Diagnosis and Navy perspective for active duty

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FIBROMYALGIA

• Diagnosis and Navy perspective for active duty
• N.Erikson CAPT MC USN
• Rheumatology Div NMCP

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FIBROMYALGIA

• What is it?
• What it isnt
• How is it classified?
• Who diagnoses and treats it?
• Active duty disposition

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FIBROMYALGIA

• What is it?
• a pain syndrome which is chronic and diffuse
• may accompany many disorders, but
• often a primary condition
• does not lead to tissue damage
• cause is unknown
• no lab abnormalities
• no structural alterations or visible
  abnormalities to exam
• poorly understood

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FIBROMYALGIA

• What it isnt
• not a rheumatic disease
• not, as a rule, recognized as disabling by the
  Navy

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FIBROMYALGIA

• How is it diagnosed?
• The American College of Rheumatology has
  published classification criteria
• primarily to define patient populations for study
• when no other evidence for systemic disease, it
  is considered primary fibromyalgia
• IN OTHER WORDS WHEN THE PATIENTS PAIN CAN BE
  EXPLAINED BY FIBROMYALGIA THERE IS NO NEED TO
  INVOKE A RHEUMATIC DISEASE EXPLANATION
• The classification criteria are entirely clinical
  and can be applied by anyone!

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1990 criteria for the classification of
Fibromyalgia

• 1. History of widespread pain.
• 2. Pain in 11 of 18 tender point sites on digital
  palpation.
• For classification purposes, patients will be
  said to have fibromyalgia if both criteria are
  satisfied. Widespread pain must have been present
  for at least 3 months. The presence of a second
  clinical disorder does not exclude the diagnosis
  of fibromyalgia

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History of widespread pain

• Definition. Pain is considered widespread when
  all of the following are present pain in the
  left side of the body, pain in the right side of
  the body, pain above the waist, and pain below
  the waist. In addition, axial skeletal pain
  (cervical spine or anterior chest or thoracic
  spine or low back) must be present. In this
  definition, shoulder and buttock pain is
  considered as pain for each involved side. "Low
  back" pain is considered lower segment pain.

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Pain in 11 of 18 tender point sites on digital
palpation.
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Pain in 11 of 18 tender point sites on digital
palpation.

• Occiput Bilateral, at the suboccipital muscle
  insertions.
• Low cervical bilateral, at the anterior aspects
  of the intertransverse spaces at C5-C7.
• Trapezius bilateral, at the midpoint of the
  upper border.
• Supraspinatus bilateral, at origins, above the
  scapula spine near the medial border.
• Second rib bilateral, at he second costochondral
  junctions, just lateral to the junctions on upper
  surfaces.

• Lateral epicondyle bilateral, 2 cm distal to the
  epicondyles.
• Gluteal bilateral, in upper outer quadrants of
  buttocks in anterior fold of muscle.
• Greater trochanter bilateral, posterior to the
  trochanteric prominence.
• Knee bilateral, at the medial fat pad proximal
  to the joint line.Digital palpation should be
  performed with an approximate force of 4 kg.For
  a tender point to be considered "positive" the
  subject must state that the palpation was
  painful. "Tender is not to be considered
  "painful."

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REMEMBER fibromyalgia

• is very common
• has no acknowledged pathologic etiology
• by itself, does not lead to loss of joint
  function or structure
• can be diagnosed and treated by ANY care
  provider - some rheumatologists have special
  interest in the primary disorder. None currently
  stationed at NMCP do.

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A WORD ABOUT ACTIVE DUTY MEMBERS

• Intolerance or inability to perform duty due to
  pain of fibromyalgia is NOT routinely considered
  a disability by the Navy
• Medical Boards for fibromyalgia ALONE are usually
  returned with fit for continued service
  dispositions

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A WORD ABOUT ACTIVE DUTY MEMBERS

• There is NO REQUIREMENT for rheumatology to
  evaluate a member to diagnose or treat
  fibromyalgia.anyone can do that.
• Rheumatology consultation is required for active
  duty members UNDERGOING REFERRAL TO THE CENTRAL
  PEB when a diagnosis of fibromyalgia is noted
• Referral to Psychiatry is also REQUIRED
• REF SECNAVINST 1850.4E

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A WORD ABOUT ACTIVE DUTY MEMBERS

• My personal recommendation for active duty with
  fibromyalgia and inability or intolerance of
  duty, PRT, and the like
• process in accordance with MILPERSMAN 1910-120
  Separation by reason of convenience of the
  government - physical or mental conditions
• NOTE the current (28 AUG 01) article does NOT
  require a PEB before this type of admin sep, and
  it may be started by the member