It’s Fibromyalgia which is not Covered by WCB Scam



It’s Fibromyalgia(FM) which is not Covered by WCB Scam

1) It has been argued chronic pain syndrome is not caused by injury, not compensatable because the AMA guide 5 th edition (for disability) does not properly rate, and is not permanent. All these arguments were denied by a Northwest Territories supreme court ruling 2005:

decision here

2) Trigger knot masquerade as Fibromyalgia spots so tender point counts can’t be made:

Back in 1997, a Dr. Dan Buskila published a paper in which he concluded that Fibromyalgia could be precipitated by whiplash

abstract here

This caused considerable alarm among insurers that did not want to be held accountable for “post-traumantic Fibromyalgia”. Here is a commentary of what happened next:

“Unfortunately, the study by Buskila that supposedly provided proof that fibromyalgia is common after whiplash injury, did not consider whether the subjects had trigger points. During the recent Myopain 2001 conference, Buskila stated that he did not know how to evaluate for trigger points . In a more recent overview, he did modify his strong statements of the 1997 study, and stated [at the time] that there is no clear evidence[of post – traumatic Fibromyalgia] (Buskila, D. and L. Neumann, Musculoskeletal injury as a trigger for fibromyalgia/ posttraumatic fibromyalgia. Curr Rheumatol Rep, 2000. 2(2): p. 104-108). When we looked at whiplash patients, 100% had clinically relevant trigger points (Gerwin, R.D. and J. Dommerholt, Myofascial trigger points in chronic cervical whiplash syndrome (abstract). J Musculoskeletal Pain, 1998. 6(Suppl 2): p. 28.)

So trigger points can masquerade as countable Fibromyalgia spots. Then how does one make a reliable diagnosis? The following are considered reasonable guidelines:

1) It is a diagnosis of exclusion when nothing else can explain problems. In an injury case this by definition should exclude diagnosing FM as considerable myofascial pain occurs after injury. A study on problems missed in insurer cases rates this is one of the number one problems missed.

2) Fibromyalgia is a disease of pain lowered pain threshold in a generalized fashion. Some of this work was done by a Dr. Gary Rollman, the Canadian Pain Society past president.:

abstract here

When I privately asked him this year if there was any easy test for pain threshold, he could not give me any.

3) FM subjects have been found to have significantly higher levels of the natural nerve pain transmitter in the spinal fluid (CSF). This chemical is called substance P. This test is not available.

4) The pain has to be widespread – in at least three body quadrant areas – this eliminates most whiplash injuries that have only upper body symptoms.

5) To engender evidence of FM, “point counts” are taken – that is, tenderness to 4 Kg of pressure to individual spots. Since it is difficult to “wing it”, special pressure devices called algometers are used. I am the only one I know who has one of those devices so I suspect there is a lot of “winging” it. Some studies of normal subjects with algometers have found that the 4 kg rating is too high. Normal women could average pain at 3.4 Kg and men at 3.7 Kg:

Article here

So applying 4 Kg pressure would render most “normal” men and women considered Fibromyalgic.

6) As mentioned in initial discussion of Buskila, you CANNOT COUNT triggers in injured areas because they are injury knots – myofascial triggers. This would mean the necessary 11/18 spots necessary for diagnoses would be unreachable.

7) One of the worse cases to diagnose would be someone with C5/6 and C6/7 neck nerve roots with their muscle “somatic” referral patterns: You could not count those.

as per:



Case in point: - lady with neck injury, left thoracic outlet syndrome with nerve damage pains down arm, Right partial steroid responsive gluteal and trochanteric bursitis and ? tears and Severe adductor strain/tendonitis right thigh.

tender points :

Suboccipital – base skull - invalid due to neck injury

Trapezius - Shoulder tips – invalid due to neck injury and certainly on left with thoracic outlet syndrome

Cervical spine C5/7 anterior transverse interspace – invalid on left because of scalene spasm from thoracic outlet syndrome

2nd ribs – invalid on left from pectoralis muscle component of thoracic outlet syndrome

Forearm points – invalid on left due to somatic pains induced down arm by thoracic outlet syndrome

Gluteal triggers- invalid on right due to gluteal bursitis/tears

Trochanteric triggers – invalid on right for same reason.

Above knee medially – invalid on right due to adductor tendoinitis

X = invalid sites

As you can see, there are only 8 valid tender points left, and in her case not many of them were tender. So it has now become impossible to do a FM point count. She did have someone attempt to diagnose her with FM but I was never convinced I could make that call.

There are specialists that will flippantly diagnose Fibromyalgia in any case of chronic pain. I can only assume they do not know what else to call it. It is called chronic widespread pain or chronic pain syndrome and this can definitely result from injury.

Case in point – young male (FM is rare in men) had a WCB injury that caused left TMJ and left Thoracic Outlet syndrome problems. Both can be incredibly difficult to treat. The thoracic outlet included the pectoralis minor muscle. AS in below article, they are very hard to treat:

Response to Treatment for Pectoralis Minor Myofascial Pain Syndrome After Whiplash Chang_Zern Hong, David G. Simon

Journal of Musculoskeletal Medicine 1(1) 89- 131, 1993

Dr. David Simpon, one of the originators of Trigger point therapy, worked on these cases. They had intensive physiotherapy for 1 hour+ 3X/week. Some needed 3-6 months. Only 1/3 responded and had a combination of injections and physiotherapy, again for 3-6 months. One third did not get better and they all showed bulging discs on MRI (not seen in responders). (This blatantly demonstrates how inadequate the physiotherapy allotments are in WCB.)

When this young gentleman did not respond as fast as WCB liked, I got a call from a WCB board doctor wanting to call this Fibromyalgia. I pointed out how unreasonable that was.

The accuracy of Fibromyalgia diagnosis by general practitioners is dismal according to this Canadian study from McGill:

Rheumatology (Oxford). 2003 Feb;42(2):263-7. Inaccuracy in the diagnosis of fibromyalgia syndrome: analysis of referrals. Fitzcharles et al.

“There is a disturbing inaccuracy, mostly observed to be overdiagnosis, in the diagnosis of FM by referring physicians.”

abstract here

In chronic pain syndrome, where the cause of the pain is not immediately evident, it is NOT acceptable practice to expediently call this Fibromyaglia. First of all, this cannot be made in the presence of injuries. Just because someone is a specialist and “feels” this is Fibromyalgia does NOT make it so. They must follow good practice – using algometer readings, eliminating areas of injury from counts and so forth. This however could lack reliability in people with disc problems of C5/6 or C6/7 origin. This would not be obvious to a casual observer who made a one visit impression.

It has been also shown that neck bulging discs (considered “normal by radiologists because normal people can have them) can foster multiple knots, mimicking Fibromyalgia:

J Formos Med Assoc. 1998 Mar;97(3):174-80.

Association of active myofascial trigger points and cervical disc lesions.

Hsueh TC, Yu S, Kuan TS, Hong CZ.

We investigated the occurrence of active myofascial trigger points in specific muscle groups in relation to the existence of cervical disc bulging at various levels. One hundred and five patients (48 men, 57 women; mean age, 45.8 +/- 12.1 yr) who had active trigger points in the neck or upper back after trauma were divided into two groups on the basis of magnetic resonance imaging (MRI) evidence of bulging disc(s). The discN group consisted of 46 patients who had normal MRI findings in the cervical spine. The other 59 patients, with mild cervical disc bulging, were assigned to the disc' group. The correlations between specific muscles with active trigger points (clinical finding) and cervical disc lesions at specific levels (MRI finding) were analyzed. There were significant associations between the level of disc lesion and the muscles with trigger points, namely C3-4 lesions with levator scapulae and latissimus dorsi trigger points; C4-5 lesions with splenius capitis, levator scapulae, and rhomboid minor trigger points; C5-6 lesions with splenius capitis, deltoid, levator scapulae, rhomboid minor, and latissimus dorsi trigger points; and C6-7 lesions with latissimus dorsi and rhomboid minor trigger points. For each disc level, the average pain intensity (assessed using a numerical analog scale) of trigger points in certain correlated muscles (as indicated above) in the disc group was significantly higher than that in the discN group (p < 0.05 for all disc levels). We conclude that active trigger points are more likely to occur in certain muscles in the presence of cervical disc lesions at specific levels.”

[I have highlighted the pattern that I see most often with cervical discs that initially caused pain down the arm, but then remitted to the point only the muscle knots remained. It’s amazing to me how often the initial nerve damage had been forgotten and it was just assumed those remaining knots existed and didn’t want to go away was somehow the patient’s fault.]

One visit assessments are only impressions and have limited value in a multidimensional problem that can take literally years to become properly diagnosed in a province where testing is so poor. (like the syringomyelia case mentioned earlier)

Calls for the diagnosis of Fibromyalgia by specialists working for insurers should be considered suspect and routinely considered inadmissible because of the conflict of interest. Thus, in a situation where the patient must be given the benefit of the doubt, measures to terminate coverage over the diagnosis of Fibromyalgia/chronic pain syndrome should be eliminated.

Chronic pain syndrome is considered a valid diagnosis and has now been accepted by the Supreme court as compensatible :

VALIC v. NORTHWEST TERRITORIES AND NUNAVUT (WORKERS’ COMPENSATION BOARD)

Northwest Territories Supreme Court

Judge Virginia Schuler

James Posynick, Counsel for Valic

Adrian Wright, Counsel for Workers’ Compensation Board

December 14, 2005

decision here

from:

Disability and Accommodation Reporter January/February, 2006

“Chronic pain compensable as permanent disability under Workers’ Compensation Act, judge holds”….

“After suffering a series of workplace accidents between 1987 and 1997, a Northwest Territories man was diagnosed with chronic pain syndrome. The Northwest Territories Workers’ Compensation Board denied his claim for permanent partial disability benefits, taking the position that chronic pain was not an “injury” and therefore not compensable under the Northwest Territories Workers’ Compensation Act. On September 5, 2000, the WCB Appeals Tribunal dismissed the worker’s appeal, relying on the Board’s Policy No. 05-03, which entitles chronic pain sufferers to treatment support only. Rejecting the worker’s argument that the denial of his claim offended his right to equality under s.15 of the Canadian Charter of Rights and Freedoms, the Tribunal said: “[T]he Board treats all cases of proven chronic pain syndrome the same. It is not an injury and therefore not compensable.” Although the Board’s Governance Council subsequently directed a reconsideration, the Appeals Tribunal confirmed that chronic pain disorder “is not a permanent impairment or disability.” On October 19, 2001, the Board revoked its direction for rehearing of the worker’s appeal.”…..

“The Northwest Territories Workers’ Compensation Board violated the equality rights guaranteed in s.15 of the Canadian Charter of Rights and Freedoms when it denied a chronic pain sufferer’s application for permanent partial disability benefits on the basis that chronic pain is neither permanent nor a disability, a Superior Court judge has ruled”

They had harsh words for the AMA Guide 5th Addition – “It is quite another thing to exclude a condition or injury completely, simply because it does not fall neatly within the rating guide.” It, in essence, renders the AMA Guide for what it is – a human rights violation. In effect, the AMA GUIDE becomes a form of hate literature perpetrated on chronic pain patients with no objective findings as either unratable or more sinisterly at a blanket 3% disability despite the level of suffering. Given this view I feel the AMA guide has no place in chronic pain sufferers which The Guide is blandly admits, [with the minimal testing used,] 80% remain undiagnosed.

Conclusions:

1) The diagnosis of Fibromyalgia cannot be made in the presence of injuries as many of the Fibromyaglia tender points are actually injury based trigger knots.

2) Chronic Pain Syndrome is now a legally acceptable diagnosis

3) Objective findings are not necessary

4) The courts recognize that there is significant unjustified bias against chronic pain sufferers.

5) Chronic pain syndrome is a recognized disability as well

6) The AMA Guide is not a useful tool in chronic pain syndrome and even worse, represents a human rights violation.

7) Given the poor state of investigations here, only 20%, instead of 80%, of chronic pain sufferers can have the source of their pain documented.

8) Hence, Chronic pain sufferers must be given the benefit of the doubt and to do otherwise is a human rights violation.

9) In this province, there is pretending to follow above human rights. But then WCB will have a specialist decide on the basis of the fact:

- a patient can touch his/her toes

- walk on his/her heels

- walk on his/ her toes

s/he must be able to work. Unfortunately for said specialist, one does not need these objective findings so deciding on this basis can no longer be valid. Any doctor or specialist must have significant research evidence to support a contention a patient can return to work (ie research showing all people who can do above maneuvers can return to work). FCE’s can guide therapy but do not predict return to work either.

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