Fibromyalgia is the subject of varying opinions among medical professionals. It is certainly controversial in the medical-legal arena. One area of disagreement is its etiology: What causes fibromyalgia? More specifically, in the context of personal injury lawsuits: Is fibromyalgia caused by traumatic injuries? If so, can it result in disability?
In a recent personal injury case, Jeremy Goodwin, M.S., M.D., opined that the injured party’s fibromyalgia was caused by the significant trauma suffered in a relatively high speed car accident. Dr. Goodwin is a neurologist and a fellowship trained adult and pediatric pain and headache specialist. He practices medicine in Oregon and California, and has taught at Oregon Health Sciences University (OHSU).
Dr. Goodwin suspected fibromyalgia when he found 14 out of 18 fibromyalgia tender points present, in conjunction with migratory arthralgias and myalgias all over the injured party’s body, on examination one month after the accident. He cautioned, however, that a diagnosis of fibromyalgia should be based upon a three month history of such pains.
Two years after the accident, Dr. Goodwin saw the injured party again and found continued widespread, debilitating pain which he then diagnosed as fibromyalgia, apparently caused by the physical and emotional trauma of the car accident. Dr. Goodwin emphatically stated that the persistence of the injured party’s pain might be causing depression and anxiety, but there was no reason to suspect a primary psychological disorder manifesting itself as a physical syndrome. The fibromyalgia (FMS) was having severe emotional and social ramifications. This is very different than psychosomatic or psychophysiologic diseases of psychological origin.
Dr. Goodwin has directed the OHSU’s Department of Neurosurgery’s Division of Pain Medicine and the Neurology Department’s Headache Clinic. He has treated many fibromyalgia patients in 8 different pain clinics from the east to the west coast. Since 1985, he has taught, lectured or published on over 50 topics, primarily related to his specialty of acute and chronic pain. At OHSU, Dr. Goodwin worked closely with Robert Bennett, M.D., Chairman of Rheumatology and one of the world’s foremost authorities on fibromyalgia.
A Neurologic Disorder
Dr. Goodwin’s opinion, based on his extensive research and working with hundreds of fibromyalgia patients, is that fibromyalgia is a neurologic disorder best described as sensory misprocessing causing sensations of which patients are not normally aware to be amplified and distorted into pain. The suffering is great and highly variable from person to person. While two thirds of these sufferers work or get by without seeking medical care, the other third suffer varying degrees of disability.
In a sworn statement, Dr. Goodwin opined that the “all over” body pain which might be expected from a high speed car accident resulted in a “bombardment” of the accident victim’s nervous system such that the cells in the spinal cord, which pick up signals and send them to the brain for further modification, distorted and amplified normal body sensations into unrelenting pain, leading the injured person to feel helpless and hopeless. This totally disabling condition had probably persisted since the accident.
Fibromyalgia, then, is a sensory misprocessing disorder of the central nervous system that may be likened to a computer functioning with a scrambled program that cannot interpret the data properly, Dr. Goodwin explained. He added that the problem cannot be found in the muscles or bones where the pain is experienced. You cannot take a picture of it or measure it electrically. There is no blood test for it. It is experienced in the nervous system like a tape loop that keeps playing and from which one has no escape.
Dr. Goodwin pointed out, however, that a considerable body of evidence shows that the spinal fluid in people with fibromyalgia has more substance P (one of the main hormones used in pain transmission) than that of those who do not have fibromyalgia. Fibromyalgia patients also differ in their ability to modulate or modify pain signals, according to a number of studies. Their brain wave patterns during sleep differ from the norm, preventing deep and restful (restorative) sleep. So, there is evidence outside the usual range of clinical testing showing that fibromyalgia patients’ bodies and brains are not functioning properly.
Fibromyalgia is not purely physical or psychological, but is a “horrible mixture of both that leads to a state of suffering that is very difficult to treat,” Dr. Goodwin said. He concluded this “post-trauma” fibromyalgia patient was completely disabled from working and had a poor prognosis until able to participate in an inter-disciplinary fibromyalgia rehabilitation and pain management program.
In another recent case, a “defense” medical expert witness (that is, one who is frequently called upon to provide defense testimony for insurance companies) acknowledged that the accident injury probably aggravated the injured person’s fibromyalgia. The expert, a neurosurgeon who also teaches at OHSU, stated with a reasonable degree of medical probability that the accident injury had increased the quantity of the injured party’s fibromyalgia symptoms. Given the controversy surrounding fibromyalgia’s etiology, this is remarkable coming from a long-time defense witness who would not be expected to acknowledge medical consequences if he had any doubt.
Fibromyalgia and Injury Trauma
Seeing injury trauma as the cause of fibromyalgia is not a new concept. In 1993, Dr. Bennett wrote in the Journal of Rheumatology:
- “The apparent initiation of the FS [fibromyalgia syndrome] by a traumatic incident, such as a road traffic accident, … has been associated with particularly severe dysfunction and an increased likelihood of being permanently or partially disabled.” 1993: 20:11 J. Rheum. 1821
Disabling total body pain syndrome (fibromyalgia) in the 1960’s had been dubbed by medical skeptics as “accident neurosis” which was “seemingly triggered by a trivial road traffic accident.” This stigmatized two generations of claimants, according to Dr. Bennett. More recent studies, such as the one appearing in the same Journal of Rheumatology as Bennett’s editorial, showed posttraumatic fibromyalgia disability persisted notwithstanding the status of any injury claim.
The apparent post-traumatic initiation of the fibromyalgia begins with focal myofascial pain syndrome at the site of the trauma which, over the course of 6 to 18 months, spreads from one area to another until the patient has total body pain, Dr. Bennett said. He added, “This history is so consistent from patient to patient that it provides compelling prima facie evidence for a posttraumatic origin.” This conclusion is also indicated by the fact that many patients who were fully functional in work and non-work activities and had good work records, found their lives irrevocably altered by the development of fibromyalgia syndrome.
Another article authored by Dr. Bennett contains evidence supporting Dr. Goodwin’s assertion that fibromyalgia represents a neurological disturbance in the patient’s sensitization to pain. This is explored in depth in Dr. Bennett’s review of numerous studies entitled “Emerging Concepts in the Neurobiology of Chronic Pain: Evidence of Abnormal Sensory Processing in Fibromyalgia” in the April 1999 issue of Mayo Clinic Proceedings (Mayo Clin Proc 1999; 74:385-398).
Dr. Bennett also explored disability resulting from fibromyalgia in his “Fibromyalgia and the Disability Dilemma: New Concepts in Understanding a Multidimensional Pain Syndrome,” published in Arthritis and Rheumatism, Volume 39, pp. 1627-1634 (1996).
Dr. Bennett noted that a useful practical resource for assessing disability in fibromyalgia patients is the American Medical Association Guides to the Evaluation of Permanent Impairment, Chapter 15 on chronic pain states. The AMA Guides overview points out: 1) pain evaluation does not lend itself to strict laboratory standards of evaluation; 2) chronic pain cannot be evaluated on the basis of degree of tissue damage (the classic medical model); 3) pain evaluation requires a thorough understanding of a multi-faceted biopsychosocial model of disease; and 4) the physician’s judgment of impairment is a blend of medical art and science characterized not so much by scientific accuracy as procedural regularity (emphasis added).
Dr. Bennett proposes a uniform approach to gathering data on which to base judgments of reasonable medical probability in evaluating the disability of FMS patients. The approach would use the model proposed by Goldenberg et al to assess the severity and impact of fibromayalgia. The Goldenberg study found the following factors to be significantly associated with severity and impaired functioning: pain level, self-assessed disability, psychological distress, pending litigation, educational level, helplessness and poor coping strategies. They recommended an independent psychological evaluation and occupational therapy evaluation (where available) and the use of validated questionnaires. Goldenberg DL, Mossey CJ, Schmid CH: A Model to Assess Severity and Impact of Fibromyalgia. Journal of Rheumatology 22:2313-2318, 1995.
Dr. Bennett concluded by recognizing that some physicians will always feel uncomfortable with assessing chronic pain and others will not have acquired the broad knowledge base needed to understand the biopsychosocial concept of disease. He suggested such physicians excuse themselves from the disability process.
Oregon is home to one of the world’s foremost authorities on fibromyalgia, Dr. Bennett. Right here in the “State of Jefferson,” we have Dr. Goodwin, a practitioner in pain medicine who stays on the cutting edge of the latest research in fibromyalgia and chronic pain. Each of these doctors has given important insights and direction relevant to legal disputes where fibromyalgia is an issue.
This article was prepared by Dennis H. Black