Fibromyalgia Case Study

Author/s

Becky Brinkworth, Lindsey Hudson, Morgan Jones, Remsing King, and Marley McGraw from the [[ http://www.physio-pedia.com/Pathophysiology_of_Complex_Patient_Problems%7CBellarmine University Physical Therapy Program's Pathophysiology of Complex Patient Problems Project.]]

Abstract

100 word limit, non-structured description

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%

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.

Summarization of Examination Findings

Working Diagnosis and Targeted Interventions

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 joints. This is also something we suggest our patient continue once she is discharged from therapy⁸. 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.

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

Findings Over time

Discussion

Summary Statement which should include related findings in the literature, potential impact on clinical practices

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