found in the relatives of individuals with 
fibromyalgia. 
They conclude: 
  That fibromyalgia and major depressive disorder share a common underlying 
abnormality, and  
  That they may be perceived as part of a wider spectrum of related disorders. 
The authors propose that major depressive disorder and fibromyalgia share a 
common ancestor which has been variously named “dysfunctional spectrum 
disorder” or “affective spectrum disorder”. 
 
                                                 
1 Hudson JI, Pope HG. The relationship between fibromyalgia and major depressive disorder. 
Rheumatic Diseases Clinics of North America 22(2);1996:285-303.  
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They conclude that the siblings of fibromyalgia include chronic fatigue syndrome, 
migraine, irritable bowel syndrome, mood disorders and anxiety disorders. 
8.3 
Other medically unexplained syndromes 
Similarities and overlaps between many other unexplained syndromes have been 
pointed out; e.g. tension headache, gynaecological syndromes and 
temporomandibular disorders. Do these disorders too represent other expressions of 
the somatisation of distress? 
8.4 
The biopsychosocial model 
From our own viewpoint as disability analysts it is essential to examine this condition 
in terms of the biopsychosocial model (Fig 2.) 
Until recently, research has focused on a mechanical perception of the disease; 
muscles are painful, therefore there must be some underlying pathological condition 
affecting the muscles; sleep is disturbed, therefore lack of sleep causes painful 
muscles. However, contributions from a number of different disciplines have 
encouraged a broader perspective and Engel’s model of a complex interaction 
between physical, psychosocial, behavioural and societal elements, the 
biopsychosocial model of disease/disability, is particularly apt in FMS. 
FMS is of course like all illnesses, particularly chronic conditions, a composite of 
physical and psychological elements which will affect the reaction of the patient to 
pain and illness.  
However many other factors are at play, and support from family and community 
alter disease expression and prognosis. The activities of the medical profession in 
investigating and treating the illness are not without impact. The demands of the 
person’s job and the influences brought to bear by the social security system and 
other insurance schemes (including, it has to be said the disability assessment) will 
also produce an effect on the overall effects of the condition and its outcome. 
The biopsychosocial construct is relevant in the disability analysis setting and 
clinically in the formulation of treatment plans. It should be used so that the decision 
makers are given informed advice regarding the level of function of the claimant.
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Predisposing factors: 
Precipitating factors: 
  

 
 
Stressful life events (acute or chronic)
 
Stressful life events (acute or 
 Psychiatric 
illness 
chronic) 
 Personality 
factors 
 Psychiatric 
illness 
   Constitutional factors (chronic 
 Medical 
illnesses 
medical illness, atopy, allergies) 
 Personality 
factors 
 
 Constitutional 
factors 
 
 
 
Physical factors 
 
Psychosocial factors 
Behavioural factors 
 
Societal factors 
(BIOPSYCHOSOCIAL MODEL 
 
OF DISEASE/DISABILITY) 
 
FMS 
 
 
Perpetuating factors: 
 
 
Untreated psychiatric illness 
 Ongoing 
psychosocial 
 
stressors 
 
Unrecognized mental illness 
 
 
Abnormal illness attribution 
  Prolonged time away from 
work 
 
 
Figure 2 - A multidimensional perspective which may be applied to FMS 
 
or chronic fatigue syndrome 
 
 
Consider how this applies to the case example (Mrs. C) 
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Criteria for FMS met in 
this area 
 
 
Fatigue/muscle 
 
pain/IBS/ 
migraine/facial 
 
pain/depression
/ atypical chest 
 
pain  
 
Minimal 
Marked 
 
Symptoms
symptoms
 
 
INCREASING DISTRESS/PAIN/HYPERALGESIA 
   
 
  Figure 3 - The distress/pain/hyperalgesia continuum 
It perhaps oversimplifies the issue to represent the tender point count as a meter for 
polysymptomatic distress (fig 3.) but it may be helpful if the analogy is widened to 
include the various somatic and psychological expressions of this group of 
conditions. It does seem likely that vulnerable people who can be classified by the 
ACR criteria as having fibromyalgia do not have a discrete disease. They are simply 
the most ill in a continuum of distress, chronic pain, and painful tender points in the 
population. 
8.5 
What’s in a name? 
Some may take the view that by giving the resulting disorder a medically respectable 
title it will contribute to illness behaviour and learned helplessness. It must be 
recognised that unless a condition is labelled there will be difficulties for physicians, 
the legal profession, insurers and benefits decision makers in dealing with these 
patients.  
Few if any insurance or social security systems will permit compensation for general 
aches, pain and misery. However, when we as a Health Care Professional 
encounter an individual who is clearly distressed and debilitated most of us will be 
content to apply a label like fibromyalgia, if the clinical evidence generally supports 
it, so ensuring that the person can be classified and handled within the system. The 
term fibromyalgia syndrome is a clinical construct that allows physicians and others 
to describe and communicate to themselves a definition of one expression of chronic 
distress (Figure 4). 
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Figure 4 - The Iceberg Model 
 
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9. 
The role of the disability analyst in FMS 
9.1 
The clinical setting  
There is no doubt that for the clinician, patients suffering from this illness pose 
diverse and complex problems relating to diagnosis and management. However, the 
mainstay of clinical management centres around a collaborative, patient, pragmatic, 
step by step approach involving the treatment of any comorbid conditions (including 
psychiatric disorders), the graded resumption of physical activity, and a cognitive 
behavioural approach by the physician. 
9.2 
The disability analysis setting  
For the disability analyst, building up a clear picture of disability and disablement can 
also be difficult and complex; the uncertain area between psychological medicine 
and general medicine is an unnerving place for non-medical decision makers and a 
challenge to us as medical advisers, particularly as our analysis and advice is based 
on a single encounter with the claimant. 
9.3 
Proposed approach 
What is certain is that we cannot continually engage in the “FMS/CFS exists/does 
not exist” debate on each occasion we encounter a claimant with these or allied 
syndromes. There is ample evidence that these troublesome, complex illnesses are 
common and genuinely disabling but we cannot shield the decision maker from the 
uncertainties and problems which surround them. 
It is necessary therefore for us to adopt an approach which is practical and 
pragmatic, and provide advice which is in keeping with the balance of current 
medical opinion. 
9.4 
Our role 
In our role as disability analysts: 
  Investigation and formulating the diagnosis are not part of our remit 
  We are not responsible for any aspect of treatment 
  We have no part to play in the alleviation of symptoms or in counselling 
  We are free of any requirement to decide on benefit entitlement 
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Our task is to:  
  Assess the history, presenting signs and symptoms 
  Confirm the diagnosis in order to support our expectations of the effects of the 
condition 
  Give an objective description of the: 
 Claimant 
 Disease 
  Extent of disablement 
and 
  On this basis provide clear, reasoned, up-to-date advice to the decision maker 
9.5 
Scope of the examination 
The physical examination should follow traditional lines, focusing on evidence of 
functional restriction in the musculoskeletal system, evidence of muscle wasting and 
general deconditioning, and any signs suggesting a comorbid condition or 
alternative diagnosis. 
9.5.1 
Mental health examination 
All claimants in whom the diagnosis of FMS or CFS has been made should undergo 
a mental health evaluation, in keeping with the current requirements of the relevant 
work strand. Normally, of course, mental state evaluation form part of the flow of the 
normal “history”, but occasionally a claimant will protest that “There’s nothing 
mentally wrong with me, doctor”.   
This should be answered by the explanation that although you accept that this is the 
case; in fairness to the claimant it has to be demonstrated in the report that all 
possible conditions have been addressed. In addition, you should point out that the 
mental health assessment undertaken in disability analysis seeks to test cognitive 
function as well as the effects of defined mental health disorders; therefore it is also 
useful in the assessment of symptoms such as fatigue and lack of concentration. 
9.6 
Disparity between findings and claimed disability  
In undertaking our task, the central problem in assessing patients with FMS, CFS 
and related disorders arises when we try to evaluate and describe a person whose 
claimed degree of disability appears to fall well outside the expected range 
suggested by the diagnosis, the clinical findings and/or the history. 
However, the disparity is a universal finding in this group of conditions; indeed it is 
one of their key characteristics. It is well documented and has been thoroughly 
investigated; it is, as near as we can judge a consistent finding. In many cases we 
cannot provide decision makers with the unequivocal answers or solutions they 
would find most palatable and the apparent anomaly must be accepted as part and 
parcel of the condition. 
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9.6.1 
Malingering  
Although apparent inconsistencies between the clinical findings and the claimed 
degree of disability are an intrinsic feature of these disorders, we must be alert for 
any areas where such inconsistencies are so unusual or conflicting as to suggest 
that the claimant is making an intentional attempt to simulate disability in the pursuit 
of gain.  The use of “malingering” and other pejorative terms should not be used but 
it is possible to describe outstanding contradictions in a way that is fair, overt and yet 
non-judgemental.    
9.7 
The disability analyst’s task 
Decision makers cannot be immune from the uncertainties that assail us as Health 
Care Professionals in evaluating claimants with disorders of this kind and we would 
suggest that our approach should be to:  
  Confirm whether the results of our assessment support the diagnosis, 
  Provide an accurate, objective account of the nature and severity of any 
abnormal clinical findings, 
  Describe and comment upon any disparity between our findings and the claims 
made by the individual, 
  Describe and comment upon any disparity between the assembled medical 
evidence and the characteristics of FMS or other allied syndromes, 
  Identify and comment upon any tendency of the claimant to deliberately 
exaggerate their symptoms or over-state their difficulties, 
  Give a pragmatic account of the intrinsic nature of the condition as it relates to 
this particular claimant, 
  Provide a prognosis. 
If we provide this service thoughtfully and in keeping with current, up to date medical 
practice we will be more than adequately fulfilling our role.  
9.8 
Other sources 
Finally, your attention is drawn to earlier modules in the CME programme relevant to 
this topic; in particular those dealing with Chronic Fatigue Syndrome and Effective 
Report Writing, and the training material relating to the biopsychosocial model and 
disability assessment. 
 
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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 concentration 
and a wide variety of somatic symptoms. 
It 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 which are outwith those characteristic of the illness 
should be clearly expressed. 
 
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11.  References 
1. Manningham 
R. 
The symptoms, nature, causes and cure of the febricula, or little 
fever. London: J Robinson,1750. 
2.  Moldofsky H. Scarisbrick P, England R, Smythe H. Musculoskeletal symptoms 
and non-REM sleep disturbances in patients with “fibrositis syndrome” and 
healthy subjects. Psychosomatic Medicine 1975;37:341-51. 
3.  Yunus MB, Masi AT, Aldag JC. A controlled study of primary fibromyalgia 
syndrome. Journal of Rheumatology 1989;16(19):62-71. 
4.  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. 
5.  Wolfe E et al. Fibromyalgia and disability. Scand J Rheumatol 1995;24:112-8. 
6.  McCain GA, Cameron R, Kennedy JC. The problem of longterm disability 
payments and litigation in primary fibromyalgia. Journal of Rheumatology 
1989;16(19):174-6.  
7.  Liang MH et al. Evaluation of social security disability in claimants with rheumatic 
disease. Annals of Internal Medicine 1991;115(1):26-31. 
8.  Wolfe F. Disability and the dimensions of distress in fibromyalgia. Journal of 
Musculoskeletal Pain 1993;1(2):65-87. 
9.  White KP, Harth M, Teasell RW. Work disability evaluation and the fibromyalgia 
syndrome. Seminars in Arthritis and Rheumatism1995;24:371-81. 
10. Wolfe F, Potter J. Fibromyalgia and work disability. Rheumatic diseases clinics 
of North America 1996;22(2):370-91. 
11. 
Hudson JI, Pope HG. The relationship between fibromyalgia and major 
depressive disorder. Rheumatic diseases clinics of North America 
1996;22(2):286-303. 
12. Demitrack MA. Chronic fatigue syndrome and fibromyalgia. Psychiatric clinics of 
North America 1998;21(3):671-692. 
13. Bennett RM. Fibromyalgia and the disability dilemma. Arthritis and Rheumatism 
1996;39(10):1627-34. 
14. Cohen ML, Quintner JL. Fibromyalgia Syndrome, a problem of tautology. The 
Lancet 1993;342:906-9. 
15. 
Wolfe F. The relation between tender points and fibromyalgia symptom 
variables: evidence that fibromyalgia is not a discrete disorder in the clinic
Annals of the Rheumatic Diseases
 1997;56:268-71. 
16. Pawlikowska T et al. Population based study of fatigue and psychological 
distress. BMJ 1994;308:763-66. 
17. Doherty M, Jones A. Fibromyalgia syndrome. BMJ 1995;310:386-389. 
18. Reid S, Wessely S, Craford T,Hotopf M. Medically unexplained symptoms in 
frequent attenders of secondary health care. BMJ 2001;322:767. 
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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.    Cases in which there is a clear history of precipitating 
 
 
trauma have a worse prognosis 
2.    Patients with FMS have reduced thresholds for the 
 
 
perception and tolerance of pressure, localised to 
specific tender points.  
3.    A patient’s belief that a physical,(e.g. viral) rather than a 
 
 
psychological cause underlies FMS is to be encouraged 
as it will improve the prognosis 
4.    Unlike CFS, sleep disorder is uncommon in FMS  
 
 
5.    Individuals with FMS have rated their quality of life 
 
 
inferior to patients with insulin dependent diabetes, 
COPD and colostomy.   
6.    Aerobic exercise reduces pain and the number of tender 
 
 
points in FMS 
7.    Pain in FMS is often least severe in the morning, 
 
 
becoming worse as the day progresses 
8.    In the 1900s particularly, much research by Gowers and 
 
 
others focused on the pain elicited by pressure 
algometry. 
 
NAME (Print) 
 
SIGNATURE: 
 
DATE: 
 
On Completion please return to your local Medical Services 
Centre
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