Week 4 Flashcards
It is common for patients with lupus to be referred to PT for what?
Referral/seek treatment for:
• Arthritis
• Weakness/fatigue
• Pain reduction
What is the role of PT in the education of patients with lupus?
- Skin Care, prevention of breakdown
- Limit sunlight exposure
- Energy conservation techniques: avoid excessive bed rest, because it makes the fatigue worse and ultimately leads to osteoporosis
What is the role of PT in the infection control of patients with lupus/RA?
Many of the medication that patients on lupus are on can weaken their immune system, and make them more susceptible to sustaining or acquiring infections
What are the types of ADs that we consider for patients especially those with RA?
Consider ADs for skeletal deformities that they may have, especially in the hand
Why may ROM or MMT be contraindicated in patients with RA or lupus?
Due to acute inflammation of the joints
In the RA population, atlanto-axial instability is common. What are some problems that patients will present with that will require immediate contact of the MD?
- Neuro signs
- Progressive neck pain
- Paraplegia
- Spasticity
- Hyperreflexia
- Ataxic gait
What are some interventions that may be contraindicated in patients with RA or lupus?
Vigorous mobilization or manipulation
What are the parameters for exercise recommendation for patients with RA or lupus?
• Exercise in short, frequent sessions throughout the
day versus one long session
• To avoid fatigue, alternate activities
• Stop activity when fatigue and pain begin
• Decrease the level of activity or remove the activity from
the program if pain lasts for more than 1-2 hours after the
end of the activity
What something really important to keep in mind for exercise in patients with lupus or RA?
Balance of rest and activity in order to avoid muscular and total body fatigue. It is also important to balance stretching and mobilization with protection
What are the things that we want to do during flare ups in patients with lupus/RA?
During flare ups, we want to make sure to increase rest, because the enflamed joints can be easily damaged, and have them resume exercise after the flare up subsides
What are some recommendations that we give to patients with lupus/RA?
• Change positions every 20-30 minutes throughout the
day to avoid static positioning
• Avoid high-impact sports and contact sports
• During inflammation flare ups, avoid excessive
bending and stooping
What are the benefits of aerobic exercise in patients with lupus?
- Reduce fatigue
- Increase QOL
- Improved functional testing scores
- No aggravation of symptoms
What were the exercise parameters that were given to patients with lupus in the RCT that was done in brazil?
3 x per week, 12 weeks
• Cardio 65-75% HRR
• Resistance 65-75% 1 rep max for 8 exercises
What were the outcome tools of the exercise parameters that were given to patients with lupus in the RCT that was done in brazil?
• SF-36, Beck Depression Inventory, SLE Disease Activity Index, 12 minute walk test
What were the results of the exercise parameters that were given to patients with lupus in the RCT that was done in brazil?
- Better than no exercise for improved QoL and physical function
- Cardio better than resistance for improved QoL
- Neither exercise group demonstrated a change in disease activity after 12 weeks of training
When comparing aquatic exercise and land exercise in patients with RA, what were the results of the study?
- Aquatics: 87% “much better or very much better”
* No significant differences in 10 m walk, functional scores, Qol, or pain scores
What were the results of the study that was done on patients with RA in order to use aerobic exercise and muscle strength training to improve pain and physical function?
- Short and long term land-based aerobic and strength training on aerobic capacity and muscle strength
- Limited evidence for + effect of short term water-based aerobic training
What were the results of the study that was done to look at the Effects of Person-Centered Physical Therapy on Fatigue Related Variables in Persons With Rheumatoid Arthritis?
Self care plan development with focus on balance of
physical and life activities resulted in:
• Reduced general fatigue
• Less anxiety
What are the common signs and symptoms around chronic pain syndromes: myofascial pain syndrome (MPS aka chronic myofascial pain, [CMP]), Fibromyalgia (FMS), and chronic fatigue syndrome (CFS)?
• Chronic, widespread pain
• Often accompanied by fatigue, sleep, memory, and mood disturbances
• May represent a central pain syndrome
- Does not r/o peripheral nociceptive input or neuropathic contributions
- Makes id of pain source less clear & thus leads to treatment difficulties
Chronic pain syndrome diagnoses often overlap and are associated with ____
Chronic pain syndrome diagnoses often overlap and are associated with anxiety and depression
What is nociceptive pain?
Pain related to damage of somatic or visceral tissue, due to trauma or inflammation
What type of pain presentation is considered to be nociceptive pain?
Acute pain
What is neuropathic pain?
Pain related to damage of peripheral or central nerves
What is centralized pain?
Pain without identifiable nerve or tissue damage, thought to result from persistent neuronal dysregulation
What are the key characteristics of acute pain?
It is a 1st time event
What are the key characteristics of recurrent pain?
- Relapsing/remitting
- Episodic vs constant
What are the key characteristics of chronic pain?
- Neural adaptation
- Sympathetic alterations
- Biopsychosocial consequences
What kind of pain is myofascial pain syndrome?
Recurrent pain
What kind of pain is fibromyalgia and chronic pain syndrome?
Chronic pain
What is hyperalgesia?
Increased pain response to a normally painful stimulus, which results from damaged peripheral pain fibers
What is primary hyperalgesia?
Pain which occurs in the injured tissue as a result of sensitization of peripheral nociceptors
What is secondary hyperalgesia?
Pain which occurs in adjacent non-injured tissues owing to sensitization within the CNS
What is apathic transmission?
The expansion of receptor fields of injured nerves
What is allodynia?
Painful response to a normally innocuous stimulus. Can be mechanical or thermal
What is mechanical allodynia?
Pain in response to light touch
What is neuropathia?
Pain caused by a lesion or disease of the somatosensory nervous system
What are the clinical characteristics of neuropathia?
- Sensory deficits, such as numbness, tingling, and prickling
- Motor deficits such as neurological weakness at the motor nerves involved
What is hypersensitivity?
Pain evoked by allodynia or painful stimulation
Distal radiation is often common and is can be accompanied by autonomic signs, such as ___
Distal radiation is often common and is can be accompanied by autonomic signs, such as *color change, temperature changes, sweating, and swelling**
What is sympathetically maintained pain?
Pain that is enhanced or maintained by a functional abnormality of the SNS
What is windup?
Progressive increase in the frequency and magnitude of firing of dorsal horn neurons produced by the repetitive activation of C fibers above a critical threshold, leading to a perceived increase in pain intensity/sensitivity
Myofascial pain syndrome, which is now known as Chronic myofascial pain (CMP), is characterized by what?
- Pain caused by fascial constrictions and multiple regional trigger points
- Non-symmetrical pain pattern
- May be in response to tissue injury
- Possible progression to FMS or CFS with chronicity and central sensitization without proper treatment
The mechanism of development for myofascial pain syndrome is based on persistent load from…?
- Low-level muscle contractions
- Uneven intramuscular pressure distribution
- Direct trauma
- Unaccustomed eccentric contractions, eccentric contractions in unconditioned muscle
- Maximal or submaximal concentric contractions
What is the hallmark symptom of myofascial pain syndrome?
The development of persistent skeletal muscle nociceptor activity, known as trigger points
What is a trigger point?
Taut, palpable bands
What are the characteristics of trigger points?
• Pain with palpation
• Can be active or latent
• Active: gives “jump sign” on palpation
• Latent: nodular/taut band w/o pain on palpation
• Secondary: hyperirritable point that becomes active as
muscular overactivity in another muscle occurs
• Possible non-radicular, referred pain w/consequences
What is an active trigger point?
It serves as the cause of the clinical pain symptom, and the illicited referred pain is responsible for the patient’s complaints
What does a latent trigger point do?
Even though it may not be an immediate source of pain, they can illicit referred pain with mechanical stimulation or muscle contraction
What is a secondary trigger point?
Hyperirritable point that becomes active as muscular overactivity in another muscle occurs
What is the initial change in the muscle that is associated with myofascial pain syndrome?
The development of the taut band
What is the pathophysiology of myofascial pain syndrome?
- Abnormal ACh release, which leads to
- Increased tension in muscle fiber which leads to
- Blood flow constriction and hypoxia, which leads to
- Disrupted mitochondrial metabolism, which leads to
- Release of sensitizing substances, which by the activation of nociceptors leads to
- Pain and tenderness, and autonomic modulation that then starts the process over again
What are the more specific details to the pathophysiology of myofascial pain syndrome that was added by Gerwin?
The SNS activity augments ACh release, and local hypoperfusion caused by the muscle contraction of the taut band, result in muscle ischemia or hypoxia, leading to an acidification of the pH. The prolonged ischemia also leads to muscle injury, resulting in the release of potassium, bradykines, cytokines, ATP, and substance P, which might stimulate nociceptors in the muscle. The end result is the tenderness and pain observed in trigger points
What are the components of the diagnostic criteria of myofascial pain syndrome?
- Taut band within muscle
- Exquisite tenderness at point on the taut band
- Reproduction of the patient’s pain
- Local twitch response
- Referred pain
- Weakness
- Restricted ROM
- Autonomic signs (skin warmth or erythema, tearing, piloerection)
What parts of the diagnostic criteria of myofascial pain syndrome is essential for the diagnosis?
- Taut band within muscle
- Exquisite tenderness at point on the taut band
- Reproduction of the patient’s pain
What are the mechanical perpetuating factors of myofascial pain syndrome?
- Scoliosis
- Leg length discrepancies
- Joint hypermobility
- Muscle overuse
What are the psychosocial perpetuating factors of myofascial pain syndrome?
- Stress
* Anxiety
What are the systemic/metabolic perpetuating factors of myofascial pain syndrome?
- Hypothyroidism
- Iron insufficiency
- Vitamin D, C, or B12 deficiency
What are the other perpetuating factors of myofascial pain syndrome?
• Infectious disease • Parasitic disease (e.g. Lyme disease • Polymyalgia rheumatica • Use of statin- class drugs
What are the medical management options for the treatment of myofascial pain syndrome?
- NSAIDS alone have limited effectiveness (injected may help)
- Muscle relaxants not effective (TrPs NOT a spasm)
When treated as a primary diagnosis, what are the non invasive management methods for the treatment of myofascial pain syndrome?
• Ultrasound therapy • TENS • Stretching techniques (e.g., spray and stretch) • Post-isometric relaxation • Trigger point pressure release • Massage
When treated as a primary diagnosis, what are the invasive management methods for the treatment of myofascial pain syndrome?
• Dry needling
• Anesthetic injections (lidocaine), an anti-inflammatory may be used alongside this
• Botulin toxin A injection (for
those resistant to conventional rx)
What are the components of the multimodal protocols that show good results in the PT management of myofascial pain syndrome?
- Combo of myofascial trigger point dry needling, spray & stretching, kinesio-taping, eccentric exercise, & pt. education
- Low visits stretched out over longer duration (i.e., 5 visits over 4 weeks)
- Some significant results seen within one rx in some studies
What are the perpetuating factors of myofascial pain syndrome that a PT may be able to correct?
- Abnormal posture
- Incorrect muscle activity or movement patterns
- Anatomical defect correction (i.e., leg length)
- Sleep hygiene
What is fibromyalgia?
A generalized soft tissue syndrome of central sensitivity that is caused by limbic and/or
neuroendocrine dysfunction
Why is fibromyalgia considered systemic?
It involves biochemical, neuroendocrine, & physiologic abnormalities
What does fibromyalgia lead to?
Disorder of pain processing and perception (allodynia, hyperalgesia)
What is the hallmark symptom of fibromyalgia?
Tender points
True or False
Patients with fibromyalgia experience heightened/augmented sensitivity to pain and other stimuli (sounds, smells, heat)
True, Patients with fibromyalgia experience heightened/augmented sensitivity to pain and other stimuli (sounds, smells, heat)
What are the usual tender points of fibromyalgia?
- Occiput
- Trapezius
- Supraspinatus
- Gluteal
- Greater trochanter
- Knee
- Lateral epicondyle
- Second rib
- Low cervical anterior aspects
What is the clinical presentation of fibromyalgia?
- Widespread chronic, unrelenting pain
- Fatigue
- Insomnia
- Impaired thought processes
- Altered sensation
- Poor physical function and balance
- Oral and ocular problems
- Headache
- Sexual dysfunction
- Psychological effects
What does the clinical diagnosis of fibromyalgia require?
- Widespread pain at least 3 months
- Presence of all of the following:
- Pain on bilateral side of body
- Pain above and below the waist
- 11 out of 18 tender sites
What are some common overlapping symptoms that occur between fibromyalgia and myofascial pain syndrome?
- Mild to severe soft tissue pain
- Headaches, migraines
- Disturbed sleep
- Balance problems/dizziness
- Tinnitus
- Memory Problems
- Unexplained swelling
- Worsening symptoms from stress, changes/extremes in weather, physical activity
What are the differentiating symptoms of fibromyalgia and myofascial pain syndrome?
- Tender points in FMS not the same as MPS TrPs
- MPS, pain generally confined to TrPs, but may refer
- FMS, pain widespread & around tender points and DOES not refer
- MPS TrPs can be eliminated
- FMS can be a progression from MPS
Even though the pathophysiology of fibromyalgia is still being debated, what are some aspect of it that has been agreed on?
- Low levels of serotonin
- Increase in substance P up to 3 folds
- Elevated levels of nerve growth factor
- Dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis which is a critical component of stress-adaptation response, and normally secretes hormones in circadian fashion but this doesn’t happen in fibromyalgia, so plasma cortisol levels remain elevated
- Central sensitization phenomena, which explains the majority of symptoms
The elevated cortisol levels found in fibromyalgia leads to.?
Weight gain, decreased mental concentration, and decreased energy levels
What does the deficiency of serotonin found in cases of fibromyalgia lead to?
Leads to sleep disturbances, and since the growth hormone is secreted during sleep, there is a decrease in growth hormone secretion, which then affects body composition, blood lipids, muscle strength, bone composition, exercise capacity and energy, cardiovascular risk, and physiological/psychological well being
How does the central sensitization in fibromyalgia occur?
By both central processes and the hypersensitization of the peripheral processes
What are the co-morbidities that accompany fibromyalgia?
• Sleep disturbances/apnea • Depression • Anxiety • PTSD • May need labs to rule out other conditions. Labs include: CBC, ESR, basic chemistry (BUN, creatine, hepatic enzymes, serum calcium), thyroid levels & Rheumatoid factor
The pharmacological management of fibromyalgia include medications that work at the neurotransmitter receptor level, in the pre or post synaptic uptake action, to do what?
The pharmacological management of fibromyalgia include medications that work at the neurotransmitter receptor level, in the pre or post synaptic uptake action, alter the concentration of the targeted neurotransmitters known to contribute to the areas of fibromyalgia
What types of medication is used in the reduction of peripheral deep tissue pain as seen in fibromyalgia?
Local anesthetics
What are anti-epileptics, and antidepressants used for in the treatment of fibromyalgia?
Improvement or prevention of central sensitization/ pain
What are GABA agonists used for in the treatment of fibromyalgia?
Normalization of sleep abnormalities. The medications used include ambien and lunesta, which can have a morning hangover effect and contribute to existing concentration difficulties
What are antidepressants used for in the treatment of fibromyalgia?
Treatment of negative affect, particularly depression
What are the best anti depressants active at the neurotransmitter level that are used in the management of fibromyalgia?
- Tricyclic anti depressants (TCAs) such as amatrypline, or psychlobenzopine
- Selective noradrenergic re-uptake inhibitors such as effexor, cymbalta, and savella
- SSRIs are not as effective, but include prozac, zoloft, celexar and paxil
What is the effect of tricyclic anti depressants in the treatment of fibromyalgia?
They increase the extra cellular levels cellular levels of serotonin and norepinephrine by inhibiting the re-uptake into the pre-synaptic terminals. These are given in a low dose and at bedtime, due to the adverse effects of drowsiness
What is the effect of selective noradrenergic re-uptake inhibitors in the treatment of fibromyalgia?
They inhibit serotonin and norepinephrine re-uptake, but they have less interaction with other receptors. They allow decreased adverse effects and enhanced tolerability. Its adverse effects include insomnia, dry mouth, constipation, and very serious discontinuation symptoms
What are the PT goals of treating a patient with fibromyalgia?
- Improve physical fitness and function
- Reduce fibromyalgia symptoms
- Optimize overall health and well-being
- Minimize effect of illness and injury on fibromyalgia symptoms
What are the considerations to recognize when treating a patient with fibromyalgia?
• Sedentary lifestyle & general deconditioning assoc. w/fibromyalgia increases
risk of chronic disease
• So, in reverse, fibromyalgia may be present in those with multiple chronic diseases!
• Greater levels of fibromyalgia symptoms assoc. w/lower aerobic fitness (but then some athletes have dx, so don’t assume!)
• Fibromyalgia in the setting of minor injuries or illnesses may sustain process of central sensitization or the patient may feel the pain more than they should
• Optimal benefits & long-term exercise adherence require care to avert exercise-related pain & fatigue and musculoskeletal injury
• Narrow therapeutic window – too little exercise = no benefits; too much = exacerbations
What are the areas that requires PT intervention when treating patients with fibromyalgia?
- Education #1!!!
- Self-efficacy: having or gaining the confidence to complete a task
- Trusting therapeutic relationship
- Stress mgmt.
- Activity mgmt
What are the characteristics of the effective method of the intervention of PT in the treatment of fibromyalgia?
Multi-modal & multidisciplinary approach
• Studies show good results with combination programs of aerobic, strengthening, and flexibility exercises
• Aquatics, however, Hauser et al (2010) shows no significant effects of land-based vs water-based aerobic activities
• Alternative therapies including Tai Chi, Nordic Walking, Relaxation & visualization, and Pilates.
• Activity continuation should be encouraged after formal therapy discharge. May consider “increased home-based daily physical activity” (pedometer step counts)
What is the best approach to the management of a patient with fibromyalgia?
“Start low, go slow” approach
What are the components of the “Start low, go slow” approach used for the management of fibromyalgia?
- Gradual progression from low-intensity to goal of at least moderate intensity
- Start just below capacity & gradual increase until at low to moderate intensity 20-30 min, 2-3x/wk
- HR not specific, just be “able to speak fluently with another person”
- Duration of at least 4 weeks
- Strengthening: start at lower resistance levels that age-predicted norms
- Reduce intensity and duration when significant post-exertion pain/fatigue experienced
- Intensity increased by 10% after 2 weeks w/o exacerbation
What is chronic fatigue syndrome?
Debilitating and complex disorder characterized by
• Intense fatigue not improved by bed rest and may be worsened by physical activity/mental exertion
• Substantially lower level of function that prior to illness
• May have flu-like symptoms at onset with progression to muscle pain & forgetfulness
• Often w/disturbance in autonomic regulation of BP & HR (lowered)
• Differing severity from person to person
• May be cyclical, alternative between wellness & illness
• Hallmarked by post-exertional malaise
• Multitude of immune and neurological symptoms
What are the symptoms shared by chronic fatigue syndrome and fibromyalgia?
- Both considered chronic pain syndrome
- Fatigue, sleep difficulties
- Stiffness
- anxiety/depression
- Frequent headache
- Sensitivity to light
- Cognitive issues
- Exertional malaise
What are the differences between chronic fatigue syndrome and fibromyalgia?
- Pain is dominant symptom for FMS; FATIGUE is dominant symptom in CFS
- FMS may be triggered by trauma; CFS may be proceeded by flu-like or infectious illness
What is the pathophysiology of chronic fatigue syndrome?
- Mostly unknown etiology
- No biomedical tests for diagnosis; must be a clinical dx & one of exclusion
- Some evidence points to infectious disease causes and there may be some significant immunological dysfunction involved
- Some have associated it with the microbiotic gut brain axis as well.
What are common pathological processes between FMS & CFS?
- HPA suppression
- Autonomic dysfunction
- Disturbed stage 4 sleep
- Decreased serotonin/suppression of growth hormone
What are the pathological processes that are not common between FMS & CFS?
- Substance P elevated in FMS but NOT CFS
* Greater exercise intolerance in CFS
What is the diagnostic criteria used for chronic fatigue syndrome?
Requires the presence of profound fatigue defined as follows:
- Symptom duration of >/= 6 months
- Causes a substantial reduction in occupational, personal, social, or educational activities
- Unrelieved with rest
- Other medical or psychiatric conditions excluded.
Also requires 4 or more of the following features:
- Post-exertion malaise lasting > 24hrs
- Impaired memory or concentration
- Non-refreshing sleep
- Pain in multiple joints without signs of inflammation
- Headaches of new type of severity
- Sore throat
- Tender cervical or axillary lymph nodes
What does the medical management of chronic fatigue syndrome focus on?
- Focus on symptom relief, improved function, & sleep disturbance
- No specific approved drug therapies
- Many similar meds as used for FMS with similar rationale
What are the characteristics of the meds used for chronic fatigue syndrome?
- NSAIDS may be more beneficial for CFS
- Anti-depressants, which are more for the association between depression and CFS and assistance with sleep difficulties
- SSRI/SNRIs may help with neuropathic pain assoc. w/CFS but do not address immune system dysregulation
What are the PT intervention parameters used for the treatment of chronic fatigue syndrome?
- Education #1!!!
- Self-efficacy
- Trusting therapeutic relationship
- Stress mgmt.
- Activity mgmt./ pacing
Patients that don’t understand the mechanisms associated with pain and fatigue typically consider pain to be more threatening. What does this result in?
- Low pain tolerance
- More catastrophic thoughts
- Less adaptive coping strategies
What are some things that patients with chronic fatigue syndrome often report that may diminish PT adherence and efficacy?
- Maladaptive thoughts
- Kinesiophobia
- Maladaptive coping strategies
Chronic fatigue syndrome has a specific PT intervention which is highlighted in the concept of ____
Chronic fatigue syndrome has a specific PT intervention which is highlighted in the concept of Graded Exercise Therapy (GET)
What are the characteristics of the Graded Exercise Therapy (GET) as it relates to the treatment of chronic fatigue syndrome?
- Shows the best clinical evidence in combination w/strategies of pacing self-mgmt. to promote energy conservation & rest
- Uses the physical stress theory to help pt develop level of tissue stress corresponding to symptom and functional maintenance
Once maintenance achieved, physical stress applied that improves stress tolerance, which includes what?
- Avoidance of excessive use of aerobic activities at first
- Begins w/short duration exercises at intensities below anaerobic thresholds
- Once no symptom exacerbation, progress to graded aerobic exercise
Why must exercise progression in patients with chronic fatigue syndrome be slow?
Exercise capacity varies greatly & post-exertional malaise may be delayed
What are the things that must be taken into account for the Graded Exercise Therapy (GET) in patients with chronic fatigue syndrome?
- Functional activities & ADL’s must be taken into account for GET
- Best outcomes when combined w/cognitive-based therapies
According to the European Journal of Clinical Investigation Exercise Guidelines for Patients with CFS, what are the components of exercise in patients with CFS?
- Time or symptom contigent
- Home exercise
- Number of sessions, session length, and duration of treatment
- Exercise modality
True or False
The time contingent approach to exercise therapy for patients with chronic fatigue syndrome is superior over symptom contingencies
True, the time contingent approach to exercise therapy for patients with chronic fatigue syndrome is superior over symptom contingencies
What should be the exercise frequency for patients with CFS, according to the European Journal of Clinical Investigation Exercise Guidelines for Patients with CFS?
10-11 sessions spread over a period of 4-5 months, excluding the exercise sessions at home
What are the parameters for home exercises for patients with CFS, according to the European Journal of Clinical Investigation Exercise Guidelines for Patients with CFS?
5 times/ week with an initial duration of 5 to 15 mins per session, gradually increased up to 30 mins
What are the exercise modalities to use or patients with CFS, according to the European Journal of Clinical Investigation Exercise Guidelines for Patients with CFS?
Aerobic (walking, swimming, or cycling)
