Establishing a Disability Claim for Fibromyalgia Condition

For many years, attempting to bring a claim for Fibromyalgia was made all the more difficult by the Social Security Administration’s seeming indifference and lack of acceptance of the disorder. In 2012, the Social Security Administration (SSA), however, promulgated Ruling 12-2P which has helped guide disability adjudicators and judges as to the manner in which such a claim should be evaluated. And for many years prior to 1990, the medical community was left without any clear guidelines as to what constituted a patient suffering from the disorder characterized as “Fibromyalgia.” In fact, doctors would routinely come to the conclusion that those who were suffering from musculoskeletal complaints, causing pain, in multiple areas of their body for which there was no good explanation (including no good cause and no good diagnosis) were suffering from what they would term “Fibromyalgia.” This would serve to provide some sense of validation to the patient that their problems were not merely psychosomatic.

However, in 1990, the American College of Rheumatology provided their own criteria for what formed the basis of a diagnosis of Fibromyalgia. From an initial standpoint, the criteria included a determination by the physician through “digital palpation” that the individual would experience pain to particular areas of the body when a force of 9 lbs. was used on various points of the body. The 18 points included both sides of the following areas of the body (that is right and left side):

  • 1) occiput (base of the skull)
  • 2) low cervical spine (back and side of the neck)
  • 3) trapezius muscle (shoulder)
  • 4) supraspinatus muscle (near the shoulder blade)
  • 5) second rib (top of the rib cage near the sternum or breast bone)
  • 6) lateral epicondyle (outer aspect of the elbow)
  • 7) gluteal (top of the buttock)
  • 8) greater trochanter (below the hip) and
  • 9) inner aspect of the kne

A finding of at least 11 positive tender points on physical examination was necessary in order to establish the condition, including the need to exclude through testing that other conditions were the cause of the individual’s pain. Examples of such tests have included blood testing for Lyme disease, for indicators of other conditions such as rheumatoid arthritis, Lupus, Lyme disease, thyroid disorder, etc. .

The American College of Rheumatology revisited the issue of diagnostic criteria for Fibromyalgia in 2010 and, these criteria formed the basis for Social Security Ruling 12-2P set forth in 2012. The ruling provides that an individual may be found to have the medically determinable impairment of Fibromyalgia assuming they meet the prior trigger point examination criteria and likewise is found to have:

  • 1) A history of widespread pain – that is, pain in all quadrants of the body (the right and left sides of the body, both above and below the waist) and axial skeletal pain (the cervical spine, anterior chest, thoracic spine, or low back) – that has persisted (or that persisted) for at least 3 months. The pain may fluctuate in intensity and may not always be present.

Social Security Ruling 12-2P additionally provides that based on the 2010 preliminary criteria, which allows for findings without the need for trigger point examination findings, that should there be a finding of the widespread pain described above and if there is found to be “six or more FM symptoms, signs, co-occurring conditions, especially manifestations of fatigue, cognitive or memory problems (‘fibro fog’), waking unrefreshed, depression, anxiety disorder, or irritable bowel syndrome.” Likewise, other causes for these co-occurring symptoms must be excluded. Some additional co-occurring symptoms that are listed as possibilities as well: chronic fatigue syndrome, irritable bowel syndrome, interstitial cystitis, temporomandibular joint disorder, gastroesophageal reflux disorder, migraines or restless leg syndrome.

Given the specificity required in diagnosing the condition and in establishing the condition as a medically determinable impairment which must be given consideration by SSA as to how it impacts an individual, it is of utmost importance that an individual is being regularly assessed by a rheumatologist who is intimately familiar with the condition. Likewise, as with all medical conditions, it is necessary to show that one remains totally disabled from a severe medical impairment despite prescribed treatment. Thus, a specialist in Fibromyalgia (a rheumatologist) will be familiar with the various medications and dosages that are typically prescribed for this condition, such as Gabapentin (brand name Neurontin), Duloxetine (Cymbalta), Milnacipran (Savella). Likewise, certain antidepressants have been shown to be beneficial in the treatment of Fibromyalgia, including Amitriptyline, Venlafaxine (Effexor), Citalopram (Celexa), Fluoxetine (Prozac) and Paroxetine (Paxil).

In providing advice and assistance to those disabled from Fibromyalgia (and with all other conditions as well), our office will undertake a detailed assessment of your treatment history to determine whether it appears additional treatment options have been left unaddressed as this 1) is beneficial to you, personally, as the goal is always to get better from one’s illness or injury and not be in need of disability benefits and 2) ensure that you have provided the SSA with the evidence necessary that you have remained disabled “despite prescribed treatment.”

Feel free to contact our office for a free assessment of your claim by calling the Law Offices of Russell J. Goldsmith at 1-800-773.8622.

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