Nursing Management of Fibromyalgia Syndrome.
Scenario: A 33-year old female presents to the clinic with complaints of widespread pain and tenderness that have persisted for the past 4 months. Additional symptoms include morning fatigue and stiffness, and difficulties with concentrating. The patient states, "I feel like my brain is in a fog," and "I feel like I am walking through quicksand on a daily basis." Even though it would be easy to diagnose this patient with fibromyalgia syndrome (FMS), other conditions should be excluded because these general symptoms are common to many diagnoses. This begins the frustration of many patients with FMS on their journey of symptom management
What Is FMS?
FMS is a nonprogressive chronic pain disorder that affects 2%-8% of the population (Clauw, 2014). Its diagnosis is generally one of exclusion and is symptom-based (Wierwille, 2012). The previous diagnostic criteria for FMS focused on chronic widespread pain with several tender spots. Because women presented with more tender spots than men, these criteria inadvertently suggested FMS was primarily a women's disorder. Newer diagnostic criteria from The American College of Rheumatology (Wolfe et al., 2010) focused more on symptoms than tender spots, possibly leading to identification of more male patients (Kodner, 2015). According to Wolfe and colleagues (2010), the newer diagnostic criteria to satisfy a diagnosis of FMS include the following:
1. Widespread pain index (WPI) 7 or higher and symptom severity (SS) scale score 5 or higher or WPI 3-6 and SS scale score 9 or higher
2. Symptoms present at a similar level for at least 3 months
3. No other disorder that would otherwise explain the pain
In addition to diffuse pain, sleep disturbances as well as mental and physical fatigue are common with FMS. Other symptoms include numbness and tingling; headache or jaw pain; and cognitive impairment, including memory problems and difficulty concentrating, identified by many sufferers as brain fog (Menzies, 2016). Associated conditions include autonomic dysfunction, swollen extremities, irritable bowel syndrome, interstitial cystitis, and premenstrual syndrome (Wolfe et al., 2010). Risk factors for FMS include family history of the disorder, depression, lifestyle choices, personality type, and traumatic experiences primarily in the earlier years of life (Wierwille, 2012).
More attention has been directed recently to the relationship of posttraumatic stress disorder (PTSD) and traumatic experiences, such as sexual abuse or rape, coexisting in many patients with FMS (Kodner, 2015). Up to 45% of patients with FMS meet the criteria for PTSD, compared to 3% of population-based control subjects (Hauser et al., 2013). Healthcare providers thus should evaluate patients with PTSD for FMS as a coexisting condition. Because FMS is a diagnosis made by exclusion, other conditions must be eliminated as a cause of FMS-like symptoms (Wierwille, 2012). Symptom overlap requires a comprehensive assessment and follow up with patients to have confidence in an FMS diagnosis.
Because FMS has no known cure, treatments include pharmacological and nonpharmacological management of symptoms. Pharmacological treatments may include antidepressants, antiepileptics, muscle relaxants, and opioids. Duloxetine (Cymbalta[R]), milnacipran (Savella[R]), and pregabalin (Lyrica[R]) are approved by the U.S. Food and Drug Administration specifically for the treatment of FMS (Kodner, 2015). Many patients would be content with simply taking a pill because of the ease of this regimen, but medications are only one part of symptom management. Nonpharmacological treatments should be considered in tandem with medications. These treatments may include aerobic exercise, acupuncture, massage, and use of psychosocial therapies such as cognitive behavioral therapy (Menzies, 2016).
Life Impact of FMS
FMS may contribute to the development of many negative behaviors that also may be seen in patients with other chronic diseases. These include social isolation because of pain and fatigue, stigmatization and lack of legitimization of their diagnosis, powerlessness in symptom improvement, and uncertainty surrounding their long-term prognosis (Lubkin & Larsen, 2013). However, compared to other patients with similar pain intensity, patients with FMS demonstrate more social and emotional responses; they may experience more anxiety and depression, have lower positive affect, and feel greater alienation from persons in their social networks (Davis & Zautra, 2013).
Because a healthcare provider cannot confirm the diagnosis of FMS by a simple laboratory test, the disorder has been dismissed summarily by some portions of the healthcare community, creating a phenomenon of believers vs. nonbelievers (Baenziger, 2016). Stigmatization of FMS as a viable diagnosis has led many affected persons to seek healthcare providers who will validate and agree to help manage their symptoms. Because of the lack of consistent treatment, the sense of hopelessness may linger for patients.
The Role of the Nurse
Due to the complex nature of FMS and possible coexisting disorders, an interprofessional approach is preferred for treatment. At the time of diagnosis, two immediate treatment goals should involve addressing and minimizing negative repercussions of pain and other stressors, and returning patients to engaging in positive social relationships despite their pain (Davis & Zautra, 2013). A long-standing commitment by healthcare professionals is needed to support physical and emotional aspects of care for patients with FMS. This creates a great opportunity for nurses to develop measurable, meaningful strategies to meet patients' needs. A great deal of the current nursing literature regarding clinical management of FMS focuses on providing patient education and support, along with nonpharmacological measures for symptom management (Menzies, 2016).
Before encountering a patient with FMS, nurses must assess their feelings and any possible biases regarding FMS. Any unrecognized biases toward FMS could affect the nurse-patient relationship (Menzies, 2016). Nurses also need to be well informed about the disease and symptom management. This knowledge will contribute to nurses' ability to establish trusting relationships with patients diagnosed with FMS. A trusting relationship is crucial because many patients may have felt abandoned in their search for treatment by many healthcare providers.
Initially, when a patient receives a diagnosis of FMS or has a preexisting diagnosis, the nurse should express validation of FMS with the patient. Validation through active listening (Jelin, Granum, & Eide, 2012) and showing empathy toward the patient's concerns can contribute to a trusting rapport. Active listening plays an important role because many patients feel isolated and misunderstood by family and friends. This rapport with patients with FMS creates greater likelihood that patients will engage in suggested non-pharmacological treatments.
Many patients with FMS have not received appropriate treatment of their symptoms and feel enslaved by them. Along with validating their symptoms, the nurse needs to encourage patients to take control of symptom management and work toward an optimal level of function. When developing interventions to meet the physical and emotional needs for patients with FMS and their families, nurses thus must stress the reasonableness of goals (Lubkin & Larsen, 2013). For example, the expectation of being pain free may be unreasonable for a patient with FMS. By establishing and meeting realistic goals, a patient may gain a sense of empowerment over symptoms.
Quality of Life Changes
The nurse can have the greatest impact on lifestyle changes to help with FMS symptom management by educating the patient about the following:
* Avoid depressants such as alcohol with the use of certain medications prescribed for FMS (e.g., muscle relaxants, opioids) because they will increase sedation.
* Proper sleep hygiene: go to bed at the same time each night, avoid daytime napping, only going to bed when sleepy (Clauw, 2014); avoid overuse of stimulates (e.g., caffeine) that may interfere with sleep.
* Develop a routine of exercise, such as tai chi or yoga (Kodner, 2015).
* Use stress management techniques, such as guided imagery or meditation (Menzies, 2016).
The nurse who decides to engage a patient with FMS about establishing an exercise regime should realize pain may hinder a patient's desire to be consistent with exercise. The nurse thus should help the patient develop a slow, incremental exercise program through which the patient can experience success. The nurse should use periodic positive reinforcement to continue to support the patient's exercise regime (Kodner, 2015).
In conjunction with active listening, the nurse can use cognitive-behavioral therapy (CBT) techniques to address a patient's feeling of powerlessness and increase the patient's symptom self-management. CBT is used to modify maladaptive thoughts (Menzies, 2016). For example, if a patient with FMS said, "My pain is so bad that there is nothing I can do about it," the nurse could help the patient reflect on that statement and discuss possible solutions. Then the nurse could suggest the patient rephrase the statement as, "No matter how bad my pain gets, there are ways that I can lessen it." If CBT can help modify maladaptive thoughts, Menzies suggested it can improve a patient's mood, perceived stress, pain coping, and problem solving.
To address the emotional aspect of a patient's family or significant other is to become engaged as an important contributor. For example, Lyons, Jones, Bennett, Hiatt, and Sayer (2013) found a disconnection in the communication between couples regarding the severity of FMS symptoms and symptom management. The nurse can serve as a bridge between the patient and family and friends. He or she can help them understand the diagnosis and identify ways to help the patient with FMS, and be available to listen to his or her personal frustrations. Borchers and Gershwin (2015) found patients with FMS were more successful with treatment and symptom management when positively supported by family and friends.
Ultimately, the nurse can offer empathy for the patient's frustrations with the complexity of managing FMS. Empathy can be expressed in simple ways, such as giving full attention to a patient and not appearing rushed, or letting him or her know it is permissible to slow the pace of life to avoid overexertion. The nurse also can express empathy and avoid being judgmental of patients who regress in their symptom management because they overextended themselves. Because some patients with FMS believe they can overcome the pain, this is not an uncommon scenario (Menzies, 2016).
Managing symptoms of FMS is complex and challenging. Nurses who have a deeper knowledge of how FMS impacts patients' lives can educate patients in self-management, facilitating a supportive environment and helping them find healthcare providers willing to offer compassionate care. Nurses must consider their own biases before interacting with patients with FMS. Nurses who use comprehensive strategies, such as listening actively, engaging the patient, validating symptoms, and remaining positive, will have a greater impact on patients' symptom management and create the overall sense of well-being desired by many patients with FMS (Menzies, 2016).
Baenziger, N.L. (2016). Painful reality: Inappropriate provider management of pain as a determinant of health care avoidance. Creative Nursing, 22(3), 151-160. doi:10.1891/1078-45184.108.40.206
Borchers, A.T., & Gershwin, M.E. (2015). Fibromyalgia: A critical and comprehensive review. Clinical Reviews in Allergy & Immunology, 49(2), 100-151. doi:10.1007/s12016-015-8509-4
Clauw, D.J. (2014). Fibromyalgia: A clinical review. Journal of the American Medical Association, 311(15), 1547-1555. doi:10.1001/jama. 2014.3266
Davis, M.C., & Zautra, A.J. (2013). An online mindfulness intervention targeting socioemotional regulation in fibromyalgia: Results of a randomized controlled trial. Annals of Behavioral Medicine, 46(3), 273-284. doi:10.1007/s12160-013-9513-7
Hauser, W., Galek, A., Erbsloh-Moller, B., Kollner, V., Kuhn-Becker, H., Langhorst, J.....Glaesmer, H. (2013). Posttraumatic stress disorder in fibromyalgia syndrome: Prevalence, temporal relationship between posttraumatic stress and fibromyalgia symptoms, and impact on clinical outcome. Pain, 154(8), 1216-1223. doi:10.1016/ j.pain.2013.03.034
Jelin, E., Granum, V., & Eide, H. (2012). Experiences of a web-based nursing intervention--interviews with women with chronic musculoskeletal pain. Pain Management Nursing, 13(1), 2-10. doi:10.1016/j.pmn. 2011.08.008
Kodner, C. (2015). Common questions about the diagnosis and management of fibromyalgia. American Family Physician, 91(7), 472478.
Lubkin, I.M., & Larsen, P.D. (2013). Chronic illness: Impact and interventions (8th ed.). Burlington, MA: Jones & Bartlett Learning.
Lyons, K.S., Jones, K.D., Bennett, R.M., Hiatt, S.O., & Sayer, A.G. (2013). Couple perceptions of fibromyalgia symptoms: The role of communication. Pain, 154(11), 2417-2426. doi:10.1016/j.pain.2013.07.018
Menzies, V. (2016). Fibromyalgia syndrome: Current considerations in symptom management. The American Journal of Nursing, 116(1), 24-32. doi:10.1097/01 .NAJ.0000476162.13177.ae
Wierwille, L. (2012). Fibromyalgia: Diagnosing and managing a complex syndrome. Journal of the American Academy of Nurse Practitioners, 24(4), 184-192. doi:10.1111/j.1745-7599.2011.00671.x
Wolfe, F., Clauw, D.J., Fitzcharles, M.-A., Goldenberg, D.L., Katz, R.S., Mease, P., ... Yunus, M.B. (2010). The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care & Research, 62(5), 600-610. doi:10.1002/acr.20140
Katie HC Poindexter, MSN Ed, RN, is Instructor, Mary Black School of Nursing, University of South Carolina Upstate, Greenville, SC.
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|Title Annotation:||Nurses as Educators|
|Author:||Poindexter, Katie H.C.|
|Date:||Sep 1, 2017|
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