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Chronic Pain Assessment and Management with an Emphasis on Fibromyalgia

Mindfulness-based and Cognitive Treatment Strategies

Combined Sections Meeting 2006San Diego, CA

February 1-5, 2006

Carolyn McManus, PT, MS, MASwedish Medical Center

Seattle, WA

The International Association for the study of pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

Pain is more than sensation. The relationship between reported pain intensity and the evoking peripheral stimulus depends on many factors, including level of arousal, anxiety, depression, attention and expectation.

Brooks J, Tracey I J Anat. (2005) 207, 19-23.

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• Insula• Somatosensory Cortices• Anterior, Middle and

Posterior Cingulate• Basal Ganglia• Posterior Parietal Cortex• Amygdala• Hypothalamus• Prefrontal Cortex

• Conscious perception of event being painful created by central processing of incoming signals

• Brain and spinal cord can modulate, but also create pain perception

Thalamus

Spinal Cord

Brainstem

Peripheral input from pain sensing nociceptors

‘C’

‘A’Brooks J, Tracey I J Anat. (2005) 207, 19-23.

FM subjects exhibited greater activity than controls over multiple brain regions in response to both nonpainful and painful stimuli.

Cook DB, Lange G, et al. Functional imaging of pain in patients with primary fibromyalgia. J Rheumatol 2004 Feb;31(2):364-78.

Application of mild pressure produced subjective pain reports and cerebral responses in FM subjects that were qualitatively and quantitatively similar to the effects produced by applying at least twice the pressures in control subjects.

Gracely RH, Petzke F, et al. Functional magnetic resonance imaging evidence of augmented pain processing in fibromyalgia. Arthritis Rheum 2002 May;46(5):1333-43.

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Pain catastrophizing is significantly associated withincreased activity in brain areas related to the anticipation of pain, attention to pain, the emotional aspects of pain in subjects with FM.

Gracely RH, Geisser ME, et al. Pain catastrophizing and neural responses to pain among persons with fibromyalgia. Brain 2004 Apr;127(Pt 4):835-43.

In summary, people with FM appear to have maladaptive increased activity in brain areasassociated with pain processing in response to nonpainful and painful peripheral stimuli.

As clinicians, our treatment choices will be enhanced by employing strategies that engage the whole process of pain perception.

Chronic pain patients were able to learn control of activity in the rostral anterior cingulate cortex, a brain region involved in pain perception and regulation.

The ability to decrease activation in the rostral anterior cingulate cortex was associated with a decrease in perceived pain intensity.

deCharms RC, Maeda F, Glover GH, et al. Control over brain activation and pain learned by using real-time functional MRI. PNAS 2005;102(5);18626-31.

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It appears that a combination of interventions, in a multimodal approach (eg. exercises combined with education and psychologically-based interventions) is the most promising means of managing patients with fibromyalgia.

Adams N, Sim J. Rehabilitation approaches in fibromyalgia. Disabil Rehabil 2005 Jun 17;27(12):711-23. Review.

In the treatment of fibromyalgia, current evidence suggests efficacy of low dose tricyclic antidepressants, cardiovascular exercise, cognitive behavioral therapy and patient education.

Goldenberg D, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA 2004 Nov;292(19): 2388-95. Review.

Mindful Awareness

Present moment Kind, compassionate, friendlyAcceptingNon-strivingCuriousBeginner’s mindSteady, unwavering

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Mindfulness meditation is the deliberate training in mindful awareness through formal and informal practices.

FormalSitting meditationWalking meditationMindful body scan

InformalIntegration onto activities of daily life

Applications of mindful awareness include:

Injury preventionReconditioning, exercisePreventing symptom exacerbationUndergoing medical proceduresQuality of lifePain management

Pain = Sensation + Our Reaction

Physical

Cognitive

Emotional

We may have no control over the onset of an unpleasant sensation, but we do have control of our response to the sensation.

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Pain = Sensation + Our ReactionPhysical CognitiveEmotional

The first step in a developing skillful responseto pain is awareness.

Mindful awareness of the sensation and our reaction to that sensation is, in itself, a skillful choice.

Mindful awareness of the breath

Diaphragmatic breathingBreathe into your waistband

Key word or phraseIn breath Out breathIn OutArriving HomePresent moment Only momentMay I Be peacefulLet go Let GodIn the kingdom of God I dwell

Awareness of the breath assists in steadying the mind and calming the body.

The mind is like the surface of a pond. When the surface of the pond is turbulent it distorts the reflection of the surrounding terrain. When the surface is still, the surrounding terrain is seen clearly.

From this stable mind, the unpleasant sensation and the reaction to that sensation can be observed.

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Pain = Sensation + Our ReactionPhysical CognitiveEmotional

Sensations are observed as sensations, thoughts are observed as thoughts, emotions are observed as emotions.

No deliberate effort is made to change, improve or strive toward anything.

Acceptance of pain. Viane I, Crombez G, et al. Pain2004 Dec;112(3):282-8.

Anyone can teach a simple 5 - 10 minute mindful breathing exercise and encourage the informal practice of mindfulness. I recommend any health care practitioner introduce these practices.

Teaching mindfulness meditation requires years of personal practice. As the instructor, you embody mindfulness and teach it, not as a brief exercise or technique, but as a way of life.

Physical

BreatheRelax

Progressive RelaxationAutogenic TrainingRelaxation Body ScanGuided Imagery

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Cognitive

Life happens. Then we tell ourselves a story about what has happened.

The story begins to take on a life of its own.We can get so caught in the story that it becomes a lens that distorts our perception.

We begin to selectively see things that reinforce our viewpoint.

We can believe and make choices based on the story, even if it has no basis in fact.

1. You are not your pain.You are not your diagnosis.

You are a whole human being, with a multitude of dimensions, and you have a medical condition, but that medical condition is not you.

There is more right with you, functioning in a wondrous and miraculous manner, than is problematic.

2. Camera lens metaphor. Choose a wide angle lens.

The mind is like the sky, pain is like a cloud.

Think of someone you love dearly. Feel that energy of love in your heart. You carry a capacityfor love that is boundless and immeasurable. By comparison the pain is small.

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3. Label pain as sensation.

4. If your best friend were experiencing this, how would you talk with or comfort your best friend?

We often carry an inner wisdom that can help us navigate difficult situations. We sometimes more easily access it for others. We need to access this inner wisdom for ourselves.

Talk to yourself in the same manner as you would talk to your best friend.

5. Anticipation and catastrophic thinking

Anticipation, catastrophic thinking and fear are often about the future, what is going to happen next.

The truth is, no one knows what is going to happen next.

It is easy to feel overwhelmed when you add the unknowns of tomorrow on to the challenges you face today.

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Plan for the future, but do not spend your life there.

The present moment is the foundation for the next moment. Today is the foundation for tomorrow.

Today is where your power resides.Taking care of yourself as best you can today is your foundation for tomorrow.

The present moment is the only moment we have for living. This is it.

6. Ask yourself:

If I keep talking to myself in this way, what kind of future is it contributing to? Is this the future I want?

Is this a story I want to give my life energy to?

What would be a healing or comforting story?

7. Water the weeds or water the flowers

If you think of life is like a big garden, we all have plants in our gardens that are not doing well.

You can spend all of your energy focusing on the plant that isn’t doing well, or you can spend sometime in other parts of your garden.

This not only gives you a more accurate experience of life, it also provides a better perspective and can help strengthen you.

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EmotionalCompassion

Life is a bumpy road with unexpected twists, turns and unforeseen weather conditions.

The price of being on this road is a human body that is vulnerable to sickness, aging and death.

You can travel that road with a mean and harsh critic, and truly have a miserable experience.

You can travel that same road with someone kind and compassionate, friendly and understanding, and the experience would be much more manageable.

The voice that travels this road with us is our own. The choice is always ours.

Loving kindness meditation

May I be peaceful and joyfulMay I be free of distress and the causes of distressMay I care for myself with love and compassionMay I awaken to my wholeness and be free

Loving kindness is extended to oneself, a loved one, a neutral person, a difficult person and to all beings.

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Exploring Pain with Cognitive Restructuring

Identify your thoughts, feelings and subsequent behaviors in response to pain.

Thoughts:

Feelings:

Behavior:

Identify automatic thoughts that are distorted, negative or exaggerated:

If you are caught in unrealistically negative or distorted thinking, identify alternative ways of thinking about your symptoms that reduce your distress:

Identify how changing your thoughts can impact your feelings and behavior:

Exploring a Difficult Situation with Mindfulness

Identify the difficult situation:

How have you reacted to this situation?Thoughts

Emotions

Physical reaction

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Observe your reaction with generous acceptance, openness, curiosity, with basic kindness and compassion and no need to criticize, judge or blame. Observe your reaction with a “beginner’s mind.” This alone is a healing practice.

Has this reaction contributed to your distress? If yes, how?

Is there a component of your reaction that you can change that would decrease your distress?

Are there unavoidable elements of this situation that are not in your power to change?

What is life teaching you? Is there something of value here?

CarolynMcmanus.comCarolyn.McManus@swedish.org

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Case Example

Patient is a 40 year old woman, married with 2young children

Diagnosed at age 34 with FM and LupusAt 39 she changed MDs, and was dx’d with

Undifferentiated Connective Tissue Disease

c/o chronic pain neck, shoulders, back, hips,both joint and muscular pain

Pain intensity 5 - 8/10

Office VisitsBefore 6 mos After

Rheumatologist 1-2 x/mo 1x/3 mosPsychiatrist 2x/mo 1x/6-8 wksPhysical Therapist 2-4x/mo 1x/2 mos

Bibliography Medical Literature Adams N, Sim J. Rehabilitation approaches in fibromyalgia. Disabil Rehabil 2005 Jun 17;27(12):711-23. Review. Astin JA. Mind-body therapies for the management of pain. Clin J Pain 2004 Jan-Feb;20(1):27-32. Review. Astin JA, Berman BM, Bausell B, Lee WL, Hochberg M, Forys KL. The efficacy of mindfulness meditation plus Qigong movement therapy in the treatment of fibromyalgia: a randomized controlled trial. J Rheumatol 2003 Oct;30(10):2257-62. Bantick SJ, Wise RG, et al. Imaging how attention modulates pain in humans using functional MRI. Brain Feb;125:310-19. Bradley L, McKendree-Smith NL. Central nervous system mechanisms of pain in fibromyalgia and other musculoskeletal disorders: behavioral and psychologic treatment approaches. Curr Opin Rheumatol 2002 Jan;14(1):45-51. Brooks J, Tracey I. From nociception to pain perception: imaging the spinal and supraspinal pathways. J Anat 2005 Jul;207(1):19-33. Burckhardt CS. Nonpharmacologic management strategies in fibromyalgia. Rheum Dis Clin North Am 2002 May;28(2):291-304. Review. Cook DB, Lange G, et al. Functional imaging of pain in patients with primary fibromyalgia. J Rheumatol 2004 Feb;31(2):364-78. Crombez G, Eccleston C, et al. Hypervigilance to pain in fibromyalgia: the mediating role of pain intensity and catastrophic thinking about pain. Clin J Pain 2004 Mar-Apr;20(2):98-102. DeCharms RC, Maeda F, et al. Control over brain activation and pain learned by using real-time functional MRI. PNAS 2005 Dec;102(51):18626-31. Glass JM, Park DC. Cognitive dysfunction in fibromyalgia. Curr Rheumatol Rep 2001 Apr;3(2):123-7. Review. Goldenberg D, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA 2004 Nov;292(19):2388-95. Gracely RH, Geisser ME, et al. Pain catastrophizing and neural responses to pain among persons with fibromyalgia. Brain. 2004 Apr;127(Pt 4):835-43. Epub 2004 Feb 11.

Gracely RH, Petzke F, et al. Functional magnetic resonance imaging evidence of augmented pain processing in fibromyalgia. Arthritis Rheum 2002 May;46(5):1333-43. Grossman P, Niemann L, et al. Mindfulness-based stress reduction and health benefits. A meta-analysis. J Psychosom Res 2004 Jul;57(1):35-43. Kakigi R, Nakata H, et al. Intracerebral pain processing in a Yoga Master who claims not to feel pain during meditation. Eur J Pain 2005 Oct;9(5):581-89. Lazar SW, Bush G, et al. Functional brain mapping of the relaxation response and meditation. Neuroreport 200 May;11(7):1581-85. Lazar SW, Kerr CE, et al. Meditation experience is associated with increased cortical thickness. Nueroreport 2005 Nov;16(17):1893-97. Lemstra M, Olszynski WP. The effectiveness of multidisciplinary rehabilitation in the treatment of fibromyalgia: a randomized controlled trial. Clin J Pain 2005 Mar-Apr;21(2):166-74. Lutz A, Greischar LL, et al. Long-term meditators self-induce high-amplitude gamma synchrony during mental practice. PNAS 2004 Nov;101(46):16369-73. Mackey SC, Maeda F. Functional imaging and the neural systems of chronic pain. Neurosurg Clin N Am 2004 Jul;15(3):269-88. Review. McManus C. Group Wellness Programs for Chronic Pain and Disease Management. Philadelphia, PA: Butterworth-Heinemann/Elsevier, 2003. Montoya P, Larbig W, et al. Influence of social support and emotional context on pain processing and magnetic brain responses in fibromyalgia. Arthritis Rheum 2004 Dec;50(4): 4035-44. Montoya P, Sitges C, et al. Abnormal affective modulation of somatosensory brain processing among patients with fibromyalgia. Psychosom Med 2005 Nov-Dec; 67(6):957-63. Ploghaus A, Narain C, et al. Exacerbation of pain by anxiety is associated with activity in a hippocampal network. J Neurosci 2001 Dec 15;21(24):9896-903. Ploghaus A, Tracey I, et al.Dissociating pain from its anticipation in the human brain. Science 1999 Jun 18;284(5422):1979-81. Sim J, Adams N. Systematic review of randomized controlled trials of nonpharmacological interventions for fibromyalgia. Clin J Pain 2002 Sep-Oct;18(5):324-36.

Singh BB, Berman BM, et al. A pilot study of cognitive behavioral therapy in fibromyalgia. Altern Ther Health Med 1998 Mar;4(2):67-70. Taylor RR. Cognitive Behavioral Therapy for Chronic Illness and Disability. New York: Springer, 2005. Tracey I, Ploghaus A, et al. Imaging attentional modulation of pain in the periaqueductal gray in humans. J Neurosci 2002 Apr 1;22(7):2748-52. Viane I, Crombez G, et al. Acceptance of the unpleasant reality of chronic pain: effects upon attention to pain and engagement with daily activities. Pain 2004 Dec;112(3):282-8. Williams DA. Psychological and behavioral therapies in fibromyalgia and related syndromes. Best Pract Res Clin Rheumatol 2003 Aug;17(4):649-65. Review. Meditation Chodron, Pema. The Places that Scare You: A Guide to Fearlessness in Difficult Times. Boston, MA: Shambhala Publications, 2001. Kabat-Zinn, J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness. New York, NY: Dell Publishing, 1990. Kabat-Zinn, J. Where Ever You Go, There You Are: Mindfulness Meditation in Everyday Life. New York, NY. Hyperion, 1994. Nhat Hanh, T. Peace is Every Step: The Path of Mindfulness in Everyday Life. New York, NY. Bantam Books, 1991. *Thich Nhat Hanh has multiple titles on the topics of mindfulness meditation and transforming suffering. Packer, T. The Wonder of Presence and the Way of Meditative Inquiry. Boston, MA: Shambhala Publications, 2002. Wallace, A. Genuine Happiness: Meditation as a Path to Fulfillment. New Jersey: Wiley& Sons, 2005. Living Well with Chronic Pain and Illness (Recommendations for your patients) Caudill, M. Managing Pain Before It Manages You. New York: Guilford Press, 1995. Fennell P. The Chronic Illness Workbook: Strategies and Solutions for Taking Back Your Life. Oakland, CA: New Harbinger Publications, Inc. 2001. Greenberger D, Padesky C: Mind Over Mood. New York: Guilford Publications, 1995.

Kabat-Zinn, J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness. New York: Del Publishing Co, 1991. Spero D. The Art of Getting Well: A Five-Step Plan for Maximizing Health When You Have a Chronic Illness. Berkeley, CA: Hunter House Publishers 2002.

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Evidence-Based Treatment of Fibromyalgia Nancy C. Rich, Ph.D.,PT,FACSM

Etiology

• Morphological, histochemical, ultrastructural changes in muscles?

• Differences in amounts of high energy phosphate metabolite concentrations (ATP, ADP, Pi, lactate)?

• Differences in muscle blood flow? • Weaker muscles? • Decreased motor unit activity?

Etiology • “… although muscular pain has been a central feature of FMS

syndrome, controlled studies of muscle fail to support a convincing role for muscle in the pathophysiology of the condition. Muscle tenderness in fibromyalgia cannot be explained on the basis of primary muscle abnormalities, either structural or functional.” (Simms, 1996)

Etiology “…these results and previous investigations support the hypothesis

that hyperalgesia in these patients with FM is due to an upregulation in the central nociceptive system.”

Sorensen et al., 1998

Etiology • “Patients with FMS have lowered mechanical and thermal pain

thresholds, high pain ratings for noxious stimuli, and altered temporal summation of pain stimuli”

Goldenberg et al. Management of Fibromyalgia Syndrome. JAMA, 2004;292:2388-2395

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Etiology • Hyperalgesia and Allodynia

– Based on changes in nociception – Hyperalgesia = an increased response to noxious stimuli – Allodynia = a reduction in pain threshold

Etiology • Robert Bennett, 1999

– Dorsal horn cells become more sensitive – Original receptive fields increase in size – New receptive fields in muscle and skin become active

Etiology • Central sensitization = hyperexcitability of CNS neurons • Pillemer et al (1999) instructed that the hyperexcitability of the CNS is

controlled by activation of N-methyl-D-aspartate (NMDA) receptors. • Substance P reacts with neurokinin (NK1) receptor sites which causes

release of excitatory amino acids which activates NMDA receptors

Etiology • Substance P can travel long distances in the spinal cord and

sensitize neurons away from the site of an injury • Russell et al, 1994: Cerebrospinal fluid of patients with FMS

was approximately 3 times that found in controls. Etiology

• Sleep disturbance – People with FMS demonstrate abnormalities of stages 1-4 – People with FMS demonstrate an average of 60% of Non-REM sleep

with alpha waves intruding, versus 25% normals

Etiology • Somatomedin C – also called insulin-like growth factor 1 (IGF-

1) – Mediates the amount of growth hormone that is secreted – Growth hormone necessary for muscle healing

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– Decreased in people with FMS – 80% of a 24 hour production of growth hormone is secreted during

stages 3 & 4 of sleep

Etiology • Bennett et al.

– Somatomedin C levels in patients with FMS were 124.7+ 47 ng/ml – Somatomedin C levels in persons without FMS were 175.2 + 60 ng/ml

Etiology • Psychological Disturbances

– “ … fibromyalgia might share a genetic abnormality with disorders such as migraine and major depression, but different genetic or environmental factors, such as susceptibility or exposure to certain viral antigens, may be necessary for the development of fibromyalgia.” (Hudson et al, 1985)

Etiology “The majority (65% to 80% of patients with fibromyalgia do not have an

active psychiatric disorder.” (Goldenberg, 1989) “…it is not clear that psychological disturbance can predict a specific

chronic pain syndrome such as FS or whether psychological disturbance is the general result of experiencing chronic pain.”

Patient Presentation • Pain… “all over” • Stiffness • Swelling • Overwhelming fatigue • Tender points • Muscle spasms or nodules • Impaired memory and concentration • Irritable bowel syndrome • Headaches • Interstitial cystitis

Patient Presentation • Paresthesias

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• Chest wall pain • Sensitivity to cold & humidity • TMJ • Non-restorative sleep • Urinary urgency • Anxiety

Trigger Point vs Tender Point • Tender Points: distinct and localized areas of soft tissue that are painful

when 4 kg of pressure is applied by pressure or a dolorimeter. Also called ‘Mechanical hyperalgesia’

• Trigger Points: local points of tenderness in a nodule or in a taut band of muscle fibers. Trigger point pain can refer away from the point.

Patient Presentation • It is important to evaluate for musculoskeletal problems

– Rotator cuff – Epicondylitis – Carpal tunnel – Plantar faciitis – Etc.

Intervention “Despite improved recognition and understanding of FMS,

treatment remains challenging.” Goldenberg et al. JAMA, 2004

Intervention “Nonpharmacologic treatments that target pain, stress, and

physical and psychological dysfunction using a variety of physical, cognitive, behavioral, and educational strategies are essential components of comprehensive treatment.”

Burckhardt CS. Rheum Dis Clin, 2002

Intervention

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• Patient education • Cognitive-behavioral strategies • Physical Training • Multicomponent strategies • Complementary and alternative medicine strategies

Intervention “There is strong evidence that intensive patient education is an

effective treatment in FMS.” Goldenberg et al. JAMA, 2004

Education “planned, organized learning experiences designed to facilitate

voluntary adoption of behaviors or beliefs conducive to health” (Health Professional Association, 1994) • One-to-one provider-patient • Organized programs • Fibromyalgia-specific self help course (Arthritis Foundation)

Education “Basic information on fibromyalgia, treatment options, self-

efficacy theory, and self-management strategies should be considered the standard of clinical care in fibromyalgia.”

Burckhardt, 2002

Cognitive-behavioral Strategies • Role of thoughts, beliefs, expectations, and behaviors on

symptoms • How to prioritize time and activities • How to balance work, leisure, and ADL

Intervention • Self-efficacy

– Sense of control • Mastery experiences

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• Modeling • Social persuasion • Physiological feedback

Intervention “There is strong evidence that cardiovascular exercise is effective

treatment in FMS.” Goldenberg et al. JAMA, 2004

Intervention “This review reports moderate to strong evidence that exercise

programs that meet ACSM guidelines for aerobic training produce short-term improvements in cardiorespiratory fitness, and pain pressure threshold of FMS tender points.”

Busch et al. Cochrane Database, 2003

Intervention • Bennett et al., (2002) found in their study that 80% of persons

with FMS had a below average level of aerobic fitness Intervention

“Aerobic exercise should be regarded as a legitimate and useful treatment component in the management of FMS. Improvement can be expected in aerobic performance, tender points, and global well-being.”

Busch et al., 2003

Intervention “This review reports moderate to strong evidence that exercise

programs that meet ACSM guidelines for aerobic training produce short-term improvements in cardiorespiratory fitness, and pain pressure threshold of FMS tenderpoints.”

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Busch et al. Cochrane Database, 2003

Exercise Training American College of Sports Medicine. The recommended quantity

and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in older adults. Med Sci Sports Exer. 1998;30:975-991.

Cardiovascular Training • Document physician permission • Guidelines from American College of Sports Medicine

– Minimal training intensity is approximately 40-50% of Heart Rate Reserve

Cardiovascular Training • Heart Rate Reserve (Karvonen formula)

– HRR = maximum heart rate minus resting heart rate – Maximum heart rate = 220 – age – Calculate % HRR (e.g. 50-80% HRR) - *may have to start much lower

for patients with FMS – Add resting HR to each value

Karvonen Formula Target HR range = ([HRmax – HRrest ] x 0.40 ? - 0.50) +HRrest

Cardiovascular Training Age = 40 Max HR = 220 – 40 = 180 Resting HR = 60 bpm 180-60 = 120 120 x .40 = 48; 120 x .50 = 60 48 + 60 = 108; 60 + 60 = 120 Target HR = 108 - 120

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* HR attained in water will be 16 bpm less than on land

Cardiovascular Training Intensity %HRR RPE Very Light <20 <10 Light 20-39 10-11 Moderate 40-59 12-13 Hard 60-84 14-16 Very hard >85 17-19 Maximal 100 20

Cardiovascular Training

• Goal is 20-60 minutes of continuous or intermittent (minimum of 10 minute bouts) of aerobic activity

• May take a year to get there!!!

Intervention Moldofsky (1976) • One group of patients performed cardiovascular exercise and had

a 29.1% increase in peak work capacity • One group performed flexibility exercises and had a 4.3%

decrease in peak work capacity Intervention

• Gowans et al., 1999 – Therapeutic pool – 20 mins walking/jogging/sidestepping/arm exercises – 5 mins of stretching pre and post – HR = 60%-70% age-adjusted max – Educational sessions on topics of posture, ADLs, sleep, relaxation, medications,

nutrition, coping skills *6 weeks of exercise (2x/week)

Outcome Measures Gowans et al., 1999 6 minute walk

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Arthritis Self-efficacy scale Fibromyalgia Impact Questionnaire Knowledge questionnaire

Results • Exercise groups improved in 6- minute walk, well-being, fatigue,

self-efficacy, knowledge Intervention

Gowans et al., 2001 • Exercise group: 10 mins stretching, 20 mins aerobic exercise at

60-75% age-adjusted max HR (first 6 weeks in a therapeutic pool, then walking and jogging in a gymnasium)

• Control Group Outcome Measures

• Beck Depression Inventory • 6-minute walk test • State-Trait Anxiety Inventory (STAI) • Mental Health Inventory (MHI) • Tender point number • FIQ • Arthritis Self-Efficacy Scale

Results • Exercise group improved in 6-minute walk distances, BDI,

STAI, FIQ, ASES, MHI Intervention

• Schacter et al., 2003 – Group 1 = Long Bout of Exercise (10 mins week 1 to 30 mins by week

9) – 1x/day – Group 2 = Short Bout of Exercise (5 mins week 1 to 15 mins week 9) –

2x/day – Control * home-based, low impact aerobics * HR started at 40-50%, increased to 65-75% by week 12

Outcome measures

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• FIQ • Pain Diagrams • Arthritis Impact Scale • Chronic Pain Self-Efficacy Scale • Tender Point Number • Treadmill Test – Peak Oxygen Uptake

Results • Dropout of 14% (ctrl), 38% (SBE), 29% (LBE) • No differences between exercise groups • SBE and LBE improved in disease severity “Out training stimulus may have been inadequate because participants found

the mode of exercise unsuitable or too difficult or because of the isolation of a home-based program…”

Intervention • Martin et al., 1996

– Group 1 exercised 20 mins walking at 60-80% max HR and 20 mins flexibility and 20 mins strength training (3x/week for 6 weeks)

– Group 2 was a relaxation group – visualization, yoga, autogenic relaxation (3x/week for 6 weeks)

Outcome Measures • FIQ • Illness Intrusiveness Questionnaire • Self-Efficacy Questionnaire • Visual Analog Scale • Treadmill – time to volitional exhaustion • Sit and Reach • Isokinetic Strength • Myalgic Score (sum of tender point scores) • Tender point (0-4 tenderness at each site)

Results • Tender point number decreased in exercise group • Myalgic Score decreased for exercise group • Aerobic fitness increased for exercise group • Sit and Reach increased for exercise group

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Intervention • Wigers et al., 1996

– Group 1 = Aerobic exercise: high intensity aerobic exercise (60-70% max HR) – 45 mins 3x/week for 14 weeks (warm-up +2 peaks of high intensity training of 3-4 mins followed by 15 minutes aerobic games (tag, ball games), ending with stretching)

– Group 2 = Stress Management- 90 mins 2x/week for first 6 weeks and then 1x/week for 8 weeks

– Group 3 = Treatment as Usual (aquatic, psychomotor treatment, medications)

Outcome Measures • Pain drawing • VAS scales for pain, disturbed sleep, lack of energy, and

depression • Pressure tenderness in 90 points • Work capacity with cycle test • Global subjective improvement – 4 step scale

Results • Aerobic exercise group improved pain distribution, tenderness of

tender points, work capacity, VAS pain, VAS lack of energy, global subjective improvement

• Stress management group improved tenderness of tender points, VAS pain, VAS depression

Intervention McCain et al., 1988 • Cardiovascular fitness group: 60 mins 3x/week for 20 weeks (10

min warm-up, cycling at >150 bpm, • Flexibility group: 60 mins 3x/week for 20 weeks

Outcome Measures • VAS pain • Body diagram – pain • Sleep quality questionnaire • Pain threshold – total myalgic score • Predicted peak work capacity • Symptom checklist – 90 - Revised

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Results • Exercise group improved in pain threshold scores, global

assessment by patient and physician Intervention

• Meyer & Lemley, 2000 – High Intensity Exercise: 40% HRR at week 1, increased 10% for the

first 4 weeks, 5% for weeks 5,6, and 10 to a max of 85% – Low Intensity Exercise: 25% HRR at week 1, increased 5% per week

for first 6 weeks, to a max of 60% at week 10 – * Exercise duration began at 12 min to 30 min for the last 4 weeks

Outcome Measures • Tender point number • Resting Heart Rate • Exercise Heart Rate • Blood Lactate • Rating of Perceived Exertion • FIQ • Beck Depression Inventory • State Anxiety Inventory • Pain Scale • Health Assessment Questionnaire Disability Index

Results • Only 8 subjects completed the study so groups were combined

for analysis • Resting HR and HR decreased • FIQ did show a trend to decrease more in the low-intensity group

Intervention Ferraccioli et al., 1987 • True EMG – Biofeedback: 15 sessions 2x/week- progressive

relaxation training • False EMG - biofeedback : no instruction • control

Outcome Measures • Number of tender points • Grip strength

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• Morning stiffness • VAS – pain • Clinical questionnaire

Results • Only true group improved in all measures

Intervention Rooks et al., 2002 • Phase I in a pool – AROM; Phase 2 on land treadmill, elliptical

device, walking on a track. Strength training on machines, hand weights, and body weight

• No control group *20 week program (60 min sessions, 3x/week)

Outcome Measures • 1 Repetition max • 6-minute walk • FIQ

Results • Improvements in strength, 6-minute walk distance, FIQ

Intervention McCain, 1986 • Exercise group: 20 week program (3x/week) at HR >150 –

bicycling • Flexibility group

Outcome Measures • Myalgic Scale – dolorimetry (pain thresholds) • VAS • Pain diagram • Predicted peak work capacity • Psychologic profile

Results

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• Exercise group improved in VAS, total myalgic score, percentage total body area of pain, psychologic profile

Intervention Mannerkorpi et al., 2000 • Exercise group: temperate pool – 1x/week for 35 mins – also 6

one hour education sessions • Control group

Outcome Measures • FIQ • Short-Form 36 • Multidimensional Pain Inventory • Arthritis Self-Efficacy Scale • Arthritis Impact Measurement Scale • Quality of Life Questionnaire • 6-minute walk test • ROM • Strength

Results • Exercise group improved in FIQ, 6-minute walk, physical

function, grip strength, pain severity, social functioning, psychological distress, quality of life

Intervention Richards and Scott, 2002 • Aerobic exercise (treadmills & bicycles) • Relaxation & Flexibility *each group met 2x/week for 12 weeks *exercise increased from two 6-minute sessions to two 25-minute

sessions per class Outcome Measures

• Self-rated change in global impression scale • Tender point number • FIQ • Chandler fatigue scale • McGill pain questionnaire (short form)

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• SF-36 Results

• 35% of the exercise group and 18% of the control group improved in the global impression scale

• Exercise group had decreased tender point counts at one year post

Why does exercise result in improvements in FMS? “Exercise whether administered short-term to unfit persons or long-term to

fit persons leads to significant alterations in opioid and non-opioid as well as neural and hormonal intrinsic pain regulatory systems. For example, strenuous exercise leads to predictable increases in serum levels of beta-endorphin-like immunoreactivity, ACTH, prolactin, and growth hormone…”

McCain, 1986

Why? “Other hypotheses suggest that exercise may improve circulation

within the muscles, improve sense of control over the body, and increase the resistance of trained muscle to microtrauma.”

Sandstrom & Keefe, 1998

Multidisciplinary “There is strong evidence that multidisciplinary treatment is effective in treating FMS.” Goldenberg et al, 2004

Multidisciplinary • Doctors (rheumatologists) • Psychologists/Psychiatrists • Physical Therapist (exercise physiologist) • Social workers • Occupational therapists • Sleep specialists • Headache specialists • Massage therapists • Acupuncturists • endocrinologists

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Exercise “The results of the present study indicate that engaging in regular exercise

and having higher exercise self-efficacy significantly predict continued engagement in exercise behavior in people with FMS. Factors such as age, employment status, depression, education level, self-efficacy for managing FMS, and the size of one’s social network also demonstrate predictive qualities.”

Oliver & Cronan, 2002

Physical Therapy Treatments • Validate the symptoms • Education • Cardiovascular Training (non-impact) • Patient needs to be sleeping well • Energy conservation • Active participation • MUST NOT increase pain or fatigue • Initially, no eccentric exercise

Physical Therapy Treatments • Musculoskeletal System • Posture correction • Ergonomics • Body mechanics • Modalities??? • AQUATIC THERAPY • Diary of flare-ups

Exercise Prescription • Minimize Muscle Microtrauma - no/little eccentric exercise • Minimize Central Sensitization - must not cause a flare-up • Emphasize low-intensity exercise • Individualized exercise • Maximize self-efficacy Jones & Clark, 2002

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Exercise Prescription • 12 week exercise program - 4 supervised visits 1st 90 min session and follow-up at 1,3,

& 9 weeks - at home pts performed 60-120 mins/week of aerobic exercise at 60-85% max HR - weekly exercise logs - examined exercise adherence 3 months post

Exercise Prescription • High in-treatment adherence predicted maintenance of exercise • Higher baseline disability predicted worse maintenance • Increased barriers to exercise predicted less exercise • Inclusion of Cognitive Behavioral Therapy produces better results (self-

efficacy) Dobkin et al., 2005

Outcome Measures • Fibromyalgia Impact Questionnaire Burckhardt CS, Clark SR, Bennett RM. The Fibromyalgia Impact

Questionnaire: development and validation. J Rheumatology, 1991;18:728-734.

Resources • American College of Rheumatology 1800 Century Place, Suite 250 Atlanta, GA 30345-4300 Phone: (404)633-3777 http://www.rheumatology.org

Resources • The Arthritis Foundation PO Box 7669 Atlanta, GA 30309-0669 1-800-283-7800 http://www.arthritis.org

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Resources • Fibromyalgia Network PO Box 31750 Tucson, AZ 85751-1750 1-800-853-2929 http://www.fmnetnews.com

Resources • National Fibromyalgia Research Association 2200 N. Glassell St. Suite A Orange, CA 92865 1-800-544-2345, ext 265

Thank You For Attending

Any Questions ?

ncrich@gwi.net Intellectual Property

This information is the property of Nancy C. Rich, Ph.D.,PT, and should not be copied or otherwise used without express written permission of the author

References

Bennett RM. The rational management of fibromyalgia patients. Rheum Dis Clin North Am 2002;28:181-199. Bennett RM. Multidisciplinary group programs to treat fibromyalgia patients. Rheu Dis Clin North Am 1996;22:351-367. Bennett RM, Burckhardt CS, Clark et al. Group treatment of fibromyalgia: a six month outpatient program. J Rheumatol 1996;23:521-8.

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Burckhardt CS. Nonpharmacologic management strategies in fibromyalgia. Rheum Dis Clin N Am 2002;28:291-304. Busch A, Schacter CL, Peloso PM et al. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev 2003; 3. Dobkin PL, Abrahamowicz M, Fitzcharles MA, et al. Maintenance of exercise in women with fibromyalgia. Arth Care Res 2005;53:724-31. Ferraccioli G, Ghirelli L, Scita F, et al. EMG-biofeedback training in fibromyalgia syndrome. J Rheumatol 1987;14:820-825. Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA; 292:2388-2395. Gowans SE, deHueck A, Voss S, et al. A randomized, controlled trial of exercise and education for individuals with fibromyalgia. Arthritis Care Res 1999;12:120-128. Gowans SE, deHueck A, Voss S, et al. Effect of a randomized, controlled trial of exercise on mood and physical function in individuals with fibromyalgia. Arthritis Care Res 2001;45:519-529. Jones KD, Clark SR. Individualizing the exercise prescription for persons with fibromyalgia. Rheu Dis Clin N Am 2002;28:419-436. Mannerkorpi K, Nyberg B, Ahlemen M, et al. Pool exercise combined with an education program for patients with fibromyalgia syndrome: a prospective randomized study. J Rheumatology 2000;27:2473-2480. Martin L, Nutting A, MacIntosh BR, et al. An exercise program in the treatment of fibromyalgia. J Rheumatology 1996;23:1050-1053. McCain GA. Role of physical fitness training in the fibrositis/fibromyalgia syndrome. Am J Med 1986;81(Suppl 3A):73-77. McCain GA, Bell DA, Mai FM, et al. A controlled study of the effects of a supervised cardiovascular fitness training program on the manifestations of primary fibromyalgia. Arthritis Rheum. 1988;31:1135-1141. Mease P. Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment. J Rheumatol 2005;32 Suppl 75:6-21. Meyer BB. Lemley KJ. Utilizing exercise to affect symptomology of fibromyalgia: a pilot study. Med Sci Sports Exercise 2000;32:1691-1696.

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Moldofsky H, Scarisbrick P. Induction of neurasthenic musculoskeletal pain syndrome by selective sleep stage deprivation. Psychosom Med 1976:38:35-44. Offenbacher M, Stucki G. Physical therapy in the treatment of fibromyalgia. Scand J Rheumatol 2000;29(Suppl 113): 78-85. Richards SCM, Scott DL. Prescribed exercise in people with fibromyalgia: parallel group randomized controlled trial. BMJ 2002;325:185-7. Rooks DS, Silverman CB, Kantrowitz FG. The effects of progressive strength training and aerobic exercise on muscle strength and cardiovascular fitness in women with fibromyalgia: a pilot study. Arth Care Res 2002;47:22-28. Sarnoch H, Adler F, Scholz OB. Relevance of muscular sensitivity, muscular activity, and cognitive variables for pain reduction associated with EMG biofeedback in fobromyalgia. Percept Motor Skills 1997;84:1043-1050. Schacter CL, Busch AJ, Peloso PM, et al. Effects of short versus long bouts of aerobic exercise in sedentary women with fibromyalgia: a randomized controlled trial. Phys Ther 2003;83:340-358. Wigers SH, Stiles TC, Vogel PA. Effects of aerobic exercise versus stress management treatment in fibromyalgia. Scand J Rheumatol 1996;25:77-86.