Page 1 of a Great Article, read on!

http://www.practicalpainmanagement.com/pain/myofascial/fibromyalgia/physical-medicine-rehabilitation-fibromyalgia

Physical Medicine and Rehabilitation for Fibromyalgia

Optimal rehabilitation outcomes in a fibromyalgia patient require that the treatment be tailored to the individual patient’s symptoms, examination findings and subject to periodic testing to allow for adjustment.

By Scott Stoney, MD

Page 1 of 4

Fibromyalgia is not only a difficult illness for patients who are forced to live with chronic pain and other co-morbid conditions, it is also perplexing to physicians who often do not have the tools necessary to feel comfortable in making an accurate diagnosis or to prescribe a successful treatment regimen. In his discussion of the pathophysiology of fibromyalgia, medications, and rehabilitation strategies, Dr. Stoney highlights the usefulness of the Fibromyalgia Oswestry Pain Questionnaire as a tool to measure pain management efficacy in this patient population.

Rae Marie Gleason

“The days of affliction have taken hold of me. My bones are pierced in the night and my sinews take no rest." —Job 30:16-17

Physical medicine and rehabilitation (PM&R), also known as physiatry, is a branch of medicine that aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities. Physical medicine and rehabilitation involves the management of disorders that alter the function and performance of the patient. Emphasis is placed on the optimization of function through the combined use of medications, physical modalities, physical training with therapeutic exercise, movement and activities modification, adaptive equipments and assistive device, orthotics (braces), prosthesis, and experiential training approaches. The major concern of the field is the ability of the person to function optimally within the limitations placed upon them by a disease process for which there is no known cure. The emphasis is not on the full restoration to the pre-morbid level of function, but rather the optimization of the quality of life for those who may not be able to achieve full restoration. A team approach to chronic conditions is emphasized to coordinate care of the patients.
Figure 1. Pain Sensing System Malfunction in Chronic Pain Normal Pain
Pain-sensing signals are initiated in response to a stimulus
They elicit a pain-relieving response
Chronic Pain
Pain signals are generated for no reason and may be intensified
Pain-relieving mechanisms may be defective or deactivated

Pathophysiology of Fibromyalgia

Fibromyalgia has been acknowledged as a disease state by the AMA, the NIH, Social Security Administration, and the American College of Rheumatology. There is a wealth of biochemical data that both substantiates this disorder and helps providers understand its pathophysiology.
The patient with fibromyalgia has demonstrated gray matter loss, with one year of fibromyalgia pain equivalent to nine years of brain aging.¹ Fibromyalgia is a chronic pain disorder affecting 2-4% of the population.² Biological and neuroimaging studies support the hypothesis that aberrant pain processing in the central nervous system (CNS) of fibromyalgia patients may represent an important underlying defect.³
A CNS mechanism may explain generalized heightened pain sensitivity of FM patients; increased levels of excitatory neurotransmitters (glutamate, substance P); may contribute to neuronal hyperactivity and central sensitization; and decreased activity of inhibitory signaling mediated through noradrenergic and serotonergic descending pathways. Biologic and genetic influences, environmental triggers, and abnormalities in neuroendocrine and autonomic nervous systems also contribute to the pathophysiology of FM (see Figure 1).
Neuroendocrine⁴ and neurotransmitter abnormalities, autonomic dysfunction, shared biological and genetic factors,⁵ psychiatric/ psychological⁶ and social distress are present in patients with fibromyalgia. The peripheral mechanism is also impaired in patients with fibromyalgia as these patients have hypersensitivity or widespread pain.
The biochemical changes seen in the CNS—the low levels of serotonin, the four-fold increase in nerve growth factor, and the elevated levels of substance P—all lead to a whole-body hypersensitivity to pain and suggest that fibromyalgia may be a condition of central sensitization or of abnormal central processing of nociceptive pain input.⁷ Evidence has suggested that suppression of the normal activity of dopamine-releasing neurons in the limbic system is the primary pathology in fibromyalgia. Increasing evidence indicates that fibromyalgia may represent a dysregulation of dopaminergic neurotransmission. Researchers have found low levels of adenosine triphosphate (ATP) in red blood cells of patients with fibromyalgia but the most widely acknowledged biochemical abnormality associated with fibromyalgia is abnormally low serotonin levels which have been correlated with painful symptoms. Many studies have linked serotonin, a neurotransmitter, to sleep, pain perception, headaches, and mood disorders.
Serotonin levels in the CNS are thought to be low due to low levels of tryptophan (amino acid precursor to serotonin) and 5-hydroxyindole acetic acid (metabolic by-product) in the spinal fluid. Investigators have proposed a link between low serotonin levels and symptoms of fibromyalgia.⁸ Moreover, many propose that low serotonin levels may cause fibromyalgia in whole or in part.
Investigators have studied the neuroendocrine aspects of fibromyalgia and have found dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis.⁹ The HPA axis is a critical component of the stress-adaptation response. In a normally functioning system, corticotropin-releasing hormone (CRH) stimulates the anterior pituitary to release adrenocorticotropic hormone (ACTH). ACTH then stimulates the adrenal cortex to produce glucocorticoids, which are powerful mediators of the stress-adaptation response.
In support of the idea of a systemic biochemical abnormality in fibromyalgia, investigators from four independent studies reported levels of substance P that were two to three times higher than normal.¹⁰
Substance P, the neuropeptide in spinal fluid, is a neurotransmitter that is released when axons are stimulated. Increased levels of substance P increase the sensitivity of nerves to pain or heighten awareness of pain. The elevated levels in the spinal cord of fibromyalgia patients cause fairly normal stimuli to result in exaggerated nociception. This results in an impairment in the normal regulation of muscle tone within the spinal cord, contributing to increased muscle tone and focal muscle spasm (see Figure 2).

Medication Meltdown

I recently was told to double my pain medication. When I did it took about a week to adjust for the most part, it's been upwards for three weeks now and they still turn me into a jittery stoner at times. 
I ended up snapping at a few people over the course of the last few weeks at my job. For the most part everyone realized I was having a hard time and accepted my apology. Except for one person, because it was their birthday. I was so incredibly out of it I barely remember the whole day and at the time I'm sure I didn't realize it was the person's birthday. Mainly because the person makes me want to scream. I apologized and told them I was sorry although I had to bite my tongue and not make excuses. They accepted for the most part and told me not to worry about it.

Another person berated me over making fun of this person. They had screwed up like seven orders in a row and me and another guy from work were teasing him about maybe throwing him out the window..... yes I realize that's mean.  Like I said I was really out of it so I'm not exactly sure of my reasoning. I just can't function without the medication and it's not like I can call out of work for a month every time I have a medication change. As it was I was filling in for someone who was sick.  I get weird on the medications and I hate huritn gpeople but my verbal filter just isn't there when I take my meds. It's gone. If I could work without them I would. With them I can work and contribute to society, I'd like to continue that way. I'm trying to tame my tongue. The only thing I"m taming is how much i take my meds though. I feel so guilty for taking them, I know i'm going to probably say something mean or insensitive when I'm on them and yet it's so damn hard to get through the day at home without them never mind work a full shift without them.

I just don't get why are people so hard on those who are on medications? I was told that I can't use it as an excuse. Okay then, next time my hip acts up and I can't walk I won't use my cane as an excuse not to mow the yard, or walk up five flights of stairs at school, or walk three blocks to a friend's house to babysit their kids.  Don't be ignorant. These people aren't stupid, or mean or cruel they just do not understand. And I've tried to explain it but they don't want to hear my side.

I don't often use being sick as an excuse for rude behavior.  However I am still rude quite a bit of the time, I even admitted that without the meds I'd still have been cranky with the guy, just not as much. And yet still resentment. Why? I don't get this???? I'm not okay! It's like blaming someone with manic depression for not acting normal when they aren't on medication. Or someone with cancer for not eating everythign on their plate when they are a guest at someone's house because they are too nauseous. Sometimes I really wish everyone could live one day in pain.

The person who took me to task did so as nicely as possible, I'm not angry with them, I'm glad that they are sticking up for the guy. Someone has to. The person even said that they gave me credit for coming to work and dealing with all the shit their when I didn't feel well. But I don't think many people really understand how NOT well I am.

I don't look haggard because I'm ugly. I look haggard because I have chronic fatigue. I'm always tired. Doesn't matter how much I sleep. I am ALWAYS in pain. People don't get that. It's ALL the time. Not wow something kinda hurts. it's ALLLLLLLLLL the time. I am in moderate pain 90% of the time. MODERATE. Someone said the other day that being mildly in pain all the time must get tiring. Really? Cause I'm an inch or so from crying some days. Some times I cry when I go to sleep or when I get up because it hurts so badly. I don't want to go to work in the morning. I just want to lay here and cry some, and then wait till they find a cure. I'm trying to trust God to help me get through it. He's doing well. It's just hard... a lot of the time. Maybe it's what's keeping me so close to him. If so then I'm glad. I need to sleep.....

A Simple Explanation of Fibromyalgia by Adrienne dellwo

Fibromyalgia is a complex condition that's difficult to understand, especially if you don't have a medical degree. Because it involves the brain and nervous system, fibromyalgia can have an impact on virtually every part of the body.

If you're trying to understand this condition in someone you know, it can be incredibly confusing. When a lot of people see a bizarre collection of fluctuating symptoms that don't show up in medical tests, they decide fibromyalgia must be a psychological problem. A host of scientific evidence, however, proves that it's a very real physical condition.

Imagine you're planning a party and expecting about 20 guests. Three or four friends told you they'd come early to help you out. But they don't show, and instead of 20 guests, you get 100. You're overwhelmed.

That's what's happening with pain signals in someone who has fibromyalgia. The cells send too many pain messages (party guests), up to five times as many as in a healthy person. That can turn mild pressure or even an itch into pain.

When those pain signals reach the brain, they're processed by something called serotonin. People with fibromyalgia, however, don't have enough serotonin (the friends who didn't show up to help), leaving the brain overwhelmed.

This is why people with fibromyalgia have pain in tissues that show no sign of damage. It's not imagined pain; it's misinterpreted sensation that the brain turns into actual pain.

Other substances in the patient's brain amplify a host of other signals -- essentially, "turning up the volume" of everything. That can include light, noise and odor on top of pain, and it can further overload the brain. This can lead to confusion, fear, anxiety and panic attacks.

Most people with a chronic illness are always sick. The effects on the body of cancer, a virus, or a degenerative disease are fairly constant. It's understandably confusing to see someone with fibromyalgia be unable to do something on Monday, yet perfectly capable of it on Wednesday.

Look at it this way: Everyone's hormones fluctuate, and even things like weight and blood pressure can rise and fall during the course of a day, week or month. All of the systems and substances in the body work that way, rising and falling in response to different situations.

Research shows conclusively that fibromyalgia involves abnormal levels of multiple hormones and other substances. Because those things all go up and down, sometimes one or more are in the normal zone and other times they're not. The more things that are out of the zone, the worse they'll feel.

Some people think fibromyalgia patients are emotionally incapable of dealing with stress, because a stressful situation will generally make symptoms worse.

The important thing to understand is that we respond to stress both emotionally and physically. A physical response, in everyone, includes a rush of adrenaline and other hormones that help kick your body into overdrive so you can deal with what's happening.

People with fibromyalgia don't have enough of those hormones, which makes stress very hard on their bodies and can trigger symptoms.

Also, when we talk about "stress" we usually mean the emotional kind, which can come from your job, a busy schedule, or personal conflict. A lot of things actually cause physical stress, such as illness, lack of sleep, nutritional deficiencies and injuries. Physical stress can have the same effect as emotional stress.


Think of a time when you were not just tired, but really exhausted. Maybe you were up all night studying for a test. Maybe you were up multiple times to feed a baby or take care of a sick child. Maybe it was the flu or strep throat.

Imagine being exhausted like that all day while you're trying to work, take care of kids, clean the house, cook dinner, etc. For most people, one or two good night's sleep would take that feeling away.

With fibromyalgia, though, comes sleep disorders that make a good night's sleep a rarity. A person with fibromyalgia can have anywhere from one to all of the following sleep disorders:

Insomnia (difficulty getting to sleep or staying asleep)
Inability to reach or stay in a deep sleep
Sleep apnea (breathing disturbances that can wake the person repeatedly)
Restless leg syndrome (twitching, jerking limbs that make it hard to sleep)
Periodic limb movement disorder (rhythmic, involuntary muscle contractions that prevent deep sleep)
Fibromyalgia In a Nutshell

A lot of illnesses involve one part of the body, or one system. Fibromyalgia, however, involves the entire body and throws all kinds of things out of whack. As bizarre and confusing as the varied symptoms may be, they're tied to very real physical causes.

Fibromyalgia can take someone who is educated, ambitious, hardworking and tireless, and rob them of their ability to work, clean house, exercise, think clearly and ever feel awake or healthy.

It's NOT psychological "burn out" or depression.
It's NOT laziness.
It's NOT whining or malingering.
It IS the result of widespread dysfunction in the body and the brain that's hard to understand, difficult to treat, and, so far, impossible to cure.
The hardest thing for patients, however, is having to live with it. Having the support and understanding of people in their lives can make it a lot easier.

This was an article from http://chronicfatigue.about.com/od/whatisfibromyalgia/a/understandfibro.htm?nl=1

Great website, highly recommend it!!!

Maybe

Have you ever wanted to hid the fact that you're sick? To mask the pain and fatigue and everything else and just pretend that you aren't chronically ill? I had a friend who asked me why I air my dirty laundry almost immediately after knowing someone. My response? When they know you're sick and have ptsd among other issues they know what they're getting into, and many leave... but at least I know that the ones who stay are for real.

I worry a lot about the future and what my life will be life. I could probably go my whole life having friends, family, even a spouse not know that I"m sick. I could do it. But would I want to? Some people say I talk about it too much, that I tell people too freely, but it's there, it's a part of my life. it's a large part actually. So what do I do? Do I screen potential dates by telling them early on? Do I only date other "sickos" people who are suffered like me? Or do I crawl into the "im sick" hole and die to relationships? I say screw everyone. I'm going to tell everyone and anyone and get people to stand up and listen for once, listen and hear about this terrible affliction that affects so many people. And many I'll find someone to stand up for me by my side.... maybe

Aching and whining

The hardest thing lately for me has been the aching pain. The kind that leaves you drained and yet you can't crawl into bed because even laying down is painful. What I'd give for a back massage right now or something to take my mind off of the pain. It's also really hard knowing that I wouldn't be in pain right now if I hadn't received bad news about mum and dad. For people who don't believe that I'm sick they sure help contribute to it

Poem from a Flare 2 Years Ago

I'm tired. Of everything really. I'm tired of the pain,
the emotional, the physical, the fog inside my brain.
I'm tired of hurting others and being hurt in return.
I'm tired of being tired, to live with this I'll never learn.
I'm tired of the nausea, the pain makes me green.
I'm tired of looking sickly, am I the sickest you've ever seen?
I'm tired of avoiding people I'm scared they won't understand.
I'm tired of always having to change, I'm tired of losing my plans.
Of having to change my hopes and dreams
Cause of course it's not God's will,
but he's my father, brother, he's my all,
and he's helping me up this hill.
I'm tired of the medications that cause bitter agony.
I'm tired of all the rules. I'm tired of wishing to be free.
I'm tired of changing who I am to suit a life I hate.
I'm tired of looking in the mirror seeing what this pain creates.
I'm a sickly weakened child who cries out in the dark.
who can't seem to keep up with you. This illness left it's mark.
And I guess I'm just tired of trying, I'm tried of trying to smile.
And I'm tired of doing it all alone, lonely all the while.

Feeling a Flare

I"m a member of the website Patientslikeme.com and a girl posted the other day a list of symptoms showing you are heading into a flare and I thought i'd share with everyone. everything in bold i'm having issues with right now... Guess who is in a flare? that'd be me.

A Fibromyalgia FLARE is a period of time when your Fibro symptoms are increased or out of control. It could last for less than an hour, or for months on end.

Flares happen if you are not on correct treatment, if you don't have your treatment adjusted at the moment, or you encounter something that throws your treatment off.

Signs of a Flare or an Approaching Flare:
Your muscles may become unreliable, you may drop things.
You may also notice muscle weakness such as when pouring liquids, turning a door knob, opening a can.
It may be hard for you to judge the weight of objects. This can result in apparently throwing things around.
Extremities may feel cold compared to the rest of the body.
You may have hot or cold waves through your entire body.
Your heart may palpitate.
You become stiff.
You hurt all over.
Increase in skin blemishes.
Sores in mouth or on tongue. Inflamed taste buds.
It may become difficult to feed yourself without spilling food or a drink.
Fibro Fog (inability to think clearly) may become worse
Depression due to the pain may worsen, as well as the pain itself.
You may have trouble finding and saying words.
Your judgment can be impaired.
You become extremely fatigued.
You want to lie down and sleep.
You are less able to sleep.
You may become depressed.
You may procrastinate.
You may become obsessive or compulsive.
You get a headache.
Urination becomes very frequent.
You may become incontinent, especially with urinary stress incontinence.
Your monthly cycle may be disrupted.
Your cuticles become sore.
You bruise easily
Bulged discs may cause more pain
Joints may pop and crackle, especially in your neck
You experience extreme pain from simple bumps.
You may become withdrawn, or have a panic or anxiety attack
You may suddenly want to leave where you are.
You may become nauseous.
You become very irritated, sometimes over the least things.
You suddenly begin to itch or have a burning sensation on your skin.
You may feel dizzy when changing your posture. This could happen when you get up after laying down, or it could happen every time you move your head.
Spatial disorientation, you can no longer tell where you are in relation to the world around you.
Aphasia - you may not recognize faces or places.
Your eyesight becomes dull. Your hearing may, as well.
Your eyes may become dry or burn.
You may have trouble seeing at night. Car lights may glare.
You may have trouble swallowing.
You may bump into walls or trip over things.
Perspiration may increase or decrease dramatically.
You may start clenching your teeth.
You may have symptoms of bursitis.
Sinus pressure.
Post nasal drip.
Hair loss.
Depth perception may also be off.