Scientific Study Results:
Cervical Spinal Cord Compression
and Chiari I Malformation in
Fibromyalgia Patients
The National Fibromyalgia Research Association funded a scientific research study coordinated by neurosurgeon, Michael Rosner, MID under the direction of Robert Bennett, M D at the Oregon Health Sciences University and under the direction of Dan Clauw, MD at Georgetown University to ascertain the percentage of people diagnosed with FM who suffer from cervical spinal cord compression and/or Chiari I malformation.
Dr. Rosner presented the results of this study at the 2000 American College of Rheumatology meeting in Philadelphia, stating that pathology of the cervical neck area and foramen magnum in both the fibromyalgia patients and the control patients appeared to be about equal.
However, Dr. Rosner also stated that the researchers of this study agreed that approximately 75% of the fibromyalgia patients in the study had abnormal neurological examinations that correlated with MRI findings compared to approximately 10% of the control patients.
Results of this study have prompted leading fibromyalgia scientific researchers to encourage physicians to execute a detailed neurological examination on all patients suspected of having a fibromyalgia diagnosis. If abnormalities are detected in several areas of the neurological physical examination, an MRI along with other tests should be considered to rule out neurological conditions causing the patient's symptoms.
Visit the NFRA website at www.nfra.net for further information.
NEUROLOGICAL EXAMINATION
A detailed examination must include tests in the following areas to illustrate a comprehensive picture of the patient's total neurological condition.
Mental status: A screening process assessing attention, orientation, immediate and short term recall, language and the ability to follow simple verbal and written commands, should be administered by the examiner.
Autonomic: General information concerning urinary, bowel and sexual function, plus balance information, should be gathered by the examiner.
Spinal Exam: The examiner should perform a visual inspection of the spine, including checking for scoliosis. Sciatic nerve involvement (Lasegue sign) should be ruled out and a general exam for other spinal conditions should ensue.
Gait and Coordination: The examiner tests for:
• Rapid alternating movements of hands, fingers, feet.
• Point-to-point movements, such as touching index finger to the nose several times.
• Romberg sign- patient stands with eyes closed for 5-10 seconds without failing over.
• Gait-the patient:
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• Walks across the room, turns and comes back.
• Walks heel-to-toe in a straight line.
• Walks on toes in a straight line.
• Walks on the heels in a straight line.
• Hcps in place on each foot.
• Does a shallow knee bend.
• Rises from a sitting position.
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Cranial Nerves: The examiner should be aware of:
• Ptosis - drooping of the upper eyelid CN III
• Facial droop or asymmetry - CN V1 I
• Hoarse voice - CINI X
• Articulation of words - CN V, VII, X, XII
• Abnormal eye position - CN I 11, IV, VI
• Abnormal or asymmetrical pupils - CN 11, 111
I Olfactory - Smell, not normally tested
II Optic (eye)
• Visual acuity - patient reads eye chart
• Screening of visual fields by confrontation - testing peripheral vision
• Testing of pupillary reaction to light
• Testing of pupillary reaction to accommodation - patient visually follows examiners finger
III Oculomotor (eye movement)
• Examiner observes for drooping eyelid
• Test for extraocular (eye) movements
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1 . Examiner stands in front of patient who is asked to visually follow his finger without moving head.
2. Patient's gaze should be checked in six cardinal directions using a cross or "H" pattern.
3. Check for nystagmus (rapid eye movements)
4. Convergence checked by examiner moving a finger toward bridge of patient's nose. |
• Pupillary reaction to light checked IV Trochlear - Extraocular inward and downward movements.
V Trigeminal - The examiner tests for temporal and messeter (jaw) muscle strength. Three divisions, forehead, cheeks and jaw, are checked for pain sensation with a sharp object. A blunt object is occasionally substituted and the patient is asked to report "sharp" or "dull." If abnormal, the three divisions are tested for temperature and touch. Corneal reflexes are checked.
VI Abducens - Extraocular (eye) lateral movement.
VII Facial - Facial droop or asymmetry are noted. The patient raises eyebrows, closes both eyes to resistance, smiles, frowns, shows teeth, and puffs out cheeks- Corneal reflexes are tested.
VIII Acoustic - Hearing test
IX - Glossopharyngeal - See vagus nerve.
X Vagus - Examiner listens for hoarseness, observes swallowing, asks patient to say 'ah" and observes soft palate and pharynx. Checks for gag reflex.
XI Accessory - Examiner checks for atrophy or asymmetry of the trapezius muscles. Checks muscle resistance of the head and shoulders.
XII Hypoglossal - Examiner listens to articulation and observes tongue in mouth and as it moves side to side protruding from mouth.
Reflexes
Deep tendon reflexes are checked and graded on a scale of 0 to 4 "plus" scale. Reflexes of the biceps, triceps, brachioradiales (forearm), abdominal, knee and ankle are checked. The Babinski response is tested by noting the response of the toes to stroking the lateral (side) aspect of the sole of the foot with the end of a reflex harnmer or other object. Extension of the big toe with fanning of the other toes is abnormal.
Sensory Exam
The examiner compares symmetrical areas on two sides of the body, the distall (outer) and proximal (center) of the extremities, and maps out the boundaries in detail when an area of sensory loss is detected. Vibrafion response is checked by using the end of a low pitched tuning fork that has been tapped and then placed on specific areas of the body including fingers, toes, wrists, elbows and clavicles. Light touch response is tested by the examiner using fingers to touch the skin on both sides of the upper and lower extremities, eliciting reactions from the patient. Position sense is checked by asking patients to close their eyes and give verbal response to position of the toes, fingers and other extremities as they are manipulated by the examiner. A sharp object is used to test 'sharp" and "dull" sensations. To test temperature response a tuning fork that has been heated or cooled (ice can be substituted), is used to touch certain areas of the body. The patient is asked to identify "hot" or"cold" when touched on specific locations- Shoulders, forearms, thumbs, little fingers, fronts of thighs, medial (center) and lateral (side) aspect of the calves, and the little toes, are areas of the body involved in conducting these tests
Motor
The examiner looks for involuntary movements, muscle symmetry, atrophy and gait- Muscles are assessed for decreased (flaccid) or increased (rigid/spastic) tone. Muscle strength is checked and graded on a scale from 0 to 5 "out of five."
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