Please respond to each classmate with at least 125 words and reference.
Classmate 1:
Fibromyalgia is a condition characterized by chronic, widespread musculoskeletal pain(Boland et al., 2022). The main symptoms of this disease are muscle stiffness, joint stiffness, insomnia, fatigue, mood disorders, cognitive dysfunction, anxiety, depression, general sensitivity, and the inability to carry out normal daily activities. Local areas of tenderness are referred to as “trigger points(Bhargava & Hurley, 2022). Most often, the patient describes a history of pain spreading in all quadrants of the body for at least three months, and when pain is caused by digital pressure in at least 11 out of 18 allogenic points, it is called tender points. “According to The 1990 ACR fibromyalgia classification criteria included tenderness of at least 11 of 18 defined tender points including the suboccipital muscle insertion bilaterally, the anterior aspect of C5 to C7 intertransverse spaces, mid-upper border of trapezius, origin of supraspinatus muscle bilaterally, second costochondral junctions, 2cm distal to the lateral epicondyles, Upper outer quadrants of buttocks bilaterally, greater trochanteric prominence and the medial fat pad of the knees (Bhargava & Hurley, 2022).
Fibromyalgia can develop at any age, including childhood, although the peak age is usually mid‐life. Fibromyalgia most commonly affects women (3 percent) more than men (1 percent), particularly those of working age between the ages of 20 and 55 years(Boland et al., 2022).
Pathophysiologic mechanisms of the disorder
Fibromyalgia is often associated as hypervigilance and dysfunctions in mono-aminergic neurotransmission, leading to elevated levels of excitatory neurotransmitters like glutamate and substance P, decreased levels of diminished levels of serotonin and norepinephrine in the descending anti-nociceptive pathways in the spinal cord, prolonged enhancement of pain sensations, dysregulation of dopamine and alteration in the activity of brain endogenous opioids.
Evidenced based treatment.
Cognitive behavioral therapy is a first-line treatment for fibromyagia. CBT incorporates the idea that changing thoughts and behaviors can improve mood and functioning. CBT helps individuals develop more adaptive ways of thinking and responding to pain, thus reducing the impact of negative thinking patterns and enhancing coping strategies. Also, patient education and exercise , such as Cardiovascular fitness training are recommended for patients as they help with pain and improve sleep. Recommended optimal cardiovascular fitness training constitutes a minimum of 30 minutes of aerobic exercise three times a week with the heart rate near the target range (Arnold et al., 2016)
Pharmacotherapy:
The three drugs for the treatment of fibromyalgia approved by the US Food and Drug Administration (FDA) are pregabalin, duloxetine, and milnacipran. The antidepressants include tricyclic medications, like amitriptyline and other selective serotonin reuptake inhibitors (SSRIs) and norepinephrine reuptake inhibitors (SNRIs), including duloxetine and milnacipran. Cyclobenzaprine, a tricyclic medication, has also been found to be effective in patients with fibromyalgia (Bhargava & Hurley, 2022).
Fibromyalgia has a negative impact on the patient’s self-image and body-image perception, as well as low self-esteem and perceived self-efficacy. It reduces functioning in physical, psychological, and social spheres and also has a negative impact on cognitive performance, personal relationships (including sexuality and parenting), work, and activities of daily life. In some cases, the patient shows suicidal ideation, suicide attempts, and consummated suicide. And sometimes perceive the illness as a stigmatized and invisible disorder (Galvez-Sánchez et al., 2019)
other professionals would you consider including in the care/treatment?
A coordinated interprofessional team approach including physicians, mid-level practitioners, nursing staff, pharmacists and physical therapists will produce the best results. Other professional teams that can be involved in the treatment of fibromyalgia, especially when the patients not responding adequately to initial therapies, include consultations with rheumatologists, physiatrists, and psychiatrists (Bhargava & Hurley, 2022). The pharmacist will help in managing the patient’s medication and also educate the patient on the harms of opioids, and encourage other methods of pain control. The key is to develop a trusting relationship with the patient to maintain compliance with treatments. The nurse should encourage the patient to quit smoking and abstain from alcohol and caffeine. A dietitian should recommend healthy foods and the need to maintain a healthy weight (Bhargava & Hurley, 2022)
References
Arnold, L. M., Gebke, K. B., & Choy, E. H. S. (2016). Fibromyalgia: management strategies for primary care providers. International Journal of Clinical Practice, 70(2), 99–112. https://doi.org/10.1111/ijcp.12757Links to an external site.
Bhargava, J., & Hurley, J. A. (2022). Fibromyalgia. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK540974/
Boland, R. J., Verudin, M. L., & Ruiz, P. (2022). Kaplan and Sadock’s synopsis of psychiatry: Behavioral Sciences Clinical Psychiatry (12th ed). Wolters Kluwer. ISBN-13: 978-197145569
Galvez-Sánchez, C. M., Duschek, S., & Reyes del Paso, G. A. (2019). Psychological impact of fibromyalgia: current perspectives. Psychology Research and Behavior Management, Volume 12(12), 117–127. https://doi.org/10.2147/prbm.s178240
Classmate 2:
Describe Fibromyalgia in terms of the following parameters:
Age-appropriate, culturally responsive, comprehensive assessment.
Fibromyalgia is a chronic disorder characterized by widespread pain, tenderness throughout the body, fatigue, and sleep disturbances. While it can affect individuals of any gender and age, it is more prevalent in women and typically manifests in middle age, with an increased likelihood of occurrence with advancing age. Additionally, fibromyalgia is not limited by race or ethnicity and is often associated with rheumatic diseases, mood disorders, and conditions causing pain, including rheumatoid arthritis, lupus, osteoarthritis, and irritable bowel syndrome.
Diagnosing fibromyalgia relies primarily on a comprehensive assessment of symptoms such as widespread pain and fatigue, as there are no specific laboratory tests or imaging modalities for definitive diagnosis. A thorough diagnostic process involves obtaining a complete medical history, conducting a physical examination, and assessing pain and symptoms. This includes an inquiry into the duration and impact of symptoms on daily activities, as well as any family history of fibromyalgia or other pain-related conditions. A psychological assessment is also integral, considering the frequent co-occurrence of depression and anxiety with fibromyalgia (Berardi et al, 2023). Additionally, certain laboratory tests, such as a general metabolic panel, complete blood count (CBC), or thyroid function tests, may be utilized to rule out other conditions. Furthermore, a functional assessment is conducted to evaluate the patient’s ability to perform daily activities and assess the impact of symptoms on their quality of life. A review of the patient’s medication history is crucial to identify any potential contributors to their symptoms. Given the overlap of symptoms with various other conditions, a comprehensive assessment is essential for an accurate diagnosis and the formulation of an effective treatment plan.
Description of postulated pathophysiologic mechanisms of the disorder- these should be linked to common symptoms observed in clients who present with this illness.
In individuals with fibromyalgia, there is a noted processing issue in the brain leading to hypersensitivity to pain perception, resulting in several associated psychological issues. While the pathophysiology of fibromyalgia is not fully elucidated, various abnormalities have been observed, including elevated levels of excitatory neurotransmitters such as glutamate and substance P, reduced levels of serotonin and norepinephrine in the spinal cord’s pain pathways, prolonged enhancement of pain sensations, dysregulation of dopamine, and alterations in brain endogenous opioids. The higher prevalence of fibromyalgia in women compared to men has been attributed to higher levels of anxiety, maladaptive coping methods, altered response to pain, elevated levels of depression, and the hormonal effects of the menstrual cycle (Bhargava & Hurley, 2023).
What behaviors on the part of the client (with either condition) would lead you to believe that they may be experiencing a psychiatric emergency?
Behaviors indicating a psychiatric emergency include suicidal thoughts or behavior, uncontrolled self-injurious behaviors, violent behavior, extreme agitation, psychosis, and disorganized thinking (APA, 2022).
Develop a general treatment plan for either disorder- what evidence-based psychotherapies would you plan to include? What evidence-based psychopharmacologic approaches (if any) would be appropriate?
When managing patients with fibromyalgia, it is essential to provide informative education about the disease and its treatment modalities. This includes implementing an exercise regimen and considering pharmacological interventions for non-responsive cases. Patient education should encompass reassurance regarding the legitimacy of fibromyalgia as a disease, as well as the impact of stress and mood disturbances on exacerbating pain. Encouraging patients to adopt relaxation techniques and stress management strategies is integral to the management of fibromyalgia. Furthermore, cardiovascular fitness training, involving a minimum of 30 minutes of aerobic exercise at least three times a week, is recommended to alleviate pain and improve sleep quality. In instances where non-pharmacologic interventions fail to control the pain, medications such as tricyclic antidepressants, SSRIs, and SNRIs can be considered. Notably, the FDA has approved pregabalin, duloxetine, and milnacipran for the treatment of fibromyalgia (Bhargava & Hurley, 2023).
The comprehensive treatment plan for fibromyalgia typically encompasses cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and psychodynamic therapy. CBT aims to identify and modify thinking and behavior patterns, while ACT facilitates patients in accepting challenging thoughts and feelings and taking steps towards their goals. Evidence-based pharmacological approaches utilizing tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors (SNRIs), or anticonvulsants may also be suitable for specific individuals. Additionally, biofeedback relaxation techniques and other holistic pain management approaches are beneficial for these patients (Berardi et al., 2023). Discuss any legal/ethical issues inherent in the care of the individual with Fibromyalgia.
Legal and ethical considerations in the treatment of individuals with fibromyalgia may encompass informed consent, confidentiality, non-discrimination, and the right to adequate pain management. An ethical concern in this context is the issue of empathy. These patients are often disregarded by medical professionals due to their diverse, widespread, and persistent pain complaints. At times, their attempts to seek treatment are misconstrued as “drug seeking” behavior. It’s important for us as providers to always bear in mind that everyone’s pain threshold is different.
How would you know if the care of this client (either in an acute episode or chronic care) exceeded your clinical competence? How would you proceed with the client’s care in this case?
It is imperative for healthcare professionals to recognize their own limitations in terms of clinical competence. If it is perceived by either the professional or the client that the level of care required for a case exceeds their expertise, it is essential to refer the client to another provider. In Georgia, nurse practitioners are not permitted to practice independently; therefore, seeking advice from a supervising psychiatrist to obtain clinical expertise is recommended. If a client’s symptoms fail to improve or worsen despite interventions, or if the client presents with complex comorbidities beyond the professional’s training, it may indicate a need for referral to another practitioner. Feeling overwhelmed or anxious about how to proceed with a client’s treatment may signify the need for specialized treatment or interventions beyond the practitioner’s scope of practice. In such cases, it is important to acknowledge the situation, recognize that the client may be better served by a different practitioner, seek consultation from colleagues and supervisors, refer the client, and explain the reasons for the referral to the client.
What other professionals would you consider including in the care/treatment of this client, and why?
A multidisciplinary team approach is necessary for the care of patients with fibromyalgia. This approach should include (Bhargava & Hurley, 2023):
Primary Care Physician: The PCP is responsible for medication management, laboratory and diagnostics checking.
Rheumatologist: Rheumatologists who specialize in conditions affecting the joints and muscles often manage fibromyalgia.
Physical Therapist: Physical therapy can help improve muscle strength, flexibility, and stamina, which can help manage fibromyalgia symptoms.
Psychologist/Psychiatrist: Mental health professionals can provide cognitive-behavioral therapy and other psychological interventions to help manage stress, improve coping skills, and address any co-occurring mental health conditions like depression or anxiety.
Pain Management Specialist: These professionals can provide specialized treatments for managing chronic pain.
Dietitian: Some patients find that certain foods trigger fibromyalgia symptoms. A dietitian can help identify potential dietary triggers and develop a balanced, nutritious eating plan.
Social Worker: They can provide support with navigating the healthcare system, accessing resources, and managing the social and emotional impacts of living with a chronic condition.
Sleep Specialist: Since sleep disturbances are common in fibromyalgia, a sleep specialist can help address these issues.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). Author. ISBN-13: 978-0890425763
Berardi, G., Eble, C., Hunter, S., & Bement, M. (2023, June 1). Localized pain and fatigue during recovery from submaximal resistance exercise in people with fibromyalgia. PTJ: Physical Therapy & Rehabilitation Journal, 103(. 6), 1D. https://doi.org/10.1093/ptj/pzad033
Bhargava J, Hurley JA. Fibromyalgia. [Updated 2023 Jun 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK540974/
Siracusa, R., Paola, R., Cuzzocrea, S., & Impellizzeri, D. (2021). Fibromyalgia: Pathogenesis, mechanisms, diagnosis and treatment options update. International Journal of Molecular Sciences, 22(8), 3891. https://doi.org/10.3390/ijms22083891
Classmate 3:
Have you seen or treated a patient with fibromyalgia? What treatment was recommended or would you recommend?
The below articles discusses the assessment with graph, pharmacology, and alternative medicine to treating fibromyalgia.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7660651/Links to an external site.
Maffei M. E. (2020). Fibromyalgia: Recent Advances in Diagnosis, Classification, Pharmacotherapy and Alternative Remedies. International journal of molecular sciences, 21(21), 7877. https://doi.org/10.3390/ijms21217877