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

 Describe someone you know with Fibromyalgia.  How do people (including therapists) respond to hearing the word ‘Fibromyalgia’?

 Restless legs  IBS  Difficulty concentrating  Headaches  Urinary problems  Numbness/tingling (non-dermatomal)  “Allergy” symptoms  Dizzy  Cold sensitivity  Anxiety  Depression & insomnia Wilke 2009

 “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.”

 11 / 18 tender points  ICD-9 Diagnosis Myalgia and myositis unspecified

 Widespread Pain Index and Symptom Severity First dgSecond dg WPI SS Wolfe et al 2010

 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

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 FatigueWaking un-refreshedCognitive

 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

 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

ACTH CRF Stress HPN Limbic System Anterior Pituitary Hippocampus Brain Stem Cortisol Adrenal Cortex

Cognitive Dysfunction Stress Hormones (CRH & Cortisol) Pain Dopamine Hippocampus Stress Wood, 2009

 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 Institutional Cultural Social Person Environment Occupation

 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.

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

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

 Expert opinion  Evidence is strong for other types of pain conditions  APS A

 Tramadol  Mirapex  Elavil  Prozac  Cymbalta  Trazodone  EULAR I A  PAS B-C  Navoban  Lyrica  Savella  Aurorix, Manerix

Life roles Habits Self-efficacy Values Interests Life Skills Goals Interpretation of Past Experiences Physical Environment Social Environment Readiness for Change

Score: X = 50 Severe impact = 70 Most commonly used Free

 Beck Depression Inventory II  Hamilton Rating Scale for Depression healthnet.umassmed.edu/mhealth/HAMD.pdf  Zung Self-rating Depression Scale healthnet.umassmed.edu/mhealth/ZungSelfRatedD epressionScale.pdf

Visual Analog Scale (VAS) Place a mark on the line to indicate how severe your pain is today. no pain ___________________________ severe pain

 ROM  Grip Strength  Timed Stair Test  No statistical differences: Self-efficacy Milwaukee O’Connor

Symptom Management: Nutritional Mind-Body Physical Lifestyle Emotional-Spiritual

 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, MD Talk 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

Mind and Body

 92 degrees  BP: not more than 150/98 or so  Exercise below the point of fatigue or pain  Dopamine  Stress Hormones

 Everyday  30 minutes (40 minutes to lose wt.)  stretching 20% strength 40% aerobic 40% (Raise your heartbeat by 50%)

 Moshe Feldenkrais  Painful movement due to improper sensory motor self-image  Cervical eye ball exercise!

 Gentle movements  Balance & ROM  Breathing & awareness  Resist the Tiger

 Stretching  Core strength  Breathing & awareness  Warrior

 Significant relief for pain, fatigue, anxiety but not function

cranial electrotherapy stimulation

transcutaneous electrical nerve stimulation High vs. Low frequency

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

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

Dysfunctional Attitude Scale 1 = Totally agree 2 = Agree very much 3 = Agree slightly 4 = Neutral 5 = Disagree slightly 6 = Disagree very much 7 = Totally disagree

Husband home late He’s cheating on me. I should be more attractive. DepressionAngerGuilt Can’t Sleep, Withdraws, Interrogates A B C

Autogenic meditation Focused meditation Mindful meditation Visualization Guided Imagery (Belleruth Naparstek) Self-Hypnosis

 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?

 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!

 Rheumatologists  Family Medicine  Internal Medicine  Pain Specialists  Support Groups

 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

 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); as summarized in National Guideline Clearinghouse 2005 Sep 19:7298National 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),  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 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,  Wilke, W. Cleveland Clinic Journal of Medicine June 2009 vol  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:  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),