Posted on August 18, 2008
The typical fibromyalgia patient is a 40-year-old woman who suffers from widespread pain above and below the waist on both sides of her body. The pain most likely began with a soft-tissue injury to her neck and back from a trauma such as a motor vehicle accident. Regular physical therapy interventions have not worked and therefore, her pain persists.
With time, the pain begins to be associated with other non-related symptoms, such as fitful or non-restorative sleep. She has seen multiple physicians and received several orthopedic diagnoses before finally receiving a fibromyalgia diagnosis from a rheumatologist.
"It's difficult to diagnose and manage fibromyalgia because it cannot be understood according to the classical medical model of disease," explained Mima Siegel, PT. A senior physical therapist in outpatient rehabilitation services at Cedars-Sinai Medical Center in Los Angeles, Siegel specializes in orthopedic injuries, fibromyalgia and chronic pain.
Siegel aims to teach fibromyalgia sufferers how to regain trust in their bodies so they may progress and achieve what they would like in life. "I teach patients to cope with the symptoms and feel comfortable enough with their bodies so they can wash dishes or go to the park with their children without worrying about pain," she explained.
Siegel has been treating fibromyalgia patients at Cedars-Sinai for 16 years and has more than 30 years of PT experience. "I have learned that I need to treat the fibromyalgia syndrome before I try to treat additional musculoskeletal pain," she commented.
Many of Siegel's patients have received PT elsewhere but complain that nothing has worked to control the pain. In order to reduce the pain of the regional barrier-the location where all pain begins-the fibromyalgia must be managed first.
If a patient injures her neck in a motor vehicle accident, for example, it is not uncommon for a PT to address the neck injury first. When the fibromyalgia is managed first, however, the regional barrier becomes easier to address.
What is Fibromyalgia?
Fibromyalgia syndrome is a rheumatic disorder that affects an estimated 3 to 6 million Americans. It is characterized by widespread pain and is diagnosed by identifying tenderness at 11 of 18 specific points in the body.
In addition to pain, fibromyalgia may be associated with a variety of other symptoms such as fatigue, sleep disorders, headaches, morning stiffness, cognition changes such as impaired memory and difficulty concentrating, irritable bladder or bowel syndrome, anxiety and depression. The pattern of symptoms, however, varies greatly among patients.
Fibromyalgia can be caused by a trauma-physical or emotional-that was not treated in the correct manner. Physical trauma is a far more common cause of fibromyalgia than emotional trauma and the trauma is usually in the upper quadrants. Patients at the Fibromyalgia and Chronic Pain Clinic at Cedars-Sinai typically experience peripheral pain that does not remain in one place.
Medication has proven only partially effective in relieving the symptoms of fibromyalgia. Many individuals have participated in PT or psychotherapy, with little success. The best treatment for these disorders is an interdisciplinary approach that helps patients change their psychological attitude, physical fitness, energy level and sleep behaviors and decrease their dependence on pain medication.
Team Approach to Pain Management
"My treatment focuses on self responsibility," Siegel said. "My goal is to help my patients regain confidence in their bodies so they can progress their exercise and activity level at home without fear of aggravating their symptoms."
The clinic has devised an interdisciplinary approach-centered on physical and occupational therapies and psychology-to assist patients in making choices. The team members may include: PT, OT, BFB/stress management, psychologist/psychiatrist, rheumatologist or physiatrist and nutritionist. The team helps the individual enhance her functional abilities and quality of life by developing restorative skills, such as self-awareness, conscious relaxation, proper exercise and self-control of mood.
Siegel executes patient evaluations to identify how widespread the pain is and the location of the tender points. "I check the tenderness and make sure that the pain is in all four quadrants to rule out other diagnoses such as regional myofascial pain or other types of soft-tissue diagnoses that are localized to one area," Siegel explained.
Judy Fishman, MA, OTR/L, works with patients on sleep disturbances and some nutrition. If more in-depth nutrition counseling is needed, then the patient is referred to a nutritionist. The patients see a psychologist regularly but have access to a psychiatrist if necessary.
"We use biofeedback with patients who are multi-symptomatic because the condition needs to be addressed from all sides," Siegel explained. "Once a patient sleeps better, the symptoms are better tolerated. When people don't sleep well they tend to be more irritable and anxious and the pain is magnified."
When a patient is first evaluated, the team meets as a group at the end of the week to share findings and recommendations. The patient may be directed to a multidisciplinary group intervention or individual sessions, depending on the level of function and need.
The clinic sees patients with both low and high levels of function. Patients with different functional capacities may be grouped together depending on the coping mechanism and the psychological findings. The group meets twice a week for six weeks. If a patient needs individual sessions, they meet in the group once a week and one-on-one once a week.
The program mostly involves stretching and cardiovascular exercises. The first session in the clinic is generally an introduction to exercise and its benefits and how to exercise with the most ease. Siegel asks her patients to begin a regular walking program at home, even if they are only able to walk five or 10 minutes at a time. "If patients tell me they cannot walk, I tell them that it's okay if they just get out of the door, look at the sunrise and go back in," she said.
Siegel plays an active role in managing symptoms. She uses the metaphor that she is a diving coach and can teach the patient how to walk slowly on the diving board and dive into the water. Once the patient dives in, however, it's her own responsibility to start swimming and if she doesn't, she will sink.
"I teach the patients two or three exercises they can do and I ask them to listen to their bodies before and after the exercise," Siegel explained. "I ask if there is any change from before and after. Ninety percent of the patients say their bodies feel more relaxed or the pain has lessened."
Siegel works with patients on postural education, mostly how to sit, sleep, drive, stand and walk with less strain on the body. She also teaches them how best to pace each activity.
"We discuss problem solving," she commented. "I ask them to identify activities at home that are difficult."
Hair washing is an activity that is frequently identified as difficult because a patient may experience pain when she raises her arms up and generally does not have the endurance to keep them raised during the activity. Siegel may suggest that the patient lean her arms on the wall while washing her hair.
Siegel discusses solutions for patients who struggle with a lack of motivation to do their prescribed exercises. For example, she may suggest using the social support of friends and family to reach goals or aiming to complete exercises in a certain amount of time.
Patients with fibromyalgia do not respond well to regular pain treatments and tend to have a lower pain threshold. This may be attributed to the fact that the patients have tenderness throughout the whole body.
Because fibromyalgia patients tend to be more sensitive, PTs need to be selective with their approaches. A hot pack ultrasound massage, for example, may feel great at the time of execution but the patient may experience increased pain two days later due to intolerance.
Fibromyalgia vs. Chronic Pain
Many other patients suffer from chronic pain which is generally defined as pain lasting more than six months in duration. With chronic pain patients, the pain has extended beyond the expected healing time. For example, when a patient sprains her ankle, the soft tissue injury will most likely disappear within six weeks. But in the case of chronic pain, the pain might continue for three to six months.
With a chronic pain patient, the functioning is more limited by pain or disability than seems necessary. "When treating a patient, we try to decrease the focus on pain and increase the functional activity," Siegel said.
As with her fibromyalgia patients, Siegel promotes self responsibility in her chronic pain patients. "The patient, in any disease, needs to play an active role in the treatment," she said. "But with a pain patient, we set up a baseline and we go from there and progress over time."
The focus with fibromyalgia patients, however, is on coping. "I help patients decrease pain and increase function by learning how to cope with symptoms," Siegel explained. "While increasing endurance, mobility and functional activity, we are educating the patient on pacing, proper breathing and relaxation."
Siegel works with both types of patients on proper body mechanics for functional activity?bending, lifting, carrying?and basic activities such as bed mobility and transfers. With fibromyalgia patients, Siegel focuses on positioning to decrease symptoms.
Siegel devises home programs for chronic pain patients that are based on active exercises. For fibromyalgia patients, however, the program includes more passive stretching and positioning.
"With both conditions, we make sure that the home program is motivational, convenient and functionally significant," she said. "But the progress with fibromyalgia is slower so as not to increase anxiety and depression. We need to be sure that they don't feel more stressed about completing the exercises."
Live Life to its Fullest
Siegel encourages patients to explore and try new things, even if it's an activity that may aggravate symptoms. "I don't want them to avoid things due to fear of what may happen," she commented. "Patients progress by trying new things, taking risks and realizing that it's not as bad as they may have feared. If they discover the risk was not worth it, then at least they know."
Siegel draws a parallel to when she goes to the gym following an exercise hiatus and comes home with sore muscles. "It's okay sometimes if an activity makes a patient sore, it's a normal reaction," she said. "I like my patients to do what they want with their life, so I tell them what they can do, rather than what they cannot do."
Rebecca Mayer is regional editor at ADVANCE and can be reached at firstname.lastname@example.org.