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Chronic Pain Assessment and Management

with an Emphasis on Fibromyalgia

Mindfulness-based and CognitiveTreatment Strategies

Combined Sections Meeting 2006

San Diego, CA

February 1-5, 2006

Carolyn McManus, PT, MS, MA

Swedish Medical Center

Seattle, WA

The International Association for the study ofpain defines pain as an unpleasant sensoryand emotional experience associated withactual or potential tissue damage, or describedin terms of such damage.

Pain is more than sensation. The relationshipbetween 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 centra l processing of

incoming signals

Brain and spinal cord can

modulate, but also create

pain pe rcept ion

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 controlsover multiple brain regions in response to bothnonpainful and painful stimuli.

Cook DB, Lange G, et al. Functional imaging of pain inpatients with primary fibromyalgia. J Rheumatol2004Feb;31(2):364-78.

Application of mild pressure produced subjectivepain reports and cerebral responses in FM subjectsthat were qualitatively and quantitatively similar tothe effects produced by applying at least twice thepressures in control subjects.

Gracely RH, Petzke F, et al. Functional magneticresonance imaging evidence of augmented painprocessing 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 withfibromyalgia. Brain 2004 Apr;127(Pt 4):835-43.

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

As clinicians, our treatment choices will beenhanced by employing strategies that engage thewhole process of pain perception.

Chronic pain patients were able to learn control of

activity in the rostral anterior cingulate cortex, a brainregion involved in pain perception and regulation.

The ability to decrease activation in the rostralanterior cingulate cortex was associated with adecrease 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 amultimodal approach (eg. exercises combined with

education and psychologically-based interventions)is the most promising means of managing patientswith fibromyalgia.

Adams N, Sim J. Rehabilitation approaches infibromyalgia. Disabil Rehabil2005 Jun 17;27(12):711-23. Review.

In the treatment of fibromyalgia, current evidence

suggests efficacy of low dose tricyclicantidepressants, cardiovascular exercise, cognitivebehavioral 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 momentKind, compassionate, friendlyAcceptingNon-strivingCuriousBeginners mindSteady, unwavering

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Mindfulness meditation is the deliberatetraining 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 havecontrol 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 ourreaction to that sensation is, in itself, a skillfulchoice.

Mindful awareness of the breath

Diaphragmatic breathingBreathe into your waistband

Key word or phraseIn breath Out breathIn Out

Arriving HomePresent moment Only momentMay I Be peacefulLet go Let GodIn the kingdom of God I dwell

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

The mind is like the surface of a pond. When thesurface of the pond is turbulent it distorts thereflection of the surrounding terrain. When the

surface is still, the surrounding terrain is seen clearly.

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

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Pain = Sensation + Our ReactionPhysicalCognitive

Emotional

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

No deliberate effort is made to change, improve orstrive 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 mindfulbreathing exercise and encourage the informalpractice of mindfulness. I recommend any healthcare practitioner introduce these practices.

Teaching mindfulness meditation requires years ofpersonal practice. As the instructor, you embodymindfulness and teach it, not as a brief exercise ortechnique, but as a way of life.

Physical

BreatheRelax

Progressive Relaxation

Autogenic TrainingRelaxation Body ScanGuided Imagery

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3. Label pain as sensation.

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

We often carry an inner wisdom that can help usnavigate difficult situations. We sometimes more

easily access it for others. We need to access thisinner wisdom for ourselves.

Talk to yourself in the same manner as you wouldtalk 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 facetoday.

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

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

Today is where your power resides.Taking care ofyourself as best you can today is your foundation fortomorrow.

The present moment is the only moment wehave for living. This is it.

6. Ask yourself:

If I keep talking to myself in this way, what kind offuture 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 haveplants in our gardens that are not doing well.

You can spend all of your energy focusing on theplant that isnt doing well, or you can spend

sometime in other parts of your garden.

This not only gives you a more accurateexperience 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 bodythat is vulnerable to sickness, aging and death.

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

You can travel that same road with someone kindand compassionate, friendly and understanding, and

the experience would be much more manageable.

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

Loving kindness meditation

May I be peaceful and joyful

May 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 subsequentbehaviors in response to pain.

Thoughts:

Feelings:

Behavior:

Identify automatic thoughts that are distorted,

negative or exaggerated:

If you are caught in unrealistically negative ordistorted thinking, identify alternative ways of thinkingabout your symptoms that reduce your distress:

Identify how changing your thoughts can impact yourfeelings 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 andcompassion and no need to criticize, judge or

blame. Observe your reaction with a beginnersmind. 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 canchange 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 ofvalue here?

CarolynMcmanus.comCarolyn.McManus@swedish.org

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Case Example

Patient is a 40 year old woman, married with 2

young childrenDiagnosed at age 34 with FM and LupusAt 39 she changed MDs, and was dxdwith

Undifferentiated Connective Tissue Disease

c/o chronic pain neck, shoulders, back, hips,

both joint and muscular painPain intensity 5 - 8/10

Office Visits

Before 6 mos After

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

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Medical LiteratureAdams N, Sim J. Rehabilitation approaches in fibromyalgia. Disabil Rehabil2005Jun 17;27(12):711-23. Review.

Astin JA. Mind-body therapies for the management of pain.Clin J Pain2004 Jan-Feb;20(1):27-32. Review.

Astin JA, Berman BM, Bausell B, Lee WL, Hochberg M, Forys KL. The efficacy ofmindfulness meditation plus Qigong movement therapy in the treatment offibromyalgia: a randomized controlled trial. J Rheumatol2003 Oct;30(10):2257-62.

Bantick SJ, Wise RG, et al. Imaging how attention modulates pain in humansusing 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 psychologictreatment approaches. Curr Opin Rheumatol2002 Jan;14(1):45-51.

Brooks J, Tracey I. From nociception to pain perception: imaging the spinal andsupraspinal 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 primaryfibromyalgia. J Rheumatol2004 Feb;31(2):364-78.

Crombez G, Eccleston C, et al. Hypervigilance to pain in fibromyalgia: themediating role of pain intensity and catastrophic thinking about pain. Clin J Pain2004 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. PNAS2005 Dec;102(51):18626-31.

Glass JM, Park DC. Cognitive dysfunction in fibromyalgia. Curr Rheumatol Rep2001 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 painamong persons with fibromyalgia. Brain. 2004 Apr;127(Pt 4):835-43. Epub 2004Feb 11.

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

Grossman P, Niemann L, et al. Mindfulness-based stress reduction and healthbenefits. A meta-analysis. J Psychosom Res2004 Jul;57(1):35-43.

Kakigi R, Nakata H, et al. Intracerebral pain processing in a Yoga Master whoclaims not to feel pain during meditation. Eur J Pain2005 Oct;9(5):581-89.

Lazar SW, Bush G, et al. Functional brain mapping of the relaxation response andmeditation. Neuroreport 200 May;11(7):1581-85.

Lazar SW, Kerr CE, et al. Meditation experience is associated with increasedcortical thickness. Nueroreport2005 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 Pain2005 Mar-Apr;21(2):166-74.

Lutz A, Greischar LL, et al. Long-term meditators self-induce high-amplitudegamma synchrony during mental practice. PNAS2004 Nov;101(46):16369-73.

Mackey SC, Maeda F. Functional imaging and the neural systems of chronic pain.Neurosurg Clin N Am2004 Jul;15(3):269-88. Review.

McManus C. Group Wellness Programs for Chronic Pain and DiseaseManagement.Philadelphia, PA: Butterworth-Heinemann/Elsevier, 2003.

Montoya P, Larbig W, et al. Influence of social support and emotional context onpain 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 Med2005 Nov-Dec;67(6):957-63.

Ploghaus A, Narain C, et al. Exacerbation of pain by anxiety is associated withactivity in a hippocampal network. J Neurosci2001 Dec 15;21(24):9896-903.

Ploghaus A, Tracey I, et al.Dissociating pain from its anticipation in the humanbrain. Science1999 Jun 18;284(5422):1979-81.

Sim J, Adams N. Systematic review of randomized controlled trials ofnonpharmacological interventions for fibromyalgia. Clin J Pain2002 Sep-Oct;18(5):324-36.

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Singh BB, Berman BM, et al. A pilot study of cognitive behavioral therapy infibromyalgia.Altern Ther Health Med1998 Mar;4(2):67-70.

Taylor RR. Cognitive Behavioral Therapy for Chronic Illness and Disability. NewYork: Springer, 2005.

Tracey I, Ploghaus A, et al. Imaging attentional modulation of pain in theperiaqueductal gray in humans. J Neurosci2002 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. Pain2004Dec;112(3):282-8.

Williams DA. Psychological and behavioral therapies in fibromyalgia and relatedsyndromes. Best Pract Res Clin Rheumatol2003 Aug;17(4):649-65. Review.MeditationChodron, Pema. The Places that Scare You: A Guide to Fearlessness in DifficultTimes. Boston, MA: Shambhala Publications, 2001.

Kabat-Zinn, J. Full Catastrophe Living: Using the Wisdom of Your Body and Mindto Face Stress, Pain and Illness. New York, NY: Dell Publishing, 1990.

Kabat-Zinn, J. Where Ever You Go, There You Are: Mindfulness Meditation inEveryday 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 thetopics 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 TakingBack Your Life. Oakland, CA: New Harbinger Publications, Inc. 2001.

Greenberger D, Padesky C: Mind Over Mood. New York: Guilford Publications,1995.

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Kabat-Zinn, J. Full Catastrophe Living: Using the Wisdom of Your Body and Mindto 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 WhenYou Have a Chronic Illness. Berkeley, CA: Hunter House Publishers 2002.

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

Etiology Morphological, histochemical, ultrastructural changes inmuscles?

Differences in amounts of high energy phosphate metaboliteconcentrations (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 FMSsyndrome, controlled studies of muscle fail to support aconvincing role for muscle in the pathophysiology of the

condition. Muscle tenderness in fibromyalgia cannot beexplained on the basis of primary muscle abnormalities, either

structural or functional. (Simms, 1996)

Etiology

these results and previous investigations support the hypothesisthat hyperalgesia in these patients with FM is due to anupregulation 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 nociceptionHyperalgesia = 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 causesrelease 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 FMSwas approximately 3 times that found in controls.

Etiology Sleep disturbance

People with FMS demonstrate abnormalities of stages 1-4People 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 secretedGrowth hormone necessary for muscle healing

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Decreased in people with FMS80% 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/mlSomatomedin C levels in persons without FMS were 175.2 + 60 ng/ml

Etiology Psychological Disturbances

fibromyalgia might share a genetic abnormality with disorderssuch 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)

EtiologyThe 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 TMJNon-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 ofmuscle fibers. Trigger point pain can refer away from the point.

Patient Presentation It is important to evaluate for musculoskeletal problems

Rotator cuffEpicondylitisCarpal tunnelPlantar faciitisEtc.

Intervention

Despite improved recognition and understanding of FMS,treatment remains challenging.

Goldenberg et al. JAMA, 2004

InterventionNonpharmacologic treatments that target pain, stress, and

physical and psychological dysfunction using a variety of

physical, cognitive, behavioral, and educational strategies areessential 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 strategiesIntervention

There is strong evidence that intensive patient education is an

effective treatment in FMS.

Goldenberg et al.JAMA, 2004

Educationplanned, 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)

EducationBasic information on fibromyalgia, treatment options, self-

efficacy theory, and self-management strategies should beconsidered 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 ADLIntervention

Self-efficacySense of control

Mastery experiences

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ModelingSocial persuasionPhysiological feedback

Intervention

There is strong evidence that cardiovascular exercise is effectivetreatment in FMS.

Goldenberg et al.JAMA,2004

InterventionThis 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

InterventionAerobic 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, andglobal well-being.

Busch et al., 2003

InterventionThis 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 TrainingAmerican College of Sports Medicine. The recommended quantity

and quality of exercise for developing and maintainingcardiorespiratory 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 RateReserve

Cardiovascular Training Heart Rate Reserve (Karvonen formula)

HRR = maximum heart rate minus resting heartrate

Maximum heart rate = 220 ageCalculate % 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 TrainingAge = 40

Max HR = 220 40 = 180Resting 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 TrainingIntensity %HRR RPE

Very Light

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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

InterventionGowans et al., 2001

Exercise group: 10 mins stretching, 20 mins aerobic exercise at60-75% age-adjusted max HR (first 6 weeks in a therapeuticpool, 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 week9) 1x/day

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

2x/dayControl* 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 severityOut 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 minsflexibility and 20 mins strength training (3x/week for 6 weeks)

Group 2 was a relaxation group visualization, yoga, autogenicrelaxation (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) 45mins 3x/week for 14 weeks (warm-up +2 peaks of high intensity training of 3-4mins followed by 15 minutes aerobic games (tag, ball games), ending withstretching)

Group 2 = Stress Management- 90 mins 2x/week for first 6 weeks and then1x/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

InterventionMcCain et al., 1988

Cardiovascular fitness group: 60 mins 3x/week for 20 weeks (10min 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, 2000High 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 weekfor 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

InterventionFerraccioli et al., 1987 True EMG Biofeedback: 15 sessions 2x/week- progressive

relaxation training False EMG - biofeedback : no instruction

control

Outcome MeasuresNumber of tender points Grip strength

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Morning stiffness VAS pain Clinical questionnaire

Results Only true group improved in all measures

InterventionRooks 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 weightNo 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

InterventionMcCain, 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

InterventionMannerkorpi et al., 2000

Exercise group: temperate pool 1x/week for 35 mins also 6one 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

InterventionRichards 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 yearpost

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

MultidisciplinaryThere 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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ExerciseThe 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 formanaging FMS, and the size of ones 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-efficacyJones & Clark, 2002

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Exercise Prescription 12 week exercise program

- 4 supervised visits 1st90 min session and follow-up at 1,3,

& 9 weeks

- at home pts performed 60-120 mins/weekof 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 ImpactQuestionnaire: development and validation.J Rheumatology,

1991;18:728-734.

Resources American College of Rheumatology

1800 Century Place, Suite 250Atlanta, GA 30345-4300

Phone: (404)633-3777http://www.rheumatology.org

Resources

The Arthritis FoundationPO Box 7669Atlanta, 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

1-800-853-2929http://www.fmnetnews.com

ResourcesNational Fibromyalgia Research Association

2200 N. Glassell St.

Suite AOrange, CA 92865

1-800-544-2345, ext 265

Thank You For Attending

Any Questions ?

ncrich@gwi.net

Intellectual PropertyThis 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

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Bennett RM, Burckhardt CS, Clark et al. Group treatment of fibromyalgia: a six monthoutpatient program. J Rheumatol 1996;23:521-8.

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