By Rosemary Frei, MSc
Winnipeg, Manitoba—There are lessons for rheumatologists and for family physicians in how courts adjudicate cases of fibromyalgia that were alleged to have been caused by or exacerbated by workplace injury, according to a new study presented at the Canadian Pain Society’s 2013 annual meeting and was published simultaneously (Fitzcharles MA, et al. J Rheumatol. 2013;40:323-328).
A team led by Mary-Ann Fitzcharles, MD, a rheumatologist and Associate Professor of Medicine, Division of Rheumatology, McGill University Health Centre, Montreal, Canada, reviewed 138 cases of fibromyalgia that had been examined by an appeals tribunal. They found that the tribunal members relied on outdated medical information, may not have taken previous health status into account, and that they put more credence in rheumatologists’ opinions than that of family physicians, despite the fact that family physicians have far more frequent contact with patients and are often more prepared to be their patients’ advocates.
“We have concerns about the frequent attribution of a somewhat trivial injury to the onset of a medical condition that is reportedly severe enough for persons to request disability compensation,” explained Peter Ste-Marie, BA, LLB, a researcher at the University of Montreal and the investigator of 2 posters on this topic. “[One of the problems is that] specialists seem to be accepted as authoritative in the law rather than acknowledging the important input of the primary care physician, who should be most knowledgeable of a patient’s global health status and the impact of the alleged work-related injury.”
The researchers parsed information from the Workplace Safety and Insurance Appeals Tribunal website (WSIAT; www.wsiat.on.ca) on all appeals of previous negative decisions for compensation.
“With the cause of fibromyalgia still unknown in the medical and scientific fields, we wanted to understand how the legal system attributes causation of this condition to a workplace injury,” said Mr Ste-Marie.
The study included 15 cases of fibromyalgia that were allegedly aggravated by a workplace injury, and another 123 cases that were alleged to have been caused by a workplace injury. These were heard by the WSIAT between June 2006 and December 2011.
Most (84.5%) of the appellants were women. Of the injuries, 66% were a single event, and the rest were gradual-onset injuries from repetitive work activity. Most of the injuries were acute rather than gradual and were more frequent in the upper limbs than in the lower back. They were all soft-tissue injuries without any persistent physical signs or symptoms that could explain the appellants’ continued symptoms, the researchers noted.
The average time between injury and diagnosis was 4.3 years among the cases of new-onset fibromyalgia. An average of 6 physicians’ opinions were cited in each case, with 91 (74%; N = 123) new-onset cases having been diagnosed by a rheumatologist and only 16 (13%) cases having been diagnosed by a family physician. The WSIAT sought the advice of a Workplace Safety and Insurance Board health consultant for 73 (59%) of the cases.
In 25% of the cases, previous health status was not discussed during the appeal. In 40% of the cases, reference was made to a fibromyalgia discussion paper published on the WSIAT website in February 2003 that Mr Ste-Marie and Dr Fitzcharles note is not peer reviewed and is inadequately updated.
Of the aggravation appeals, 67% were accepted, as were 59% of the appeals of patients with new-onset fibromyalgia.
The adjudicators were more than twice likely to allow an appeal based on a rheumatologist’s evidence than that of a family physician’s. They also were relatively unlikely to rely on the number of tender points—which is congruent with current medical thinking—or on the temporality of the cases.
Dr Fitzcharles reviewed the evidence presented in each case and agreed with the tribunal decisions in 76% of the new-onset cases and in all of the aggravation cases.
“This finding is both surprising and reassuring—that even with the differences applicable to medical versus legal evaluation, agreement was generally consistent,” the researchers concluded.
Nonetheless, they also warn that “the diagnosis of fibromyalgia, a condition characterized by subjective symptoms and without an objective confirmatory test, may be used dishonestly by some persons seeking compensation benefits. In this context, physicians should be vigilant when playing a role in secondary gain situations.”