Researchers and clinicians have found it useful to formulate the "fibromyalgia" diagnosis in order to promote research, evaluate treatment programs, and improve patient management. The World Health Organization, in developing the International Classification of Disease (ICD), has incorporated fibromyalgia in the tenth revision of ICD; fibromyalgia is number M79.0.

A consensus conference on fibromyalgia took place in Copenhagen on August 20, 1992, as part of the Second World Congress on Myofascial Pain and Fibromyalgia. Fibromyalgia was defined as:

1. History of widespread pain.
   
   

   Definition.

   Pain is considered widespread when all of the following are present: pain in both sides of the body, pain above and below the waist. In addition, axial skeletal pain (see cervical spine, anterior chest, thoracic spine or low back) must be present. 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:

   at the suboccipital muscle insertions.

   
   

   Low cervical:

   at the anterior aspects of the intertransverse spaces at C5-C7.

   
   

   Trapezius:

   at the mid-point of the upper border.

   
   

   Supraspinatus:

   at origins, above the scapular spine near the medial border.

   
   

   Upper Rib:

   upper lateral aspects of the second costochondral junction.

   
   

   Lateral Epicondyle:

   two cm distal to the epicondyles.

   
   

   Gluteal:

   in upper outer quadrants of buttocks in anterior fold of muscle.

   
   

   Greater Trochanter:

   posterior to the trochanter at the prominence.

   
   

   The Knees:

   at the medial fat pad proximal to the joint line.

   
   

   Digital palpation should be performed with the approximate force of 4 kg. A tender point has to be painful at palpation, not just "tender."¹
   

   Diagnosing Fibromyalgia

   A review of current literature indicates that fibromyalgia is, in fact, a distinctive syndrome that can be diagnosed with clinical precision by first understanding the definition of fibromyalgia and how to detect it.
   
   From the clinical perspective, the diagnosis is often present when the patient presents with unexplained widespread pain or aching, persistent fatigue, generalized stiffness, non refreshing sleep, and multiple tender points.² Since these pain complaints may somewhat mirror the pain complaints of myofascial pain, there is a potential for confusion in the diagnosis. However, "myofascial pain syndrome" patients have localized pain distribution and limited number of tender points. Fibromyalgia patients often have the profile of persistent fatigue, widespread stiffness, and nonrestorative sleep. Additionally, myofascial pain syndrome patients are usually responsive to specific fascial therapy and fibromyalgia patients are not. ³
   

   Can Motor Vehicle Collision Trauma Cause Fibromyalgia?

   In a word, yes. In 1992, Greenfield, et al.,⁴ termed the phrase "reactive fibromyalgia" to mean fibromyalgia precipitated by trauma. In that study, researchers investigated the frequency of a recognizable trauma event such as motor vehicle accident, work injury, surgery, or sports injury in a consecutive series of patients at a rheumatology clinic. One hundred twenty-seven patients were identified as having fibromyalgia. Ninety eight or 77% had "primary fibromyalgia," and twenty nine or 23% percent had "reactive fibromyalgia." The precipitating events in the reactive fibromyalgia patients were classified as traumatic injury incident in 14 cases, surgery in 11 cases, and medical in 4 cases. The authors noted patients with reactive fibromyalgia are more likely to have loss of employment (70 percent), receive disability compensation (34 percent), and reduced physical activity (45) percent. The authors concluded:
   

   We identified a precipitating event occurring prior to the onset of fibromyalgia in 23 percent of consecutive patients seen in a university hospital rheumatology clinic in a suburban private rheumatology practice. Those with reactive fibromyalgia had a more disabling disease course, which resulted in greater reduction of physical activity, more frequent loss of employment, and a greater likelihood of compensation ?for disability than in patients with fibromyalgia without a precipitating event. The occurrence of fibromyalgia following an initiating event may represent the onset of a long-standing pain syndrome that results in considerable pain, social, and financial disability.⁵ [Emphasis added]

   In 1993, Dr. Goldberg, in a presentation to the American College of Rheumatology, stated patients with post-traumatic fibromyalgia were identical to the patients with idiopathic fibromyalgia. Further, that 55 to 60 percent of his fibromyalgia patients ascribed the onset of symptoms of fibromyalgia to a traumatic or infectious event.⁶
   
   In 1994, Waylonis and Perkins published a report describing their follow-up study of 176 individuals seen between 1980 and 1990, in whom a diagnosis of post-traumatic fibromyalgia was made.⁷ Sixty-seven people in that study completed a lengthy questionnaire and underwent a physical examination using the American College of Rheumatology criteria to confirm or deny the presence of fibromyalgia at the time of follow up. A total of 60.7 percent noted the onset of symptoms after a motor vehicle accident, 12.5 percent after an on the job injury, 14.3 percent after other various traumatic events, 7.1 percent after surgery, and 5.4 percent after a sports-related injury.
   

   Fibromyalgia's Long-Term Prognosis

   Individuals who develop post-traumatic fibromyalgia following automobile accidents or other negligence events such as trip and falls, bicycle collisions, or construction site injury are well advised to consult experienced personal injury attorneys to assist them with their injury claims. Insurance companies have been especially resistant to accepting fibromyalgia as a condition caused by trauma, especially in the context of auto accident related claims. At some point in time, a competent personal injury attorney will ask the treating doctor to give an opinion regarding "causation" and prognosis. The ability to quantify and recover damages for reasonable and necessary future care, future pain and suffering, and disability often depends on the doctor's understanding of the factors influencing prognosis. Chronic residual symptoms may be encountered with or without objective findings.
   
   In 1990, Ramano⁸ reported a short-term follow up of 14 patients with post-traumatic fibromyalgia. Dr. Ramano noted that 9 of 14 patients continued to require treatment two years after settlement of their claim. In this paper, it is noted that post-traumatic fibromyalgia patients often have litigation involved. This retrospective study of 14 patients was made in an effort to ascertain the likelihood of malingering. The author reports that the mean age of the 14 patients studied was 37 years. All had classic post-traumatic fibromyalgia syndrome with a chronic musculoskeletal problem that started immediately after a traumatic event. Twenty-three percent went to trial, 77 percent settled out of court. All were given a monetary award. Interestingly enough, the vast majority (77 percent) returned to a rheumatologist for continued treatment, suggesting that patients who meet fibromyalgia diagnostic criteria are not malingering and are indeed in need of medical assistance.
   
   Ramano's conclusions are supported by Waylonis and Perkins in "Post-Traumatic Fibromyalgia: A Long-Term Follow-Up." In that study, the author concluded:
   

   Eighty-five percent of patients with a previous diagnosis of post-traumatic fibromyalgia still had symptoms and physical evidence of the condition ten years later. They were for the most part identical to the fibromyalgia patient who developed their symptoms spontaneously. These results closely parallel the findings of Gargan and Bannister and support the concept that symptoms of post-traumatic fibromyalgia do not disappear when litigation has been completed.⁹ [Emphasis added]

   Conclusion

   Fibromyalgia is now recognized as one of the more common chronic pain syndromes, and its diagnosis has proven to be equally as frustrating as its treatment¹⁰ Achieving a better understanding of the fibromyalgia diagnosis by the physician and counsel may help patients avoid extensive and time-consuming workups only to learn that they have been misdiagnosed and have a chronic permanent condition.
   
   If one of your patients is involved in a motor vehicle collision, a trip and fall, pedestrian or bicycle injury or construction site injury, and presents with chronic pain symptoms, rather than second-guessing yourself or the patient, it is recommended you refer your patient or have the treating doctor refer the patient to a specialist in rheumatology or one otherwise familiar with fibromyalgia. Moreover, if the cause of the fibromyalgia condition is trauma from an accident caused by someone else, then it is recommended that your patient seek the advice of an attorney who focuses on personal injury and insurance law who is familiar with the fibromyalgia condition.
   
   The knowledgeable and experienced personal injury attorneys at Adler Giersch PS stand ready to assist you and your patients through our offices in Seattle, Bellevue, Everett and Kent.
   
   (1)“Consensus Document on Fibromyalgia: The Copenhagen Declaration," Journal of Musculoskeletal Pain, Vol. 2, No. 3, pp. 295-312.
   (2)Ibid., p299.
   (3)Ibid.
   (4)S. Greenfield, M. Fitzcharles, J. Esdaile, “Reactive Fibromyalgia Syndrome,” Arthritis and Rheumatism, 1992, Vol. 35, No. 6, pp. 678-680.
   (5)Ibid., p. 680.
   (6)D. Goldenberg, “Presentation to the American College of Rheumatology,” San Antonio, Texas, Nov. 7-11, 1993.
   (7) G.W. Waylonis, R. H. Perkins, “Post-Traumatic Fibromyalgia: A Long-Term Follow Up,” American Journal of Physical Medicine and Rehabilitation,
   1994, Vol. 73, pp. 403-412.
   (8)T.W. Ramano, “Clinical Experiences with Post-Traumatic Fibromyalgia Syndrome,” West Virginia Medical Journal, 1990, Vol. 86, pp. 198-202.
   (9)G.W. Waylonis, R.H. Perkins, “Post-Traumatic Fibromyalgia Syndrome,” American Journal of Physical Medicine and Rehabilitation, 1994, Vol. 73,
   p. 408.
   (10)D.L. Goldenberg, “Fibromyalgia Syndrome: An Emerging But Controversial Condition,” JAMA, 1987, Vol. 257, pp. 2782-2787.