Dealing with Chronic Pain in Fibromyalgia~ A holistic approachDawn Johnson, MSN, BA, RN, CNHP

The Basics of FibromyalgiaAffects 6 million people in the

U.S.Widespread musculoskeletal pain

and stiffnessFatigue, sleep problems,

cognitive disturbances, depression often associated

Diagnosis: Hx of pain for at least 3 months and pain in at least 11 of 18 tender points

Diagnostic Tender Points

www.fibroandfatigue.com/images/tender-points.jpg

The Pain Cycle

SleepPain makes it hard

to sleep then lack of sleep makes

painworse

MoodLimits that it putson life can lead to

depression

ActivityPain and lack of

energy make it hard to be

active

EnergyCoping with pain

takes energy

DepressionAffects 20-70% of fibromyalgia

patientsSeen as a byproduct of the

disease, not depression causing fibromyalgia

Many report decreased quality of life

May lose hope related to chronic nature of the disease

The Woman’s ExperienceTransitions

◦Daily, family, social, working life◦Learning to live with changes◦“Experience of transitions is

apparently something that is invisible to almost everyone except the women themselves” (Soderburg, Lundman, 2001)

◦“FM is the choreographer of activity and relationships” (Soderburg, Lundman, 2001)

Family IssuesFrom the husband’s perspective:

◦Increased responsibility and workload

◦Learning to read woman’s needs◦Being supportive/understanding◦Lack of information on disease

(Soderberg, Strand, Haapala, & Lundman, 2003)

Family responseThe family will respond in one of

three ways◦FMS brings the family closer together◦The family experiences minimal

change in role responsibility◦There is a negative effect on family

members as a result of the illness

Affect on Family Family watch the pain and feel

helpless to make it go awayThey feel helpless in distracting

the FMS sufferer long enough to enjoy a bit of life

They hear differing stories from healthcare providers and read conflicting stories in media

Having a child with FMOften show fewer tender points,

have more stomachachesDifficulty including non-affected

children of the familyNeed for educating

teachers/friends/familyChild struggles with

relationships/fitting in

GenomicsYanus et al (1999)Studied genetics of 40

multicase FMS families

Confirmed the possible existence of a possible gene for FMS that is linked with the HLA region

Results are considered preliminary and more studies need to be carried out

Genomics

Stormorken and Brosstad, (1992)Noticed that family clustering and sensory

urgency indicate a genetic predisposition to FMS

AssessmentAssess what modalities have

been used by the client and what modalities they are willing to try

How does the illness affect the client’s work and social activities?

How is the client’s family affected?◦Instrumental activities◦Nurturing activities

How does it affect their sexuality?

AssessmentsAssess client assertivenessAssess any mood and concentration

problemsAssess family strengths and

weaknessesIdentify losses related to chronic

painDetermine how family and friends

contribute to the pain cycleDetermine QOL via questionnaires

Functions of the family unitSexual wellbeingEmotional supportPhysical assistance with

everyday tasksRecreational activity and social

commitments

Pain Logs

Encourage client to keep a diary to track pain, symptoms, modalities, and help identify pain triggers

InterventionsThe first goal for FMS help is to

help break the pain cycleInform the client that finding the

right treatments takes time and that plans may change as health and life situations change

Let family know how they are involved in the pain cycle without knowing it and let them know how to help break the pain cycle

InterventionsImportance of healthcare professional

believing patientIdentifying stressorsTeaching self-talk principles, decreasing

catastrophizingTeaching moderationPlanning: working towards realistic goalsHumorRelaxation

Usual Medical TreatmentsNSAIDS and aceaminophenTramadol (Ultram)Muscle relaxants (Flexeril, Soma,

Zanaflex)Tricyclic antidepressants (Elavil,

Emitrip)SSRIs (Zoloft), SSNRIs (Cymbalta)ExerciseRest, massage, acupuncture/pressureCognitive behavioral therapy

Role of Complementary Treatments in FMSMassageAcupunctureMeditationRelaxationBiofeedbackCounselingHerbs and Bach flower

therapyArt/ Music/ Pet therapyChiropractic/ OsteopathyAromatherapy

Lessening the fear of painFear of physical pain is a major cause of

painFour techniques to help manage fear of

pain:◦ Visualization◦ Breath awareness◦ Nonjudgmental appreciation of body

sensations, including sensations of pain◦ Mobilization of psychological strength

(Bacci, I, 2000)

Strategies to reduce stress

Plan your daySimplify your scheduleGet organizedTake occasional

breaksExercise regularlyGet enough sleepEat wellChange the paceBe positiveStay connectedBe patient

ModerationBreak apart lengthy taskMix activities, put those that take

a lot of effort with those that require minimal effort. Plan priority tasks at the time of day clients have the most energy

Rest periodically Work at a moderate pace

RelaxationDesignate a time for family

relaxationRelaxation helps the body

recuperateRefreshes one mentally,

physically, and emotionallyAllows the individual to focus

away from the painGives one a sense of control over

pain

Benefits of relaxation

Relieves the stress that aggravates pain

Prevent muscle spasms

Decreases muscle tension

Benefits correlate to effort and motivation one has in learning the skill

Physiological Changes

Relaxation helps to decrease:◦ Blood pressure◦ Respiratory rate◦ Heart workload◦ Muscle tension

Types of RelaxationRelaxed breathingProgressive muscle relaxationAutogenic relaxation Imagery

Assertive BehaviorOccurs when the client acts in the

one’s best interest and takes responsibility for expressing one’s needs, feelings, and ideas honestly and directly

Does no put down others in a direct, purposeful way

Uses “I statements” Role play often helps in implementing

assertiveness into one’s lifestyle

Exercise

Encourage family walks or activities

Swimming, aqua aerobics or yoga are good activities

Moderate do not do too much on good days and nothing on bad days

ExerciseStart session with warm-upStretch before and after exercise

gently and do not bounceInform clients that they may have

some soreness at firstWear appropriate shoes that fit and

supportUse heat and ice as directedMake sure it is OK with provider to

start and exercise program

Nutrition

Encourage a healthy diet low in animal fat and high in fiber

Include a variety of fruits and vegetables

Weight loss can help decrease pain

Sleep Hygiene

Avoid caffeinated beverages or stimulants prior to bedtime

Wake up and go to sleep at similar times each day

May use essential oils or herbs to promote sleep and relaxation

Family involvement

People with a solid support system have advantages to those without solid support

Family supportThose with family support:

◦Cope better with chronic pain◦Are less likely to experience

depression◦Are more independent◦Recover faster from illness◦Have a stronger immune system◦Have lower blood pressure◦Have lower cholesterol◦Live longer

Family Needs

Caregivers have four needs◦ Physical◦ Emotional◦ Spiritual◦ Financial

Family involvement

Encourage loved one to make an effort to control pain and be active

Help distract loved one from pain

Help create safe, comfortable surroundings. Reduce noise and glare

Family and Friend involvement

Family cooks a healthy meal togetherGo for a walk togetherEncourage family member ask

questions and to listen to the clients answers

Take time; be patientEncourage client to describe to

family how they can helpEncourage family to educate

themselves about the symptoms that may signal a flare

Family involvementSuggestions for the family:

◦ Encourage the family to learn about chronic pain◦ Do not let conversations lead to talking about

pain◦ Encourage family not to hover over client◦ Join in activities◦ Encourage family not to give up activities “for

the client’s sake”◦ Encourage family to be available to listen to the

client◦ Encourage family to take care of themselves◦ Encourage family to work as a unit to SOLVE

problems

SOLVE problems

State the problemOutline the

problemList possible

solutionsView

consequencesExecute the

solution

Dealing with Pain BehaviorsPain behaviors are things people

say or do that signal they are in pain

These include◦Wincing◦Groaning◦Frequently talking about pain◦Avoiding others◦Being irritable with family, friends,

coworkers

Dealing with pain behaviorsFamily response may fall into two

categories:◦Punishing◦Caretaking

Best response for family is to be neutral and not respond to the behavior

Developing a support systemAnswer phone callsAccept invitations to events, even if it is

difficult at first Do not wait to be invited somewhere, take

initiative and call someoneSet aside past differences and approach your

relationships with a clean slateTake part in community events or family get-

togethersStart a conversation with a person next to

you at a local gatheringTalk about things people are interested in

and be an active listenerDo not give up on existing

Finding supportTake part in community events or

family get-togethersStart a conversation with a

person next to you at a local gathering

Talk about things people are interested in and be an active listener

Do not give up on existing relationships

Goal Setting

SMART GoalsSpecific- what is you wantMeasurable - How much do you wantAchievable- Something you can

achieveRealistic- The goal is realistic for youTime- The goal will be accomplished in

a time periodExample: I will incorporate 30 minutes

of stationary biking into my schedule 3 days a week for 2 months.

Family Contracts

Have client sign a contract with their support system that they will exercise, stay involved in enjoyable activities, refrain from pain talk, etc..

Make sure to include rewards and consequences.

Difficult Day PlanningStart planning for a difficult day

on a good dayDifferentiate between an acute

emergency and a difficult dayIdentify signs of a flare What behaviors would lead to a

difficult day?

Difficult Day PlanningReview what has worked in the pastIdentify support people and resources

and what they might do to help get one through a difficult day

What should one avoid on a difficult day?

Picture oneself getting through a difficult day

Reward oneself for making it through a difficult day

ConclusionFMS is a treatable syndromeGood family and support system

relationships are linked to better control of FMS symptoms

FMS is treated with a combination of medication, complementary therapies, and lifestyle changes

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USA.Paulson, M., Norberg, A., & Soderberg, S. (2003). Living in the shadow of fibromyalgic pain:

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fibromyalgia from the perspective of the husband. Journal of Advanced Nursing, 42, 143-50.

Soderberg, S., & Lundman, B. (2001). Transitions experienced by women with fibromyalgia. Health Care for Women International, 22, 617-631. .

Stormorken, H., & Brosstad, F. (1992). Fibormyalgia: family clustering and sensory urgency with early onset indicate genetic disposition and thus a “true” disease.

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