CLEARING THE FOG Occupational & Physical Therapy for the Client with Fibromyalgia

Overview

What is Fibromyalgia? Evidence base for treatment Assessment Occupational & Physical Therapy Spreading the word (and getting paid!) Conclusion

Personal Stories

Describe someone you know with Fibromyalgia.

How do people (including therapists) respond to hearing the word ‘Fibromyalgia’?

WHAT IS FIBROMYALGIA?

Clinical Presentation

Restless legs

IBS

Difficulty concentrating

Headaches

Urinary problems

Numbness/tingling (non-dermatomal)

“Allergy” symptoms

Dizzy

Cold sensitivity

Anxiety

Depression & insomnia

Wilke 2009

Clients Say

“I always feel like I have the flu.”

“I hurt all over. My muscles are always sore.”

“I feel like I am in a fog. I can’t think straight.”

“ I used to be a type A person. Now I can’t get out of bed.”

“If I could just sleep for a week.”

“Old” Dg Criteria Fibromyalgia

11 / 18 tender points

ICD-9 Diagnosis 729.1Myalgia and myositis unspecified

New Diagnostic Criteria 2010

Widespread Pain Index and Symptom Severity10

9

8

7

6

5

4

3

2

1

First dg Second dg

WPISS

Wolfe et al 2010

Widespread Pain Index 0-19

Jaw: left, right Chest, Neck Shoulder girdle:

left, right Upper arm: left,

right Lower arm: left,

right

Back: upper, lower Hip (buttock,

trochanter): left, right

Upper leg: left, right Lower leg: left, right

Symptom Severity 0-12

Severity over past week:0 no problem1 slight or mild problems, generally mild or intermittent2 moderate, considerable problems, 3 severe: pervasive, continuous, life-disturbing problemsSomatic symptoms:0 no symptoms1 few symptoms2 a moderate number of symptoms3 a great deal of symptoms

Fatigue Waking un-refreshedCognitive

A Little review

The limbic system

Structures

Hypothalamus- control of ANS and hormones

Anterior Pituitary- master gland Adrenal Cortex- sit on top of kidneys Hippocampus- memory and reward,

dampens anxiety Limbic system- emotions and central

relay station

Messengers

Serotonin- mood, sleep, depression Dopamine- reward chemical, runner’s

high Norepinephrine- stress, flight or fight Glutamate- excitatory amino acid Endorphins- reduce pain Substance P- binds with pain neurons Cortisol- stress hormone, released by

adrenal cortex

What we know

Increased amount of Substance P in CSF

Pain uniquely related to NMDA receptor fxn

Serotonin levels abnormal Multi-neuroendocrine disturbances,

day-night rhythms, too much estrogen

TELL ME WHERE IT HURTS

ACTH

CRF

Physiology of FM

StressHPNHPN

Limbic System

Limbic System

Anterior Pituitary

Hippocampus

Brain StemBrain Stem

Cortisol

Adrenal Cortex

Adrenal Cortex

Fibromyalgia Pain Cycle

Cognitive Dysfunction

Stress Hormones (CRH & Cortisol)

Pain

Dopamine

HippocampusStress

-0.89

Wood, 2009

Evidence for treatment

SOURCE OF EVIDENCE

EULAR (European League Against Rheumatism) Carville et al 2008

APS (American Pain Society) Buckhardt, 2005

evidence source I to V evidence strength A to D

Spirituality

Cognitive

Affective

Physical

Self-

care

Productivity

Leisure

Physical

Inst

itutio

nal

Cultural

Social

Person

Environment

Occupation

Comprehensive Assessment

Multidisciplinary Approach

non-pharmacological and pharmacological treatment modalities

tailored according to pain intensity, function, associated features, such as depression, fatigue and sleep disturbance in discussion with the patient.

Heated pool treatment

Improved pain and function Drop-out was low EULAR II B APS A

Aerobic and Strengthening Exercise

Can benefit some Evidence is not as strong EULAR II C APS mostly B

Cognitive behavior therapy

Expert opinion Evidence is strong for other types of

pain conditions APS A

Medications

Tramadol Mirapex Elavil Prozac Cymbalta Trazodone

EULAR I A PAS B-C

Navoban Lyrica Savella Aurorix, Manerix

ASSESSMENT

Occupational Profile: OCAIRS

• Life roles

• Habits

• Self-efficacy

• Values

• Interests

• Life Skills

• Goals

• Interpretation of Past Experiences

• Physical Environment

• Social Environment

• Readiness for Change

www.moho.uic.edu

Fibromyalgia Impact Questionnaire

Score: 0-100

X = 50

Severe impact = 70

Most commonly used

Free http://www.myalgia.com/FIQ/fiq.pdf

Depression

Beck Depression Inventory II www.ibogaine.desk.nl/graphics/3639b1c_23.pdf

Hamilton Rating Scale for Depression

healthnet.umassmed.edu/mhealth/HAMD.pdf

Zung Self-rating Depression Scalehealthnet.umassmed.edu/mhealth/

ZungSelfRatedDepressionScale.pdf

Pain

www.cebp.nl/vault_public/filesystem/?ID=1478

Visual Analog Scale (VAS)

Place a mark on the line to indicate how severe your pain is today.

no pain ___________________________ severe pain

Other measures

ROM Grip Strength Timed Stair Test

No statistical differences:

Self-efficacyMilwaukeeO’Connor

Symptom Management:

Nutritional

Mind-Body

Physical

Lifestyle

Emotional-Spiritual

Nutrition

Fibromyalgia Diet

Avoid:

MSG (“natural seasonings”)

Aspartame

Caffeine Use: Splenda instead of sugar & cruciferous

vegetables

Smith et al 2001

Magnesium Citrate- Mg is natural antagonist of the NMDA receptor

Dextromethorphan- post exertional burn Delsyn cough syrup

Patrick Wood, MDTalk to FM support group 2004

OTC

Fibromyalgia Cocktail

Beta blocker like pindolol, 2.5 – 10 mg at bedtime

Tricyclic antidepressant like imipramine. Low dose at first and work up to as high as you can.

Melatonin – 3 mg at bedtime DHEA – Have your physician monitor your

levels. You can get too much DHEA and then you get a beard.

B Complex Omega 3 fish oil

Movement TherapiesMind and Body

Aquatic Exercise

92 degrees BP: not more than

150/98 or so Exercise below the

point of fatigue or pain

Dopamine Stress Hormones

Exercise Long-term Goal

Everyday 30 minutes (40 minutes to lose wt.) stretching 20%

strength 40%

aerobic 40%

(Raise your heartbeat by 50%)

Feldenkrais

Moshe Feldenkrais

Painful movement due to improper sensory motor self-image

Cervical eye ball exercise!

Tai Chi Gentle movements

Balance & ROM

Breathing & awareness

Resist the Tiger

Yoga Stretching

Core strength

Breathing & awareness

Warrior

Physical Modalities

Acupuncture

Significant relief for pain, fatigue, anxiety but not function

Alpha Stim

cranial electrotherapy stimulation

TENS Unit

transcutaneous electrical nerve stimulation

High vs. Low frequency

Lifestyle

Stress Management

Assertive communication Time management Day timer To-do list Say ‘no’ at work Career change?

Energy Conservation

Evaluate sleep Short naps only Regular schedule Work smarter Pace Re-arrange

environment

Pain, NO GAIN!

Prioritize

Emotional/Spiritual Healing

Cognitive Therapy

Dysfunctional Attitude Scale

1 = Totally agree2 = Agree very much3 = Agree slightly4 = Neutral5 = Disagree slightly6 = Disagree very much7 = Totally disagree

ABC’S OF REBT

Husband home late

He’s cheating on me. I should be more attractive.

DepressionAngerGuilt

Can’t Sleep, Withdraws, Interrogates

AB

C

Meditation

Autogenic meditationFocused meditationMindful meditationVisualizationGuided Imagery (Belleruth Naparstek)Self-Hypnosis

Questions to help guide verbal processing: Describe how this experience felt to you. How real did the beach seem to you? What was in the box? What did it look like? How did it feel to receive this gift? What special meaning does this gift have for you? What did you do on the beach? How did that feel? What are some ways you could incorporate some of that into

your life right now? What are some circumstances in which you might want to

return to this place?

Self Efficacy

Therapeutic relationship Positive self-esteem is highly correlated

with internal locus of valuation i.e. self worth not dependent on what other people think

And getting paid!

SPREADING THE WORD

Finding Referral Sources

Rheumatologists Family Medicine Internal Medicine Pain Specialists Support Groups

Bill Correctly

Group Neuromuscular Re-education Activities of Daily Living Warm Water Exercise

Client education must take place during normal billable sessions.

2 hours 3x week for 6 weeks if possible

References Buckhardt CS, Goldenberg D, Crofford L, et al. Guideline for the management of

fibromyalgia syndrome pain in adults and children. Glenview (IL): American Pain Society (APS); 2005. as summarized in National Guideline Clearinghouse 2005 Sep 19:7298

Carville, S. F., Arendt-Nielsen, S., Bliddal, H., Blotman, F., Branco, J. C., Buskila, D., et al. (2008). EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Annals of the Rheumatic Diseases, 67(4), 536-541.

R. C. Cork, P. Wood, N. Ming, C. Shepherd, J. Eddy & L. Price : The Effect of Cranial Electrotherapy Stimulation (CES) on Pain Associated with Fibromyalgia . The Internet Journal of Anesthesiology. 2004 Vol 8 Number 2

Smith, J., Terpening, C., Schmidt, S., & Gums, J. (2001). Relief of Fibromyalgia symptoms following discontinuation of dietary excitotoxins. Ann Pharmacother, 35, 702-706.

Wilke, W. Cleveland Clinic Journal of Medicine June 2009 vol. 76 6 345-352 Wood, P. B., Holman, A. J. (2009). An Elephant Among Us: The Role of Dopamine

in the Pathophysiology of Fibromyalgia. The Journal of Rheumatology 36: 221-224

Wolfe, F. Clauw, D., Fitzcharles, M., Goldenberg, D., Katz, R., Mease, P, Russell, A, Russell, J, Winfield, J., Yunus, M. (2010). The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care and Research, 62 (5), 600-610.

QUESTIONS?

www.robinsteed.pbworks.com