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LOTA Spring Conference 2009 Slide 2 What is Fibromyalgia? Evidence base for treatment Assessment Occupational Therapy Spreading the word (and getting paid!) Conclusion Slide 3 Describe someone you know with Fibromyalgia. How do people (including therapists) respond to hearing the word Fibromyalgia? Slide 4 Slide 5 Restless legs IBS Difficulty concentrating Headaches Urinary problems Numbness/tingling (non-dermatomal) Allergy symptoms Dizzy Cold sensitivity Anxiety Depression & insomnia Slide 6 11 / 18 tender points 2009 ICD-9-CM Diagnosis 729.1 Myalgia and myositis unspecified Slide 7 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 cant think straight. I used to be a type A person. Now I cant get out of bed. If I could just sleep for a week. Slide 8 Slide 9 Slide 10 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 Slide 11 Serotonin- mood, sleep, depression Dopamine- reward chemical, runners 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 Slide 12 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 Slide 13 Slide 14 ACTH CRF Stress HPN Limbic System Anterior Pituitary Hippocampus Brain Stem Cortisol Adrenal Cortex Slide 15 Cognitive Dysfunction Stress Hormones (CRH & Cortisol) Pain Dopamine Hippocampus Stress -0.89 Slide 16 Slide 17 Spirituality Cognitive Affective Physical Self-care Productivity Leisure Physical Institutional Cultural Social Person Environment Occupation Slide 18 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. Slide 19 Improved pain and function Drop-out was low Slide 20 Can benefit some Evidence is not strong Slide 21 Expert opinion Evidence is strong for other types of pain conditions Slide 22 Tramadol Mirapex Elavil Prozac Cymbalta Navoban Lyrica Savella Aurorix, Manerix Slide 23 Slide 24 Roles Habits Personal Causation Values Interests Skills Goals Interpretation of Past Experiences Physical Environment Social Environment Readiness for Change www.moho.uic.edu Slide 25 Score: 0-100 X = 50 Severe impact = 70 Most commonly used Free http://www.myalgia.com/FIQ/fiq.pdf Slide 26 Beck Depression Inventory II www.ibogaine.desk.nl/graphics/3639b1c_23.pdf 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 Slide 27 www.cebp.nl/vault_public/filesystem/?ID=1478 Visual Analog Scale (VAS) Slide 28 ROM Grip Strength Timed Stair Test No statistical differences: Self-efficacy Milwaukee OConnor Slide 29 Symptom Management: Nutritional Mind-Body Physical Lifestyle Emotional-Spiritual Slide 30 Slide 31 Avoid: MSG (natural seasonings) Aspartame Caffeine Use: Splenda instead of sugar & cruciferous vegetables Slide 32 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 Slide 33 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 Slide 34 Mind and Body Slide 35 92 degrees BP: not more than 150/98 or so Exercise below the point of fatigue or pain Dopamine Stress Hormones Slide 36 Everyday 30 minutes (40 minutes to lose wt.) stretching 20% strength 40% aerobic 40% (Raise your heartbeat by 50%) Slide 37 Moshe Feldenkrais Painful movement due to improper sensory motor self-image Cervical eye ball exercise! Slide 38 Gentle movements Balance & ROM Breathing & awareness Resist the Tiger Slide 39 Stretching Core strength Breathing & awareness Warrior Slide 40 Slide 41 Significant relief for pain, fatigue, anxiety but not function Slide 42 cranial electrotherapy stimulation Slide 43 transcutaneous electrical nerve stimulation High vs. Low frequency Slide 44 3-Planar Fascial Fulcrum Approach Integrative Manual Therapy Technique Soft Tissue Myofascial Release Approach. Indirect neuromusculoskeletalfascfial augmentation. Integrates with other manual techniques. Utilized for acute and severe inflammatory. Fibromyalgia, edema, adhesions, venous, and lymphatic congestion. Myofascial Release- Harriet Leggett, LOTR Slide 45 Occupational Therapy and Myofascial Release (MFR) Focus on clients structure and function. Motor function includes: mobility, flexibility, strength, endurance, balance, coordination, proprioception, and more. Function is defined as the requirements for ADL: strength, balance, coordination, exteroception, proprioception, and other functions. Structure includes: systems on a cellular level which may include dysfunctions of the joints, organ, circulatory, ligaments, tendons, capsule tissues, muscle fibers, neural tissues, connective tissue, and fascia. Slide 46 Fascia Tough specialized connective tissue. Functions in a 3-dimensional web from our head to toe. Separates, supports, binds, connects, and defends the entire body. Slide 47 Concepts of Soft Tissue MRF Technique 3-Planar concept Fulcrum concept Release Slide 48 Slide 49 Get with your flavor team Slide 50 Assertive communication Time management Day timer To-do list Say no at work Career change? Slide 51 Evaluate sleep Short naps only Regular schedule Work smarter Pace Re-arrange environment Slide 52 Slide 53 Slide 54 Slide 55 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 Slide 56 Husband home late Hes cheating on me. I should be more attractive. DepressionAngerGuilt Cant Sleep, Withdraws, Interrogates A B C Slide 57 Autogenic meditation Focused meditation Mindful meditation Visualization Guided Imagery (Belleruth Naparstek) Self-Hypnosis Slide 58 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? Slide 59 Therapeutic relationship Positive self-esteem is highly correlated with internal locus of valuation i.e. self worth not dependent on what other people think Slide 60 And getting paid! Slide 61 Rheumatologists Family Medicine Internal Medicine Pain Specialists Support Groups Slide 62 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 Slide 63 Questions? www.robinsteed.wikidot.com