Dr Jenner discusses the challenges of Fibromyalgia for medico legal cases in January’s edition of Your Expert Witness
The challenges of Fibromyalgia for medico legal cases
By DR CHRISTOPHER JENNER MB BS FRCA FFPMRCA, Consultant in Pain Medicine at Medicolegal Associates Ltd
Fibromyalgia syndrome (FMS), is a chronic and widespread pain disorder which is characterised by widespread body pain, poor sleep, tiredness, fatigue, cognitive disturbance and a constellation of other symptoms. Anyone can develop fibromyalgia, although it affects around seven times as many women as men. The condition typically develops between the ages of 30 and 50, but can occur in people of any age, including children and the elderly.
It’s not clear exactly how many people are affected by this disorder, although research has suggested it could be a relatively common condition. Some estimates suggest nearly 1 in 20 people may be affected to some degree. One of the main reasons why it’s not clear how many people are affected is because fibromyalgia can be a difficult condition to diagnose.
Unfortunately, the cause of fibromyalgia is unknown, but there are thought to be multiple factors involved and that it is related to abnormal levels of certain chemicals in the brain and changes in the way the central nervous system process pain messages from the body. Scientific research shows that patients who suffer from the pain of fibromyalgia have changes that occur in the peripheral and central nervous systems. These changes make patients hypersensitive and more likely to experience pain and other fibro symptoms.
Clinical examination findings may reveal multiple trigger points – these are taut bands of muscle which, when palpated on examination, reproduce pain. In contemporary practice a more useful diagnostic tool is to use the American College of Rheumatology criteria for a diagnosis of FMS. This criteria specifically looks at pain location, fatigue, sleep disturbance and cognitive disturbance, along with a checklist of 40 associated symptoms.
Multi-disciplinary treatment tailored to the patient’s needs is recommended to help improve some of the symptoms and make the condition easier for the individual to manage. Treatment tends to be a combination of anti-neuropathic and analgesic medication, talking therapies such as CBT and counselling, life style changes such as graded and paced exercise programmes and relaxation techniques.
The medicolegal challenges facing solicitors surrounding fibromyalgia arise from the subjectivity of symptoms, causal attribution and reported symptoms sufficiently severe to cause disability. While fibromyalgia is accepted as a medical condition, the diagnosis is susceptible to misuse due to the subjectivity of symptoms.
The number of legal cases involving fibromyalgia is on the increase, as is the incidence of fibromyalgia symptoms starting after a trauma such as road traffic accident. The trauma suffered can also exacerbate fibromyalgia in sufferers.
Difficulty can arise when the original trauma is limited, relatively minor or the expected improvement does not happen. Also a range of other symptoms associated with fibromyalgia can occur. This is when the fibromyalgia diagnosis may be missed for some time or challenged.
The assessment and diagnosis of disability in chronic pain states, including fibromyalgia, can be difficult due to its subjectivity and complexity. An assessment by an expert in pain medicine at this stage is usually extremely valuable. Furthermore, chronic pain can be particularly challenging for the courts to understand in terms of the prototypical perception of disease that associates pathogenesis with tissue damage or dysfunction.
The expert in pain medicine will be able to assist the court in assessing the level of resulting disability.