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  • Tip Less than 20

    I thought it might be interesting to start a thread in which only people who have posted less than 20 times on this site should participate. We'll see if I'm right. The seed for this thread is the following two articles on fibromyalgia. Start how you want to start; with questions, critiques, assertions, take sides, whatever.

    Fibromyalgia: Could it be in your mind?

    and the response to that article

    Dr. Wolfe's reply



    "It is our attitude at the beginning of a difficult undertaking which, more than anything else, will determine its successful outcome."
    William James
    Attached Files
    Last edited by bernard; 22-03-2006, 06:49 AM. Reason: added pdf
    "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

  • #2
    hi jon
    since i appear to be the most qualified in terms of no of posts,i'll take the plunge
    fibromyalgia has always been a rather intriguing syndrome to me.having seen patients that somewhat fulfill the criteria,it still remains a grey area.
    and frustrating to treat...
    in the article,Dr Hadler,though goes overboard with his theory,but i think he has a point.sometimes i have been thinking about the social constructs of pain.the hospital i work in has a high input of muslim patients.in these ladies expression in any way is rather restrained.so sometimes pain becomes a typical and only source of expression.the symptoms can often mimic FM yet the clinicals prove otherwise.
    but yes there is enough evidence of the existence of FM as a clinical entity,summarised here
    http://www.rheuma21st.com/archives/c...ro_benett.html
    i dont know how to incorporate certain words in the links as u guys do...
    with more understanding of chronic pain,FM is here to stay

    cheers

    anurag
    Last edited by bernard; 21-03-2006, 06:56 PM.

    Comment


    • #3
      Just to be clear I don't plan on participating in this thread past starting the topic. Where it goes from here is up to the U-20's.

      anaurag, thanks for the additional link.
      Last edited by Jon Newman; 21-03-2006, 07:46 PM.
      "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

      Comment


      • #4
        Jon,

        Labels allow us to discuss a group of common symptoms (like fibromyalgia) or a treatment technique (like simple contact) that may otherwise be difficult and wordy to describe. It is a vehicle that helps us communicate. Unfortunately, these labels may hold different meanings for others (referring physicians and patients) that bring unwanted assumptions to the discussion. You explain simple contact and the constructs behind it carefully and repeatedly yet some people don't "get it"; I explain pain physiology and pathomechaics to a patient or doctor, but if they cannot get past their assumptions, they will not "get it". Ultimately, a chronic pain patient who cannot accept their pain as something other than an indication of terrible pathology struggles to gain any control and therefore I struggle to help them. I think both articles touched on this, but I felt that Dr. Wolfe had a better understanding (based on my assumptions).

        Rich

        PS How do you like these blue skies we are having? I live in the Upper Peninsula, a stones throw away from you.

        Comment


        • #5
          O.K Jon, I'll play with the U-20'ers.

          Rich -
          I agree that labels can be useful, and necessary at times, in order for medical individual's to discuss a group of common symptoms related to specific individuals. But, as already indicated in the articles and by yourself, this practice can be limiting and sometimes damaging. In my experience, often once the patient has been "labeled" with FM, other symptoms are overlooked, and simply written off as symptoms from the "FM". A common response from medical personel is something like this: "of course you are having pain, you've got fibromyalgia". Unfortunatley, many patients then accept this as an appropriate explanation for any/all symptoms. I have definitely seen this diagnosis over-used, and even occasionally abused, by medical personel, adding to my already frustrated state in dealing with my patients with this diagnosis. Maybe it would be more appropriate to use FM simply as a description of a group of complex symptoms, versus a diagnosis.

          As for the psychosocial aspect of FM, certainly it has been my experience that many of these individuals demonstrate some aspect of distress, as do many of my other patients dealing with acute and chronic pain. Considering that many FM patients have been dealing with chronic pain for some time, with far reaching effects into their personal, social, recreational, and occupational lives, and considering they often have physicians who dismiss them once they have the diagnosis of FM, it is not suprising that they should demonstrate some distress or other pshychosocial problems...I think I would too. I suspect, in a lot of cases, the psychosocial difficulties arose more as a result of their symptoms, and not as the cause.

          Other thoughts??

          T

          Comment


          • #6
            Originally posted by Tracy
            In my experience, often once the patient has been "labeled" with FM, other symptoms are overlooked, and simply written off as symptoms from the "FM". A common response from medical personel is something like this: "of course you are having pain, you've got fibromyalgia". Unfortunatley, many patients then accept this as an appropriate explanation for any/all symptoms. I have definitely seen this diagnosis over-used, and even occasionally abused, by medical personel, adding to my already frustrated state in dealing with my patients with this diagnosis. Maybe it would be more appropriate to use FM simply as a description of a group of complex symptoms, versus a diagnosis.


            T
            Tracy,

            I agree with you completely, and I think this is true of many diagnoses we see including herniated disc, osteoarthritis and many others.

            Regarding the psychosocial aspects, my thought process is as follows: pain leads to psychosocial changes, psychosocial changes create a chemical brain envirnoment that leads to increased pain. Assuming this is true, then changing the way a person thinks about pain may begin to change the assumptions that led to the psychosocial changes in the first place.

            This is part of changing the assumptions that resulted from the labeling with fibromyalgia, herniated disc, etc. In this way I think the psychosocial aspects for these patients are addressed by us without trying to psychoanalyze people.

            Rich

            Comment


            • #7
              Rich -

              Regarding the psychosocial aspects, my thought process is as follows: pain leads to psychosocial changes, psychosocial changes create a chemical brain envirnoment that leads to increased pain.
              Do you feel the reverse is also true? In other words, do you believe that psychosocial problems/distress can lead to pain, thereby increasing the psychosocial components, etc.? I believe I have seen both cases in my practice. More often than not, I prob. see more a combination of the two...pain that is exacebated by psychosocial stressors. I think as therapists, it is important to recognize these stressors that affect our patients, do what we can within our scope of practice to help our patients deal with these stressors, and refer on to other professionals if/when necessary. Never-the-less, in my opinion, when pain seems to be primarily related to psychosocial components, the pain is still very real for the patient. Is my therapy going to have a profound effect on these individuals?...prob. not, at least not until they have an appropriate avenue to deal with these issues.

              Grouping all individuals with FM into a category of psyhosomatic classifications is not at all useful or appropriate. Each patient should be seen as an individual, with unique symptoms, needs, and "stressors". Once we are able to do this, appropriate interventions can then be implemented. Isn't this how ALL of our patients should be treated??

              Tracy

              Comment


              • #8
                Tracy,

                I agree with you 100%. I would be happy if none of my patient's were labeled with a diagnosis other than pain, but labels are clearly a part of the current medical framework. Let's take it one more step. Should we attempt to educate and persuade or referral sources to use pain as the diagnosis for our patients? What pros and cons come out of this idea?

                Rich

                Comment


                • #9
                  Oh Jeez-
                  (you know, from the movie Fargo?...) - never mind, it's very hard to convey humor in a forum like this!

                  Anyway, if we are playing the hypothetical game here...personally, my favorite diagnosis that comes written on the script from the MD is "low back pain", or "shoulder pain", as this leaves me with a blank slate and without the patient arriving with any preconceived notions about their condition. Often, these diagnoses come from the family practitioners or the nurse practitioners, but rarely from the orthos or other specialists.
                  Should we attempt to educate and persuade or referral sources to use pain as the diagnosis for our patients?
                  Prob. wouldn't be too hard to persuade the family docs, etc. but the specialists would never go for it, and my suspicion is that we would be greatly resented, with some attempts to discredit us. And frankly, I think the APTA would have a melt-down at such an attempt!! With all the talk of the APTA trying to make PT's more autonomous and credible, especially as potential primary providers, it is unlikely things would go in this direction. And as PT's we are not able to make a diagnosis, other than our "working diagnosis". This would have to change if we become primary care providers, but again, it is unlikely we could get away with "low back pain"...doesn't look very credible to the powers that be!

                  Another obstacle to using general diagnoses is the insurance companies...I'm sure you've dealt with the dictionary sized book of CPT codes...every possible diagnosis you could ever imagine. I can imagine smoke rolling off their computers and their case managers' head at the mere suggestion of such a thing!

                  And finally, I'm not even sure the patients would accept it, in this day and age of "there must be something wrong with me and I want a name for it". I have personally dealt with patients who come in with a general diagnosis of "thoracic pain", who ask the question "so what's wrong with me?" After careful patient education regarding their condition (i.e. there's a lot of dysfunction surrounding the scapular region, with movement limitations, muscle imbalances, abnormal neurological function, etc.), they often say, "yes, but what's wrong with me?". It's the nature of people to want to label or categorize things, to have a "reason" for things, and in the case of patients with illness or pain, they've been conditioned to expect a name for their problem.

                  Diagnoses have their usefulness in regards to information regarding certain conditions or groups of symptoms/conditions, and can help quide our treatment. It becomes limiting when medical professionals use tunnel vision with the diagnosis, use it inappropriately (i.e. "you've got global pain so it must be fibromyalgia"), etc. Personally, I will continue to evaluate each patient on an individual basis and develop treatment strategies appropriately.

                  It would be interesting to hear from PT's from outside the US regarding their experience with medicos and diagnoses, their freedom to treat as they see appropriate, direct access, making PT diagnoses, etc.

                  Anyone??

                  T

                  Comment


                  • #10
                    Hi Tracy

                    As a PT in Australia, I thought I might offer some answers to your last question.(There are virtually no Aust PTs who contribute to the board)

                    Diagnoses: Medical diagnoses are often inaccurate. Often, just stated as 'degeneration' or 'OA' or PFS or disc bulge, and so on. We use our own working diagnoses; after assessment.

                    We in Aust have had autonomy since 1976; so we treat referrals as courtesy notes. Patients, however, have often visited the doctor prior to coming to us, especially if they are in a lot of pain.
                    Nevertheless, we can't assume the doctor has cleared 'red flags'.

                    We have complete freedom to treat as we see fit; in private practice the same principle applies. The exception to that are the orthopaedic post- surgical referrals - they have protocols, usually developed in cahoots with the doctor.
                    I think it would be good to have 'pain' as a nominal diagnosis, but it is vague. However, if the patient wants a 'label', and most do, education usually can assure them that a label is not necessarily required. Depends how much useful information they have received from their doctors; sometimes we need to reassure them with education that their spine is not falling apart and what is on XR is not the origin of their pain, but may be a contributing factor to the cause for pain.

                    I probably shouldn't be responding at all in this forum, as it is intended only for our new arrivals. However, hope it has been helpful.

                    Nari

                    Comment


                    • #11
                      Thanks for you input Nari -

                      Sounds a lot like the area I practice in...lots of freedom to do therapy as I see appropriate, unless it's post-surgical protocols. My state (Idaho) has direct access; I think there are a few states left that are not direct access. Interestingly, most insurance companies won't pay for the therapy unless the patient has seen an MD and has a script for therapy, regardless of direct access.

                      T

                      Comment


                      • #12
                        Sorry for being fashionably late with my comments. Great discussion so far everyone. Just thought I would chime in with a few thoughts to stimulate more discussion.

                        Regarding the psychosocial aspects, my thought process is as follows: pain leads to psychosocial changes, psychosocial changes create a chemical brain envirnoment that leads to increased pain.
                        .

                        Rich,

                        I think you are on to something, but maybe there is something else missing. For example, what kind of pain are you speaking of? I have had pain before (having passed two kidney stones), yet I did not seem to follow along your suggested path. Perhaps we need to include some amount of vulnerability. But how do we assess that? And if that vulnerability is removed, what would be the expected outcome? I don't mean these questions to be directed just at you, but all the U-20ers.


                        Tracy,

                        Thanks for your insights so far as well. I have also enjoyed reading your material. But I did have some questions (again for everyone) on this statement:

                        It's the nature of people to want to label or categorize things, to have a "reason" for things, and in the case of patients with illness or pain, they've been conditioned to expect a name for their problem.
                        Are you suggesting that it is human nature to expect a diagnosis/explanation or that we are conditioned to expect that. And if the answer is the former, then how can we expect that to change? Should we expect that to change? I think you are suggesting the latter, and if so, I would tend to agree. Perhaps diagnoses do have their place, however. Maybe they would be helpful amongst the health professionals, at least those that understand them and know how they may apply to the patient presentation. Otherwise, I would agree that a little bit of knowledge (i.e. a diagnosis) in the wrong hands (i.e. relatively uneducated patients) can be a dangerous mix.

                        I'm hoping that this all make sense to everyone else, like it does in my head. I also hope my quote references come out okay, as this is my first time trying them. Thanks for the great discussion so far, and I invite any comments (from U-20ers).

                        Wes

                        Comment


                        • #13
                          Crazy Pole -

                          Welcome to the discussion!

                          Rich,

                          I think you are on to something, but maybe there is something else missing. For example, what kind of pain are you speaking of? I have had pain before (having passed two kidney stones), yet I did not seem to follow along your suggested path. Perhaps we need to include some amount of vulnerability. But how do we assess that? And if that vulnerability is removed, what would be the expected outcome? I don't mean these questions to be directed just at you, but all the U-20ers.
                          I think it may also have to do with duration of symptoms/pain. I am sure that passing kidney stones can be compared quite effectively to childbirth (quite possibly the closest any man can come to experiencing childbirth?) Having never passed a kidney stone (let's hope it stays that way), I am not sure of the typical duration of this pain. But having gone through excrutiatingly painful pitocin induced labor (the CIA should use pitocin as a means of extracting information from people!!), which only lasted about 5 hours, I think I can relate to the pain you must have felt. Granted, this is extreme pain, but can you imagine your pyshological condition if this had lasted a week, a month, or years?? Can you imagine you psychological condition had you only had 1/3 the amount of pain and it lasted a week, a month or a year?? Vulnerability is surely a key component. As is, I suspect, many other factors including an individual's pain tolerance, coping mechanisms, support systems, etc. It is certainly a complex issue.

                          Perhaps we need to include some amount of vulnerability. But how do we assess that?
                          I assess this by intuition during all of my evals, is it accurate?...I don't know, I'd like to think I am sensitively intuitive, and I can "size" my patients up pretty quickly, I think, after the first eval. But to do it on a formal basis? I guess this would take a dreaded questionaire (just what my patients want to do, is fill out more paperwork!). Care would need to be taken to be sure that it wasn't interpreted as moving out of our scope of practice and into the Pysch. realm. If it was used as a screen, an "identifier", and used appropriately for our knowledge of how to approach the individual, with the understanding that the patient be referred out for additional counseling if necessary, then this may be helpful.

                          Are you suggesting that it is human nature to expect a diagnosis/explanation or that we are conditioned to expect that.
                          I think maybe it's a bit of both. In my experience, most people like nice/neat categories or labels, or "boxes" to place things or people into. But I think a lot of it is due to the American culture (can't speak for other countries here) of what I like to call "talk show culture"... people need something to blame for their troubles (of course, it's not themselves!), it's the other guys' fault, or "I'm screwed up because of my parents", etc. etc. If people have a name for something, i.e. "fibromyalgia", it's easier to accept the disease as the blame. It provides a "reason" for the pain. Does that make any sense at all (it makes perfect sense in my small little brain!).

                          Good questions/discussion - thanks all!

                          Tracy

                          Comment


                          • #14
                            Hi all,

                            I read through your discussion with great interest. Over the last two years I saw a couple of patients with the diagnosis "Fibromyalgie" so that I got interested to improve my knowledge about that disease and the treatment routines as well.
                            At the beginning I always started to work on the symtomes (back pain, shoulder pain, etc.) - I didn't know better. But I learned that these fibromylagia-patients were often immunocompromised people and today I believe in two things:

                            1. aerobic exercises
                            2. nutrition

                            All that to fix acid-base metabolism.


                            Xaniel
                            "Use only that which works, and take it from any place you can find it." Bruce Lee

                            Comment


                            • #15
                              Hi Xaniel,

                              Welcome to the discussion. I'll consider myself a part of this discussion yet, though I have since passed 20 posts.

                              But I learned that these fibromylagia-patients were often immunocompromised people and today I believe in two things:

                              1. aerobic exercises
                              2. nutrition
                              If I'm not mistaken, I believe that the Cochrane Database tends to agree with your approach. Certainly, lifestyle and perceptual changes seem necessary. How to affect those changes is the challenge. I suspect that massage and passive modalities are not appropriate engines, despite their frequent requests on MD orders.

                              At the Explain Pain course I attended recently, the instructor suggested that there is a genetic component to chronic pain. He didn't elaborate, and I have not yet searched further. I reckon that some people are predisposed to chronic pain, such as alcoholism. When the right factors mix together, it can brew quite a storm. This may speak slightly to the vulnerability issue I mentioned early in the thread.

                              Anyway, thanks for bringing back this blast from the past. It helped me realize how much better I think I understand pain since this thread started.

                              Wes
                              Last edited by Crazy Pole; 27-04-2007, 07:00 PM. Reason: grammar

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