Fibromyalgia Case Study


Author/s

Becky Brinkworth, Lindsey Hudson, Morgan Jones, Remsing King, and Marley McGraw from the Bellarmine University Physical Therapy Program's Pathophysiology of Complex Patient Problems Project.

Abstract

Fibromyalgia is a diagnosis that has become more prevalent in recent years. These patients are often sent to Physical Therapy for treatment of fatigue, weakness, range of motion deficits, and pain. Exercise and pain management techniques can be utilized with these patients to address musculoskeletal-related dysfunction while also having a positive effect on psychosocial issues often accompanying Fibromyalgia.


We have included a link to a short informational video about Fibromyalgia from the Mayo Clinic website (referenced below)

https://m.YouTube.com/watch?v=Pbu7XvDNPxQ

Patient Characteristics

Patient is referred to physical therapy after being involved in a motor vehicle accident (four months ago) and continuing to have ongoing pain and stiffness. Patient is 42 years old, female, Caucasian, and lives alone in her apartment. She was working as a receptionist at time of accident but is not currently able to work due to pain. Patient has a family history of rheumatoid arthritis and fibromyalgia. She has no history of significant alcohol or recreational drug use. Patient has had no past surgeries, no history of cancer. She is currently taking Prozac for her depression and anxiety. She was referred to physical therapy by her primary care physician. She has never been to physical therapy before today.

Examination

Subjective: Patient suffered from onset of back pain following MVA on November 15, 2014. After the accident the patient immediately complained of pain in her middle thorax and spine, her neck, and lower extremities. Patient also reports having difficulty sleeping and feeling fatigued and stiff in the mornings. Finally, patient has noticed problems with cognitive issues such as concentrating and the pain has impacted performing daily activities including cooking, cleaning, and working as a receptionist. She hopes to return to work and daily activities with less pain.
Patient reports seeing her primary care physician following the accident. The doctor recommended routine labs and had had x-rays done showing no fractures. The lab values (CBC, CMP, erythrocyte sedimentation rate) were all normal. Physician referred her physical therapy to help with her pain and fatigue.

Objective:
Body pain diagram: pain noted cervical spine, bilateral shoulders, low back, bilateral hips, bilateral knees
VAS: 8/10
Resting Vitals:

  • Resting BP = 140/90
  • HR = 88

Skin inspection: no abnormal rash or markings, skin temperature appeared normal
Reflexes: 2+ bilateral
Sensation: hypersensitivity noted in non-dermatomal patterns
MMT:

  • Shoulder ABD bilateral= 4/5
  • Shoulder Flexion bilateral= 4-/5
  • Hip extension bilateral = 4-/5

PROM: WNL
AROM: decreased AROM noted in cervical spine, lumbar spine, and shoulders

  • ROM deficits most likely due to self-limiting behavior caused by pain

Tenderness: trigger points noted over multiple points (12 of 18 predesignated sites)
Edema: noted in bilateral knees and wrists
Fibromyalgia Impact Questionnaire: 50
Fatigue Severity Scale: 40
ODI: 78%

Fibromyalgia Pain Chart.JPG

http://www.mayoclinic.org/diseases-conditions/fibromyalgia/multimedia/tender-points/img-20007586

Clinical Impression

Patient is 42 year old female with ongoing pain lasting >3 months after a traumatic event. Her symptoms are indicative of fibromyalgia and include widespread pains (both sides of body, above and below waist) that affect ADLs, fatigue, sleep disturbance, stiffness, non-dermatomal hypersensitivity, and cognitive impairments. Upon physical examination, tenderness was noted in 12 of 18 tender points identified by the Fibromyalgia diagnostic criteria3. Passive range of motion was normal; however, active range of motion was limited most likely secondary to widespread pain. Laboratory tests and x-rays were clear. Patient reports of depression and anxiety are also associated comorbidities with Fibromyalgia6.

FibromyalgiaSymptoms.jpg

http://www.fibrocenter.com/fibromyalgia-symptoms.aspx

Intervention

The focus of our treatment included the following components: improving muscle and joint function, decreasing pain, decreasing fatigue, and assisting in avoiding triggers that worsen the symptoms of fibromyalgia. Treatment includes approaches in managing pain and improving overall function for individuals with fibromyalgia.
Our therapy approach included all of the following: aquatic therapy; land-based therapy; guided imagery/relaxation techniques; patient education; and heat and electrical stimulation for pain management. We found this to be the most successful approach in order to properly educate our patient on the importance of strength and mobility training, pain management, and decreasing overall fatigue.

The purpose of promoting aquatic therapy for this individual was to decrease the fatiguing component that is often an issue with fibromyalgia patients. This approach allows our patient to tolerate an increased amount of therapy with less overall stress on her joints8. This is also something we suggest our patient continue once she is discharged from therapy. We also wanted to incorporate some land-based therapy in order to improve our patient’s overall strength that will coordinate with her activities of daily living9. Exercises for land-based therapy included: strengthening of anti-gravity and postural muscles such as erector spinae, gluteus muscles, etc. We also instructed our patient relaxation techniques such as deep breathing, diaphragmatic breathing, and modified plantigrade positioning to use when she experiences anxiety or fatigue10.

Diaphragmatic Breathing.JPG

http://www.mayoclinichealthsystem.org/~/media/.../RelaxedBreathing.pdf


Other important aspects of our therapy approach included patient education and pain management techniques. We educated our patient on appropriate times to use the breathing techniques, how to manage fatigue, and the importance of staying active10. Pain management for our patient incorporated the appropriate use of heat and electrical stimulation to manage her symptoms of fibromyalgia.

Outcomes

Following treatment our patient showed improvements in ROM, strength, pain, and fatigue as demonstrated by the following objective measurements at discharge.

VAS: 4/10
AROM: WNL
MMT:

  • Shoulder ABD bilateral= 4+/5
  • Shoulder Flexion bilateral= 4+/5
  • Hip extension bilateral = 4+/5

Tenderness: trigger points noted in upper trapezius, erector spinae, guteus maximus, gastroc-soleus complex, and pectorlis major lateral attachment sites
Fibromyalgia Impact Questionnaire: 42 (clinical significance as evidenced by MDIC)11
Fatigue Severity Scale: 29
ODI: 50% (clinical significance as evidenced by MDIC)11
Fatigue Severity Scale.JPG

http://www.saintalphonsus.org/documents/boise/sleep-Fatigue-Severity-Scale.pdf

Discussion

Our patient had several risk factors for the diagnosis of fibromyalgia including her sex and age. Fibromyalgia is most commonly diagnosed in women between the ages of 30-50 years. This patient also has several comorbidities associated with fibromyalgia including sleep disturbances, depression, and anxiety6. Clinical signs and symptoms of fibromyalgia which the patient presented with include myalgia, fatigue, stiffness, tender points of palpation, hypersensitivity noted in non-dermatomal patterns, and cognitive difficulties4.


This is important information to note not only with our patient case but with the growing number of patient cases related to fibromyalgia. Stress, illness, disease or anything the body perceives as a threat are risk factors for those who develop FMS. But why one person develops this condition, whereas others with equal or worse situations do not, remains a mystery. It is important when taking a patient's history to collect all necessary past medical history, as this disease can be easily mistaken and it's complete initiation with regards to pathophysiology is unknown.

Related Pages

Fibromyalgia Network: educational materials on fibromyalgia syndrome6
www.fmnetnews.com

American Fibromyalgia Syndrome Association: research,education, and patient advocacy6
www.afsafund.org

National Fibromyalgia Association: increase fibromyalgia awareness and improve treatment options6

www.fmaware.org

Fibromyalgia Research Foundation: metabolic basis of fibromyalgia and treatment6
www.drlowe.com

References

1. Arnold LM, Clauw DJ, Mccarberg BH. Improving the recognition and diagnosis of fibromyalgia. Mayo Clin Proc. 2011;86(5):457-64.
2. Bennett R, Bushmakin A, Cappelleri J, Zlateva G, Sadosky A. Minimal clinically important difference in the Fibromyalgia Impact Questionnaire. Journal Of Rheumatology [serial online]. June 2009;36(6):1304-1311. Available from: CINAHL, Ipswich, MA. Accessed March 26, 2015.
3. Diagnosing Fibromyalgia. FIBROCENTER: Your source for information and education about chronic widespread pain. Pfizer. http://www.fibrocenter.com/diagnosing- fibromyalgia.aspx. Published 2012. Accessed March 26, 2015.
4. Disease and Conditions: Fibromyalgia. Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/fibromyalgia/basics/risk-factors/con-20019243. Updated February 20, 2014. Accessed March 4, 2015.
5. Goodman CC, Fuller KS. Pathology: Implications for the Physical Therapist. Edition 3. St. Louis, MO: Saunders Elsevier; 2009.
6. Goodman CC, Snyder TEK. Differential Diagnosis for Physical Therapists: Screening for Referral. 5th ed. St. Louis, MO: Elseiver Saunders; 2013.
7. Hauser W, Wolfe F. Diagnosis and diagnostic tests for fibromyalgia (syndrome) Reumatismo. 2012;64(4):194–205.
8. Lima T, Dias J, Cardoso J, et al. The effectiveness of aquatic physical therapy in the treatment of fibromyalgia: a systematic review with meta-analysis. Clinical Rehabilitation [serial online]. October 2013;27(10):892-908. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed March 28, 2015.
9. Lonnemann, E. Disorders of Skeletal Function: Rheumatic Disorders and Connective Tissue Disorders. [PowerPoint]. Louisville, KY: Bellarmine University DPT Program; 2015.
10. Meeus M, Nijs J, Vanderheiden T, Baert I, Descheemaeker F, Struyf F. The effect of relaxation therapy on autonomic functioning, symptoms and daily functioning, in patients with chronic fatigue syndrome or fibromyalgia: a systematic review. Clinical Rehabilitation [serial online]. March 2015;29(3):221-233. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed March 28, 2015.
11. Rehabilitation Measures Database. Rehabilitation Institute of Chicago. http://www.rehabmeasures.org/default.aspx. Published 2010. Accessed March 26, 2015.