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http://www.imj.ie/Issue_detail.aspx?issueid=+&pid=3654&type=Papers MJ
Official Journal of the
Irish Medical Organisation
IMJ Online Paper
Assessment of Fibromyalgia & Chronic
Fatigue Syndrome: A New Protocol
Designed to Determine Work Capability
– Chronic Pain Abilities Determination
(CPAD)
M Kelly, R Gagne, JD Newman, C Olney, C Gualtieri,
D Trail
Dr Michael Kelly – with his characteristic energy and
enthusiasm – played a significant part in bringing
this paper to fruition.
Sadly, he passed away shortly before publication,
and we, his fellow co-authors, dedicate the paper to
his memory.
Abstract
The objective was
to design a protocol to assess
work ability in people suffering ill-defined painful and
disabling disorders, the outstanding prototype of
which is fibromyalgia/chronic fatigue syndrome
(FM/CSF).Following an extensive literature search,
the most appropriate components of current methods
of assessment of physical and cognitive abilities
were incorporated into the protocol, occasionally with
appropriate modification to suit the specific
requirements of the individual. The initial part of the
assessment consists of a standard history taking,
principally focusing on the patient's self-reported
physical and cognitive abilities and disabilities, as
well as the completion of established pain and
fatigue scales, and relevant disability
questionnaires. Following this,
physical and cognitive
abilities are objectively assessed on two separate
occasions, utilizing computerized hand-held
dynamometers, inclinometers, algometers, and force
dynamometers. Specific work simulation tests using
the industrial standards Methods-Time-Measurement
testing are availed of, as is aerobic testing using the
Canadian Aerobic Fitness Test (CAFT).
Objective computerised neuro-cognitive testing are
also utilised as an integral component of the
assessment. All results are then subject to specific
computerized analysis and compared to normative
and standardised work-based databases. The
designed system produces reliable, consistent and
reproducible results. It also proves capable of
detecting any inconsistencies in patient input and
results, in addition to being independent of any
possible assessor bias. A new protocol has been
designed to determine the working capability of
individuals who suffer from various chronic disabling
conditions, and represents a significant step forward
in a difficult but rapidly expanding area of medical
practice.
Introduction
Chronic painful or debilitating disorders such as
Fibromyalgia (FM) and Chronic Fatigue Syndrome
(CFS) are a common cause of work disability1,2.
There are no pathological, radiological, or laboratory
findings that establish diagnosis or degree of
disability.
This study is not structured to confirm or
refute diagnosis but rather to assess ability to work
as the individual variation in degree of disability
between FM/CFS sufferers is so great. Traditional and
even newer physical and psychological assessments
used to detect degree of disability in other disease
states, have severe limitations when applied to
FM/CFS. Therefore improvement in quality and
reliability of work assessments is a matter of great
importance. Also necessary are more objective
testings, in so far as can be achieved. These tests
need to be reliable and reproducible. Furthermore
they must be independent of patient variability of
effort that is often not taken into account in such
settings. At the very least, inconsistency of patient
reliability must be readily detectable. Assessments
should further be free of examiner subjectivity, a
factor again which is not taken into account, and
could explain the reason for very large discrepancies
noted between the most eminent of doctors. Whilst
there might be little difference in medical opinion
with regard to diagnosis, there is often a substantial
disparity in opinion on work capacity.
To overcome these issues, many doctors use
traditional Functional Capacity Evaluations (FCE) to
assist them in their assessment of work capacity.
The traditional FCE is however more suited to assess
ability/disability in the better recognized diseases
such as arthritis or discogenic spinal disease. There
are however a number of important concerns with
using the FCE in more ill defined disorders such as
FM and CFS, or indeed other chronic pain states.
The
traditional FCE does not consider the 'good day/bad
day' phenomenon, which this group of patients
frequently complain of. Conclusions are drawn on the
basis of a single assessment which may be on a
good or bad day. The traditional FCE does not
address sustained work capacity over an eight-hour
day in spite of the fact that easy fatigability is a
common symptom. Pain levels are not monitored pre-
and post-exercise to document the effects of
exertion on the patient. Evaluations often do not
include exercise capacity testing which is often a
problem for FM/CFS patients and has an important
role in determining cardiovascular endurance and
abnormal fatigue. Testing of reproducible physical
activities to the limit of endurance and
comfort are not performed. Cognitive tests are not
part of the current FCE protocols.
Method
It is important to bear in mind that this protocol is
designed for assessment of work capacity. The
physical and cognitive components of the
assessment are performed on two separate days,
with an intervening rest day. An integral part of the
system is the inclusion of a new software programme
that assesses the acquired functional data. In
addition to assessing physical capacity it can detect
any inconsistency or failure of effort on the part of
the patient (whether it be conscious or
subconscious). The results of the tests are then
compared to well established and peer reviewed
normative3,4,5 and work referenced databases.6,7,8
The new protocol has four sections. Firstly, a clinical
history is taken with specific regard to describing
symptoms, aggravating and alleviating factors that
might affect work capacity, and activities of daily
living. Note is made of past and current treatments
as well as their efficacy and side-effects. At review
after a 24-hour rest period, any alteration in
symptoms is documented. Secondly, as the
assessment is one of work ability, specific, validated
scales and questionnaires play an important role in
the qualification and quantification of pain,
discomfort, and fatigue, which are common in such
patients.
Well established scales and questionnaires are
therefore used, which include the Fibromyalgia
Impact Questionnaire (FIQ); the Chalder Fatigue
Scale, to measure the affects of CFS on a patient
over the multi day period in an effort to qualify
fatigue patterns; the Visual Analogue Scale (VAS) to
measure pain prior to, during, and post-assessment;
and the Beck Depression Inventory. All responses are
collated and scored by the protocol software. The
FIQ and VAS are repeated on day two of the
assessment. Thirdly, a number of physical tests are
carried out, which include, grip and pinch strength
testing, using a computerized hand-held
dynamometer; a range of spinal movements are
tested, using computerized inclinometers; tender
point assessment is measured using a computerized
algometeri9-12 (three control sites are tested to
ensure reliability); static strength testing13-15 is
undertaken using a computerized force dynamometer
for strength determination; specific work simulation
tests are performed using the industrial standards
Methods-Time-Measurement (MTM) tests, which
allow for the extrapolation of test data to work
ability over an average 8-hour work day; and aerobic
testing using the six minute walk test16, and/or the
Canadian Aerobic Fitness Test (CAFT).
These physical tests are performed on both day one
and two of the assessment. Finally,
as cognitive
impairment can be a symptom of FM/CFS and often
includes poor concentration, poor memory, learning
difficulties, "brain fog", and poor problem solving
capabilities17, the CNS Vital Signs assessment
(CNSVS)18 which comprise a number of well
researched and reliable computerized tests of
neuro-cognitive function is undertaken. The CNSVS
battery of tests is designed to take less than 30
minutes on each test day, and contains five specific
elements which are, visual memory testing (VMT) for
immediate and delayed memory recall; symbol digit
coding (SDC) for visual perception and complex
attention ability; the stroop test (ST) for reaction
time and information processing; shifting attention
test (SAT) for ability to shift from one instruction to
another; and the continuous performance test (CPT)
for sustained attention and reaction time. These
cognitive tests are repeated on day two of the
assessment.
Discussion
The protocol is designed such that strength and
range of movement are measured and compared to
abilities estimated over an average eight hour work
day. It can identify those who have cognitive and
physical impairment and assess its degree, and
further identify those who consciously or
subconsciously exaggerate their disability. This
protocol utilises an extensive combination of valid
and reliable physical and cognitive testing. It is
performed over a two day period, with a rest day in
between. This is just one of the features that will
prove more acceptable to both patients and their
doctors. Furthermore, it both incorporates testing
over a period of time and takes into account the
effect work may have on the patient's symptoms.
The fact that the results of testing are compared to
both normative and work referenced databases
should further clarify matters and be a major help to
doctors who assess work capacity in such patients.
Following
testing and analysis of the computerized
results for range of movement, strength, specific
work activity simulation, aerobic endurance, cognitive
capacity, fatigue measures, and pain levels, it is
possible to extrapolate and compare the patient's
performed abilities against their required job
demands, providing an informed objective conclusion
as to their return to work capabilities.
Both the physical and cognitive computerized tests
will also provide information on the reliability of
effort demonstrated by the individual throughout the
two days of testing.
This protocol is designed only to assess work ability
and does not in any way supplant the role of medical
practitioners or replace medical assessment. FM and
CSF are examples of disorders without standard
medical tests to confirm or refute their presence or
absence in any given individual. While there are
diagnostic criteria laid down, they are neither
sensitive nor specific, with many authorities
questioning their usefulness in clinical practice. It is
not surprising therefore, that assessment of
disability in such patients is very difficult. This novel
protocol should be of value to patients, their doctors
and also to independent medical examiners. The
protocol is the first to effectively incorporate
systems which address all the main areas of concern
expressed by specialists about current disability
assessments in people with FM/CSF in particular, and
more generally concerning many ill-defined chronic
pain syndromes. In addressing all concerns, great
care was taken in the design of the protocol to
eliminate as much subjectivity as possible on the
part of the examiner and patient alike. The new
methodology will provide the necessary factual
evidence required to support the medical opinion.
This protocol should represent a significant forward
step in assessment of work ability in a very difficult
area of medical practice.
References
1. Wolfe F. Fibromyalgia Syndrome: A Consensus
Report on Fibromyalgia and Disability. J Rheumatol
1996; 23:534-9.
2. McCain GA, Cameron R, Kennedy JC. The problem
of long term disability payments and litigation in
primary FMS. J Rheumatol 1989; 16 (suppl 19):
174-176.
3. Mathiowetz, V et al. Grip and Pinch Strength:
Normative Data for Adults. Arch Pys Med Rehab
1985; Vol. 66: 69-72.
4. Mayer TG et al. Progressive Iso-inertial Lifting
Evaluation: A Standardized Protocol and Normative
Database. Spine 1998; Vol 13: 993-997.
5. Guides to the Evaluation of Permanent Impairment
American Medical Association; 4th ed: 112-135.
6. Prabhu, V. & Baker, M. (Eds). Industrial
Engineering: Techniques for Improving Operations
1986.
7. Long. Revised Handbook for Analyzing Jobs 1991
Washington, D.C.; U.S. Government Printing Office,
McGraw Hill. 1991.
8. Maynard, H.B., Stegemerten, G.J. & Schwab, J.L.
(1948). Methodstime Measurement. New York:
McGraw-Hill. 1948.
9. Okifuji A, Turk DC, Sinclair JD, Starz TW, Marcus
DA. A Standardized Manual Tender Point Survey.
Development and Determination of a Threshold Point
for the Identification of Positive Tender Points in
Fibromyalgia Syndrome. J Rheumatol 1997; 24:2.
10. Pekka, J. Reliability, Validity, Reproducibility of
Algometry in Diagnosis of Active and Latent Tender
Spots and Trigger Points DOI:
10.1300/J094v06n01_05 Copyright Year: 1998: 61 -
72.
11. Pekka J. Algometry in Evaluation of Trigger Points
and Referred Pain. DOI: 10.1300/J094v06n01_04
Copyright Year: 1998: 47 - 60.
12. Russell IJ. The Reliability of Algometry in the
Assessment of Patients with Fibromyalgia Syndrome.
Muscle Pain Syndromes and Fibromyalgia: Pressure
Algometry for Quantification of Diagnosis and
Treatment Outcome. Journal of Musculoskeletal Pain
1998; Vol. 6.
13. Chaffin, DB. Pre-employment Strength Testing:
An Updated Position. Journal of Occupational
Medicine 1978; Vol. 20.
14. Badges D. Work Practices Guide to Manual
Lifting, NIOSH.
15. Chaffin, D. Ergonomics Guides: Ergonomics Guide
for the Assessment of Human Static Strength.
American Industrial Hygiene Association Journal July
1975.
16. Pankoff BA et al. Reliability of the 6 Minute Walk
Test in people with Fibromyalgia. Arthritis Rheum
2000; 13: 291—5.
17. Hudson JL, Pope HG. The Concept of Affective
Spectrum Disorders. Mallieres Clin Rheumatol 1994;
8: 839-856.
18. Gualtieri, CT & Johnson, LG, Reliability and
Validity of a Computerized Neurocognitive Test
Battery, CNS Vital Signs. Archives of Clinical
Neuropsychology 2006; 21: 623-643.
Authors' details for correspondence' (i.e., Name,
Address, Email, etc.)
JD Newman
FormHealth Ltd., 51 Colney Hatch Ave,.
London N10 1LJ, UK
References
No References
© Copyright 2004 - 2005 Irish Medical Journal
* * *
And therein lies the problem: I can do almost anything once. According to the Jamar Dynamometer test, I have grip strength of 50+ pounds. What it doesn't tell you is that after I've been using my hands for 8 hours straight (typing, stitching, whatever), I may not be able to lift a cup without using two hands.
I've been evaluated for about an hour at a time, and I can usually function for an hour on the adrenaline rush of exam pressure. I can also schedule my naps around the exam. What no one has ever done is evaluate me over 8 hours. My testimony that I could work for a maximum of 2 hours and then had to nap for 2 hours was never substantiated by testing. It was extrapolated from my ability to function for one hour that I could function for 8 hours, which is not the case. In fact, if they were to sit me at a desk and tell me to do something for 8 hours, I'd probably pass out from sitting upright that long, or fall asleep at the desk, or, if I was typing, start dropping things as my hands reach the point of paralytic muscle weakness.
And, the fact that I "could" get to work on Monday does not prove that I could get to work on Tuesday; the last time I tried an office job, the exertion of commuting the first day made the second day very difficult; the third day I was in bed till the very last minute I could leave the house to get to work on time and fell on the couch the instant I walked in the door, and stayed in bed the next two days trying to recuperate. Eligibility for disability benefits is based on the inability to "sustain employment", i.e., if you work 8 hours Monday and then have to stay in bed till the following Monday, working Monday doesn't prove you're employable. You've got to be able to show up reliably, 5 days a week.
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