Appendix B: Medical Evaluation of LEOs with Fibromyalgia
A thorough but focused history and physical are critical in the evaluation of LEOs with fibromyalgia. The key symptoms of fibromyalgia are diffuse widespread pain, fatigue, and sleep disturbances for at least 90 days not caused by any other medical condition.
The widespread pain frequently covers at least six sites which may include the head, upper extremities, chest, abdomen, lower extremities, buttocks, and upper and lower back and spine. However, the pain may initially be localized such as the neck and shoulders. Fibromyalgia patients frequently describe the pain throughout their muscles but also state that their joints hurt and have swelling even though joint swelling is not typically present on examination.
The fatigue is persistent and moderate to severe in intensity. Activity endurance is poor with minor activities aggravating pain and fatigue. However, prolonged inactivity also worsens symptoms of pain and fatigue. Pain is worse in the morning when waking up similar to various rheumatic diseases such as rheumatoid arthritis and polymyalgia rheumatica. Patients do not typically get restful sleep waking up frequently and having difficulty getting back to sleep.
Cognitive symptoms present in the majority of fibromyalgia patients and consist of attention difficulties and difficulties completing tasks requiring rapid changes in thought. The cognitive symptoms are commonly referred to as “fibro fog.” The Public Safety Medicine Task Group strongly recommends a baseline mental health evaluation for all LEOs with fibromyalgia to assess for any cognitive impairment and mental illness. If a neuropsychological evaluation is indicated, it should ideally be performed by a doctoral-level, board-certified neuropsychologist.
Approximately 30-50% of fibromyalgia patients present with depression and/or anxiety.12-16 More than 50% of fibromyalgia patients present with tension-type and migraine headaches. Many fibromyalgia patients also present with paresthesia in both upper and lower extremities, symptoms suggestive of irritable bowel syndrome, abdominal and chest wall pain, symptoms suggestive of interstitial cystitis/painful bladder syndrome, symptoms of autonomic nervous system dysfunction such as orthostatic hypotension and altered heart rate variability, dry eyes, and Raynaud’s phenomenon without the thermographic and microvascular abnormalities seen in primary Raynaud’s phenomenon. Hearing loss is also 4 to 5 times more common in fibromyalgia patients compared to the regular population. Some fibromyalgia patients have also reported various degrees of environmental hypersensitivity such as increased pain and fatigue due to changes in weather, sounds, and lights.
The prevalence of fibromyalgia is higher in patients with chronic inflammatory rheumatological conditions such as rheumatoid arthritis, psoriatic arthritis, and spondylarthritis, and also in patients with osteoarthritis and regional pain disorders.
On the physical exam it presents with tenderness on modest palpation at multiple soft tissue sites to include but not limited to the upper mid-trapezius muscle, lateral epicondyle, second costochondral junction, greater trochanter. Usually, fibromyalgia patients are not as tender over joints compared to muscular tissue. There is no edema or erythema of the joints. Neurologic examination may show minor motor and sensory abnormalities, or deficits not attributed to any other condition. Some of these patients may meet the criteria for a small-fiber neuropathy or a peripheral neuropathy.
Fibromyalgia does not cause significant abnormalities in routine lab testing such CBCs, CMPs, and acute phase reactants such as ESR. Routine imaging studies (e.g., X-Rays, MRIs, CT-Scans, ultrasound) do not show any significant abnormalities secondary to fibromyalgia. However, abnormalities in specialized neuroimaging such as functional MRI have been demonstrated in fibromyalgia patients in research studies. Any specialist consultations and any other ancillary testing should be guided by suspicion of any co-morbid conditions that present with the fibromyalgia. The Public Safety Medicine Task Group strongly recommends that all LEOs diagnosed with fibromyalgia by a non-rheumatologist be seen by a board-certified rheumatologist to confirm the diagnosis of fibromyalgia.