Fibromyalgia Diagnosis and Treatment

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Table of Contents

Introduction
Cause of Fibromyalgia
Diagnosis
Medical management/Treatment of fibromyalgia
Implications of Fibromyalgia illness
Vocational rehabilitation in fibromyalgia patients
Conclusion
Reference list

Introduction

Falvo (2005) writes on the medical and psychosocial aspect of chronic disease including fibromyalgia. Fibromyalgia is defined as a rheumatologic disease in which the patient experience widespread pain, coupled with aching and stiffness of muscles and/or joints, plus fatigue, sleep disturbances, and broadly distributed sites of tenderness (tender joints) (Millea & Hollaway, 2000, cited in Flavio, 2005, p. 421).

The pain and uneasiness linked to fibromyalgia are spread, occurring in the hips, lower back, shoulders, and neck and other sites. The author refutes fibromyalgia as a degenerative disease because it does not cause damage to joints or bones; therefore, there is no definitive diagnostic test or objective findings that can validate the condition.

Because of the lack of exceptional laboratory tests applied for diagnosis of the condition, diagnosis is centered on individuals’ testimony of history and symptoms, regarding the identifiable tender points as the major diagnostic indicator. Falvo (2005) notes that fibromyalgia can manifest other symptoms besides musculoskeletal pain, such as irritable bowel syndrome or headaches.

Falvo (2005) argues that this condition can occur parallel with other sevre rheumatic disorders including rheumatoid arthritis and lupus. Moreover, psychological signs of depression and anxiety often accompany fibromyalgia.

This chronic illness can impact an individual’s quality of life and can lead to interpersonal challenges due to its symptoms. The author underscores the significance of validating the individual’s symptomatic complaint in that it helps restores self-esteem and self-control, assisting them to adjust to their symptoms.

Cause of Fibromyalgia

According to the findings of Liu, Mantyh, & Basbaum, (1997), enduring physical or emotional abuse subjected to a person may produce some physiological alterations in that individual. It has been proven that a substantial group of people diagnosed with this illness that were subject to chronic stress from physical and emotional abuse, shared a common physiological outcomes.

These outcomes include increased levels of N-methyl-D-aspertatesubstance P (NMDA-SP) and a rise in the expression of c-fos, which is a protein released under stress and found in neurons corresponding with pain. These outcomes considerably point to chronic stress as an impetus for hyperalgesia in FMS.

The resultant hyperalgesic state is a product of chronic muscular hypersensitivity to fatigue and pain, denoted as a stress-induced, diathetic, neuromuscular hyperalgesic condition (Ellis, n.d).

Benett (1999) concluded that an ultimate understanding of pathogenesis of non-nociceptive pain is prerequisite for disqualifying FMS as a somatoform disturbance. Moreover he proposes that there may be needed a review of the concept of somatoform abnormalities, to classify them under clinical conditions by virtue of the knowledge physiology.

The author defined the neurological pain course as gush of nerve impulses that emanates from nociceptors in visceral or somatic tissues (p. 386). In the course, nerve “impulses travel in peripheral nerves, with a first synapse in the dorsal horn and a second synapse in the thalamus, and end up in the cerebral cortex and other supraspinal structures.

This results in a pain experience and the activation of reflex and later reflective behaviors” (p. 386).

Normally, nociceptor-driven pain is effectively eliminated. Nevertheless with chronic pain, the association between nociception and resuscitation from pain is out of place or even absent and, thus pain endures.

Usually the pain threshold escalates with palpation, though it decreases in FMS (Kosek, Ekholm, & Hansson, 1996). Ellis, (n.d) presumes that this may be as a result of the absent or insufficient resuscitation of nociceptor signals.

It is increasingly becoming evident that fibromyalgia has a genetic predisposition (Medscape, 2006). Progressively, the author argue that first-degree relatives of people indicating fibromyalgia are eight times at risk of developing the illness compared to the general population.

This condition has been often associated with polymorphism in serotonergic 5-hydroxytryptamine (HT) 2A receptor, the catecholamine o-methyl transferase enzyme, the serotonin transporter and the dopamine 4 receptor. These polymorphisms reportedly have influence on the transportation or metabolism of monoamines, compounds that are responsible for sensory processing and stress response (Medscape, 2006).

Diagnosis

Ellis (n.d) asserts that the key observations useful in the diagnosis of FMS are; i) a history of extensive pain, lasting for three months minimum and; ii) the recognition of pain in eleven out of eighteen tended sites on palpation.

However, there are specific psychological and neuroendocrine factors that have been perceived to be virtually exhibited in FMS sufferers. Other diagnostic elements hat can give a comprehensive and accurate results are:

Assessment of continuing stress as indicated on a score of state-trait anxiety.
Assessment of the different physiological outcomes common in fibromyalgia patients that include though not necessarily limited to:

Assessment for weak thyroid stimulating hormone (TSH) response and the decreased free serum calcitonin and calcium.
Assessment for changed hypothalamic-pituitary-adrenal axis (H-P-A) because of exaggerated adrenocortricotropic hormone feedback to coticotropin-releasing hormone (CRH) and subsequent decreased secretion of cortisol.
Assessment for increased levels of substance P.

Medical management/Treatment of fibromyalgia

By virtue of being a chronic condition, only relative enhancement can be provided. Fibromyalgia patients may find neck support in sleep or abdominal exercise to alleviate stress on the lower back useful.

Aerobic exercise including swimming or walking are valuable in relieving pain and tenderness and helping regarding sleep disturbances. Current studies have proven that hyperbaric oxygen therapy can be effective in treatment of the disease (Falvo, 2005).

Hyperbaric oxygen therapy

Hyperbaric oxygen therapy refers to administration of 100% oxygen at two or three folds the atmospheric pressure. It specifically used for treatment of specific musculoskeletal conditions including chronic osteomyelitis (Sugihara et al., 2004, cited in Falvo, 2005, p. 425).

This strategy works by renovating the body’s immune system against infection and increasing frequency at which the system can destroy pathogens.

Patients inhale hyperbaric oxygen in an atmosphere of a specially deviced cylindrical single-occupant chamber through mask hoods, or designed tubes that are introduced into the trachea. The duration and intensity of therapy depends on the rationale for treatment. For musculoskeletal conditions, therapy may average 90 minutes (Falvo, 2005).

Physical therapy

According to Falvo (2005), this strategy encompasses various approaches that are usually conducted by a physical therapist or his/her assistant. The form of physical therapy is based on the specific musculoskeletal condition. It is usually aimed at increasing or sustaining a joint’s variety of motion, increasing muscle tenacity, alleviating pain or teaching skill for ambulation.

Some procedures include therapeutic exercise, either active or passive. Passive exercise involves the therapist or a mechanical instrument performs the exercise on the body part. While active exercise involves the patients performing a special exercise program under the supervision of the physiotherapist or his assistant.

Other techniques may concern applying heat or cold massage to relax muscles or for pain relieve. Heat may be exerted using hot packs, whirlpool births, infrared radiation, or hot soaks.

Medication of fibromyalgia (MedicineNet, 2011 April)

Antidepressants: The most useful medication in the treatment of this chronic illness customarily has been trycyclic antidepressants. Although, popular in management of depression it is administered during bedtime at fractions of the doses used in the treatment of depression.

Trycyclic antidepressants help alleviate fatigue, resuscitate muscle spasm and pain, and facilitate deep, restorative sleep in fibromyalgia patients. Scientists posit that tricyclic function by interfering with serotonin, a neurotransmitter. Examples of tricyclic antidepressants popularly used in this regard are; doxepin (sinequan) and amitrypatyline (Elavil) (MedicineNet, 2011).

Fluxetine: there is substantial evidence that adding fluxetine (Prozac), or analogous medication, with low-dosage amitryptyline increases muscle pain relief, alleviate depression and anxiety in fibromyalgia patients. This combination is additionally more useful in enhancing restorative sleep and a general perception of well-being.

The two combinations tend to neutralize the adverse effects each may cause. Tricyclic antidepressants can induce tiredness and fatigue, whereas fluxetine can cheer up and make patients more alert. In addition research has proven that Lorazepam (Ativan) was effective in relieving symptoms.

Prozac has additionally been proven to be appropriate as a monotherapy with certain fibromyalgia patients. Trazodone can be administered at bedtime to enhance sleep if patients express hypersensitivity to trycyclic antidepressant

Pregabalin (Lyrica): this medication was approved in 2007 to be used distinctively for treatment of fibromyalgia. Probably, this medication act through blockade of pain impulses in fibromyalgia patients. Its advantages lie in the flexibility of its dosing which can be shifted to meet the demands of the persisting symptoms. A related drug, gabapentin may also be employed in the treatment of the chronic illness.

Duloxetine and milnacipran: the brand names are cymbalta and savella respectively. This drug combination has been conceived recently to be useful in the treatment of this disorder. These drugs have been proven to be useful in alleviating pain and improving function in fibromyalgia sufferers. Duloxetine has been useful in the treatment of depression and in alleviating pain in psychotic, including depression and anxiety.

Pain relievers: Many other medications can be employed for the alleviation of fibromyalgia pain. Such pain relievers are; cortisone, tramadol, cyclobenaprine (muscle relaxant), nonsteroidal anti-inflammatory drugs (NSAIDs), and guaifenesin.

Other strategies include; use of cast, assistive devices, orthoses, traction, and surgery.

Implications of Fibromyalgia illness

Illness is defined as the ultimate feeling of out-of-control (McDaniel, Hepworth, & Doherty, 1997, p. 7). Normally, ill individuals experience the despair to exercise some control over their lives such that they distress upon loosing their capacity to control significant outcomes in their lives.

Thus, when people have a sense of individual control regarding their illness, they have a high tendency to have an optimistic physical and psychological adjustment to chronic condition [including Fibromyalgia] than their inverse (Shapiro, Shwartz, & Astin, 1996).

A hermeneutic-phenomenological evaluation of 12 women’s live experience with fibromyalgia outlined the themes of coping, ambivalence, and powerlessness (Ranhein & Holand, 2006). The testimonies of these women depicted their efforts to control and manage the serious symptoms of their illness and their struggles to alleviate their sense of powerlessness that emanate from fatigue, pain and immobility.

Victims of chronic diseases such as this have, who develop efficient methods for controlling their utmost serious symptom tend to posses a more optimistic attitude and reduced sense of powerlessness (Larsen, 2009).

Seaman and Lewis (1995) found that powerlessness was linked with activity limitations and psychosocial indications, and mounting powerlessness was connected with failing health status. The theme of powerlessness in chronic illness is a fluctuating and complex matter. This phenomenon, can be caused by individual characteristics and outlook or induced by the changing nature of the disease; Fibromyalgia.

It is inherent at same time imminent in the chronic illness. Nevertheless, the sense of powerlessness retreats and advances throughout the course of the disease as the patient negotiate between loss and control and steer through the varying landscape of their enduring realities.

Also, factors such as the ability to manage symptoms and the degree of physical limitations can influence people’s experience with sense of powerlessness (Larsen, 2009).

Clearly, fibromyalgia can have serious implications on the sufferer’s different aspects of live. These aspects may include education, training, and employment.

Implication on employment

Resells (2003) argues that fatigue, chronic pain and faults in processing and arranging cognitive experiences impact negatively on the patient’s capacity to compete in the labor force. They impact on his/her ability to focus. S/he may find annoying the extensions of tasks which normally are done over a short period.

Often, patients exhibit intolerance for repetitive tasks or prolonged standing or sitting. Stress and unpleasant climatic conditions can prominently worsen the FMS symptoms. Clearly, such employees cannot meet the expectations of the employer and as such jeopardize their job. They often get dismissed from work due to their low productivity.

Further, the author asserts that the patient may exhibit lack of endurance because of physical or mental fatigue. S/he may express intense deterioration of symptoms with initially tolerated amounts of mental and physical functions leading to reactive symptoms.

Other sources of work disability in FMS include; the lack of endurance, the randomness of symptom dynamics on a daily and even hourly basis, as well as the incidence of delayed reactive fatigue, pain and cognitive abnormalities.

This requires prolonged time in the morning for patient to get going and many require frequent rest during the day. It in turn hinders patients from embarking on regularly planned tasks that are typically necessary for work-related functions and prerequisite in the competitive labor force.

Implication on education

Loss of mental acuity by patient can manifest in various ways including; poor concentration; problem in making and consolidating memories; incapacity to plan tasks and increased time required to complete a task; and emotional imbalances resulting from the impairment.

This means that the student who suffers this illness often perform unsatisfactorily. This serves to worsen the condition due to frustration, leading to stress. This problem usually aggravates the effects of physical fatigue.

In addition, short-memory failure exhibited by the patient undermines the efficiency of a task because intentions are initiated and forgotten and much energy and time is wasted locating lost items and they constantly need to reorganize disrupted tasks. This means that students experience challenges in recalling facts, and procedures. The patients often will fail their exams and fail to progress in academics.

Vocational rehabilitation in fibromyalgia patients

The following factors have a significant bearing in the vocational rehabilitation of patients with fibromyalgia. They are:

Disability

Resells (2003), suggest that the ability of the patient to engage and function sufficiently in rehabilitation programs must be reviewed through a long period with focus on long term range collective effects subsequent to a period spent in the program and the recurrence of symptoms.

Disability can emerge in the emotional, cognitive and physical realms in different proportion of activity and impairment. In this regard various factors have a bearing in FMS patient’s rehabilitation. They include; effects of the symptoms, lack of patient endurance, impaired neurocognitive ability, unpredictability of symptom instability, and cumulative outcome.

Assessment

Examination by an by accredited occupational therapist (OT) or occupational specialist who is educated on fibromyalgia syndrome, and experienced in assessing disability may be useful though the treating physician should supervise and coordinate any rehabilitation interventions (Resells, 2003). Patient’s assessment can be carried out at home or workplace.

In home assessment, an OT can avail significant background information on the routine function at home, including self care, endurance, maintenance of home and so forth. The degree of function at home has direct implication for the degree of function at workplace. In this regard the OT can assist the sufferer with energy conservation values and in pacing their performance (Resells, 2003).

Workplace assessment, on the other hand, affords specific information on mental, physical, social, environmental and emotional job requirements. The author suggests that the assessment ought to be done on the job place as much as possible.

All jobs must be assessed for aggravators to improve ergonomics, vary job responsibilities and positions, and enable flexibility in planning if employer based on the employers cooperation.

Rehabilitation potential

Resells (2003) argues that the fibromyalgia patient’s medical treatment must be optimized before any rehabilitation program is considered. Importantly, the treating doctor must direct and coordinate the management and rehabilitation interventions.

Rehabilitation staff must be knowledgeable about fibromyalgia syndrome. Also, the Pathophysiology of the disease must be considered and reflected in the rehabilitation program. Noteworthy, the rehabilitation program must be set based on the patient’s general demands and routine shifts in the patient’s symptoms and functional limits.

The patient should be given the space to exercise autonomy in regard of the pace, complexity and duration of the program. In addition the attending physician must guarantee that the patient’s symptoms are checked consistently to detect cumulative outcomes.

Importantly, a work hardening programs which undermines the Pathophysiology of fibromyalgia and/or the patient’s autonomy are improper for the patient and will aggravate the patient’s symptoms and clinical condition.

Conclusion

Suffers of fibromyalgia syndrome (FMS), argues Levy (1999), should know how its effects can impact adversely on the patients ability to sustain steady employment. The American with Disability Act (ADA) was enacted in 1990 to address the civil rights of the disable. This act aims to level the grounds for disabilities to sustain equal participation in the society.

The law prohibits discrimination of the FMS patient through job application and recruitment protocols, hiring, firing, promotion, reimbursements, training, leaves among others. Also, it concerns privileges and conditions of employment including insurance, company parking lots, and so forth.

Reference list

Falvo, D. R. (2005). Medical and psychological aspects of chronic illness and disability. London: Jones and Bartlett Publishers.

Ellis, L. E. (n.d). Etiology, Diagnosis and Treatment of Fibromyalgia: A Practical and Effective Approach. Compelling Counseling Interventions Article 16. Web.

Kosek, E., Ekholm, J., & Hansson, P. (1996). Sensory dysfunction in fibromyalgia patients with implications for pathogenic mechanisms. Pain, 68(2-3), 375-383.

Larsen, P. D. (2009) Illness behavior. In P. D. Larsen & I. M. Lubkin (Eds). Chronic illness: Impact and intervention. Ontario & London: Jones & Bartlett Publishers.

Levy, A. S. (1999). The Americans With Disabilities Act: What Persons With Fibromyalgia Need to Know. National Fibromyalgia Partnership, Inc.

McDaniel, S. H., Hepworth, J. & Doherty, W. J. (1997). The shared emotional themes of illness. In S.H. McDaniel, J. Hepworth, & W. J. Doherty (Eds). The shared experience of illness: stories of patients, families, and their therapist. New York: Basic Books.

MedicineNet. (2011). Fibromyalgia: what is the treatment for fibromyalgia? MedicineNet.

Ranhein, M. & Holand, W. (2006). Lived experience of chronic pain and fibromyalgia: Women’s stories from dailiy life. Qualitative Health Research, 16(6), 741-761.

Resells, J. I. (2003). The fibromyalgia syndrome: a clinical case definition for practitioners. Binghamton: Haworth Medical Press.

Seaman, M., & Lewis, S. (1995). Powerlessness, health and mortality: AS longitudinal study of older men and mature women. Social Science in Medicine, 41(4), 517-525.

Shapiro, D. H., Schwarz, C. E. & Astin, J. A. (1996). Controlling ourselves, controlling our world: psychology’s role in understanding positive and negative consequences of seeking and gaining control. American psychologist, 51, 1213-1230.

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