HOW CAN PT HELP WITH FIBROMYALGIA?
I was recently asked in an open forum how PT can help fibromyalgia. I hope the summary of this article sheds light on how important of a role PT’s play in this ailment.
“…Fibromyalgia syndrome (FMS) as a syndrome characterized by chronic widespread pain and tenderness in at least 11 of 18 predefined tender points”
First, when something is characterized as a “syndrome” it means that there is a cluster of symptoms that are common amongst people, but there is no definite test in order to prove that it is the cause of symptoms.
This makes FMS difficult to treat and understand because we don’t have a specific test in which to try to “fix” the underlying cause.
This article will go into what we know about FMS and what is hypothesized about FMS to further the patient’s knowledge of how PT can help.
“…prevalence rates between 0.5% to 6%”
This means that in the general population we will see this diagnosis between 5 in 1,000 and 6 in 100. Depending on the setting that a PT works in, the prevalence rate may be much higher. I can say personally that this is either the primary diagnosis or a secondary diagnosis in about 25% of my current caseload.
“…high comorbidity with other disorders, particularly chronic fatigue syndrome and mental disorders, including depression and anxiety disorder”
FMS is not frequently a diagnosis on its own. The patient with FMS may also have other issues such as chronic fatigue, which is not the same as FMS. The person may also have a psychological issue, which may play a role in FMS.
“FMS is not only a chronic pain syndrome but also consists of a whole range of symptoms referring to effort intolerance and stress intolerance, as well as hypersensitivity for pain and other sensory stimuli”
Fibromyalgia goes well beyond pain only. The patient with FMS is not frequently able to tolerate a great deal of activity without worsening of symptoms. This is a major role for the PT to educate the patient regarding when it is safe to push harder and when the patient may need to back off activity in order to allow the system (read that as body as a whole) to calm down. A good book for this topic is “A World of Hurt” by Annie O’Connor and Melissa Kolski.
Hypersensitivity is a key finding in FMS and this will be spoken about later in the article.
“The precise etiology and pathogenesis of FMS remain undefined, and there is no definite cure”
When I read this, it sounds doom and gloom, but if you read it more like a science person instead of as a layperson it makes sense. If we don’t know the cause of a specific action, then we can’t possibly know how to stop the action or prevent it in the first place.
“It is not our intention to advocate that physical therapists are able to manage a complex disorder such as fibromyalgia on their own”
Because there are multiple components to the syndrome (remember the psychological issues spoken of earlier), this is not a problem that can be handled by one professional without help from others. As PT’s, we can play a role in managing this process, but that’s it…we play a role.
“Fibromyalgia syndrome is characterized by sensitization of the central nervous system, which explains the majority of, if not all, symptoms…Once central sensitization is established, little nociceptive input is required to maintain it…an increased responsiveness to a variety of peripheral stimuli, including mechanical pressure, chemical substances, light, sound, cold, heat, and electrical stimuli…results in a large decreased load tolerance of the senses and the neuromuscular system.”
When your nerves are more sensitive, then the sensations that you feel such as pain, heat, pressure, etc may be felt quicker and more intense than those without this syndrome. This is the concept of little nociceptive input (pain input) is required to maintain sensitivity. For instance, when someone has a lower threshold for pain (not an ego thing) then smaller deviations will cause pain. I have treated patients that claimed to have increased pain from being touched by a feather! It is real and the patient’s experience of pain cannot be denied.
“…pain facilitation and pain inhibition is influenced by cognitions, emotions, and behaviors such as catastrophizing, hypervigilance, avoidance behavior and somatization”
This is a great article because the authors did a great job of attempting to summarize FMS in a concise manner. Pain is an experience. It doesn’t mean that a tissue is injured, as pain can be felt in the absence of injury. A person can also have a severe injury and not have pain. A person’s emotional state can override the pain response. For instance, I experienced a major injury to my face in which my nose was pulled from my face during a weightlifting movement. I had no pain until I actually saw the injury in a mirror. The injury was unchanged from the minutes of standing at the bar until I went into the locker room and saw the injury. What changed was my mental state. I started worrying about severe damage, financial concerns, loss of work etc. All of these are the same worries that everyone else has when they experience a pain that is not explained (this is the definition of catastrophizing).
Avoidance behavior means that a person will stop performing activities because of fear of making symptoms worse. Finally, somatization indicates that a person experiences symptoms in the absence of a test that can show anything is actually causing the pain.
Avoiding activity and catastrophizing actually causes a change in the nervous system in that it may sensitize the spinal cord.
“…abnormal functioning of the stress system seems to occur mostly in the aftermath of a long period of overburdening by physical and emotional stressors and to be precipitated by an additional trigger in the form of an acute physical or emotional event.”
Now you, as the reader, can see why PT’s can’t solve this puzzle alone. There are so many variables that play a role in this syndrome that more than one professional needs to be involved in the care.
“…many patients with FMS have maladaptive illness beliefs, cognition, and behaviors that preclude successful rehabilitation.”
The primary intervention that takes place in therapy, almost regardless of the diagnosis, is education. When a patient understands their own beliefs and how they may play a role in hindering progress, we have actually reached a milestone. This is very much based in education. If we can educate the patient enough regarding pain and more importantly how to respond to pain and its meaning, then we can progress towards other interventions. If we can’t teach the patient or come to a mutual understanding regarding pain and how it is thought to work, then progress will be difficult. As stated in the following portion of the article; “Poor understanding of pain may lead to the acquisition of maladaptive attitudes and behavior in relation to pain”. This means that the number one treatment that PT’s can offer to patients with FMS, and any other pain disorder for that matter, is education.
“…more adequate pain beliefs lead to increased confidence, which, in turn, leads to increased activity levels. An education course directed at improving self-efficacy for the management of the pain disorder ameliorated symptom severity and improved physical function”
We have to break the cycle of pain. This may be achieved by breaking any part of the cycle. The thought is that if we can increase a person’s activity level, or tolerance, that we could improve or decrease how sensitive the nerves are to outside stimuli. This would allow a person to slowly tolerate more and more activity with less pain over time. This is considered graded exposure.
“Evidence in support of activity management alone for those with FMS is currently unavailable. However, it is generally included in cognitive behavioral therapy.”
The thought is that if we can reduce the stress (think physical, emotional and otherwise) that a person is experiencing, that we would be able to reduce flare-ups. This is a good thought, but hasn’t been proven. What we know is that we need to increase activity levels because there are many good benefits from an active lifestyle such as decreased risk of mortality, increased lifespan, and improved quality of life.
“Limited evidence supports that use of spinal manipulation and moderate evidence supports the use of massage therapy in patients with FMS”
There are many in the field of PT, including the American Physical Therapy Association, has stated that the passive use of physical therapy should be questioned if it is the primary treatment. Passive therapy is treatment done TO the patient instead of done BY the patient. This “passive therapy” also fosters the dependence of the patient on the therapist.
When a patient is dependent on a therapist for improvement, the winner is always the therapist and his/her bank account. In the end, we want to empower the patient to take control of his/her pain status and start to experiment with activity in order to establish a baseline activity that can be performed without flare-ups.
“Strong evidence supports aerobic exercise, and moderate evidence supports muscle strength training for the management of FMS”
This is an easy statement to make, but many patients tell me that “they couldn’t tolerate any exercise”. This is where the therapist-patient team (therapeutic alliance) really comes into play. It is the therapist’s job to listen to the patient in order to provide treatment strategies that will improve the patient’s fitness levels, WITHOUT flaring-up symptoms.
“Physical exercise is troublesome for many patients with FMS due to activity-induced pain, especially for patients with severe disabilities”
This statement sums up the challenge of physical therapy and the challenge for the physical therapist. A patient with FMS cannot be issued a check-list of exercises to perform in the clinic. There has to be a relationship of trust between the therapist and the patient. When a patient comes into the clinic, he/she trusts that the therapist is issuing interventions with the patient’s end-goal in mind. If, at any time, the patient feels that the therapist is not providing GREAT care, then the patient needs to leave and find a therapist that treats them as a person and not a number! This is important and will come up again towards the end of the article.
“Nonspecific factors such as the patient’s emotional processing of the encounter with the health care professional, the quality of the therapeutic alliance, and the patient’s treatment preferences may be important in predicting therapeutic outcomes.”
THIS IS HUGE! The emotional processing of the encounter….Read that again….How the patient perceives being treated during the session plays a role in the outcomes. When we know that there is an emotional component to FMS, it is our responsibility to ensure that we accommodate this by trying to provide the best experience as possible. This starts from the initial phone call and progresses through the initial visit. This perception starts prior to the patient coming into the clinic. The patient needs to be heard and feel important in order to get the best results. I would say that this should hold true to all patients and not just for those with chronic pain or FMS.
Thanks for reading and I hope it was helpful.
Excerpts taken from:
Nijs J, Mannerkorpi K, Descheemaeker F, et al. Primary Care Physical Therapy in People with Fibromyalgia: Opportunities and Boundaries Within a Monodisciplinary Setting. Phys Ther. 2010;90(12):1815-1822.