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Wednesday, March 01, 2006

DISABILITY HELP INFO!

Dr. Richard Podell: Fibromyalgia, Chronic Fatigue Syndrome, and Disability Evaluation
ImmuneSupport.com03-01-2006 By Richard N. Podell, M.D.105 Morris AvenueSpringfield, NJ 07081973 218-9191; fax: 218-1199; www. DrPodell.org


FIBROMYALGIA, CHRONIC FATIGUE SYNDROME AND DISABILITY EVALUATION: A Seminar For Disability Attorneys and for Persons with Fibromyalgia or Chronic Fatigue Syndrome who need to understand the process of disability litigation.


Dr. Podell is clinical professor in the Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School. He is a member of the International Myopain Society and of the American Chronic Fatigue Syndrome Association. He practices internal medicine with a special interest in fibromyalgia and chronic fatigue syndrome in Springfield and Somerset, New Jersey.
This essay adapts from Dr. Podell’s address to the 9th National Conference on Litigating Disability Insurance sponsored by the American Conference Institute, February 23, Miami, Florida. The American Conference Institutes provides educational programs for attorneys who serve both claimants/plaintiffs and insurance companies/defense. Dr. Podell served as the medical expert on Fibromyalgia, Chronic Fatigue Syndrome and related disorders.

1. The syllabus labels fibromyalgia and chronic fatigue syndrome as “subjective disorders”. We are asked to address this question: what is do we mean by “subjective physical disorders” and how do these differ from “non-subjective” physical disorders? “Subjective physical disorder” is not an actual medical diagnosis or a validated medical term. Nevertheless, it can be useful as a concept for understanding certain issues relevant to disability evaluation.
The term “subjective physical disorder” has been employed to refer to medical conditions for which we have not identified specific findings on physical exam or laboratory tests that can reliably serve as proxy measures of disease severity. This non-specificity increase the reliance we must place on the patient’s self-reports of how they feel and function and the evaluation of their credibility through medical records and the opinion of their physicians.
Migraine headache, tension headache, irritable bowel syndrome, irritable bladder syndrome, etc might also be considered as “subjective physical disorders”. However, this essay will focus here on fibromyalgia (FMS) and chronic fatigue syndrome (CFS), because of their prominence for disability claims.
Clinical Differences between Fibromyalgia/Chronic Fatigue Syndrome and “traditional” causes of disability such as angina, emphysema, lumber disc disease, rheumatoid arthritis.
Traditionally, disability insurance carriers have worked more with “non-subjective” physical disorders. That is, condition for which it can be argued that certain physical exam or lab findings might correlate fairly well with illness severity and/or performance limitation.
Thus, if a person claims disability because of severe angina it might be argued that we should see EKG abnormalities suggesting ischemia during the course of an exercise stress test. If severe emphysema, walking fast for 20 minutes should make them huff and puff. Chest x-ray and lung function tests should be abnormal. If a person has a disabling lumbar disc protrusion, we might expect to see the disc protrusion displayed on an MRI.
There might be limitation of motion while bending. Certain physical movements should increase pain. If a person were disabled due to rheumatoid arthritis, we might expect to find joint deformity, limited of motion, and. perhaps a high sedimentation rate–suggesting active inflammation.
The world would be simpler if we could apply similar reasoning to every physical illness. However, we cannot.
The American College of Rheumatology Criteria for the diagnosis of fibromyalgia requires one "subjective" along with one objective (actually, semi-objective) element. That is, the patient must complain of chronic wide spread pain affecting all 4 quadrants of the body and also report abnormal pain over at least 11 of 18 predesignated sites (known as tender points), when a standard quantifiable degree of pressure is applied to these sites.
This tender point criteria is objective in the sense that we apply an “objective” degree or pressure, and might also observe wincing or other “objective” signs of pain. However, it is also subjective in the sense that it requires the patient to report that they feel pain.
Also tender point counts are not etched in stone. They may vary from day to day. And there is only a weak correlation between the number of tender points that are painful and disease severity and limitations of function. Indeed, the dividing line between fibromyalgia (11+ abnormal tender points) and chronic pain syndrome (10 or fewer tender points)–this dividing line is somewhat arbitrary.
Diffuse fibromyalgia like pain with fewer than 11 tender points is called chronic pain syndrome. In principle, some person with chronic pain syndrome could be so limited as to not be able to work, while others, with fibromyalgia, might well be able to carry on with their jobs.
Why have medical specialists defined fibromyalgia using criteria that are in a large part “subjective”?
Fibromyalgia’s defining symptom is wide spread chronic pain. Symptoms, by definition, are and are meant to be “subjective”. They must therefore be based on a patient’s self-report. Thus, the criteria that define the illness requires that we depend on the patient’s self-reports.
Unstated, but assumed, is that the validity of these reports depend, to a large degree, on the patient’s credibility. In clinical practice physicians have to make judgment about the truth and accuracy of their patients’ reports. We do this using a combination of the physician’s medical judgment about the illness, the physician’s judgment about the patient’s character, the patient’s prior medical records, and how well the patient’s reports and actual life style match the known characteristics of their illness.
These methods of evaluation all share elements of subjectivity i.e. requiring the patient’s self report, objectivity i.e. medical records, pharmacy prescription, old diaries, etc are objective documents, and partly an exercise of independent medical judgment i.e., are normally expected to become highly skilled at evaluating the credibility of their patients. Of course, as a rule, physicians tend to believe their patients–unless there is reason not to.
A disability insurance company, of course, does not share this obligation. They can and should look critically at whether an individual claimants self reports are in fact true and accurate.
Unfortunately, at present, we often have no standard “ruler”, “thermometer” or “tricoder” that can objectively” measuring disease severity in fibromyalgia or chronic fatigue syndrome. Such measures might become available in the future e.g., neuroimaging techniques that measure the activity of pain centers in the brain; but for practical real world testing we’re not likely to have these anytime soon.
Fortunately, in research rather than “real world” practice settings scientists have made progress using objective means to validate the self-reports for patients with “subjective physical disorders”. The data is especially strong for fibromyalgia, but is also fairly good for chronic fatigue syndrome.
These research studies “objectively” confirm that typical patients with fibromyalgia actually do perceive the pain they report. They also prove that fibromyalgia patients perceive the pain they report at much lower levels of stimulus than do persons who are healthy.
This increased sensitivity or pain augmentation has been given the name “neural sensitization”. Neural sensitization is at its core a physical process, reflective of changes in the structure and function of the pain signaling pathways, primarily within the spinal cord and the brain. (The accompanying article discusses this research in some depth.)
Think of the central nervous system’s pain signaling pathways as the volume knob on a radio. In fibromyalgia the volume is turned up to very high. Thus low level stimuli that causes only minor pain in “normal” persons, causes greater pain in persons among persons with fibromyalgia. The technical name for this amplification is hyperalgesia.
Similarly, stimuli that normal individuals do not perceive as painful or distressing, are perceived as pain or paresthesia in the fibromyalgia patient. The technical term for this is allodynia. Anatomically, neural sensitization may reflect an increase in the size of pain transmitting nerve cells, neurotransmitter alterations, and increased cross connecting synapses among nerve cells that signal pain.
Functional MRI studies provide compelling support for the neural sensitization. Both normal individuals and fibromyalgia patients show changes in the degree of blood flow in certain areas of the brain just at the time that they report feeling pain.
However, among fibromyalgia patients these regional blood flow changes occur at much lower levels of stimulus than they do for normals. Similar findings have been documented using other “imaging” tools including SPECT scan and cerebral evoked potentials. In addition to having a lower initial pain threshold, repeated stimulation causes pain intensity to increase more rapidly in fibromyalgia patients than similar stimulation increases pain in normals. Once the stimulus stops, pain levels decline for both normal persons and those with fibromyalgia. However, pain fades more slowly among those with fibromyalgia.
With fibromyalgia, one can cause pain to continue without fading if one continues to apply a very mild level of further stimulus. This same level of mild stimulation does not maintain pain when applied to normals.
Fibromyalgia patients’ pain signaling differs from normals in other important ways. For example, normal persons become temporarily less sensitive to pain shortly after they’ve exercised. With fibromyalgia we see the opposite. Fibromyalgia patients after exercise are more sensitive to painful stimuli, not less.
The key studies that document neural sensitivity in fibromyalgia were independent of potential confounding factors including co-morbid depression, disability litigation or patient expectations.
There is clear consensus in the fibromyalgia research and clinical community that neural sensitization is a major characteristic of fibromyalgia. There is an up-regulation, augmentation or sensitization of the central nervous system’s pain signaling pathways. These physical changes can be measured in a research setting, but such testing is not yet available for normal clinical evaluation.
Thus, contrary to what we once imagined, the “end organ damage” of fibromyalgia is not primarily in the muscle, joints or in the peripheral nerves. Rather it lies within the pain signaling pathways of the spinal cord and the brain, targets that we don’t test with our standard exams.

2. How can we go from our general understanding of FMS and CFS, to apply this understanding to an individual patient?
We knowing that, as a group, fibromyalgia patients accurately report their pain. However, this does not tell us for sure whether any one specific individual with fibromyalgia is reporting accurately or truthfully.
The number or intensity of tender point abnormalities does not tell us. A person can be very tender on a given day and still be able to work, or not too tender at all and still be disabled. Indeed, the sensitivity of tender points can vary from day to day.
Psychological distress is one of many factors that can affect the pain sensitivity of tender points. Nor aside from tender points, are there any other physical exam findings or laboratory tests whose absence means that fibromyalgia is not present, or that it is mild versus severe.
Thus, fibromyalgia patients typically have fairly normal muscle strength, no swelling of joints, normal range of motion, normal peripheral nerve examination, and normal interaction on the kind of “light” mental status examination that would typically be done by internists or neurologists.
However, the opposite is not true. Sub-sets of fibromyalgia patients fairly often have specific physical exam or test abnormalities, that, when present, is evidence that their disease is severe–although not necessarily disabling.
Thus, a subset of patients with fibromyalgia (and chronic fatigue syndrome) have abnormalities of blood pressure and/or heart rate, especially when they remain standing for an extended period. They may have orthostatic hypotension (low blood pressure with standing) and/or postural orthostatic tachycardia syndrome (POTS--heart rate increase with prolonged standing).
To the degree that these conditions are substantial and fail to respond to medical treatment, their presence can support a claim of disability. In contrast, normal orthostatic findings cannot be used as proof that the disease is mild or not disabling.
Another subset of patients with severe fibromyalgia and/or chronic fatigue syndrome report cognitive difficulties–“brain fog”--decreased ability to concentrate and or think quickly, especially with complex or multi-tasked problems.
Typically, these persons appear normal on standard office clinical and mental status examination. However, often, but not always, formal neurocognitive testing demonstrates defects consistent with their self-reports. Formal neurocognitive testing should be done in most cases where cognitive difficulties are a major reason why a person claims they cannot work.
In some circumstances neurocognitive testing results can underestimate the degree of disability. Thus, patients typically appear for testing on their relatively “good” days, not on their worse days. Many patients “rest up” for several days before the day of testing so they can do their best effort.
Plausibly, test scores might be lower on “bad” days, and/or if the “exertion” of testing had to be repeated 5 days a week for several weeks or months–as in a work setting–not just for one or two sessions.
On the other hand, a specific test score that is substantially lower than that expected for a person of high intelligence and substantial education, might still fall within the average range, despite the reduction caused by disease. In that case, the lower than expected score would be evidence of a substantial disease effect; but it would remain open for debate over how important that deficit would be with regard to a specific job and level of performance.
With regard of patients who complain of “brain fog” but do not show deficits on cognitive testing, little research has been done with regard to the potential “mechanisms” involved in causing such symptoms.
However, recent research suggests that the mental fatigue that these persons report may relate to the greater effort they require to concentrate. That is, they might do the test as well as others, but have to work much harder to do so. If one pushes on this long enough, increased fatigue and poor concentration might be the result.
Dr. Lange, a neuropsychologist at the New Jersey Medical School and her colleagues have made important contributions. Lange’s work is important enough to discuss in some detail ( Lange G, Steffner, J , Cook, D et. Al. Objective evidence of cognitive complaints in Chronic Fatigue Syndrome: A BOLD fMRI study of verbal working memory., NeuroImage 2005; 26: 513-524):
In her first studies patients with CFS but no psychological illness showed (on MRI) a significantly larger number of brain abnormalities on T2 weighted images than did persons who had CFS plus psychological illness. These “mentally healthy” CFS patients also showed more MRI abnormalities than did health controls.
These “mentally healthy” CFS patients had mostly of small, punctuate, subcortical white matter hyperintensities, found predominantly in the frontal lobes. Lange wrote: This frontal lobe pathology could explain the more severe cognitive impairment previously reported in this subset of CFS patients. Thus, CFS patients have more anatomical changes in the brain than do healthy controls–independent of whether or not they also have psychological illness.
Lange et al then extended her work to study chronic fatigue syndrome patients using functional MRI, a research imaging system that tracks changes in blood flow in different regions of the brain. Here, Lange all showed that patients with severe chronic fatigue syndrome, when challenged with a mental task, had to recruit many more areas of the brain to fulfill the task than did controls. This was true not only for patients with chronic fatigue syndrome who had abnormalities demonstrated on standard neuropsychological testing, but also on those who neurological test scores were normal.
This confirms that there is something wrong with brain function among chronic fatigue syndrome patients, that current standard neuropsychological tests may be unable to detect.
In these patients, they are able to fulfill the initial challenge adequately in the short term, but have to exert substantially greater mental effort to do so. This is consistent with the clinical observation that many CFS patients can think clearly for short periods, but pay the price of increased symptoms and decreased function after prolonged effort.
Lange’s paper supports this view:
“Individuals with CFS appear to have to exert greater effort to process auditory information as effectively as demographically similar health adults. Our findings provide objective evidence for the subjective experience of cognitive difficulties in individuals with CFS.”
The Bottom Line: People with CFS might be able to accomplish a short term task fairly well, but they have to work harder to do so. Maintaining that extra effort for many hours at a time, repeated over many days–this might be expected to tend to “wear them out”.
Thus, Lange’s findings (and those of others) tends to support the accuracy of self-report for fibromyalgia patients as a group. Similar studies support the accuracy of self-report for groups of patients with fibromyalgia. This gives plausibility to the self-reports of an individual with these conditions who claims to be disabled. But, of course, the credibility of those claims for each individual has to be evaluated for that individual on its own merits.
Conclusion:For many or most persons with fibromyalgia (and chronic fatigue syndrome), there is no physical examination sign or standard laboratory test result that we should expect to distinguish mild versus moderate versus severe disease.
Therefore -- except for certain subgroups where cardiovascular or neurocognitive abnormalities are documented -- medical expert and insurance evaluators should not expect (or require) that the presence or absence of any specific “objective” finding reliably distinguish between a disabled and a non-disabled person with FMS/CFS.
One patient/claimant can struggle through her job despite aching muscles and fatigue. Another patient/claimant cannot, and is limited to activity of say, just 3 hours a day. On standard physical exam, standard mental status exam, and standard lab tests, these two individuals are very likely to look the same.
As of 2006, such standard exams lack the ability to tell these two individuals apart–despite their great difference in the their abilities and stamina for sustaining activity.
The non-conclusive nature of physical findings and laboratory tests, places an increased burden on the patient’s documented reported history–and its credibility–as the main means currently available for judging the capacity of an individual to sustain work.

3. What reasons do persons with fibromyalgia and/or chronic fatigue syndrome usually give to support their belief that they are unable to work? This question is crucial because, to have face validity, any tool we decide to use to help us judge disability, has, at the very least to address the credibility of the specific claims that the patients are offering.
In an idealized form these are the four most common scenarios described by patients with severe FMS/CFS. In practice, most patients report a mix of three or all four of these scenarios.
Scenario A. “My pain is bad even when I do nothing. However, if I am active for, say a half hour, –even if I am sitting-- my pain usually gets worse. I might feel this immediately and it might improve after a rest. I then go back to activity for another short period.
However, if I repeatedly push my limits this way, the pain worsens more, accumulating with the total activity of the day. On most days the total amount of time I can do even intermittent activity is very limited, e.g. a total of two to three hours. If I exceed these tight limits my pain usually flares for 24 hours or more. These flare-ups might begin several hours later or the next day (which is common) or even several days later. If I push for several days in a row, then the delayed flare up will be much more severe, and will tend to last longer.”.
Scenario B. My fatigue and poor stamina keeps me from working. I feel tired and my stamina is poor even when I do little. However, if I do even light activities for, say, 30 minutes, my fatigue worsens further and my stamina declines. If I keep pushing beyond these limits I become worse still. If I then rest for 30 minutes or so, I might be able to be active for another 30 minute. But on most days I’m good for only two or three hours a day of activity, even with breaks to rest. If I do more, my fatigue often worsens. These flare ups might last for 24 hours or more. The flare-up might begin several hours later, or the next day or even several days later. If I push for several days in a row, then the flare up will be much more severe, and will tend to last longer.”
Scenario C. “My mental concentration is poor. If I do substantial mental or physical activity my ability to concentrate worsens. The more I do the worse I get. I used to be able to read technical articles and follow what’s happening in meetings. Now this is very difficult. I have to reread articles to try to understand them. I cannot pick up and retain facts in meetings. I do okay in normal conversations, but have trouble “finding” words. It’s especially hard for me to think quickly, multi-task and doing complicated tasks.
If I push to do cognitive work beyond my limits my mental concentration worsens (as does my pain and fatigue). If I do to much physical activity, my cognitive abilities suffer.
If push my limits for one day, my concentration (and other symptoms) will be worse later that day or the next. The more intensely, the longer, or the more often I push, the worse and the longer the flare up of symptoms will likely be.
Scenario D. Unpredictable Variability in Severity of Symptoms: I am pretty limited even on my relatively “good days”; but, I also have much worse than usual “ bad” days when I can do almost nothing at all. These very bad days may occur if I’ve pushed too much on the day before. But, they can also occur unpredictably, even if I watch myself. On these bad days I can usually do little more than get out of bed. No major tasks are feasible.
No expert on fibromyalgia or chronic fatigue syndrome doubts that a significant number of persons with these conditions legitimately experiences one or more of these scenarios. However, that fact with respect to a group, does not by itself tell us whether the claims made by any one individual are, in fact, true and accurate. What tools do we have to help make this judgment with regard to a specific individual?

4. How do physicians evaluate the severity of illness for patients with FMS/CFS when they present in the clinical setting?
In normal clinical practice physicians usually make it a practice to believe what their patients tell them–unless and until they have reason to doubt them.
One reason for doubt might be if the patient’s report are not consistent with the typical pattern of their disease. For example, it would be very atypical for a patient with FMS or CFS to feel typically 100% well and be highly active for weeks at a time, only to plunge back into severe illness for weeks at a time thereafter.
Variation in symptoms from day to day or month to month is typical for severe FMS/CFS, but most the upswings are still fairly limiting. (Some CFS/FMS patients will refer to periods of being "almost normal." However, they usually see this in comparison to a very low baseline. Close questioning will usually reveal that their energy reserves are still limited.)
Another reason for doubt might be information from the patient spouse, or other observer claiming that the patient habitually engages in activities that are inconsistent with their self-reports.
For example, persons with disabling fatigue and pain due to FMS/ CFS cannot typically play vigorous singles tennis three times a week on a consistent or regular basis. (Such activity might be tolerated once in a while, but would typically flare up their symptoms later that day or the next.)
Another reason that’s highly relevant to the individual’s credibility is the medical judgments of physicians who know the patient well. Physicians who have developed a relationship with a patient will typically develop a medical opinion about their reliability.
By and large, the judgment of a patient’s credibility made by their long-term treating physician has more respect than does that of a physician who has seen the patient only once, or, if an opinion is based just on a review of the file, not at all.
In some charts one can often sense from the physician’s note whether or not the physician has any substantial reservations about the accuracy or truthfulness of the patient’s self-reports. However, in other charts, we cannot tell.
One practical problem is that many physician’s notes are often not very detailed. As important, the physician’s main focus is most on issues other than quantifying the severity of symptoms or functional impairment. We are often much more interested in making a diagnosis and recommending treatments, than in asking or writing down how long a person can sit in a chair or type on a keyboard.
Thus, a typical physician’s visit note might read something like:
Still tired and achy. Ultram helped a little, but had to stop due to nausea. Will send to PT and perhaps try Cymbalta.
This person’s illness might be mild, moderate or severe. One cannot tell from this note. If specifically asked to, the physician might have chosen to direct questions in a different way, toward assessing severity and function. However, in real world practice, other priorities take precedence. In an ideal world, physicians might directly quote the language of all their patients’ complaints. In practice, our notes are highly selective and condensed. Of course, one would not expect the dermatologist looking at a rash to ask about fatigue.
Despite these limitations, the medical records remain the most important tool we have.
When litigation occurs, these limitations cause a problem for both claimants and defense.
If there is little or no mention of functional limitations in the chart, one cannot necessarily conclude that function was normal or that no limitations were reported. Physicians may regard complaints about reduced function as more a vocational than medical concern. We’re normally most concerned about a host of other issues.
Another practical problem is that many physicians don’t know enough about the normal pattern of fibromyalgia, such as the post-exertional flare phenomenon. We tend to only see what we look for, and only look for what we know. So, clinical records are often silent, on what, in litigation, may turn out to be very important points.
We also face problems due to the patient’s limitations as a communicator, e.g., limitations imposed by the duration of time allowed for a visit, the patient’s purpose for certain visits being unrelated to her FMS/CFS complaints.
Please note: An important study extended observation on the flare-up phenomenon to include data on the cumulative effects of very modest degrees of exertion. ((Black C and McCully K Time course of exercise induced alterations in daily activity in chronic fatigue syndrome, Dynamic Medicine 2005, 4:10)
Six individuals with chronic fatigue syndrome were given a daily walking programs of only 15 to 25 minutes a day with the hope of increasing their daily activity. Activity was measured by an accelometer worn at the waist. Initially these patients were able to increase their daily activity and were able to reach a daily level similar to that of sedentary controls. However, this increased exertion was also at the price of increasing CFS symptoms. Overall mood, daily fatigue and time spent each day with fatigue all worsened over the course of four weeks as the exercise program progressed.
In order to further examine the idea of a “daily activity limit” a detailed analysis of each subject’s activity each day was performed...a distinct pattern was observed. During the first 4-10 (average of 7) days of exercise, our CFS subjects spent an average, approximately 23 minutes each day exercising.
This indicates that the subjects were not only complying with the prescribed exercise, but also were able to reach the daily exercise target...However, over the final 3 weeks of prescribed exercise, the average time spent each day exercising fell to approximately 8 minutes per day...In contrast, sedentary control subjects responded to a similar daily walking program by increasing their total daily activity 25-30% for the first week, and were subsequently able to maintain this increase for three additional weeks.
Unlike our initial interpretation that CFS subjects could maintain an activity increased over four weeks, it is now apparent that the CFS subjects were only able to sustain the prescribed increases in activity for 4-10 days.
We believe the reduction in total daily activity levels, primarily from a reduction in time spent exercising, observed during the following 3 weeks were related to greater symptoms of fatigue. These results indicate that the CFS patients in the current study were more likely than controls to develop exercise intolerance.

5. In a legal setting, how can we judge the validity of the patient’s reports? In particular, what is the validity of the FCE? Physicians in practice are predisposed to believe in the “good faith” of their patients. In the setting of litigation, a frequent issue becomes, when is this assumption valid and when is it not? What tools can we use to evaluate whether what the patient now reports is truthful and accurate?
Because physical exam and lab findings are usually not useful for measuring disease severity, one of the most important sources of relevant evidence is a thorough review of the patient’s medical records, both currently and in the past.
Do these “objective” document or contradict the patient’s reported claims? Are these records 1) consistent with the patient’s self report in their disability application? 2) self-consistent within and among different health records? 3) consistent with the pattern of illness typically seen among persons with severe FMS/CFS?
Also from the records one can usually judge whether an adequate work up has been done for other potential causes of illness, and whether the patient has had an adequate course of standard treatment.
In addition to the medical records other “objective” evidence can, in principle, be brought to bear. However, each has its potential weak points along with its strengths, and must be judged judiciously, and not be misused. For example: Information from the patient’s diary; testimony from family members, co-workers, neighbors; videotape surveillance.

6. The special case of the Functional Capacity Evaluation (FCE) The FCE, as now done, asks a patient to light or moderate activities such as stooping, crawling, squeezing, balancing over a period of several hours. In some cases the testing is repeated on the next day. The examiner then uses the findings over these short periods of time to extrapolate out from this short term data to a judgment about how the subject would fare if similar levels of activity had to be sustained for eight hours a day, forty hours a week, week after week and month after month.
For fibromyalgia and chronic fatigue syndrome, is there a scientific or logical basis for making such extrapolations from such short term activity to any conclusion about the ongoing ability to sustain productive work. In brief, the answer has to be a very firm no.
Please recall, the main reasons people with fibromyalgia and chronic fatigue syndrome claim they cannot work is because pushing past their physical limits causes symptoms to flare, typically with a delay of several hours or a day. They can often do a task for several hours, but if they do too much they then pay the price of being worse the next day. This is the delayed post-exertional flare-up phenomenon. This is characteristic of patients with severe FMS/CFS.
These patients also report that their worsening with exertion tends to be cumulative. That is, five days of trying to push through causes much more severe and longer flare-ups than does just one day of over-doing. These patients also report that, unpredictably, they have days where they are even much worse, and can barely get out of bed. These are the reasons they claim they can’t work.
Does the current FCE of short term activities even seek to address the accuracy of these self-reports. It does not attempt to do so. The current FCE is short term only, makes no effort to ask how the patient felt the next day, and makes no attempt to evaluate function that is in any way comparable to the 40 hours a week required for a job.
(In reviewing the raw data in FCE records, I sometimes sees notation that the patient complained of feeling worse during or after the session. But almost never do the examiners refer to these complaints in forming their conclusions about what the patient can or cannot do. I have never seen a report where the examiner calls or visits the patient the next day to access for the expected post-exertional flare-up effects.) Therefore, the (FCE) as currently used, has no face validity that would justify its algorithms for extrapolating to conclusions about whether a person with FMS/CFS can work. It’s like looking for a lost quarter under the bright street lamp despite having dropped it in a less well-lit area half a block away. The FCE, as now set, is a classic example of looking in the wrong place.
To be relevant to the actual claims that claimants make, FCE procedures require modification to specifically assess the severity of symptoms and functional consequences in the hours and days after the testing. Just as important, the FCE needs to develop valid methods of assessing how persons feel and perform after multiple successive days of activity, five days a week and four weeks a month, not just for a few sessions.
It would be convenient if one could extrapolate from performance done over several hours, to the ability to sustain performance over days or weeks. However, there is no substantial data that would validate such extrapolations in the case of FMS/CFS. Indeed, most data, and basic logic, argues strongly against it.
Is there any objective scientific evidence that would justify an extrapolation from the short term FCE to a conclusion about ability to sustain continuing performance?
Implicit in the use of FCE for FMS/CFS is an unproved (and probably false) assumption that the claimant’s performance during one or two several hours sessions of activity, can be extrapolated out to predict how they will fare if similar activities are repeated, say eight hours a day, on a regular basis over days, weeks and months.
However, there is not valid evidence to support this assumption. Indeed, for FMS and CFS, there has been almost no attempts to even try to test the “extrapolation assumption.
To assess whether there was any science behind applying the FCE to FMS/CFS I searched the medical literature data base of the National Library of Medicine. This data base contains essentially all English Language medical publications since 1966, and also a large number of foreign language publications. Based on the National Library of Medicine’s data base there are no published controlled studies at all that support the validity of any currently standard FCE protocol for predicting or extrapolating the disability status of persons with FMS or CFS.
On November 7, 2005, I submitted the keywords: functional capacity evaluation and fibromyalgia. This search yielded only one single reference. ( Valkeinen, et al. Changes in knee extension and flexion force, EMG and functional capacity during strength training in older females with fibromyalgia and healthy controls. Rheumatology . 2004 Feb;43(2):225-8.)
Valkeinen’s study did not address the validity of the FCE, and was not relevant to our issue. Rather it showed that 13 elderly females with fibromyalgia could be trained to improve muscle strength and walking speed.
A search using the keywords functional capacity evaluation and chronic fatigue syndrome disclosed five articles. None of these articles provided any evidence to support the validity of the FCE for patients with CFS. Indeed, their conclusions tend to point to the contrary.
Article #1: Ross, et. al. (Arch Intern Med. 2004 May 24;164(10):1098-107.) reviewed the literature on how to measure, monitor and treat disability in patients with chronic fatigue syndrome (CFS). The conclusion states:
For questions of disability and employment in CFS, the limitations inherent in the current literature are extensive. Methodologically rigorous, longitudinal, and interventional studies are needed to determine baseline characteristics that are associated with the inability to work and interventions that are effective in restoring the ability to work in the CFS population. Simple and consistent evaluations of functional capacity in patients with CFS are needed. Article #2: Nijs J De Meirleir K Wolfs S, Duquet W.(Clin Rehabil. 2004 Mar;18(2):139-48.)
CONCLUSIONS: These results suggest a moderate association between exercise capacity and activity limitations/participation restrictions in patients with CFS. The observed correlations lack strength to predict activity limitations/participation restriction based on exercise capacity parameters. Disability evaluation in CFS should therefore encompass both exercise capacity testing and measurements at the activity/participation dimension
Article #3: Barrows, D (Am J Occup Ther. 1995 Apr;49(4):327-37.):
Abstract: Chronic Fatigue Immune Dysfunction Syndrome (CFIDS) is estimated to affect 2 to 5 million people in the United States. Despite its high incidence, persons with CFIDS have been neglected by the medical community mainly because there is no singular confirming diagnostic test or proven effective treatment.
The CFIDS population is incorrectly stereotyped as upper-middle-class, white, female hypochondriacs; consequently, symptoms often are belittled or ignored. In reality, CFIDS is a severe medical condition that affects women, men, and children of any race and often causes long-term or total disability.
The results of a modified functional capacity evaluation developed by the author and completed on 86 persons with CFIDS between 1988 and 1990 confirm that this population has severe physical and cognitive disabilities that affect their professional, familial, and social lives. The results of these evaluations are used to present a profile of persons with CFIDS that can serve as a basis for understanding this population and for guiding intervention.
Please note, this study documented disability in a group of patients with CFS, using their own FCE protocol. They did not assess or attempt to validate any of the standard FCE protocols. Nor did they attempt to validate their own protocol against actual work-place measurements of the ability to work.
Article #4: Morriss, R et. Al. Psychosom Res. 1998 Nov;45(5):411-7.)
The Chalder fatigue scale is widely used to measure physical and mental fatigue in chronic fatigue syndrome patients, but the constructs of the scale have not been examined in this patient sample.
We examined the constructs of the 14-item fatigue scale in a sample of 136 chronic fatigue syndrome patients through principal components analysis, followed by correlations with measures of subjective and objective cognitive performance, physiological measures of strength and functional work capacity, depression, anxiety, and subjective sleep difficulties.
There were four factors of fatigue explaining 67% of the total variance. Factor 1 was correlated with subjective everyday cognitive difficulties, concentration difficulties, and a deficit in paired associate learning. Factor 2 was correlated with difficulties in maintaining sleep. Factor 3 was inversely correlated with grip strength, peak VO2, peak heart rate, and peak functional work capacity. Factor 4 was correlated with interview and self-rated measures of depression.
The results support the validity of mental and physical fatigue subscales and the dropping of the "loss of interest" item in the 11-item version of the fatigue scale This study did not address any of the standard FCE protocols or attempt to validate their use for extrapolating from any test to predict the actual ability to work.
The fifth study was a clinical trial for treating chronic fatigue syndrome with an antiviral medicine. It did not evaluate any FCE protocols.
Therefore, so far as can be determined from the published medical literature there are no published studies that attempt to validate any of the currently used FCE protocols with regard to their validity for predicting disability among persons with FMS or CFS.
Validating current FCE protocols’ use for other medical conditions is beyond the scope of this essay. However, the available literature certainly shows a degree of controversy and skepticism with regard to the ability to extrapolate work status from the FCE–even in conditions which have been relatively well researched such as low back pain.
For example, see Pranksy and Dempsey from the Liberty Mutual Research Institute for Safety, Center for Disability Research (J Occup Rehabil. 2004 Sep;14(3):217-29.):
Physicians, employers, insurers, and benefits adjudicators often rely upon functional capacity evaluations (FCEs) to determine musculoskeletal capacity to perform physical work, often with legal or occupational consequences.
Despite their widespread application for several decades, a number of scientific, legal, and practical concerns persist. FCEs are based upon a theoretical model of comparing job demands to worker capabilities. Validity of FCE results is optimal with accurate job simulation and detailed, intensive assessments of specific work activities.
When test criteria are unrelated to job performance, or subjective evaluation criteria are employed, the validity of results is questionable. Reliability within a subject over time may be adequate to support the use of serial FCE data collection to measure progress in worker rehabilitation.
Evaluation of sincerity of effort, ability to perform complex or variable jobs, and prediction of injury based upon FCE data is problematic. More research, especially studies linking FCE results to occupational outcomes, is needed to better define the appropriate role for these evaluations in clinical and administrative settings.
Innes and Stroker, in their internet essay on the Validity of work-related assessments concluded: As with reliability, most work-related assessments have limited evidence of validity. A number had insufficient evidence on which to base an assessment of the level of validity. Of those that had adequate evidence, validity ranged from poor to good.
Work-related assessments with adequate evidence of moderate to good validity included some attachments of the BTE Work Simulator, DOT-RFC, EPIC Lift Capacity, ERGOS Work Simulator, MESA/System 2000, PWPE, Singer/New Concepts VES, Smith PCE, Spinal Function Sort, Valpar CWS and Work Ability Mk III. Other instruments had contributory evidence that began to establish moderate to good validity. These included AME, ARCON, Cal-FCP, Isernhagen FCE, Lido WorkSET, PILE, WEST Standard Evaluation and the Work Box.
There was, however, no instrument that demonstrated moderate to good validity in all areas. Very few work-related assessments were able to demonstrate adequate validity in more than one area, or with more than one study, even when contributory evidence was included. This highlights the need for further research to be conducted in this area. Test developers, clinicians and academics are strongly encouraged to continue investigating the validity of work-related assessments.
The acceptance of work-related assessments on the basis of their longevity in the marketplace and clinic should not be assumed to equate with adequate validity.
Should we design an FCE protocol that actually observes patients for ay 8 hours a day, for a full 5 day week.? In some ways that might make sense, if such a protocol could then be validated to demonstrate validity with respect to long term ability to work. However, based on our knowledge of FMS and CFS, this degree of vigorous testing would be expected to seriously exacerbate illness in a subset of patients, creating a hazard that would not be acceptable ethically (not to mention the potential legal implications).
If the FCE is to be used at all, it must be redesigned to specifically address the four common scenarios reported by claimants, including the post-exertional flare up problem, cognitive/concentration complaints, and the fact that an FCE takes place over one or two days, while work is ongoing.
Current FCE protocols for CFS/FMS lack any validated bases for extrapolating from the ability of a subject to function during an observation period of several hours to predict their ability to maintain themselves in a work setting on an ongoing basis. Until such validation research is performed and published, current FCE, protocols lack even face or construct validity application to FMS and/or CFS. Current evidence does not support its use.

7. Chronic Fatigue Syndrome. How do we diagnose it?
As of 1994, an expert panel report convened by the Center for Disease Control provided these opinions:
The chronic fatigue syndrome is a clinically defined condition characterized by severe disabling fatigue and a combination of symptoms that prominently features self-reported impairments in concentration and short-term memory, sleep disturbances, and musculoskeletal pain
Diagnosis of the chronic fatigue syndrome can be made only after alternate medical and psychiatric causes of chronic fatiguing illness have been excluded. No pathognomonic signs or diagnostic tests for this condition have been validated in scientific studies; moreover, no definitive treatments exist for the chronic fatigue syndrome.
Recent longitudinal studies suggest that some persons affected by the chronic fatigue syndrome improve with time but that most remain functionally impaired for several years
Now, fast forward to early 2006. Progress has been made in validating this condition. Chronic Fatigue Syndrome is accepted as a real and physical ailment, although its cause and its mechanism are not well understood.
Physicians who specialize in chronic fatigue syndrome, are generally in agreement on these as medical facts:
1. CFS is a real and a primarily physical illness. In principle, CFS is distinguishable from psychological and other physical illnesses.
2. Misclassification can occur i.e. where fatigue caused by psychological problems is incorrectly attributed to CFS ; where fatigue due to CFS is incorrectly attributed to psychological illness. A sophisticated medical judgment may be required to judge the relative importance of physical versus psychological factors.
Non-specialist physicians typically accept the above conclusions. However, some remain skeptical.
What Medical Work Up is Required before diagnosing chronic fatigue syndrome (CFS)?
CFS (like FMS) is partly a diagnosis of exclusion. That is, often (but not always), other conditions that produce similar symptoms have to be ruled out in order to diagnose FMS or CFS.
The Center for Disease Control Criteria for CFS were designed to identify patients for research studies. These criteria exclude persons from research studies on CFS if they have also had schizophrenia, melancholic depression, untreated hypothyroidism, morbid obesity and certain other conditions.
Such persons could, in principle, suffer from CFS but they are not put into research studies of CFS, since the co-occurrence of these other conditions, makes it difficult to determine which disease is contributing how much to their symptoms.
However, other diseases are fully compatible with the diagnosis of CFS, and do not exclude persons from participation in research studies on CFS. Thus, one can have depression, anxiety, rheumatoid arthritis, etc., at the same time as CFS and/or FMS. When there are several co-occurring conditions, the physician must judge how much each co-occurring condition contributes to a specific individual’s disability.
In theory, a person with mild CFS and severe depression could be disabled primarily due to their depressive. In that case properly treating their depression would still leave them still somewhat tired due to CFS, but able to work. Another individual might have severe CFS plus mild, moderate or severe depression. If CFS is severe, then treating their depression is likely to improve mood, but is not likely to much improve their physical stamina/CFS.
One way to distinguish the effects of CFS vs. depression is to look at the patient’s response to physical exertion. Persons with CFS/FMS typically become worse after physical exertion. In contrast, persons with depression as their main problem do not usually feel worse after physical exertion. Indeed, many people with depression tend to feel better with exercise.
The 1994 CDC Criteria specifically allows the diagnosis of CFS in the presence of each of the following conditions: 1. Any condition defined primarily by symptoms that cannot be confirmed by diagnostic laboratory tests, including fibromyalgia, anxiety disorders, somatoform disorders, nonpsychotic or nonmelancholic depression, neurasthenia, and multiple chemical sensitivity disorder.
(Please note: The DSM-IV definition of somatoform disorder forbids making the diagnosis of somatoform disorder if there is a concurrent physical ailment that can account for the patient’s symptoms e.g. fibromyalgia or chronic fatigue syndrome.)
2. Any condition under specific treatment sufficient to alleviate all symptoms related to that condition, and for which the adequacy of treatment has been documented. Such conditions include hypothyroidism for which the adequacy of replacement hormone has been verified by normal thyroid-stimulating hormone levels or asthma in which the adequacy of treatment has been determined by pulmonary function and other testing.
3. Any condition, such as Lyme disease or syphilis, that was treated with definitive therapy before development of chronic symptomatic sequelae.
4. Any isolated and unexplained physical examination finding, or laboratory or imaging test abnormality that is insufficient to strongly suggest the existence of an exclusionary condition. Such conditions include an elevated antinuclear antibody titer that is inadequate to strongly support a diagnosis of a discrete connective tissue disorder without other laboratory [tests], or when there are multiple conditions present, one important task for the medical expert is to judge how much each condition contributes to the patient’s limitations, and the degree to which treatment for a co-occurring illness is likely to improve the patient’s pain, stamina or other limitations.

8. What is appropriate medical treatment for FMS and CFS?
FMS: Currently, there are no FDA approved drug treatments for FMS. However, more than a half dozen medicines have at least one double blind study showing some benefit. However, less than half the patients in these studies benefit from any given medicine.
Intolerance due to side effects are very common. For persons with severe FMS, while the degree of improvement is occasionally impressive, most often the degree of improvement is fairly modest.
An appropriately slowly graded exercise program is helpful in fibromyalgia; doing no exercise at all may, over time, make things worse. However, for persons with severe disease, the amount of exercise tolerated is often very limited. Pushing past their limits, may make patients worse.
Exercise often must be started at very low levels, and advanced very slowly. The degree of improvement with even a well-programmed regimen is typically fairly modest. Even an appropriate exercise program would usually not bring a disabled patient to the point where he or she can return to work.
Cognitive Behavioral Therapy (CBT) a kind of short term, practical reality based counseling tends to be helpful. Many persons with any severe chronic illness, including CFS and FMS, tend to fall into a negative style of thinking. This may exacerbate both physical and emotional issues. However, the benefit from CBT, while often worth having, is also usually fairly modest.
If depression or anxiety become a problem, these should be treated. Often the primary care physician can do that quite well. In other cases, referral to psychiatrist or psychologist should be considered.
For Chronic Fatigue Syndrome, we have less research on treatment than we do for fibromyalgia. There are no FDA approved treatments. Indeed, there are no medicines on the market with any good double blind studies suggesting benefit for this disease. Very low level exercise and CBT are probably useful, but, for persons with severe disease, the degree of improvement with these methods is typically fairly small.

9. What should we make of the frequently used phrase: The medical records fail to show any objective evidence that the patient is unable to perform the duties of his or her job? This phrase is another example of “looking in the wrong place”.
This discussion is analogous to and partly repeats the issues discussed in sections, # 1-4 above. However, because this phrase or a close variant is used so often, it should be addressed directly.
When a physician or case worker states that “there is no objective evidence” one wants to infer that the writer believes that one should be able to find “objective evidence” if the patient were disabled.
It implies that there is some finding on physical exam or lab test that should be present when one is disabled and absent when one is not. The problem with this inference is that it is medically false. The reasons for this conclusion has already been discussed. Hence, this use of the “no objective evidence” phrase is, at its core, misleading.
Consider this case. We line up two 33 year old women with CFS and Fibromyalgia. One is completely unable to work because of markedly reduced physical stamina. The other is tired and achy but able to get through a 40 hour work week. How should these two differ on physical exam, or lab tests?
All experts on FMS and CFS would agree, that there is no finding observable on an office physical examination or laboratory test that should reliably distinguish between the two persons. Their standard examination should look just the same.
To suggest that there should be physical exam or lab findings that distinguish between these two–a kind of “Do you still beat your wife” question-- misunderstands the nature of FMS and CFS. Of course, this brings us back to the patient’s reported history, its consistency and credibility, as the fundamental issue.


Richard N. Podell, M.D. Clinical Professor, Dept. of Family Medicine, UMDNJ-Robert Wood Johnson Medical School
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Tuesday, February 28, 2006


This is me! :)  Posted by Picasa

Update!

Hello everyone! Hope all is well! It has been awhile since I last updated everyone on me so here I go..........................

My last doctors appointment was 2-23. Dr. B had been sick the whole week before I came so he had not yet looked at my capsule endoscopy pictures so I did not get to find out about those. We did however take a look at all the medications I was taking. He took me off half of my medications. He increased my Effexor to 150 mg a day. My body went through a 72 hour period of withdrawal symptoms from not being on the medications. That was really bad. My fibromyalgia is flared up big time. I am in so much pain its ridiculous! I almost feel stupid because I was in pain before while I was on the meds and complained all the time. Now being off the meds I feel a million times worse and feel so bad for ever complaining before. I talked to the doctor and complained about my pain. He seems to think that the Effexor is going to be cure all. I am leery on this but I guess we shall see. I am going to tell him though tomorrow that I have to go back on my Sanctura for my bladder. Going off that was NOT GOOD, and I am not going to continue being off it! My bladder has been a MESS! So, that is really all thats been going on. We shall see how this all pans out. I am starting to have a negative feeling about this doctor. But as a human I like him so I am going to keep seeing him and go from there. I had such high hopes. Oh well, we just have to wait and see. I go back to see him tomorrow. He should have my results of the capsule pictures. HE BETTER anyways! OH! The last blood results showed that my blood count went up a 1/2 a point which is good. It shows that wherever I was bleeding from is starting to heal itself. I was VERY happy about that. So, I will fill you in as soon as I can about any new news or developments I have.

Have a great day!

YANA

Monday, February 20, 2006

Update!

Hello everyone! How is everyone doing? Hopefully all is going well.

Just thought I would post a quick update of whats been going on with me. Nothing to exciting to report. Last week Thursday I went in for the Capsule Endoscopy. Was real easy. Although the belt that was around me being held with suspenders was less than attractive. :)~ I also had some more blood work drawn. They want to make sure that my blood count didn't drop some more.

I go this Thursday again back to Binghamton to get all the test results and to see what happens from there. I am very interested in what he has to say. When I had to return the machine back to the hospital I got to see a few pictures of my small intestine. A lot of them were not clear, thanks to some food still lingering in there, so she said I might need to redo it again. Wasn't to happy to hear that. We did see a couple clear pictures and one showed a bright red spot so there is definitely something going on in there. I didn't stay for the whole download so there were TONS of pictures I didn't get to see. Hopefully they were better.

So, thats about it my way. I've been very tired which is to be expected. Still not feeling well. Not a surprise there. BP was still a smidgen high which I wasn't to thrilled about. Now that my BP pills were increased to 2 a day it shouldn't have been where it was. It was 139/90 which is still not great. It should be in the 120/80's! I see my primary doctor the 13th of March so hopefully by then its better or if it isn't he will have another plan of attack. I told him the last time I saw him that I should just move in with him because I see him more than I do anyone else. He laughed. I am glad I have such a good doctor with a good sense of humor and understanding.

So, I guess I am going to close for now. As soon as I know more I will update you all. Much love to all of you.

~~~~~YANA~~~~~

Saturday, February 18, 2006

6 Serious Medical Symptoms
By Jeanie Lerche DavisWebMD Feature
Reviewed By Michael Smith, MD


Like red-light warnings on the dashboard, the human body sends out a flare when something's awry. Chest pain, shortness of breath, dizziness -- those are some familiar medical symptoms.
But other problems can creep up on you, too -- aches and pains, lumps and bumps. When are they important, when are they not?

In his book, Your Body's Red Light Warning Signals, Neil Shulman, MD, provides a head-to-toe owner's manual for the human body. His book lists hundreds of medical symptoms that could mean life or death, or serious disability.

Shulman, a professor of internal medicine at Emory University School of Medicine in Atlanta, has authored numerous medical books and scientific papers. It's serious stuff, stuff he likens to "terrorists inside our bodies," he tells WebMD. The symptoms are "killing way too many people. There's tremendous suffering and horrible death which could be avoided, but people don't know that something's wrong."

In fact, it happens all the time, a symptom is missed -- and it leads to a tragic ending. Or it's caught just in time, and a life is saved. Quite literally, it's that dramatic, Shulman tells WebMD.
Here are "six flags" -- six medical symptoms -- you should keep in mind:


1. If you have unexplained weight loss and/or loss of appetite, you may have a serious underlying medical illness. "If you're on a diet, you're expecting this to happen. But if you're eating the same way -- and now have to adjust your belt a few notches tighter -- you could have a serious problem," Shulman says. "With ovarian cancer, the opposite is true," he says. "Fluid builds in the abdomen, and women think they are gaining weight. But if you have been at the same weight range for years, and doing nothing different, see a doctor."


2. Slurred speech, paralysis, weakness, tingling, burning pains, numbness, and confusion are signs of a stroke, and you should get to an appropriate emergency center immediately. Early treatment may prevent permanent damage to the brain or even save your life. Slurred speech can often go unnoticed, says Shulman. However, you might have a blood clot in a blood vessel going to the brain or bleeding in a blood vessel.Other indicators


3. Black, tarry stools may indicate a hemorrhage from an ulcer of the stomach or the intestine. It is important to stop the bleeding and to rule out cancer as a cause. What you eat changes the color of stools. But black, tarry stools mean there may be bleeding higher in the intestine, says Shulman. It could be a sign of a bleeding ulcer or cancer in the intestine.


4. A headache accompanied by a stiff neck and fever is an indicator of a serious infection called meningitis. In fact, if you can't put your chin on your chest, that's a sign you may have bacterial meningitis, says Shulman. You need antibiotics immediately to kill the bacteria before it infects and scars the brain.


5. A sudden, agonizing headache, more severe than any you have felt before, could mean you are bleeding in the brain. Go to an emergency room immediately. A brain aneurysm is rare, but it can happen -- even in people under 40. "It can be very disastrous if it's not treated," says Shulman. If you have a severe, crushing headache, you may have an aneurysm, which is a blood-filled pouch bulging out from a weak spot in the wall of a brain artery. If treated before it bursts, it could save your life.


6 a. For women: Vaginal bleeding after menopause is a waning sign of possible cancer.
Some women are in denial when they discover postmenopausal bleeding. "Others think it's a little cut, or something in their urine," says Shulman. But bleeding after menopause is a sign of uterine cancer, which is treatable if caught early.

6b. For men: A lump in your testicle with or without a small lump in the groin could be serious. Testicular cancer is more commonly found in testicles that did not naturally descend from the abdomen to the scrotum. Guys, when you take a shower, check yourself, says Shulman. "That doesn't mean you have to do it every day, but once in awhile. It's so simple, simpler than washing your hair. It becomes an automatic thing, then it's easier to remember. If you know what 'normal' feels like, then you'll know when it feels abnormal."

'Squeaky Wheel' Works
It's an old, old saying: The squeaky wheel gets the grease. But it's vitally important in medicine, says Shulman. If you know something's not right with your body -- if you've got that severe, crushing headache, but doctors aren't taking it seriously -- stand up for yourself.
Tell doctors you know it could be a problem -- "I want you to rule this out," you should say. If they balk, here's your line: "I want you to write on the chart that you refused to do proper tests." Doctors are human; they get tired and distracted. It helps to get extreme, to get their attention, says Shulman.

"Sometimes you have to make a scene," he tells WebMD. "The one person most likely to be concerned about whether you live or not is you. You have the greatest empathy for yourself."
All adults -- from senior year of high school and up -- should be familiar with standard medical symptoms, to help them preserve their good health.



Originally published July 7, 2003.Medically updated Feb. 15, 2006.



SOURCES: Your Body's Red Light Warning Signals. Neil Shulman, MD, professor of internal medicine, Emory University School of Medicine, Atlanta.

Friday, February 17, 2006

Spicier Sex Life

Eat Your Way to a Spicier Sex Life
By Jennifer WarnerWebMD Feature
Reviewed By
Brunilda Nazario, MD


Forget perfume, the keys to spicing up your sex life may already be in your kitchen.
Researchers say the smell, taste, and even appearance of certain foods can act as potent aphrodisiacs that not only get you in the mood for love, but also may even make you a better flirt and lover. And knowing what foods are appropriate at each stage of the sex and mating process can maximize these effects.
"Different foods have different nutrients and substances that affect the body physiologically in different ways, that's why different foods work for different stages," says clinical sexologist Ava Cadell, PhD. "Some foods lower inhibitions, some get the blood flowing directly to the genitalia, and some foods release happy hormones."
Cadell has grouped aphrodisiacs into three groups based on the physiological effects they have on the body and how those effects can enhance sexual performance at each stage of a person's sex life.

Foods for Flirting

When looking for a potential mate, Cadell says it's important to choose foods that secrete chemicals and hormones that make you happy in order to increase self-confidence, lower inhibitions, and make you a better flirt.
Flirt-friendly foods include:
Chili peppers. Spicy foods get the heart pumping and induce sweating.
Bananas. They contain chemicals that reportedly have a mood-lifting effect on the brain and raises self-confidence.
Carrots. Their phallic appearance and high-fiber content may induce sexual desire.

Foods for Seduction
In the next stage, seduction, aphrodisiacs can help trigger the release of sex hormones, such as testosterone, provide a quick energy boost, and increase blood flow to the genitals to get the body "in the mood" for love.
At this stage, Cadell says it's important to create a visual stimulation with foods that look like the genitalia, such as oysters, fresh figs, or carrots.
"Anything that is visually erotic is automatically going to set your brain in motion," says Cadell. "Second, certain foods release hormones, like testosterone in women that makes them more sexually aggressive and adventurous."
Other foods for seduction include:
Shrimp. High in iodine, shrimp and other types of seafood are vital to the thyroid gland, which is vital for energy.
Chocolate. Not only does chocolate provide a jolt of caffeine, the plant has a flower that looks like sex organs.
Ginger. This root reportedly increases blood flow to the genitals in both men and women.
Olives. Green ones are believed to make men more virile, while black ones increase women's sex drive.
Tomatoes. Known as "love apples" by Puritans, they have a reputation as a sexual stimulant.
Apples. Since Adam and Eve, this fruit has been synonymous with temptation.
"My favorite thing is that when you're with someone is to feed each other with the most seductive foods you can find," says Cadell, "like an asparagus where one person can start at one end and another at the other end and you meet in the middle."
Cadell says not only is asparagus a sexy, long, phallic-looking food, but it's rich in potassium, phosphorus, calcium, and vitamin E that can aid in hormone production and raising energy levels.

Foods for Sexual Performance

When it comes to the final stage of exploration and orgasm, even the scent alone of some aphrodisiacs may be enough to increase sexual arousal and enhance performance.
"Depending on where you are in your relationship you may want to use different food odors and tastes, since 90% of taste is smell, to get the different responses you're looking for," says Alan R. Hirsch, MD, neurological director of the Smell and Taste Treatment and Research Foundation in Chicago.
In a study that looked at what scents stimulated sexual arousal, Hirsch found every food aroma they tested triggered a sexual response in men, and some foods had more dramatic effects than others.
"For example, cheese pizza increased penile blood flow by 5%, buttered popcorn by 9%, and lavender and pumpkin pie by 40%," Hirsch tells WebMD. "So you may want to start with something like cheese pizza to begin with."
In comparison, floral perfume only prompted a 3% increase in blood flow to the penis among men. Among women, the smell of men's cologne actually lowered blood flow to the vagina.
The study also found that the scent of lavender and pumpkin pie was a powerful sexual stimulant for women, but the combination of Good and Plenty (licorice-flavored candy) and cucumber was the most potent sexual scent in increasing blood flow to the vaginal area.
Unlike with men, the study found that some food smells actually inhibited sexual desire in women, such as cherries and the odor of barbeque or roasting meat.

A Smorgasbord of Aphrodisiacs

Hirsch says there are a number of different theories about why foods have such a strong effect on sexual attraction and performance, but it's likely a combination of physiological and psychological responses at work. Because the effects of different foods are linked to past experiences, the sexual potency of various tastes and smells naturally vary greatly from person to person.
That's why both Cadell and Hirsch recommend having fun with trying different aphrodisiacs to see what adds the right spice to your sex life.
"Have a smorgasbord of aphrodisiacs, because they're not all going to appeal to everybody," says Cadell.
According to the FDA, there is no scientific proof that any over-the-counter aphrodisiacs or foods can treat sexual dysfunction. In fact, over-indulgence in food or drink is a sure way to doom sexual performance and dampen desire.
But while aphrodisiacs may not be a quick fix all your sexual problems, Cadell says the natural aphrodisiacs found in foods are not dangerous.
"Let's be honest, the most erotic organ is the brain. So if you think something will turn you on, I guarantee it will," says Cadell. "There has always been a correlation between food and sex because they are two of greatest pleasures known to mankind, and both appetites need to be fulfilled."

Originally published Jan. 26, 2004.
Medically updated February 2006.


SOURCES: Ava Cadell, PhD, clinical sexologist in private practice in Los Angeles and author of Twelve Steps to Everlasting Love and Between the Sheets. Alan R. Hirsch, MD, neurological director, Smell and Taste Treatment and Research Foundation, Chicago. FDA. WebMD Feature: "Aphrodisiacs Through the Ages." WebMD Feature: "Want Better Sex?"

Midnight Snacks

Midnight Snack Won't Pack Fat
(By Daniel DeNoonWebMD Medical News)
(Reviewed By Louise Chang, MDon Thursday, February 02, 2006 )

Feb. 2, 2006 - A midnight snack won't make you fatter than a midmorning munch, monkey studies show.
It's a widely accepted truism that food eaten after dark is more fattening than the same food eaten in the light of day. And there's a reason to believe this: The body does slow down at night.
Researchers have tried to look at the issue, but it's been hard to do a definitive study in humans. That's why Judy L. Cameron, PhD, senior scientist at the Oregon National Primate Research Center in Beaverton, looked at 20 female monkeys instead.
To mimic human menopause, Cameron's team removed the monkeys' ovaries. To mimic human junk food, the researchers fed the monkeys a high-fat diet. And because some of the monkeys ate about two-thirds of their calories at night, Cameron and colleagues were able to look at the effects of nighttime meals.
"The outcome was, there was no difference at all," Cameron tells WebMD. "Whether they eat by day or by night, monkeys have an equal probability of gaining weight. So weight gain depends on how many calories we eat, and not when we eat them."
When not doing monkey research, Cameron is professor of physiology and pharmacology, obstetrics and gynecology, and behavioral neuroscience at Oregon Health & Science University in Portland. She and her colleagues report their findings in the current issue of Obesity Research

Weight Gain Knows No Clock
None of this surprises Leslie Bonci, MPH, RD, director of sports nutrition at the University of Pittsburgh Medical Center and nutritional consultant to the Pittsburgh Steelers football team.
"People just assume that after 6 p.m., calories that will become fat go straight to your butt," Bonci tells WebMD. "But the body is clueless about what time it is when you eat too much. It knows how to store calories every hour of the day."
For most of us, this is good news.
"We don't have those lifestyles where we go to bed when the sun goes down," Bonci says. "If it were true that nighttime eating made you fat, everyone in Spain would be obese -- because they don't eat dinner until 10 p.m."
The myth that midnight snacks cause fat can be harmful, Cameron says, if your weight loss plan is simply to stop eating when the sun stops shining.
"The story one wants people to take home is you should watch your calorie intake," she says. "Whenever you take in calories, they are going to matter. It is one thing not to eat at night. But if you want to lose weight, don't eat so much during the day. Just not eating at night is not an effective strategy."

The Key to Weight Control
Even though they ate a high-fat diet -- nearly quadrupling their calories -- not all of Cameron's monkeys gained weight. A few got fat. Some stayed lean.
What happened?
"It was mostly due to activity level," Cameron says. "The strongest predictor of weight gain in adult monkeys was how active they were. Very active animals did not gain weight, and very sedentary animals gained quite a bit."
But these are just monkeys -- aren't they? Actually, Cameron says that monkeys are a lot like humans in terms of how they eat, sleep, and exercise.
"We think monkeys are a very, very good model for humans," she says. "As far as we can tell, their mechanisms of weight gain are the same as humans."
A real problem with obesity research is that it's almost impossible to know for sure how much human study participants actually eat and exercise. That's not a problem in monkey studies. Cameron says we can look for more information to come from her monkeys -- including studies on the impact of menopause and hormone replacement on weight.





SOURCES: Sullivan, E.L. Obesity Research, December 2005; vol 13: pp 2072-2080. Judy L. Cameron, PhD, senior scientist, Oregon National Primate Research Center, Beaverton; professor of physiology and pharmacology, obstetrics and gynecology, and behavioral neuroscience, Oregon Health & Science University, Portland. Leslie Bonci, MPH, RD, director of sports nutrition, University of Pittsburgh Medical Center; nutritional consultant to the Pittsburgh Steelers and the Pittsburgh Ballet Theatre company.© 2006 WebMD Inc. All rights reserved.


Love Secret of Happily Married Couples

Love Secret of Happily Married Couples
(By Miranda HittiWebMD Medical News )
(Reviewed By Ann Edmundson, MDon Thursday, February 09, 2006)

Feb. 9, 2006 -- Want a better love life that goes beyond Valentine's Day romance? Prize your partner's happiness and well-being above your own, a new survey suggests.
Those feelings -- called altruistic love -- are at the heart of the survey, which included more than 1,300 people, 60% of whom were married.

The findings:
Married people with lots of altruistic love for their spouse had happier marriages.
Married or not, altruistic love for a significant other was tied to higher levels of general happiness.
The survey was part of the General Social Survey, directed by Tom W. Smith, PhD, of the National Opinion Research Center at the University of Chicago.

Rate Your Own Altruistic Love
Curious about your own level of altruistic love? Rate how strongly you agree or disagree with these statements:
I would rather suffer myself than let the one I love suffer.
I cannot be happy unless I place the one I love's happiness before my own.
I am usually willing to sacrifice my own wishes to let the one I love achieve his/hers.
I would endure all things for the sake of the one I love.
By a long shot, the majority of survey participants agreed or strongly agreed with those statements.
Nearly nine in 10 agreed or strongly agreed with the first statement. About seven in 10 agreed or strongly agreed with the second statement. About eight in 10 agreed or strongly agreed with the last two statements.

Happier in Marriage
Married people "that express a high sense of altruistic love toward their significant other turn out to have much happier marriages," Smith tells WebMD.
Altruism is usually defined as helping others without getting anything back, Smith notes. "In this case, it turns out there is a positive payback," he says.
Married people get a "significant increase" in marital happiness if they have "this kind of self-sacrificing, put-the-interest-of-the-other-before-my-own-interest perspective on their romantic and close relationships," says Smith.
Altruistic love can create a positive cycle in relationships, he adds.
"I'll say I put my wife's interests ahead of mine," Smith explains. "Well, she appreciates that and she does the same back to me, and it strengthens the relationship and it leads to a happier marriage. So, I think that's the mechanism."
More studies are needed to check that theory, Smith says.

Not Just for Married People
Married people were more likely to rank high in altruistic love than the unmarried. But altruistic love was a boon for everyone -- no wedding band required.
"Having feelings of altruistic love toward the significant other -- a spouse, co-habitating partner, a simple romantic interest, which hasn't gone as far as either of those relationships -- not only leads to greater marital happiness but general increase in general happiness in one's life," Smith says.
Humans are "both self-interested and self-sacrificing," he notes. "I think sometimes we think of us as only in competition and material benefit and whatnot, and there's clearly more to human psychology than that."


SOURCES: National Opinion Research Center, University of Chicago: "Altruism and Empathy in America: Trends and Correlates." Tom W. Smith, PhD, director, General Social Survey, National Opinion Research Center, University of Chicago. News release, University of Chicago.

Wednesday, February 15, 2006

Nascobal® (Cyanocobalamin, USP)





Nascobal avoids the gastrointestinal tract by delivering vitamin B-12 directly to the bloodstream through blood vessels in the nose. This product is ideally suited for patients with gastric surgeries where absorption of B-12 from foods and oral supplements may be either poor or does not occur at all.
No more need for painful B-12 shots. Nascobal Nasal Spray is the only FDA approved alternative to intramuscular B-12 injections
Convenient, patient self administered nasal spray for treating B-12 deficiency. One puff, one nostril, once weekly
Clinically proven smooth and consistent B-12 blood levels compared to intramuscular injection
Each Nascobal bottle provides a 2 month supply of 8 doses, with only one-co-pay.
Available everywhere. Ask your doctor or nurse for a prescription
For more information, please visit http://www.obesityhelp.com/et.php?u=704777&n=241&r=http://www.nascobal.com or call 1-866-528-4750*This product is not indicated for patients with sensitivity to cobalt and/or vitamin B12 or any component of this medication.
Hello to everyone! Just thought I would post an article on what I might have going on inside of me right now! Hopefully not, but if it is it can be an easy thing to fix. Lets hope so anyways. Hope all is well! MWAH!



SMALL BOWEL BLEEDING AND CAPSULE ENDOSCOPY
(Max Tilson, M.D. and John R. Saltzman, M.D., Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts)


1. What is the Small Bowel?
The small bowel (or small intestine) is the longest portion of the intestinal tract. It is called "small" because it is thin or narrow compared to the "large" bowel, but it is much longer than the large bowel. The small intestine is the organ of nutrient absorption, and as such it is a vital organ. It is hard to reach with instruments passed by either the mouth or the anus because it is located between the stomach and the large bowel.



2. What is Small Bowel Bleeding?
Intestinal bleeding, including from the small bowel, occurs when an abnormality on the inner lining begins to bleed. It may bleed slowly (causing anemia or low blood count) or may cause a hemorrhage. Fortunately, only 3-5% of all gastrointestinal bleeding comes from the small bowel, and most of these abnormalities lie within reach of the standard endoscope used to evaluate the stomach and upper small bowel. An endoscope is a tube instrument with a light and camera at one end passed through the mouth) after receiving a sedative). A longer instrument called an enteroscope can reach further into the small bowel.

3. Why is it Difficult to Find the Source of Small Bowel Bleeding?
Determining the source of gastrointestinal (GI) bleeding that originates in the small bowel (the area of the intestine between the stomach and the colon) is one of the major diagnostic challenges facing gastroenterologists. Many small bowel causes of blood loss go undetected because the small bowel is long and hard to reach and therefore difficult to evaluate. The small bowel is constantly contracting and relaxing making visualization impossible for more than a few seconds. In addition the small intestine is much more mobile than either the stomach or colon, making endoscopy much more difficult. X-ray studies may be unable to pinpoint exact locations of abnormalities so that if masses or bleeding lesions are found, their location is difficult to accurately describe to the surgeon for removal. Finally the small bowel is more then 17 feet long, which is much longer than any of the instruments currently available.

4. What Causes Bleeding from the Small Bowel?
The causes of bleeding in the small bowel are different from those in the colon or the stomach. The most frequent causes of large bowel (colon) bleeding are polyps, diverticulosis or cancer. Upper GI (esophagus, stomach or duodenum) bleeding sources are most frequently associated with ulcers. However, unlike the colon and the upper GI tract, 70-80% of small bowel blood loss that is significant enough to warrant investigation is caused by abnormal blood vessels that lie within the wall of the small bowel. These abnormal blood vessels called AVMs (arteriovenous malformations) are invisible to standard X-rays. Other, less common causes of small bowel bleeding include both benign (non cancerous) and malignant (cancerous) tumors, Crohn's disease (an inflammatory bowel disease) and ulcers.

5. What Tests are Performed to Detect Bleeding From the Small Bowel?
X-ray studies continue to have a role in the evaluation of small bowel bleeding, as 20-25% of bleeding episodes that originate in the small bowel are caused by abnormalities in the intestinal wall that can be seen by standard or specialized X-ray studies. Fortunately, most of the causes of bleeding in the small bowel are AVMs that, once treated, are of little consequence. However, both benign tumors as well as malignant cancers can be found in the small bowel, so X-ray testing remains a good initial test.
The two X-ray tests most commonly used in the evaluation of the small bowel are the small bowel follow-through and enteroclysis. The small bowel follow-through test is a series of abdominal X-rays that are taken at different times after a patient drinks a white chalky fluid called barium that shows up clearly on X-rays. The test allows the doctor to see the lining of the intestine for any irregularities as the barium flows along its course. The test is good for large abnormalities, but can miss many smaller ones. However, it is safe, easy to tolerate, and can demonstrate irregularities in the bowel that are unreachable by standard endoscopy.
A second X-ray test, the enteroclysis study, is similar to the small bowel follow-through in that it uses barium to visualize the inner wall of the small bowel. It is more invasive because it requires a small tube called a catheter to be slowly advanced from the nose down the esophagus, through the stomach and into the small bowel, to allow for air and barium to be instilled. The advantage of this study is that pictures from enteroclysis have better resolution so abnormalities missed by the small bowel follow-through test may be detected. A disadvantage of the enteroclysis study is that it can be an uncomfortable examination due to the presence of the catheter and the use of air to distend the small bowel while taking pictures. The study is also not perfect at finding abnormalities. Two major limitations of these radiographic studies are 1) neither can detect AVMs that are the most common causes of small bowel bleeding, and 2) if an abnormality is seen, there is no way to apply immediate treatment to stop the bleeding or to take biopsies to confirm a diagnosis.
The best way to find most of the causes of small bowel bleeding is to directly look at the small bowel with an endoscope. Most abnormalities that cause small bowel bleeding lie within reach of either a standard endoscope, or a much longer endoscope called an enteroscope that can reach further into the small bowel. If neither one of these is successful at finding the cause, surgical assistance may be needed, where in the operating room, a surgeon pushes the endoscope through the intestine, allowing full examination of the entire small bowel. The advantage of endoscopy is that it allows the doctor to treat the cause of bleeding at the time of discovery (for blood vessels), or biopsy suspicious masses or polyps. Endoscopy is safe, reliable and effective, and is often used as a first step in the evaluation of bleeding that arises in the small bowel, although the technique involving surgery is generally reserved as a last resort. Recently, a new technique called capsule endoscopy has emerged as an effective way to evaluate the small bowel for bleeding.

6. What is Capsule Endoscopy?
In 2000, a group of doctors from England reported the use of a new instrument for determining the causes of small bowel bleeding. The device, the endoscopic capsule, is 1-1/8 in long and 3/8 in width, the size of a large pill, and held a battery with a 6 hour lifespan, a strong light source, a camera and a small transmitter. Once swallowed, the capsule begins transmitting images of the inside of the esophagus, stomach and small bowel to a receiver worn by the patient. After 6 hours the patient returns the receiver to the doctor who loads the information into a computer and then can review in detail the 6 hours of pictures of the capsule passing through the intestine looking for abnormalities that are possible sources of bleeding. The patient passes the capsule through the colon and it is eliminated in the stool and discarded. The capsule is safe, easy to take and has had only rare reported side effects. However, the capsule can get stuck in the small intestine if there has been prior abdominal surgery causing scarring or due to any other condition that causes narrowing of the small intestine. If the capsule becomes stuck, surgical removal is necessary.

7. How Effective is Capsule Endoscopy at Detecting the Source of Small Bowel Bleeding?
In an initial study, investigators showed that the capsule was better than routine endoscopy or enteroscopy at locating small beads that had been implanted into an animal's intestine. Other studies have shown the capsule is more effective than small bowel x-rays at finding the cause of bleeding. In 2001, the first human studies reported that capsule endoscopy not only found all of the bleeding sources seen using standard endoscopy, but also an additional bleeding cause in 56% of patients for whom traditional endoscopy had not been successful. In 2002 and 2003, numerous scientific presentations showed the use of capsule endoscopy in obscure GI bleeding, as a screening tool for patients with genetic predisposition for small bowel cancer, for small bowel Crohn's disease and for small bowel malabsorption. The capsule endoscope is now the new first line test for evaluation of small bowel GI bleeding in many medical centers.
However, capsule endoscopy technology is not perfect. Although it is better than other available techniques to detect sources of small bowel bleeding, capsule endoscopy does not detect all sources of small bowel bleeding. Like X-rays, the capsule is purely diagnostic and cannot be used to take biopsies, apply therapy or mark abnormalities for surgery. Moreover, the capsule cannot be controlled once it has been ingested, so that once it has passed a suspicious abnormality, its progress cannot be slowed to better visualize the area.
Despite these limitations, it is increasingly clear that capsule endoscopy has a place in the evaluation of small bowel bleeding, and that it will replace some standard diagnostic techniques currently in use. The technology is not yet at a point where it can adequately visualize enough of the colon wall. However, one day the use of the capsule endoscopy may be extended to routine colorectal cancer screening.

8. Treatment of small bowel bleeding:
Whether diagnosed by routine endoscopy, enteroscopy or capsule endoscopy, once the cause of small bowel bleeding is determined, the treatment is straightforward. In cases of AVMs, a small amount of electric current can be delivered through the endoscope to destroy the abnormality. If the AVM is discovered during endoscopy, the treatment can be applied immediately without requiring further endoscopy. If found with the capsule, the options include a repeat endoscopy or an enteroscopy if the AVMs are within reach, or surgical assistance as described above to help reach the site. Polyps can be removed with an endoscope. Cancers require surgical removal. Other causes of small bowel bleeding can be treated medically (Crohn's disease).

9. Conclusions:
Bleeding from the small bowel is a rare cause of GI blood loss. Cancers, inflammatory bowel disease and infection account for 20-25% of all small bowel bleeding, while AVMs account for the vast majority of causes. Endoscopic therapy is limited to the parts of the bowel within its reach and is the only minimally invasive way to apply direct treatment to bleeding sources or take biopsies. The development of the endoscopic capsule has changed the way in which gastroenterologists will approach GI bleeding from the small bowel. With further development and innovation, capsule endoscopy will improve the management of this condition.

Monday, February 13, 2006

FOUR POSSIBLE CAUSES OF YOUR PAIN AND FATIGUE:
1. Low Thyroid Levels Despite Normal “Standard” Blood Test Results. Have you been told over and over your thyroid levels are normal? You may actually have severely low thyroid not detected by standard tests.
2. Adrenal Exhaustion. Adrenal exhaustion is often the cause of serious fatigue. Sophisticated blood/urine tests required for an accurate diagnosis are often not done. The strength and health of your adrenal system are critical to you.
3. Undiagnosed Chronic Infections and Yeast Overgrowth. Frequently, patients have active bacterial and viral infections like Epstein Barr or Mycoplasma, which can drain your body’s immune system. Often, fatigue or muscle pain results from an undetected chronic infection that never improved.
4. Underlying Mitochondrial Dysfunction. The mitochondria are the energy producers of the cells and are critical for normal functioning. Dysfunction results in the cells starving for energy with patients fatigued, lacking energy, unable to overcome infections and more.
Find out why these conditions occur and how Fibromyalgia & Fatigue Centers can work with you to overcome your pain and fatigue by treating the symptoms, not just masking them. There is help and hope!
Get your life back…Come to our free monthly educational seminar, which includes a tour of our Center, a presentation by our staff physician, and an opportunity for you to meet the staff and learn about our treatment approach.

Call a Center nearest you to reserve your seat today:

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