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Chronic Pain

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Therapeutic Exercise Prescription Concepts Applied to Patients Diagnosed With Fibromyalgia

Pain is defined as an “unpleasant feeling, conveyed to the brain by sensory neurons” (Medical Dictionary, 2013). Pain is a subjective interpretation, which describes location, intensity and nature of sensory information resulted from noxious stimulation of nerve endings. The emotional response and other various conscious or unconscious responses add to the concept of pain. Acute pain usually results from tissue damage and it usually ends once the injury is healed. Chronic pain is a long term condition related to a persistent or degenerative disease or it doesn’t have an identifiable cause. Although there are different opinions about when a patient can be declared as suffering from chronic pain (after six months or twelve months), the presence of such sensation after the healing period usually leads to this diagnosis. One of the diseases with a generalized chronic pain as a symptom, which continues to generate many debates in the medical world, is fibromyalgia.
Fibromyalgia, a disorder that affects the overall system and has an effect of generalized chronic pain, will be delineated in this paper, including its causes, manifestation, and part of the process of managing this disease in which a kinesiologist would have a central role.
Fibromyalgia, estimated to affect 4% of the population, is a compilation of symptoms accompanying pain, which include fatigue, stiffness and sleep disturbance, along with psychiatric conditions such as depression, anxiety or post-traumatic stress disorder. There are different opinions in the literature in regards to the placement of fibromyalgia as a mental or somatic disorder. The International Classification of the Diseases categorizes fibromyalgia as a diagnosable disease of musculoskeletal and connective tissue, as a functional somatic syndrome and not just a mental disorder as many specialists consider it.
Such syndromes as chronic pain and chronic fatigue have been in the center of literature for centuries. Fibromyalgia, a concept that incorporates the two syndromes received a lot of attention from researchers who tried to outline the epidemiology, pathophysiology and genesis of this entity.
Causes of fibromyalgia
The causes of fibromyalgia are not really known, however various hypotheses on the subject have been formulated. One hypothesis mentions central sensitization, which means that the patient has a lower threshold for pain caused by increased reactivity of pain-sensitive cells in the spinal cord or brain. Neuropathic pain and depression often accompany fibromyalgia and the reason appears to lie in the existence of genetic abnormalities. The evidence mentioned in literature suggests that pain in fibromyalgia is a result of abnormal function of pain pathways due to inflammatory processes. Also, the volume of neurones is set too high and a hyper excitability is generated in the pain processing pathways along with underactivity of inhibitory pain pathways in the brain, all resulting in the affected individual experiencing pain. A facilitated withdrawal reflex points to proof of spinal cord hypersensitivity. (Banic et al. 2003). Neurochemical abnormalities occur also in the centers that regulate mood, sleep and energy levels and this is the reason why fibromyalgia is associated with depression or fatigue.
Poor sleep habits of people diagnosed with fibromyalgia suggests that their serotonin levels are low, resulting in increased pain sensitivity.
Some researchers suggest that stress and poor physical conditioning contribute to development of fibromyalgia. All these mechanisms are part of an array of theories, none of which are supported by conclusive evidence.
Symptoms of fibromyalgia Fibromyalgia is diagnosed based on patient experience of stiffness and muscle pain, as there are no measurable findings on X-rays or most lab tests. However, high levels of protein in the bloodstream, as measured in one test, can help confirm a fibromyalgia diagnostic. While this disorder doesn’t cause any damage in the joints, the constant aches, fatigue, problems with sleep and often depression, can have a deep impact on an individual’s life. A unique symptom associated with fibromyalgia is the presence of tender points. When pressed, these points become painful, whereas a healthy individual would feel only pressure. Pain, as a main symptom of this disease, is now recognized by the medical community to be real and not only in patient’s head, as has been believed. The segment of the population that is mainly affected by this disorder is comprised of middle aged women. It is suggested that genetics might have a role, although no gene was identified as being responsible. (Chang, 2011) One of the debilitating effects of fibromyalgia is pain accompanied by fatigue. The patient can be exhausted right from the beginning of the day. Both symptoms interfere with daily life activities. The patient also may have trouble sleeping with often episodes of awakening during the night, which causes insufficient recovery not giving the body a chance to replenish its reserves. Depression is often seen in patients with fibromyalgia and it is believed to be a cause of modified chemistry within the brain and generates difficulties with concentration, hopelessness and loss of interest in favourite activities.
Management of fibromyalgia The goal of the treatment for this disease is to minimize pain, sleep disturbances and mood disorders. One of the methods used is medication, which includes over the counter pain relievers or prescription drugs such as Cymbalta, Lyrica and Savella. Another path taken in treating this condition is exercise. Exercise is a very delicate way of treating fibromyalgia because the dosage is of paramount importance: lack of exercise could lead to an increased intensity of symptoms and a high volume of physical exercise could generate the same effect. Individuals, who suffer with fibromyalgia, although anxious about exercise, can safely participate in regular, appropriate physical activity. (Books, 2000)
Howard Smith, a specialist in pain medicine, states that when one is engaged in consistent exercise such as cardiovascular activity, strengthening and flexibility will likely improve the quality of life by reducing pain and increasing fitness level.
In the past twenty-five years there has been a lot of interest manifested in literature about the importance of exercise in fibromyalgia management. In addition to aerobic and strength training, researchers have been supporting such activities as tai chi, yoga, Nordic walking and vibration technique. The intensity, duration and frequency should be prescribed according to the individual’s reaction in order to avoid worsening of the symptoms. It was found in research that the ideal intensity would be around fifty to sixty percent of the heart rate. The repetitive movements aim to improve function and some components of physical fitness. Exercise is a subset of physical activity, the latter implying bodily movements with less structure and planning. Several studies are mentioned in the literature which demonstrated that patients can participate in moderate to vigorous exercise. However, there is also a lot of evidence to illustrate that patients have a lot of difficulties engaging in higher intensity activity and also have hard time sustaining a regular activity due to the increased pain. In 1998 the first randomized controlled trial was initiated to study the effects of exercise in persons suffering from fibromyalgia. Since then, the number of research studies has grown significantly and aquatic and land exercise has been scrutinized in order to reveal the effect on people who are suffering from this disease.
Aerobic exercise was proved to reduce pain, fatigue, depression and improve fitness levels. Strength training and a combination of resistance training with an aerobic component with added flexibility in the mix provided large improvements in physical function. When comparing land-based exercise with aquatic exercise, it was discovered that neither form of exercise is superior. (Hauser et al. 2010).
A shortcoming of such studies lies in not giving enough consideration to the post workout effects, such as muscle stiffness and fatigue, or problems of the musculoskeletal system. These effects can cause a high drop-out rate in the randomized control trials, calling into question the results of some studies.
In general, most of the exercise programs are integrated in a bigger picture and used in conjunction with medication, educational programs, stress-management strategies, relaxation training and electromyographic feedback. This integrated approach has been proved over the years to be very effective in the case of fibromyalgia patients. Through medical imaging, the exercise at a higher intensity has been reported to be a contributor to achieving “greater responses in pain regulatory brain regions while receiving painful stimuli”. (McLoughlin et al, 2011).
Holistic, mind-body forms of exercises, such as tai chi, yoga, and Pilates are of great benefit for people with fibromyalgia. A tai chi session (warm-up, self-massage and movements) or a yoga program (five to seven times a week for 120 minutes for approximately six months) were used as models in research. Studies of the effects of tai chi after a period of three months showed a far superior health related quality of life beyond the effects of exercise and pharmacological interventions. Similar positive results were obtained in a group of women who practiced yoga for a month with a frequency of four times per week. Pilates was proved to make a difference in the first four weeks of a planned period of three months. After the initial month, the individuals from the study group showed no positive or negative difference compared to the control group. All these studies underline the fact that a mind-body, holistic approach to exercise may be the right path to take for people suffering from fibromyalgia. Other methods that involve exercise were investigated for the contribution they bring in management of fibromyalgia. Whole body vibration (Gusi et al. 2010) platform was used as a base surface for execution of movements and it was found to be a great solution to improve balance. Because it was used in combination with exercise sessions, the study couldn’t make a clear delimitation between the contributions of those two in regards to overall improvements. Nordic walking, which involves the use of poles that generate a higher activity in the upper body, was investigated by Mannerkorpi et al. As a moderate intensity exercise it brought significant improvements in the subjects who performed a pre and post six minute walk test. The moderate intensity produced a higher physiological adaptation and it was well tolerated by the individuals involved.
The downfall of recommending exercise to manage the disease is that it was observed and recorded that adherence to the program is low, because the pain and the other symptoms are preventing the affected individuals from participating on a regular basis. An effective solution to this problem was to involve the patients more often in a higher level of lifestyle activities. In three months of home-based daily activities, the experiment group increased overall physical activity and improved fibromyalgia symptoms and decreased lower back pain.
While programs that promote physical activity can produce changes that are clinically relevant, it is imperative for the future research to focus on supports to maintain increased levels of general lifestyle activities in order to improve tolerance for subsequent exercise programs and increase exercise adherence.
References
Altan L, Korkmaz N, Bingol U, Gunay B. (2009). Effect of Pilates training on people with fibromyalgia syndrome. Abstract
Banic, B., Petersen-Felix, S., Andersen, O., Radanov, B.P., Vilinger, P.M., Arendt-Nielsen, L., Curatolo, M. (2003). Evidence for spinal cord hypersensitivity in chronic pain after whiplash injury and in fibromyalgia. Journal of the International Association for the Study of Pain. Issue 1, volume 107, Jan2004

Books-Bigellow. S. (2000). Fibromyalgia: Simple relief through movement

Busch, A.J., Webber,S.C., Brachaniec, M., Bidonde, J., Dal Bello-Haas, V., Danyliw, A.D., Overend, T. J., Richards, R.S., Sawant, A., Schachter, C.L. (2011). Exercise Therapy for Fibromyalgia. DOI: 10.1007/s11916-011-0214-2
Caliw, D.J. (2007).The pathogenesis of chronic pain and fatigue syndromes, with special reference to fibromyalgia. Abstract
Chang, L. (2011). A visual guide to fibromyalgia. Retrieved from http://www.webmd.com/fibromyalgia/ss/slideshow-fibromyalgia-overview

Gusi N, Parraca J.A., Olivares P.R., Leal A, Adsuar J.C. (2010). Tilt vibratory exercise and the dynamic balance in fibromyalgia: A randomized controlled trial. Abstract

Häuser W, Klose P, Langhorst J, Moradi B, Steinbach M, Schiltenwolf M, Busch , A., (2010). Review Efficacy of different types of aerobic exercise in fibromyalgia syndrome: a systematic review and meta-analysis of randomised controlled trials. Abstract.

Jones KD, Liptan GL.(2009). Exercise interventions in fibromyalgia: clinical applications from the evidence.. doi: 10.1016/j.rdc.2009.05.004.

McLoughlin MJ, Stegner AJ, Cook DB. The relationship between physical activity and brain responses to pain in fibromyalgia. (2011). Pages 1-12.

N Engl J Med. (2010). A randomized trial of tai chi for fibromyalgia. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMoa0912611#t=articleDiscussion

Sanudo B, Hoyo M, Carrasco L (2010).The effect of 6-week exercise program and whole body vibration on strength and quality of life in women with fibromyalgia

The Free Dictionary by Farlex, Medical Dictionary (2013). Retrieved from http://medical-dictionary.thefreedictionary.com/pain
Wang C, Schmid CH, Rones R, Kalish R, Yinh J, Goldenberg DL, Lee Y, McAlindon T (2006). A randomized trial of tai chi for fibromyalgia. Abstract

Wikipedia (2014), Chronic Pain. Retrieved from http://en.wikipedia.org/wiki/Chronic_pain

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