Transcript How Pain Works - robinsteed

CLEARING THE FOG
Occupational & Physical Therapy for the Client with
Fibromyalgia
Overview
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What is Fibromyalgia?
Evidence base for treatment
Assessment
Occupational & Physical Therapy
Spreading the word (and getting paid!)
Conclusion
Personal Stories
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Describe someone you know with
Fibromyalgia.
How do people (including therapists)
respond to hearing the word ‘Fibromyalgia’?
WHAT IS FIBROMYALGIA?
Clinical Presentation
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Restless legs
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“Allergy” symptoms
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IBS
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Dizzy
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Difficulty concentrating
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Cold sensitivity
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Headaches
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Anxiety
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Urinary problems
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Depression & insomnia
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Numbness/tingling (non-dermatomal)
Wilke 2009
Clients Say
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“I always feel like I have the flu.”
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“I hurt all over. My muscles are always sore.”
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“I feel like I am in a fog. I can’t think straight.”
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“ I used to be a type A person. Now I can’t get
out of bed.”
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“If I could just sleep for a week.”
“Old” Dg Criteria Fibromyalgia
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11 / 18 tender points
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ICD-9 Diagnosis 729.1
Myalgia and myositis
unspecified
New Diagnostic Criteria 2010
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Widespread Pain Index and Symptom Severity
10
9
WPI
SS
8
7
6
5
4
3
2
1
First dg
Second dg
Wolfe et al 2010
Widespread Pain Index 0-19
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Jaw: left, right
Chest, Neck
Shoulder girdle:
left, right
Upper arm: left, right
Lower arm: left, right
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Back: upper, lower
Hip (buttock, trochanter):
left, right
Upper leg: left, right
Lower leg: left, right
Symptom Severity 0-12
Fatigue
Waking un-refreshed
Cognitive
Severity over past week:
0 no problem
1 slight or mild problems, generally mild or intermittent
2 moderate, considerable problems,
3 severe: pervasive, continuous, life-disturbing problems
Somatic symptoms:
0 no symptoms
1 few symptoms
2 a moderate number of symptoms
3 a great deal of symptoms
A Little review
The limbic system
Structures
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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
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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
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TELL ME WHERE IT HURTS
Physiology of FM
Stress
Limbic
System
Brain
Stem
HPN
Hippocampus
CRF
Anterior
Pituitary
ACTH
Cortisol
Adrenal
Cortex
Fibromyalgia Pain Cycle
Cognitive Dysfunction
Stress
Hippocampus
Stress Hormones
(CRH & Cortisol)
Pain
-0.89
Dopamine
Wood, 2009
Evidence for treatment
SOURCE OF EVIDENCE
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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
Comprehensive Assessment
Occupation
Affective
Spirituality
Person
Cognitive
Physical
Leisure
Physical
Environment
Multidisciplinary Approach
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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
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Improved pain and function
Drop-out was low
EULAR II B
APS A
Aerobic and Strengthening Exercise
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Can benefit some
Evidence is not as strong
EULAR II C
APS mostly B
Cognitive behavior therapy
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Expert opinion
Evidence is strong for other types of pain
conditions
APS A
Medications
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Tramadol
Mirapex
Elavil
Prozac
Cymbalta
Trazodone
EULAR I A
PAS B-C
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Navoban
Lyrica
Savella
Aurorix, Manerix
ASSESSMENT
Occupational Profile: OCAIRS
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Life roles
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Habits
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Self-efficacy
Values
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Interests
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Life Skills
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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
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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 Scale
healthnet.umassmed.edu/mhealth/ZungSelfRatedD
epressionScale.pdf
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Pain
Visual Analog Scale (VAS)
Place a mark on the line to indicate how severe your
pain is today.
no pain ___________________________ severe pain
www.cebp.nl/vault_public/filesystem/?ID=1478
Other measures
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ROM
Grip Strength
Timed Stair Test
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No statistical
differences:
Self-efficacy
Milwaukee
O’Connor
Symptom Management:
Nutritional
Mind-Body
Physical
Lifestyle
Emotional-Spiritual
Nutrition
Fibromyalgia Diet
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Avoid:
MSG (“natural seasonings”)
Aspartame
Caffeine
Use: Splenda instead of sugar & cruciferous
vegetables
Smith et al 2001
OTC
Magnesium Citrate- Mg is natural antagonist
of the NMDA receptor
 Dextromethorphan- post exertional burn Delsyn
cough syrup
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Patrick Wood, MD
Talk to FM support group 2004
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Fibromyalgia Cocktail
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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 Therapies
Mind and Body
Aquatic Exercise
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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
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Everyday
30 minutes (40 minutes to lose wt.)
stretching 20%
strength
40%
aerobic
40%
(Raise your heartbeat by 50%)
Feldenkrais
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Moshe Feldenkrais
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Painful movement due to
improper sensory motor
self-image
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Cervical eye ball exercise!
Tai Chi
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Gentle movements
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Balance & ROM
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Breathing & awareness
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Resist the Tiger
Yoga
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Stretching
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Core strength
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Breathing & awareness
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Warrior
Physical Modalities
Acupuncture
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Significant relief for pain, fatigue, anxiety but
not function
Alpha Stim
cranial electrotherapy stimulation
TENS Unit
High vs. Low frequency
transcutaneous electrical nerve stimulation
Lifestyle
Stress Management
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Assertive communication
Time management
Day timer
To-do list
Say ‘no’ at work
Career change?
Energy Conservation
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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
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7
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Totally agree
Agree very much
Agree slightly
Neutral
Disagree slightly
Disagree very much
Totally disagree
ABC’S OF REBT
B
He’s cheating
on me. I should
be more
attractive.
Depression
Anger
Guilt
C
A
Husband
home late
Can’t Sleep, Withdraws, Interrogates
Meditation
Autogenic meditation
Focused meditation
Mindful meditation
Visualization
Guided Imagery (Belleruth Naparstek)
Self-Hypnosis
Questions to help guide verbal processing:
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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
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Therapeutic relationship
Positive self-esteem is highly correlated with
internal locus of valuation i.e. self worth not
dependent on what other people think
SPREADING THE WORD
And getting paid!
Finding Referral Sources
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Rheumatologists
Family Medicine
Internal Medicine
Pain Specialists
Support Groups
Bill Correctly
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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
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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?
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