Fibromyalgia is a tough diagnosis even for the experienced physician. A disorder of musculoskeletal pain throughout the body that is not explained by another systemic or rheumatologic disorder, its discomfort must persist at least three months. It’s also known as fibrositis, myofascial pain syndrome, chronic pain disorder and muscular rheumatism. After osteoarthritis, it is the second most common rheumatic disorder and is estimated to occur in up to 5 percent of the population.
Fibromyalgia was historically a diagnosis of exclusion. After other systemic diseases were ruled out, fibromyalgia became the diagnosis by default. Originally published almost 25 years ago, the diagnostic criteria emphasized chronic widespread pain with a series of tender or trigger points. As these are far more common in women, the diagnosis criteria led to almost exclusively female incidence. Now the criteria are more symptoms-based, and the estimate has been lowered to about two out of every three cases being in women. While most common between the ages of 30 and 50, fibromyalgia can develop at any age, even in childhood, and there is no predominant culture or ethnic group.
Fibromyalgia is considered a disease of pain regulation. Centralized pain can be documented as early as adolescence and is experienced in different regions of the body at different times. There are different central nerve patterns of pain that don’t respond to treatment or to surgery on specific trouble spots. The pain is mostly along muscles and ligaments and very common in back, hips, neck and shoulders. There can be multiple tender points on exam. Headaches, generalized fatigue and sleep disorders often accompany this disease.
Fibromyalgia also has other characteristics that help in an earlier diagnosis. Family members may have a history of chronic pain, and genetic factors have been reported. Environmental factors that are stressors involving acute pain can be ones such as chronic fatigue syndrome, viral infections or even psychological stress. About 50 percent are genetic and 50 percent environmental when twin studies are evaluated.
The diagnosis of fibromyalgia is made on history and physical exam. Fibromyalgia is best suspected in those with multifocal pain that has no specific explanation. Often blood tests ruling out systemic illness or autoimmune vascular diseases have to come back negative before settling on the diagnosis. There is no specific lab test for fibromyalgia. Widespread pain that is present for three months or more without another disorder that would explain it best fits the diagnosis of this disease.
Treatment for fibromyalgia remains difficult. Medication such as antidepressants may help, as they aid in disrupting pain cycles. Gabapentin, given in seizure disorders but also in chronic neurologic pain, is also used with varying degrees of success. Education, cognitive behavioral therapy and exercise all have shown positive benefits. Straight pain medication has shown to be of only transient benefit and may sometimes even worsen the symptoms.
In underwriting, chronic pain is the major factor. Associated depression, accidents, overuse of drugs and alcohol, and effects of constant emotional stress all play into risk assessment. Those who tolerate the disease well and have stable working and medication histories can qualify for preferred issue. When mobility, employment history, medication overuse or psychological conditions are associated with fibromyalgia, rating is centered on the specific associated problems and their prognosis.
Robert Goldstone, MD, FACE, FLMI
Goldstone, board certified internist and endocrinologist, is vice president and chief medical officer for Pacific Life and Pacific Life and Annuity. He has extensive brokerage and life insurance experience, having been medical director at both MetLife Brokerage and Transamerica Occidental Life. Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World since 1990. Goldstone can be reached by telephone at 949-420-8390. Email: firstname.lastname@example.org.