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CLEARING THE FOG Occupational & Physical Therapy for the Client with Fibromyalgia
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Overview
What is Fibromyalgia? Evidence base for treatment Assessment Occupational & Physical Therapy Spreading the word (and getting paid!) Conclusion
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Personal Stories
Describe someone you know with Fibromyalgia.
How do people (including therapists) respond to hearing the word ‘Fibromyalgia’?
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WHAT IS FIBROMYALGIA?
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Clinical Presentation
Restless legs
IBS
Difficulty concentrating
Headaches
Urinary problems
Numbness/tingling (non-dermatomal)
“Allergy” symptoms
Dizzy
Cold sensitivity
Anxiety
Depression & insomnia
Wilke 2009
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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.”
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“Old” Dg Criteria Fibromyalgia
11 / 18 tender points
ICD-9 Diagnosis 729.1Myalgia and myositis unspecified
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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
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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
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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
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A Little review
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The limbic system
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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
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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
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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
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TELL ME WHERE IT HURTS
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ACTH
CRF
Physiology of FM
StressHPNHPN
Limbic System
Limbic System
Anterior Pituitary
Hippocampus
Brain StemBrain Stem
Cortisol
Adrenal Cortex
Adrenal Cortex
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Fibromyalgia Pain Cycle
Cognitive Dysfunction
Stress Hormones (CRH & Cortisol)
Pain
Dopamine
HippocampusStress
-0.89
Wood, 2009
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Evidence for treatment
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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
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Spirituality
Cognitive
Affective
Physical
Self-
care
Productivity
Leisure
Physical
Inst
itutio
nal
Cultural
Social
Person
Environment
Occupation
Comprehensive Assessment
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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.
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Heated pool treatment
Improved pain and function Drop-out was low EULAR II B APS A
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Aerobic and Strengthening Exercise
Can benefit some Evidence is not as strong EULAR II C APS mostly B
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Cognitive behavior therapy
Expert opinion Evidence is strong for other types of
pain conditions APS A
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Medications
Tramadol Mirapex Elavil Prozac Cymbalta Trazodone
EULAR I A PAS B-C
Navoban Lyrica Savella Aurorix, Manerix
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ASSESSMENT
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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
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Fibromyalgia Impact Questionnaire
Score: 0-100
X = 50
Severe impact = 70
Most commonly used
Free http://www.myalgia.com/FIQ/fiq.pdf
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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
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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
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Other measures
ROM Grip Strength Timed Stair Test
No statistical differences:
Self-efficacyMilwaukeeO’Connor
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Symptom Management:
Nutritional
Mind-Body
Physical
Lifestyle
Emotional-Spiritual
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Nutrition
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Fibromyalgia Diet
Avoid:
MSG (“natural seasonings”)
Aspartame
Caffeine Use: Splenda instead of sugar & cruciferous
vegetables
Smith et al 2001
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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
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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
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Movement TherapiesMind and Body
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Aquatic Exercise
92 degrees BP: not more than
150/98 or so Exercise below the
point of fatigue or pain
Dopamine Stress Hormones
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Exercise Long-term Goal
Everyday 30 minutes (40 minutes to lose wt.) stretching 20%
strength 40%
aerobic 40%
(Raise your heartbeat by 50%)
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Feldenkrais
Moshe Feldenkrais
Painful movement due to improper sensory motor self-image
Cervical eye ball exercise!
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Tai Chi Gentle movements
Balance & ROM
Breathing & awareness
Resist the Tiger
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Yoga Stretching
Core strength
Breathing & awareness
Warrior
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Physical Modalities
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Acupuncture
Significant relief for pain, fatigue, anxiety but not function
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Alpha Stim
cranial electrotherapy stimulation
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TENS Unit
transcutaneous electrical nerve stimulation
High vs. Low frequency
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Lifestyle
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Stress Management
Assertive communication Time management Day timer To-do list Say ‘no’ at work Career change?
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Energy Conservation
Evaluate sleep Short naps only Regular schedule Work smarter Pace Re-arrange
environment
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Pain, NO GAIN!
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Prioritize
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Emotional/Spiritual Healing
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Cognitive Therapy
Dysfunctional Attitude Scale
1 = Totally agree2 = Agree very much3 = Agree slightly4 = Neutral5 = Disagree slightly6 = Disagree very much7 = Totally disagree
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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
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Meditation
Autogenic meditationFocused meditationMindful meditationVisualizationGuided Imagery (Belleruth Naparstek)Self-Hypnosis
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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?
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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
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And getting paid!
SPREADING THE WORD
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Finding Referral Sources
Rheumatologists Family Medicine Internal Medicine Pain Specialists Support Groups
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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
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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.
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QUESTIONS?
www.robinsteed.pbworks.com