Tamar S. Ference

Relationship Between Performance Validity Testing, Disability Status, and Somatic Complaints in Patients With Fibromyalgia

Fibromyalgia is a chronic pain-related disorder that typically includes cognitive complaints as well as non-specific somatic complaints, such as fatigue and sleep disturbance (Wolfe et al., 2010). Fibromyalgia has also been shown to be associated with a high rate of failure on performance validity testing (PVT), which has not been examined with respect to other self-reported symptoms that are now part of the diagnostic criteria for the disorder. We evaluated 85 patients with fibromyalgia who completed objective measures of pain, sleep, and fatigue along with symptom validity measures (Word Memory Test or Test of Memory Malingering and Reliable Digit Span). Three groups were formed based on effort testing: Two PVTs Failed, One PVT Failed, and No PVTs Failed. We also formed three groups based on disability status: On Disability, Applying for Disability, and Not on Disability. A total of 37% of the patients failed one or both PVTs. PVT group analyses were significant for daily pain, weekly pain, and sleep, but not fatigue. Disability status analyses were significant for daily pain, weekly pain, and fatigue, but not sleep. The implication of this study is that PVT performance and disability status are associated with exaggeration of non-cognitive symptoms such as pain, sleep, and fatigue in persons with fibromyalgia. This study reinforces the importance of effort testing when working with medical populations.

The Relationship Between Performances on Neuropsychological Symptom Validity Testing and the MCMI-III in Patients With Fibromyalgia

Fibromyalgia is a disorder that frequently presents with both cognitive complaints and psychiatric symptoms. This study investigated the association between Symptom Validity Test (SVT) performance and psychiatric symptoms as measured by the Millon Clinical Multiaxial Inventory-III (MCMI-III), a common measure of psychopathology. A total of 72 fibromyalgia patients at a tertiary care clinic completed the MCMI-III, an embedded cognitive symptom validity test (Reliable Digit Span), and a stand-alone cognitive symptom validity test (the Word Memory Test or Test of Memory Malingering). Of these patients, 21% failed a stand-alone SVT, whereas an additional 15% failed both a stand-alone and embedded SVT. Individuals who failed both stand-alone and embedded cognitive SVTs had higher scores on a number of MCMI-III personality subscales and had elevated scores on MCMI-III modifying indices compared to individuals who passed cognitive SVTs. Moreover, SVT performance was significantly correlated with multiple MCMI-III scores, including modifying indices, as well as the somatoform, depression, and anxiety subscales. In sum, cognitive and psychological symptom validity scores were significantly related. Given the new emphasis on cognitive complaints as part of the fibromyalgia diagnostic criteria, neuropsychological evaluation of both cognitive and psychological symptom validity should be a part of a comprehensive diagnostic assessment.

Assessing the prevalence of autoimmune, endocrine, gynecologic, and psychiatric comorbidities in an ethnically diverse cohort of female fibromyalgia patients: does the time from hysterectomy provide a clue?

Background This retrospective chart review investigated differences in the prevalence of medical comorbidity between women with fibromyalgia (FM) (n=219) and a control group women with chronic pain (CP) without FM (n=116). The specific aims were to compare the prevalence of autoimmune, psychiatric, endocrine, gynecologic pathology, the relationship between timing of gynecologic surgery, and pain onset. We additionally sought to compare the number of comorbidities in an ethnically diverse cohort. Methods This was a retrospective chart review of patients seen in FM or CP clinics at an academic medical center in 2009–2010. Results Logistic regression modeling found that gynecologic, endocrine, and autoimmune diagnoses were independently associated with a diagnosis of FM. Detailed analyses showed that thyroid disease (P<0.01) and gynecologic surgery (P<0.05) were significantly more common in FM. Women with FM were more likely to have multiple autoimmune, endocrine, gynecologic, or psychiatric pathologies. A relationship was observed between the timing of gynecologic surgery and pain onset in FM, with more surgeries observed in the years just prior to pain onset or in the year after pain onset. A similar pattern was not found in the control group. Conclusion This study demonstrates that autoimmune, endocrine, and gynecologic pathologies occur more commonly in women with FM than in those with CP, which is consistent with findings in less ethnically diverse samples. Moreover, a relationship was found between timing of pain onset and gynecologic surgery. A larger prospective study of the relationship between gynecologic surgery and pain onset in FM is warranted.

Assessing the perceptions of fibromyalgia syndrome in united states among academic physicians and medical students: Where are we and where are we headed?

Abstract Objectives: Fibromyalgia syndrome [FMS] is a common condition, often diagnosed in the primary care setting, causing diffuse pain with additional somatic symptoms. Many physicians have questioned the existence of FMS due to an unclear pathophysiological origin and its overlap with other somatic syndromes. We sought to assess the perceptions of FMS among United States medical students and internal medicine and family medicine trained physicians working in an academic hospital. Methods: Residents and attendings working in a local teaching hospital were given questionnaires during undergraduate medical education sessions and academic conferences in internal medicine and family medicine. Medical students received surveys during small group sessions and through student mailboxes. Results: Seventy-two internal and family medicine trained physicians and 211 medical students were surveyed. In assessing whether FMS was primarily physiological or psychological in origin, 66% of physicians compared to only 29% of medical students [p < 0.001] chose a psychological etiology. Among physicians, women [82%] and American medical graduates [77%] were more likely to endorse a psychological mechanism than their counterparts [53% p < 0.010, 50% p = 0.022, respectively]. Additionally, when physicians were asked whether they believed FMS was an “actual illness,” 19% responded “no.” Conclusions: Fibromyalgia syndrome continues to be a controversial illness in the United States, especially when compared with values attained from international studies. Although current academic physicians appear to be skeptical of FMS’s existence or its potential physiological mechanisms, medical students are more likely to support a physiological mechanism.

Poster 358 Gabapentin Causing Neurologic Dysfunction Leading to Falls.

Disclosures: Joslyn Gober: I Have No Relevant Financial Relationships To Disclose Case/Program Description: This is a case of a middle-aged woman being treated for fibromyalgia with gabapentin. The dosage was slowly increased in the setting of unrelenting pain. Unfortunately, soon afterward, she became unstable and uncoordinated, resulting in multiple mechanical falls. Complete neurological workup was negative. Initially, there was not a concern that gabapentin could be the culprit, especially since she was prescribed what is considered a low dose for fibromyalgia: 900 mg daily (300 mg TID). When the etiology remained unknown, gabapentin was slowly tapered as the possible cause, and sure enough, her falls ceased. Setting: Outpatient Physiatry Clinic. Results: Gabapentin is a well-known, commonly used medication for treating various neurologic and pain conditions. It was produced as an anticonvulsant that acts by binding the alpha-2-delta subunit of the voltage-gated calcium channels within the central nervous system. By doing so, it decreases the release of excitatory neurotransmitters, such as glutamate. Gabapentin is believed to be relatively safe and tolerable. However, adverse events may occur more often than anticipated, even at low doses. Discussion: Although gabapentin is known to be renally excreted and should be used with caution in those with renal impairments, it appears to have effects in the absence of renal dysfunction as well. Perhaps, there should be more concern and consideration regarding its adverse effects and neurologic toxicities before being prescribed. After this case, other fibromyalgia patients with falls due to gabapentin were noted. Conclusions: Gabapentin is a commonly used medication in the management of chronic pain conditions, including fibromyalgia. It is often first choice for many clinicians as it is not known to have severe side effects. However, a loss of balance was found to be associated with gabapentin, which can be dangerous as it could easily lead to other injuries. Patients and physicians should be aware of the unusual neurologic side effects with the use of gabapentin. Level of Evidence: Level V

Does Improved Confidence in a Disease Relate to Increased Knowledge? Our Experience with Medical Students

Dear Editor, Though knowledge regarding the mechanisms involved in fibromyalgia (FM) is improving, many physicians lack confidence in both their understanding and ability to diagnose FM, citing difficulty due to the variable presentation, poorly understood pathophysiology, and challenging diagnostic criteria [1]. We sought to address the confidence of medical students in their understanding of the etiology of FM in order to identify possible early misconceptions that may decrease eventual confidence in their understanding and management. The study consisted of a brief questionnaire given to medical students attending the University of Miami Miller School of Medicine, a United States allopathic school. This institution granted the project IRB approval. We divided students into two sample groups: preclinical and clinical students. Preclinical students included first year students as well as second year students who had not yet received lectures on musculoskeletal diseases. Clinical students had completed all organ-system lectures as well as at least 6 months of their required clinical clerkships. Students were asked to choose the statement that …

Direct to consumer advertising's effect on medical students: The case of fibromyalgia

Test anxiety (TA) is an underestimated and widespread problem among students (Neuderth et al. 2009). Like other anxiety disorders, untreated TA can lead to chronicity and aggravation of the symptoms. Also, it has been shown that TA becomes more severe in the course of the studies. Teaching medical students in their first semesters, we recently initiated a program which enables affected students to face their TA problem early (Tektas & Paulsen 2012). However, detailed data about the prevalence of TA among German medical students is lacking so far. For this purpose we performed an anonymous-questionnaire based cross-sectional examination among medical students of our faculty. We evaluated the frequency of self-reported TA and whether and how far selfreported TA is affecting study performance and alcohol, nicotine as well as drug consumption/abuse among medical students, as especially those have detailed knowledge of negative consequences and the range of drugs requiring prescription. About 909 students in their first to fifth year of education participated in the study. 29.9% of the students answered that they believe they would suffer from TA. Applying a screening method, we were able to detect only these students who are seriously and objectively affected by TA. This method included the consideration of typical symptoms which could be indicated by the participating students. With this classification, it could be shown that approximately 10% of the students are affected by TA, which is similar to the results of other studies considering students of other disciplines. We could show that students affected by TA are older and significantly less successful in their first state exams when compared to students of the control group. Also, they show a different substance consumption/abuse behaviour as they are smoking tobacco much more often and also consume distinctly more often drugs requiring prescription (beta-blockers, benzodiazepines and methylphenidate) and stimulating drugs (amphetamines, cocaine), but less cannabis and alcohol when compared to students not affected by TA. Regarding the lecturer’s attitude and awareness towards students affected from TA, more than 50% of the students in the first and second year and 70% of the students in the thired to fifth year stated that the lecturers are not considerate of students with obvious TA. Our results show that distinctly more efforts have to be made to offer special programs which enable affected students to face the problem as TA can lead to several negative long-term consequences among students.

Poster 202: A Rare Case of Single Upper Extremity Lymphedema in a Patient with Systemic Lupus Erythematosus: A Case Report

Disclosures: Matthew Moore: I Have No Relevant Financial Relationships To Disclose Case/Program Description: The patient originally presented to the emergency department with a 2-day history of right forearm and hand numbness and profound weakness in wrist extension. On initial physical exam, the patient showed an inability to extend the wrist and had decreased sensation to light touch in the radial nerve distribution of the forearm and hand. To rule out any acute neurological pathology, a CT of the cervical spine and head was performed which revealed extensive diffuse idiopathic skeletal hyperostosis (DISH) involving the C3-T1 vertebrae. A diagnosis of right wrist drop due to nerve impingement likely secondary to DISH was made. EMG/NCV revealed electrodiagnostic evidence of a focal demyelinating neuropathy of the right radial nerve above the level of the elbow. On further evaluation by PM&R the patient admitted to progressive dysphagia and worsening range of motion of the cervical spine for the past year. Setting: Outpatient PM&R Clinic. Results: The patient is a 63-year-old man diagnosed with right sided wrist drop likely due to nerve impingement secondary to DISH. The patient is currently pending evaluation by orthopedics as he may be a candidate for surgical intervention. Discussion: DISH of the cervical spine can present with wrist drop. Conclusions: DISH can present with a variety of symptoms; most commonly neck, back, and extremity pain. In this case, the patient presented with a chief complaint of wrist drop and later admitted to an associated decrease in ROM of the cervical spine and dysphagia. This case emphasizes the need for a thorough history, physical and workup in patients who present with unusual findings. Level of Evidence: Level V

Poster 277 Serotonin Syndrome Masked by Fibromyalgia: A Case Report

Fibromyalgia is a disorder characterized by widespread myalgia, fatigue, and hyperesthesia. It also may present with mood fluctuation, insomnia, and memory issues. It has 1.75% prevalence in the US, affecting approximately 3.94 million persons. Although the full pathophysiology is still unknown, it is widely believed to be secondary to a lower pain threshold in the central nervous system, termed “central sensitization”. This hyperactivity can be attenuated by activating the pain modulatory circuit of the CNS3. Selective Serotonin Reuptake Inhibitors (SSRIs) are most likely active in this circuit, and have proven efficacy as adjunct therapy in management of pain due to fibromyalgia. This effect is independent of its antidepressant activity, so use of these drugs is not limited to patients with fibromyalgia and depression.

The Role of Physiatry in the Management of Primary Congenital Lymphedema: A Case Report

Interventions: Not applicable. Main Outcome Measures: Recovery to grade IV or above at the point when patients require no more than supervision with the easiest self-care tasks (eating, grooming, and bowel and bladder management) but up to total assistance for the most demanding task (stair climbing). Results or Clinical Course: Physical grade IV was reached by 34% of those initially below it. Seven independent predictors were assigned the following points: age (<70 years1⁄42; 70-79 years1⁄41; >79 years1⁄40), time between initial and final grade assessment (1 to 2 days1⁄40; 3 to 7 days1⁄44; 8 or more days1⁄45), absence of renal failure1⁄41, no receipt of non-oral feeding1⁄43, admission physical grade (I1⁄40; II1⁄43; III1⁄44), admission cognitive stage (I or II1⁄40; III1⁄42; IV or V1⁄43; VI or VII1⁄44), and the type of rehabilitation services received (consultative1⁄40; comprehensive1⁄44). The proportions of patients recovered to physical grade IV in the 1st (score 9), 2nd (score1⁄410-12), 3rd (score1⁄413-15), and 4th (score>15) score quartiles were 2.72%, 11.38%, 28.96%, and 60.34%, respectively. The area under the receiver operating curve was 0.84 and 0.83 for the point system in the derivation and validation cohorts, respectively. Conclusions: Clinicians can forecast likelihood of recovery to or above the physical grade IV benchmark. At the first point when physical assistance with bowel and bladder management is no longer required, this benchmark represents a particularly meaningful recovery target.