Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Fibromyalgia


Related Terms

  • Fibromyositis
  • Fibrositis
  • Medically Unexplained Widespread Pain
  • Muscle Pain Syndrome
  • Muscular Rheumatism
  • Psychogenic Rheumatism
  • Tension Myalgias

Differential Diagnosis

Specialists

  • Clinical Psychologist
  • Family Physician
  • Internal Medicine Physician
  • Neurologist
  • Occupational Therapist
  • Pain Medicine Physician/Pain Specialist
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Rheumatologist

Comorbid Conditions

  • Anxiety
  • Depression
  • Personality disorder
  • Sleep disorders

Factors Influencing Duration

In FM, the factors influencing perceived disability are unknown because there are no scientifically valid studies addressing this issue.

Medical Codes

ICD-9-CM:
729.0 - Rheumatism, Unspecified, and Fibrositis
729.1 - Myalgia and Myositis, Unspecified; Fibromyositis NOS; Fibromyalgia

Overview

Fibromyalgia (FM) is a term used to describe several interrelated chronic conditions characterized by chronic widespread musculoskeletal pain and tenderness at multiple specific points, associated with abnormal pain processing, sleep disturbances, fatigue, stiffness, and psychological distress such as anxiety and depression. The symptoms of FM are perceived as if they originate in the musculoskeletal system. A history of the diagnostic criteria for this condition elucidates the difficulties involved in making a diagnosis.


Historically, starting in around the 1800s, the term neurasthenia was used for this condition. That term still has an ICD-9-CM code (300.5) and an international ICD-10 code (F48.0 as one of "other neurotic disorders"), but it is not, in any edition of the DSM, a recognized diagnosis by the American Psychiatric Association. In the early 1900s the term "fibrositis" replaced neurasthenia, and in the 1970s, Smythe and Moldofsky proposed diagnostic criteria for fibrositis.

In 1990, the American College of Rheumatology (ACR) noted specific criteria for the diagnosis of this disorder (Wolfe 1990), which by then had become known as FM. The criteria were as follows: 11 of 18 specific areas of the body painful to light palpation using 4 kg of pressure with the examiner's thumb, and widespread pain that must last for at least 3 months (Wolfe 1990). Widespread pain is defined by the number of body regions involved (greater than 3) and by a pattern of pain that involves the upper and lower body, both sides of the body, and both the axial skeleton (cervical spine, anterior chest, thoracic spine, or low back) and the limbs. The tender point count and multiple pain locations were all the committee on diagnosis required for a diagnosis to be established, but they noted that these individuals usually also had morning stiffness, fatigue, and sleep disturbances. In this system, FM could co-exist with another disorder, with the result that an individual could have both rheumatoid arthritis and fibromyalgia, or could have both lupus and fibromyalgia.

In 2010, the ACR published revised criteria for diagnosis of fibromyalgia (Wolfe 2010). Since very few primary care physicians were performing an exam for tender points, the committee this time deleted all physical exam findings as criteria for diagnosis, with the exception that FM could no longer co-exist with a second condition, if that second condition could explain the individual's pain.

In the 2010 system, 3 criteria must be satisfied:
(1) Widespread pain index (WPI) >= 7 and symptom severity (SS) scale score >= 5 or WPI of 3 to 6 and SS scale score >= 9.
(2) Symptoms have been present at a similar level for at least 3 months.
(3) The patient does not have a disorder that would otherwise explain the pain.

There are 19 potential locations in which the individual may complain of pain, and counting the total number of locations, the WPI score will be 0 to 19. The locations are neck; jaw, left; jaw, right; shoulder girdle, left; shoulder girdle, right; upper arm, left; upper arm, right; lower arm, left; lower arm, right; upper back; chest; abdomen; lower back; hip (buttock, trochanter), left; hip (buttock, trochanter), right; upper leg, left; upper leg, right; lower leg, left; and lower leg, right.

The 3 most important symptoms are each rated on a 0 to 3 intensity scale, contributing 0 to 9 points toward the ultimate SS score. These symptoms are: fatigue, waking from sleep unrefreshed, and cognitive symptoms (commonly nicknamed "fibrofog").

The remaining 0 to 3 points of the SS score come from counting the "other" symptoms of FM. Having a few symptoms = 1 point, a moderate number of symptoms = 2 points, and a great deal of symptoms = 3 points. The somatic symptoms that qualify for inclusion are muscle pain, irritable bowel syndrome, fatigue/tiredness, thinking or remembering difficulty, muscle weakness, headache, pain/cramps in the abdomen, numbness/tingling, dizziness, insomnia, depression, constipation, pain in the upper abdomen, nausea, nervousness, chest pain, blurred vision, fever, diarrhea, dry mouth, itching, wheezing, Raynaud's phenomenon, hives/welts, ringing in ears, vomiting, heartburn, oral ulcers, loss of/change in taste, seizures, dry eyes, shortness of breath, loss of appetite, rash, sun sensitivity, hearing difficulties, easily bruising, hair loss, frequent urination, painful urination, and bladder spasms.

The 2010 criteria were published in an article that quantified how well the criteria performed. Of 829 individuals evaluated who had been previously diagnosed with FM, 25% did not meet the 1990 case definition but were considered by their physicians to have FM. Of those who met the 1990 case definition as having FM, 86% were diagnosed as still having FM by the 2010 criteria. Thus most, but not all, individuals who have this illness will be classified as having FM by both the 1990 and the 2010 criteria.

Both the 1990 criteria committee and the 2010 criteria committee recognize that there is a continuum from easily defined cases of not having FM (having no medically unexplainable symptoms) to more difficult cases of not having FM (having multiple medically unexplainable symptoms but not having enough criteria for an FM diagnosis) to having FM (meeting the diagnostic criteria). Thus FM is not a black-and-white condition as is cancer, but rather is a continuum similar to fasting blood glucose or blood pressure.

In a study done to evaluate how well physicians could recognize individuals who did not have FM, but rather were pretending to have it (in order to evaluate physicians' ability to detect malingerers seeking disability benefits), three groups of individuals were evaluated by FM experts. One group actually had FM, a second group was comprised of normal individuals asked to honestly report any symptoms they might have and to behave honestly in physical examination, and the third group contained normal individuals given information about FM and asked to try to fool the examiners by simulating FM. The third group (the simulators) understood they would be paid more for participating if they successfully fooled the examiners into diagnosing FM (Khostanteen). One-third of the simulators were misdiagnosed as having FM, and one-fifth of the real FM individuals were labeled as simulators by the physicians.

The diagnosis of FM may depend more on the specialty of the physician seeing the individual than on the symptoms that are present, A study from Seattle (Buchwald) evaluated individuals diagnosed with FM from the university rheumatology clinic, individuals diagnosed with chronic fatigue syndrome from the same university's immunology/infectious disease clinic, and individuals with "multiple chemical sensitivity" from the private office-based practice of physicians specializing in "clinical ecology." The individuals with these different diagnostic labels were indistinguishable as they all had the same symptoms, and none had objective findings. Thus, if an individual goes to a rheumatologist, the diagnosis may be FM, if an individual goes to a physiatrist, the diagnosis may be myofascial pain, or if an individual goes to an infectious disease specialist, the diagnosis may be chronic fatigue syndrome.

Individuals with FM frequently have co-morbid mental disorders. An outpatient study (Uguz) evaluated 103 individuals with FM by the 1990 criteria at a university rheumatology clinic, along with 83 normal controls who were matched for socioeconomic demographics. Experienced psychiatrists diagnosed Axis I mental disorders in 48% of the FM individuals and in 16% of the controls, and Axis II personality disorders in 31% of the FM individuals and 13% of the controls.



There does not appear to be a known cause of FM. Theories include chemical changes in the brain (central sensitization), sleep disturbances, viral or bacterial infection, nervous system abnormalities, and changes in muscle metabolism. Hormonal changes and psychological stress may be additional triggers.

Although FM can be disruptive, it is neither progressive nor life-threatening.

Incidence and Prevalence: In one study, FM was found to be present in 4.9% of men and 7.7% of women in the US (Vincent). However, another source estimates that FM is approximately 7 times more common in women than in men (Masi).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Risk factors for FM include being female and having a family history of the disorder. Being overweight and having a low level of exercise/activity are risk factors. There is a statistical association with childhood sexual abuse, physical abuse, emotional abuse, and neglect, although these are not present in all cases.

There are no known causes of, or pathophysiology for, FM. For more information, refer to "Disease and Injury Causation," pages 222-227.

Source: Medical Disability Advisor



Diagnosis

History: Individuals with FM report pain on both sides of the body, above and below the waist, and in the axial skeleton. They may also report fatigue and disturbed sleep, stiffness, anxiety, depression, facial pain and headache, mental stress, heightened sensitivity (to noises, smells, and bright lights), irritable bladder, irritable bowel syndrome, painful menstruation, and dizziness.

Physical exam: Findings on physical examination are unremarkable in persons suspected of having FM. According to the 1990 criteria, a diagnosis of FM requires that individuals report pain on digital palpation (gentle palpation or evaluation with dolorimeter) in at least 11 of 18 specific tender points, which are located in many different body regions. If the 2010 criteria are used, there is no physical exam finding that is a criterion or that quantifies severity or relates to prognosis. The physical exam may detect objective evidence of other disorder(s) that would explain pain, and thus that would eliminate FM from diagnostic consideration.

Tests: There are no routine hematologic, urine, biochemical, or imaging tests that are diagnostically or prognostically useful in FM. Extensive diagnostic testing is not useful, is not cost effective, and should be discouraged. The absence of objective testing for this condition complicates diagnosis.

Source: Medical Disability Advisor



Treatment

Medications prescribed to reduce pain and improve the quality of sleep include antidepressants, muscle relaxants, and, rarely, sedatives or prescription sleeping pills for a short time. Nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids are generally not beneficial. In general, treatment for FM that targets the musculoskeletal system directly (massage, manipulation, electrical stimulation) does not appear to be helpful. Local anesthetics, with or without corticosteroids, may be injected into tender areas, but these provide no long-term solution. FM is amenable to light exercise therapy and to cognitive behavioral interventions. Cognitive behavioral therapy may be useful for helping individuals with FM manage stress and cope with a chronic condition. Exercise is proven to be an effective treatment, but individuals with FM frequently dislike doing exercises that hurt, with the result that they discontinue the prescribed exercise program without gaining the benefit available.

The three FDA-approved medications for FM include one anticonvulsant (pregabalin or Lyrica), and two antidepressants (duloxetine or Cymbalta, and milnacipran or Savella).

A systematic review of the randomized controlled trials involving drugs for which the manufacturer was applying for FDA approval for use in FM involving 18 studies and 3,546 individuals found that 18.6% of individuals responded to a placebo with a > 50% pain reduction, and 10.9% dropped out of the studies due to perceived side effects of the placebo (nocebo response), complicating assessment of the individuals’ responses to medications (Hauser).

Source: Medical Disability Advisor



ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
 
Chronic Pain
 
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines



Prognosis

FM is a chronic condition. Although symptoms may vary in intensity, they are unlikely to disappear completely. Symptoms fluctuate over time, and individuals may qualify for the diagnosis, later improve and not meet criteria, and still later have a flare-up and once again meet diagnostic criteria.

A multidisciplinary rehabilitation unit in Texas reported on 449 individuals with chronic disabling musculoskeletal pain. Of these individuals, 11% met ACR criteria for chronic widespread pain but not for FM, while 23% met criteria for FM by the 1990 criteria in addition to their work injury diagnosis (Howard). All had the identical treatment by the multidisciplinary rehabilitation team. Compared to work injury individuals without FM, those with both FM and work injury were 9.6 times less likely to return to work after treatment. At one year follow up, the FM individuals were 4.3 times less likely to have remained at work than those without FM (Howard).

Source: Medical Disability Advisor



Rehabilitation

FM is often a diagnosis of exclusion, which means that the diagnosis is confirmed when other diseases are ruled out. By the time FM is diagnosed, many individuals are already in the chronic stage of the disease.

The goal of rehabilitation for individuals with FM is to preserve function despite the chronic limitations inherent in this condition. Individuals with FM usually benefit from outpatient rehabilitation that includes active stretching and gentle strengthening exercises performed regularly. Individuals learn to stretch tight areas and strengthen muscles in the extremities and the upper and lower back. Physical training, including low-impact aerobic exercises, may improve function and decrease pain when combined with patient education (Busch; Karjalainen). Water exercise, when available, has been shown to be beneficial for these individuals (Gowans). A systematic review and meta-analysis of 35 separate randomized controlled trials found that both land-based and water-based aerobic exercise is effective (Hauser).

Affected individuals may also benefit from consultation with an occupational therapist, who can instruct them in modified activities of daily living, and with a psychologist, who can support them in coping with a chronic condition and address the frequently present co-morbid mental disorder. A multidisciplinary treatment approach will help address both the physical and psychological aspects of FM (Karjalainen).

A long-term, independent exercise program should be initiated before the individual is discharged from rehabilitation.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistFibromyalgia
Occupational or Physical TherapistUp to 10 visits within 12 weeks
Multidisciplinary RehabilitationPer the rehabilitation center’s protocol
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

There are no complications caused by fibromyalgia.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Because individuals with FM have symptoms, but no objective findings on physical examination and normal findings on diagnostic testing, there is no objective medical basis upon which to predicate work restrictions or accommodations (biomedical model).

The US Social Security Administration published updated 2012 criteria (Federal Register) for the assessment of total disability due to FM. They accept a diagnosis made by either the 1990 or the 2010 criteria, although they differ with the 1990 criteria and specify that another disorder that could explain the pain would eliminate FM as a basis for a disability claim (although the claim could still be based on the other rheumatologic disorder). They state that subjective symptoms can limit capacity, although this is actually incorrect, because symptoms limit tolerance, not capacity. They state they use their usual “5 step” process to evaluate work ability for FM claimants, as they do for claimants with other conditions.

For more information, refer to "Work Ability and Return to Work," pages 427-432.

Risk: Risk is not an issue for working despite FM. The Americans with Disabilities Act test of significant risk of substantial harm that is imminent is not applicable. While symptoms of pain and fatigue may increase with activity, this pain does not constitute “substantial harm.” There are no published medical reports of individuals being harmed by activity.

Some medications used in FM treatment are sedating, and some safety sensitive jobs may exclude those taking sedating medications on the basis of risk by either government regulation (such as pilots and commercial drivers) or employer policy.

Capacity: Capacity is hard to measure in FM. Individuals self-limit activity due to symptoms, which may fluctuate over time, with the result that self-limitations of activity also fluctuate. Thus a prior assessment of capacity may underestimate the performance an individual is willing to demonstrate today, just as it may overestimate the performance next week. When tested on a cardiopulmonary treadmill or a bicycle, individuals typically self-terminate the test due to pain or fatigue prior to reaching the anaerobic threshold, showing that it is tolerance and not capacity creating limitations.

Individuals with FM are frequently deconditioned as the result of a sedentary lifestyle, but their level of conditioning can improve with activity, or it can further decrease with activity restriction.

Tolerance: Tolerance for symptoms such as pain and fatigue is typically the issue in FM. The individual can choose to work or participate in an activity despite symptoms, or the individual can choose not to participate because of symptoms. These variations are not something that physicians or medical testing can evaluate or substantiate.

Accommodations: Individuals with FM have multiple differing symptoms, and an activity that increases symptoms for one individual may not affect another. Thus, if employers wish to accommodate individuals with FM, they may discuss with the employee the specific activities that increase symptoms beyond the individual’s tolerance, and what accommodations help minimize those activities.

Source: Medical Disability Advisor



Maximum Medical Improvement

180 days.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Have similar conditions been ruled out?
  • Has diagnosis of FM been established?
  • Does individual exhibit tenderness to light palpation at 11 of 18 specific points?
  • Does individual have sleep disturbances? Fatigue? Stiffness? Anxiety or depression?
  • Have symptoms been present for at least 3 months?
  • What was widespread pain index score for the 19 potential locations?
  • What was symptom severity score?
  • Does individual have a comorbid condition that may explain symptoms? Has a psychologist or psychiatrist evaluated the individual for comorbid mental disorder?

Regarding treatment:

  • Has appropriate medication been prescribed?
  • Has individual tried light exercise therapy and cognitive behavioral therapy?
  • Have treatments resulted in unwanted side effects?
  • Have medical advice reinforced inappropriate illness behaviors?

Regarding prognosis:

  • Have psychosocial factors such as family and workplace dynamics been considered?
  • Have mental and behavioral disorders (depression, anxiety, sleeping disorders) been considered?
  • Have inappropriate illness behaviors (symptom exaggeration, malingering) been considered?

Source: Medical Disability Advisor



References

Cited

"Fibromyalgia." MayoClinic.com. 20 Feb. 2014. Mayo Foundation for Medical Education and Research. 30 May 2014 <http://www.mayoclinic.org/diseases-conditions/fibromyalgia/basics/definition/CON-20019243>.

"Titles II and XVI: Evaluation of Fibromyalgia." Federal Register 77 143 (2012): 43640-43644.

Buchwald, D. , and D. Garrity. "Comparison of Patients with Chronic Fatigue Syndrome, Fibromyalgia, and Multiple Chemical Sensitivities." Archives of Internal Medicine 154 (1994): 2049-2053.

Busch, A., et al. "Exercising for Treating Fibromyalgia Syndrome." Cochrane Database of Systematic Reviews 3 (2002): CD003786. National Center for Biotechnology Information. National Library of Medicine. 17 Nov. 2004 <PMID: 12137713>.

Gowans, S. E., et al. "Six-Month and One-Year Follow Up of 23 Weeks of Aerobic Exercise for Individuals with Fibromyalgia." Arthritis and Rheumatism 51 6 (2004): 890-898.

Hauser, W. , et al. "Efficacy of Different Types of Aerobic Exercise in Fibromyalgia Syndrome: A Systematic Review and Meta-analysis of Randomized Controlled Trials.." Arthritis Research and Therapy 120 (2010): R79.

Hauser, W. , et al. "Placebo and Nocebo Responses in Randomised Controlled Trials of Drugs Applying for Approval for Fibromyalgia Syndrome Treatment: Systematic Review and Meta-analysis." Clinical and Experimental Rheumatology 30 6 (2012): 78-87.

Howard, K. J. , et al. "Fibromyalgia Syndrome in Chronic Disabling Occupational Musculoskeletal Disorders." Journal of Occupational and Environmental Medicine 52 12 (2010): 1186-1191.

Karjalainen, K., et al. "Multidisciplinary Biopsychosocial Rehabilitation for Neck and Shoulder Pain Among Working Age Adults." Cochrane Database of Systematic Reviews 2 (2003): CD002194. National Center for Biotechnology Information. National Library of Medicine. 17 Nov. 2004 <PMID: 10796458>.

Khostanteen, I. , et al. "Fibromyalgia: Can One Distinguish It From Simulation: An Observer-blind Controlled Study ." Journal of Rheumatology 27 11 (2000): 2671-2676.

Masi, Alfonse T. "Fibromyalgia." The Merck Manual of Home Health Care. Ed. Mark H. Beers. 2nd ed. Whitehouse Station, NJ: Merck Research Laboratories, 2003. 415-417.

Melhorn, J. Mark, and William Ackerman, eds. Disease and Injury Causation, Guides to the Evaluation of. AMA Press, 2008.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

Uguz, F. , et al. "Axis I and Axis II Psychiatric Disorders in Patients with Fibromyalgia." General Hospital Psychiatry 32 (2010): 105-107.

Vincent, A. , et al. "“Prevalence of Fibromyalgia: A Population-based Study in Olmsted County, Minnesota, Utilizing the Rochester Epidemiology Project." Arthritis Care Research 65 5 (2013): 786-792.

Wolfe, F., et al. "The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia.." Arthritis and Rheumatism 33 2012 (1990): 160-172.

Wolfe, F., et al. "The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity." Arthritis Care and Research 62 5 (2010): 600-610.

Source: Medical Disability Advisor






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