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Fibromyalgia
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Fibromyalgia - December 7, 2004 6:35:00 AM
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scottybolton
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From: Amsterdam
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Hello all,
I am a Canadian student (2nd yr) who is studying physiotherapy in the Netherlands. I am searching for evidence based material regarding the assessment and treatment methods of fibromyalgia. I was wondering if there are any great minds out there who would like to share their wealth of information with me...please. I have been looking on pubmed, medical journal sites, etc and would like to discover other sources as well. A big thanks to all that can take time out of their busy schedule to help me,
Sincerly,
ScottyBolton
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Re: Fibromyalgia - December 7, 2004 6:56:00 AM
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Dr.Wagner
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From: Indianapolis
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I am not sure the phrase evidence based and fibromyalgia can actually be used in the same sentence. ;)
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Re: Fibromyalgia - December 7, 2004 8:26:00 AM
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Yogi
Posts: 403
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From: San Antonio, Tx., USA
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You said a mouthful there, Doc. Thanks for providing my prescribed daily laugh. Scott, any therapy treatment other than palliative, I'd love to see even a case study on, let alone evidence. Anyone that knows of anything, chime in.
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Re: Fibromyalgia - December 7, 2004 9:03:00 AM
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FLAOrthoPT
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From: West Palm Beach
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I know we all hate this diagnosis, as do I. And I do know there are some studies out there with some valid reliability, but frankly I have my own opinions regarding fibromyalgia. I believe it is misdiagnosed as such. I will only treat dysfunctons, so with a good eval I will often see it truly present as multiple peripheral neural tensions/irritations combined with one heck of a postural stress syndrome. That is these people tend to have such stress and if you delve deep, tend to be A-type personality, female mid 20s to mid 40s, in the midst of bad happenings in their life and on top of that may have some significant mental or physical trauma or abuse in their past and carry all this stress in their posterior postural muscles upper traps etc. Well you then throw in some peripheral neural restrictions and now they have "global" symptoms, pain with palpation (which may be psycho somatic) and they get labeled. Well, I have found that the best treatment is to do:
A)a very thorough eval
B) treat the true dysfunctions if any
C) do not get them dependent on therapy as the only means of "maintaining" their pain levels
D) NEVER ask them about their pain or to rate their pain, if they discuss it fine, but do not prompt them to do so...many of these patients become in some sort of sick way only able to identify their lives through their pain, it becomes some sort of subconscoius wanting desire to have this pain and use this pain as a rule for their day...
E)Get them on a steady routine of postural strengthening or aquatic exercises that they can progress into an independent program
F)Don't tell them fibro doesn't exist, just do not attribute any of their pain to it..in fact they become obsessed with the Dx and many of them become such experts that it kind of becomes thier destiny..they read that fibro patients tend to do this and that, and low and behold they come down with those symptoms...so, remember that a "fibro fog" even though a lot of them experience this, i think you'll find anyone with a lot of stress will at times report feeling somewhat detached from their world
G)discourage the patient from taking pain or muscle relaxant meds for this if you can appropriately do so, let them take some "happy" pills instead
H)strongly encourage them to see a pain psych, I am telling you..90% of the time their is some sort of issue under the surface that you may or may not be awarfe of...case in point, had a patient with SI dysfunction, overweight with bad postural habits at her desk, postural stress, stress at home with new husband and integrating new family, multiple hypomobile cerv and thoracic joints secondary to prolonged forward head posture, and knew fibro inside and out..read every book about it...well only until I referred her on to a specialist (in my mind a female Faaomt at the time was better equiped to deal with some of her pubic symph problems) well, after seeing this lady on and off for over 2 years this female therapist found out in about 3 visits that she had been sexually abused when she was younder and subsequently had some real tonal issues in her adductors and stress, etc..well after seeing pysch for a bit, she is MUCH better...
well that is my 87 cents
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Re: Fibromyalgia - December 7, 2004 1:04:00 PM
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pablo w
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From: Canberra
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Scott,
You've probably come across all sorts of evidence on the mechanisms underlying fibromyalgia.
What I have found to be the most important aspect of helping a patient manage their symptoms is improving their understanding of the condition. If they've done a lot of reading, they will already have very strong opinions about what is wrong and this woul make the job harder.
My summary of fibromyalgia (hopefully it is similar to what you already know):
1. Pain described as "muscular" in upper and lower body (different from myofascial pain syndrome - but let's not talk about that).
2. Multiple tender points (at specified sites) but also lowered pressure pain threshold elsewhere.
3. Diagnosed by exclusion, symptoms, and tender point count (13 out of 18).
4. High incidence of sleep disturbance.
5. High incidence of fatigue (parallels with chronic fatigue syndrome).
6. High incidence of irritable bowel syndrome.
7. Abnormal nociceptor activity (as evidenced by dermatographia: scratch the skin of a fibromyalgia patient with a fingernail, and watch a rapid axon reflex response/weal mediated by a release of substance P from C nociceptors). This suggests it is not just "psychological".
8. Often have "poor posture" whatever that is.
9. Physically deconditioned.
10. Muscle biopsies find evidence of oxidative stress (as in fatigue) but not much else as far as abnormal histology.
11. Increased muscle soreness compered to "normals" after exercise.
12. Higher incidence of injuries to the spinal column (particularly cervical spine). Interestingly, recent research (Sterling M, Jull G) finds a group of patients following neck trauma in MVA have lowered temperature and pressure pain threshold in the area of pain but also in the rest of the body... This does not seem to be associated with psychological variables.
There's probably more. My recommendations are to understand pain physiology, understand stress physiology, listen to the patient (they will tell you what is wrong with them), educate the patient, start them on some appropriate self-management strategies, keep your hands off unless you find something you can treat (but don't focus the treatment on these "dysfunctions"), refer to an appropriate psychologist if appropriate, include exercise with gradual progression in their management, educate about pacing, ask tem to set specific, achievable and realistic goals, progress the goals accordingly, don't expect 100% pain relief...
I wouldn't go as far as never asking about their pain. That's why they come in the fisrt place. See how they are managing (the pain self efficacy questionnaire is a good one).
The focus is on self-management. Read lots of the relevant literature, but read it with caution. There are strong opinions and some persuasive arguments out there, make sure you understand both sides.
Pablo
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Re: Fibromyalgia - December 7, 2004 1:41:00 PM
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FLAOrthoPT
Posts: 1011
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From: West Palm Beach
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and you'll be their crutch the rest of their lives if you follow that advice..maybe too long associated with a apin management clinic, but I couldn't disagree any more. So, good that you've come here to listen to some difering opinions and formulate your own. By the way everything you described as symptoms can be found in someone with extreme stress. Wouldn't a change in the sympathetic nervous system from heightened stress cause a lot fo the same symptoms including IBS, stressful points, etc..wouldn't all of these symptoms be magnified with postural stress, repeated stressful events be it physical such as car accident or other trauma or mental such as car accident, abuse, or other trauma. I think your explanation (pablo) is a great explanation, but not so sure it is actually in the patients best interest if you are trying to get them better. I still say if you try to treat pain, in ANY patient, you are asking for let downs, there are too many circumstances to pain including patient's past history of pain, etc that you CANNOT control. Stick with treating dyfunctions and read this list...no kidding they have pain: overweight, deconditioned, postural stress, repeated spine disorders....so do you call this a disease? or or a compendium of symptoms that you wanted to give a name. Like I said, I will totally disagree, but read both, digest both, and find an answer, no one knows for sure (maybe because it is like searching for a unicorn), so come up with a treatment solution that works best for your patients and for you. Unfortunately I feel that too many people baby these patients and help rationalize their pain which feeds into some sick syndrome that they are actually in one manner wanting of...I am done rebuting, please DO read pablo's explanation because he will make up about 80% of the popular opinion on this subject...
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Re: Fibromyalgia - December 7, 2004 1:54:00 PM
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chiroortho
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I don't think I'd be willing to treat another FM patient that wasn't willing to start, right from day one, aquatic exercise. FlaOrthoPT makes some very good points.
I've had many patients with this 'dx', but only a handful that to my knowledge overcame it to resolution.
I can find the 'typical tender points' on anyone that is oriented to gravity. Is it possible that even the Academy of Rheumatology has become PC (won't advise it's members to just say 'we don't know what's wrong with you?')?
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Greg Priest, DC, DABCO
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Re: Fibromyalgia - December 7, 2004 2:11:00 PM
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Jon Newman
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From: Amherst, WI
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FLAOrthoPT,
It would seem to me that you may have read Pablo's post incorrectly (or perhaps I did). He starts by making sure everyone is talking about the same diagnosis by describing what he understands the diagnosis to be. Then he goes on to give, what seems to me to be very sound advice. Namely focus on education regarding pain physiology and self management skills while encouraging movement and goal directed behavior. How could that make them dependent or be a bad thing?
Personally I don't hate the term fibromyalgia any more than SI joint dysfunction or piriformis syndrome.
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Fibromyalgia - December 7, 2004 2:13:00 PM
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FLAOrthoPT
Posts: 1011
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From: West Palm Beach
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gotta love the si joint dysfunction...love it..now there's something you can actually assess, treat, re-assess....mmmm such a good thing...but yes I skimmed his post and it looks a lot better now that i actual read it...
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Re: Fibromyalgia - December 7, 2004 2:35:00 PM
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SJBird55
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From: Michigan
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Florida, Pablo's recommendation regarding self-management is in line with the Arthritis Foundation and with the literature that I have read. The goal isn't to reduce the pain to zero... the goal is improved self-efficacy and improved coping skills. And, yes, there are some self-management strategies that can help with reducing symptoms that patients can do independently... imagery, diaphragmatic breathing, heat, relaxation.... Pablo's recommendations wouldn't probably lead to a patients being dependent on anyone except themselves.
I just read something recently somewhere on a functional MRI... there are some goofy things that occur in patients with both chronic back pain and patients with fibromyalgia - compared to "normal" (whatever that is). Supposedly the active areas of the brain are pretty darn similar in both of these populations after a non-noxious stimulus. So that tells me that there is also some kind of central mechanism/component involved.
Florida, I believe that you just might want to do a bit more reading on fibromyalgia. I do agree that the condition does at times seem to be a catch all diagnosis or a diagnosis arrived at via ruling out everything else... the question of what came first the chicken or the egg? There are actual physical changes - literature does indicate what Pablo posted. I've recently read fMRI changes. I know that serotonin is a factor which also has an effect on a lot of the symptoms of complaint. I thought that I had read that the muscle fibers in folks with fibromyalgia were different than normal too.
Yes, these patients do get hung up on doing a ton of reading and focusing on themselves to a greater degree than the typical patient. But, hey, if you hurt all the time and you keep it the first thing in your mind 100% of the time I would think that that's what someone would do. There isn't a cure... we have a very large role in providing options to the patient on how life can happen. I'm also not saying that a psychologist isn't important. I'd say it's a patient by patient kind of thing.
I think an important aspect that needs to be told to these patients in particular is that the condition is not a progressive condition nor is it a life-threatening condition. I believe it is also important to tell them that at this point in time there is no cure. The condition is their buddy and they can try to get along with their new buddy and adapt their ways and change their lifestyle... or they can continue life as they have been - butting heads with their new buddy and living in an increased level of pain on a continual basis. Physical therapy really isn't the answer if the patient isn't ready to embrace the idea that their life needs to change in order to accommodate their new buddy. I also try to introduce the idea that life is full of experiences... this is one experience for them that is life-altering and even though the pain isn't enjoyable and no one would probably choose the fibromyalgia experience that some aspect in their lives may be better because of the experience.
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Re: Fibromyalgia - December 7, 2004 3:04:00 PM
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FLAOrthoPT
Posts: 1011
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From: West Palm Beach
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I do not disagree, just wish i had fluffy bunnies in my world at all times, I am sometimes to a fault a pragmatic realist. However, I still think that the guy (or gal) who has worked in manual labor his whole life and has such arthritic joints that they can barely button their shirts has just as much reason to "give up" and be a slave to their disease but often you do not see these people even telling others that they have nay pain at all, in fact ask them how theya re feeling and they'll tell you Great! I just wonder what it is that so many people with Fibro actual look for this diagnosis as some justification for them to be in pain and some sick desire to have others caring for them and being overly empathetic because they can tell them they have this disease. I think the more we as healthcare professionals feed into this, we are doing them a diservice. I have a SLAP tear I work with every day. Sure it bothers me at times, but I do not think one of my patients or co-workers other than the mri tech even knows that I have it. I do not let it consume me I do not ask others to treat me different or feel sympathy for me, etc. I just find that too often these patients cling on to this as some red badge of courage and are quick to tell you:"oh i have fibromyalgia." I do not even here my patients with MS this comsumed with their diagnosis, especially a diagnosis so vague, and probably incorrect in many of the cases, and one which has no real treatment other than to over drug someone. So this is how I feel about fibro and it is based on real life experience of working with a pain management group. Once in a blue moon I could get someone with "fibro" to actually be 100% pain free by working on them as if they were a postural stress patient with lots of behavioral modification, muscualr postural endurance training, thoracic and cervical vertebral and muscualr mobility, taking some onus as thier own pain management specialist, and lots of dynamic neural-fascial releases. So if they have no more pain and no more symptoms is fibro then cured?? Or did they not have it in the first place. I just wish the MD/DO wasn't so quick to label so that the patient didn't fall into some strange "self-efficacy" role that the disease seems to attract or the patient's who typically have the disease seem to want...
good night
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Re: Fibromyalgia - December 7, 2004 3:18:00 PM
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nari
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From: Australia
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Florida
I do know what you are getting at;this misnamed disease has a big iatrogenic factor tied to it.
It has a large central sensitivity component and also this problem: People with ongoing pain of unknown origin will cling to diagnoses; regardless of what it is. They will cling to therapists who treat them nicely, but can any of us seriously say what sort of irrational thinking and potential codependency will develop with 'fibro' - it is not like visible generalised arthritis, it is not highly respected like MS.
None of us knows just what personality changes occur after many months of pain- unless we have been there.
To this extent it is probably a hands-off condition for PTs, and lots of education, goal setting and clear planning ahead. Codependency must be avoided at all costs, and this can happen provided it is quite clear that the work to feel better has to come from the owner of the pain..
Nari
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Re: Fibromyalgia - December 7, 2004 3:19:00 PM
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FLAOrthoPT
Posts: 1011
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From: West Palm Beach
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agreed
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Re: Fibromyalgia - December 7, 2004 3:26:00 PM
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PTupdate.com
Posts: 1477
Joined: October 8, 2001
From: Pittsburgh, PA USA
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Here is one source you could review:
EFFECTS OF AEROBIC EXERCISE ON PAIN PERCEPTION, AFFECT, AND LEVEL OF DISABILITY IN INDIIDUALS WITH FIBROMYALGIA. Physical Therapy, vol. 74, NO. 4, April 1994.
And this one I really liked:
TEST OF A NURSING INTERVENTION TO PROMOTE ADJUSTMENT TO FIBROMYALGIA. Orthopaedic Nursing, May/June 2001, Vol. 20, No. 3
The first article above brought a comment on the forum on my own site, and I replied as follows:
Thanks for the great reply. You are right, such a touchy subject when discussing with a patient. Basically, I inform them that the condition is a physical manifestation of a psychological issue, and then quickly make sure they know I am talking about a supratentorial issue, and that they are not "whacko". I stress the point that every person alive, including myself, has had a stress headache, GI issues from stress, etc. We all have it, but some bodies take it to a higher level, and that constant tension/stress actually changes the physiological make-up of muscle/connective tissue, leading to pain. After all, try flexing your bicep for years on end and see how it feels!
Sure, we at times are acting like a personal trainer. Don't worry about it....our job it to get the patient better and improve function. We don't always have to touch the patient or use modalities to achieve this goal.
For a while, I was xeroxing the article from the Nursing Journal (abstracted somewhere on this site) regarding the multi-disciplinary approach to FM and giving it to the patients....giving them the chance to read and decide what to do. Now, I cannot find the journal to copy!!!
One problem that really comes into play is the fact that some of these people are just plain woosies (sic). They have been wishy washy all their lives, never participated in ANY athletic/sporting programs, and really can't, won't, dont' want to exercise. They are horrible with HEP and visit compliance, and most of their own problems are their own **** fault. For us to think we are going to change 30-50 years of bad attitude and lazy behavior is plain wrong. Give them your best shot, and dont' feel guilty if they dont' stick with it.
That pretty much sums up my feeling on the matter.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Fibromyalgia - December 7, 2004 3:27:00 PM
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pablo w
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From: Canberra
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FLAOrthoPT,
I am now not sure if you agree or disagree with what I wrote, I'm thinking we have complemetary opinions rather than contradictory ones.
I know that there is a high correlation between symptoms of fibromyalgia and prolonged stress. Not everyone under stress develops these symptoms however. Is it genetic? Is it social? Is it psychological? Is it mechanical? If we knew I guess we would intervene accordingly.
If our treatments work, great, let's keep doing them, but also try to find out why and let others know. If they don't work, then either we are doing it wrong or doing the wrong thing or not picking the right patient. What evidence there is on fibromyalgia is scarce, but the best evidence revolves around exercise, antidepressants, and self management strategies. As far as I know everything esle is anectdotal, but I don't know everything. A lot of the literature on fibromyalgia contains very strong opinions and often biased, we need to keep an open mind.
Great discussion.
Pablo
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Re: Fibromyalgia - December 7, 2004 3:30:00 PM
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FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
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agreed pablo, and duffy, when do we go into practice with each other? Cannot agree with you on any more subjects...
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Re: Fibromyalgia - December 7, 2004 4:19:00 PM
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PTupdate.com
Posts: 1477
Joined: October 8, 2001
From: Pittsburgh, PA USA
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Boy, doesn't even join my website and wants to go into practice with me!!
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Fibromyalgia - December 7, 2004 5:41:00 PM
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FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
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didnt know there was a website to join?! I'll go check it out..I mean I see your name, just never ventured...
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Re: Fibromyalgia - December 8, 2004 1:49:00 AM
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SJBird55
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From: Michigan
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Florida... brown-noser. LMAO
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Re: Fibromyalgia - December 8, 2004 4:27:00 AM
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scottybolton
Posts: 3
Joined: November 29, 2004
From: Amsterdam
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Wow...I better hit the books on this topic. Thanks for all of the interesting points of view. Sometimes it is difficult to find a book that outlines real life patient situations! Thanks for offering yours. Very much appreciated!
Scott Bolton
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