Chronic Pain, Fibromyalgia, & CAM Lecture Review

Objectives

• Compare and contrast the pathophysiology, clinical manifestations, and medical/nursing management of clients experiencing complex alterations in comfort, specifically Fibromyalgia.

• Examine risk factors and complications associated with fibromyalgia across the lifespan and nursing care directed at improving health, wellness, and decreasing illness.

• Compare and contrast various assessments, diagnostics, medications, treatments, and procedures used to manage fibromyalgia, including complementary and alternative therapies for chronic pain.

• Apply the nursing process as a framework to provide age-appropriate, culturally sensitive care for clients experiencing disorders of comfort.

• Plan, prioritize, and implement evidence-based nursing care for clients with disorders of comfort, including teaching strategies for client/research and best practices.

• Explore alternative therapies used in the treatment of clients with disorders of comfort.

• Evaluate patient and family use of alternative therapies to determine safety and the need for patient or family education.

Pre-Class Reading

• Potter (11th ed): Chapter 44 - Pain

• Adams (6th ed.): Chapter 10

• Lewis (12th ed): pp. 1725-1726, pp. 93-104, pp. 138-145

• Potter (11th ed): Chapter 32

Pain: Definitions and Types

• Definition: An unpleasant sensory and emotional experience associated with actual or potential tissue damage. The most reliable indication of pain is self-report.

• Types of Pain:

  • Acute Pain:

    • Unpleasant sensory and emotional experience associated with tissue damage that results from acute injury, disease, or surgery.

    • Has short duration.

    • Usually has a well-defined cause.

    • Decreases with healing.

    • Is reversible.

    • Ranges from mild to severe intensity.

    • May be accompanied by anxiety and restlessness.

    • Manifestations reflect sympathetic nervous system activation (e.g., increased heart rate $(\uparrow \text{HR})$, increased respiratory rate $(\uparrow \text{RR})$, increased blood pressure $(\uparrow \text{BP})$).

  • Breakthrough Pain: Additional pain that "breaks through" the pain being managed by the mainstay analgesic drugs.

  • Nociceptive Pain: The result of actual or potential tissue damage or inflammation, often categorized as somatic or visceral.

  • Persistent Pain (AKA Chronic Pain):

    • Pain that persists or recurs for an indefinite period—usually more than $3$ months.

    • Often involves deep body structures.

    • Is poorly localized and difficult to describe.

    • Lasts longer than several months (usually longer than $3$).

    • May or may not have a well-defined cause.

    • Begins gradually and persists.

    • Is exhausting and useless.

    • Ranges from mild to severe intensity.

    • May be accompanied by depression and fatigue, as well as decreased functional ability.

    • Predominantly behavioral manifestations (e.g., flat affect, altered activity, fatigue, withdrawal).

Pain Assessment: PQRST

• PQRST is a common mnemonic used for pain assessment.

Fibromyalgia

• Definition:

  • A chronic pain syndrome, not an inflammatory disease.

  • Common in women aged $30-50$ years.

• Precipitating Factors:

  • Chronic Fatigue Syndrome

  • Lyme disease

  • Trauma

  • Flu-like illness

  • Deep sleep deprivation

• Pathophysiology:

  • The true cause is not known.

  • Thought to be multifactorial with "abnormal cortical processing, reductions in inhibitory pain modulatory mechanisms, and molecular changes to the pain pathway" (Gyorfi et al., 2022).

  • Meaning: The problem might be a result of overactive nerves in the central nervous system (CNS), which can cause a more intense response to pain.

• Symptoms:

  • Pain, stiffness, and soreness of muscles, tendons, and joints/trigger points.

  • Fatigue.

  • Numbness/tingling of extremities (paresthesia).

  • Sensitivities to odors, lights, sounds.

  • Headaches, jaw pain.

  • GI Issues: Abdominal pain, diarrhea, constipation, heartburn.

  • GU Issues: Dysuria, frequency, urgency, pelvic pain.

  • Cardiovascular: Dyspnea, chest pain, dysrhythmias.

  • Visual: Blurred vision, dry eyes.

  • Neurological: Forgetfulness, concentration problems (brain fog, fibro fog).

• Pneumonic - PAIN MISTED:

  • Pain (wide-spread)

  • Altered sleep (insomnia, unrefreshing sleep)

  • Irritable bowel syndrome

  • Numbness and tingling (paresthesia)

  • Memory problems (brain fog, fibro fog)

  • Irritability

  • Stiffness (especially in the morning)

  • Tender points

  • Exhaustion (fatigue)

  • Depression (or anxiety)

• Trigger Points: Specific anatomical locations where pressure elicits pain. The pain is often described as burning or gnawing.

  • Occiput: Suboccipital muscle insertions.

  • Trapezius: Midpoint of the upper border.

  • Supraspinatus: Above the medial border of the scapular spine.

  • Gluteal: Upper outer quadrants of buttocks.

  • Low cervical: Anterior aspects of the intertransverse spaces at C5-C7.

  • Second rib: Second costochondral junctions.

  • Lateral epicondyle: $2$ cm distal to the epicondyles.

  • Greater trochanter: Posterior to the trochanteric prominence.

  • Knee: Medial fat pad proximal to the joint line.

• Diagnosis:

  • No specific test to diagnose fibromyalgia.

  • Requires a long-term diagnosis.

  • There is a genetic component.

  • New Diagnosis Criteria:

    • Pain for >3 months.

    • Additional symptoms.

    • No other underlying medical condition.

• Nursing Management:

  • Integrated therapy combining pharmacological and complementary medicine.

  • Self-care strategies: Limit caffeine and alcohol, avoid substances that disrupt sleep.

  • Patient education is crucial.

• Medications:

  • Pregabalin (Lyrica)

  • Duloxetine (Cymbalta)

  • Amitriptyline (Elavil)

  • Trazadone (Desyrel) - specifically for elderly patients.

  • Tramadol (Ultram)

  • NSAIDs (Nonsteroidal Anti-Inflammatory Drugs)

  • Muscle Relaxants

Complementary & Alternative Medicine (CAM)

• CAM Definition: Diverse therapies and healing systems outside of "mainstream healthcare."

  • May be used together or on their own.

  • Although often referred to as the same thing, "complementary" and "alternative" are different concepts.

    • Complementary: Non-mainstream medicine used in conjunction with conventional medicine.

    • Alternative: Used instead of conventional medicine.

    • Integrative: Traditional and complementary approaches are used in a coordinated way to improve wellness.

  • A significant challenge is the lack of clinical research on efficacy.

• Benefits of CAM from a Pharmacology Perspective:

  • Used to reduce the need for medications.

  • Reduction of medications leads to:

    • Reduced risk of side effects and adverse effects.

    • Improved compliance with therapeutic regimens.

• Systemized Healthcare Practices (Whole Medical Systems): Complete systems of theory and practice that have evolved independently from or parallel to conventional biomedicine.

  • Ayurveda:

    • One of the oldest systems of medicine, practiced in India since the first century AD.

    • Views illness as an imbalance among body systems.

    • Links health to the individual and society.

    • Focuses on balance and lifestyle.

    • Treatments balance the doshas using a combination of dietary and lifestyle changes, herbal remedies and purgatives, massage, meditation, and exercise.

    • Includes eight branches: internal medicine, surgery, treatment of head and neck disease, gynecology/obstetrics/pediatrics, toxicology, psychiatry, elder care and rejuvenation, and sexual vitality.

  • Traditional Chinese Medicine (TCM):

    • An ancient healing tradition identified in the first century AD.

    • Views illness as blocked or imbalanced Qi (vital life energy).

    • Holistic approach: Mind, body, and spirit are connected.

    • Focuses on balancing yin/yang energies.

    • Uses a set of systematic techniques including acupuncture, herbal medicines, massage, acupressure, moxibustion (use of heat from burning herbs), Qi Gong (balancing energy flow through body movement), cupping, and massage.

    • Fundamental concepts are derived from Taoism, Confucianism, and Buddhism.

  • Native American Healing:

    • Emphasizes harmony with land, mind, and body.

    • Tribal traditions are individualistic, but similarities include the use of sweating and purging, herbal remedies, and ceremonies (e.g., sweat lodges, chanting, drumming, dance) where a spiritual healer (shaman) contacts spirits for direction in healing.

    • Often utilizes healing herbs and botanical remedies.

  • Curanderismo (Traditional Latino/Folk Healing System):

    • Healers include herbalists, midwives, counselors, and bodyworkers.

    • Incorporates a humoral model for classifying food, activity, drugs, and illnesses, and a series of folk illnesses.

    • The goal is to create a balance between the patient and the environment, thereby sustaining health.

    • Involves rituals, cleansing rites, and prayer.

    • Aims for healing at physical, spiritual, or mental levels.

  • Homeopathic Medicine:

    • Developed in Germany and practiced in the United States since the mid-$1800$s.

    • A self-healing system, assisted by small, highly diluted doses of remedies or medicines.

    • Based on the theory that certain diseases can be cured by substances that would produce similar symptoms in a healthy person.

    • Prescribed substances (remedies) are made from naturally occurring plant, animal, or mineral substances.

    • Used in acute and chronic disorders to stimulate the vital force of the body so it can heal itself.

  • Naturopathic Medicine:

    • Holds the same view of human physiology, body functions, and disease processes as conventional medicine.

    • A system of therapeutics focused on treating the whole person and promoting health and well-being rather than an individual disease.

    • Goal is the restoration of health and normal body function rather than the application of a particular therapy.

    • Therapeutics include herbal medicine, nutritional supplementation, physical medicine, homeopathy, lifestyle counseling, and mind-body therapies.

    • Oriented toward assisting the person's internal capacity for self-healing (vitalism).

    • Virtually every CAM therapy is utilized.

• Botanical Healing:

  • Herbal Medicine: Using plants to treat illness/symptoms.

  • Aromatherapy: Uses essential oils of plants where the odor or fragrance plays an important part.

• Biologically Based Therapies (Natural Products): Involve consuming specific diets or supplements.

  • Dietary Supplements: Defined by the Dietary Supplement Health and Education Act of $1994$. Used to supplement dietary/nutritional intake by mouth; contain one or more dietary ingredients, including vitamins, minerals, herbs, or other botanical products.

  • Herbal Medicines: Plant-based therapies used in whole systems of medicine or as individual preparations.

  • Macrobiotic Diet: Predominantly a vegan diet (no animal products except fish); initially used in cancer management; emphasis on whole cereal grains, vegetables, and unprocessed foods.

  • Mycotherapies: Fungi-based (mushroom) products.

  • Orthomolecular Medicine (Megavitamin): Increased intake of nutrients such as vitamin C and beta-carotene; treats cancer, schizophrenia, autism, and chronic diseases like hypercholesterolemia and coronary artery disease.

  • Probiotics: Live microorganisms (mostly bacteria) similar to beneficial microorganisms in the human GI system; also called "good bacteria."

  • The "Zone" Diet: Dietary program requiring eating protein, carbohydrate, and fat in a $30:40:30$ ratio (% of calories) to balance insulin and other hormones for optimal health.

• Manual Healing Methods (Manipulative and Body-Based Methods): Involve movement of the body with a focus on body structures and systems.

  • Chiropractic Medicine: Manipulating the spinal column; includes physiotherapy and diet therapy.

  • Massage Therapy: Manipulating soft tissue through stroking, rubbing, or kneading to increase circulation, improve muscle tone, and provide relaxation.

  • Acupuncture: Traditional Chinese method of producing analgesia or altering body function by inserting thin needles along meridians; direct needle manipulation influences deeper internal organs by redirecting Qi.

  • Acupressure: Applying digital pressure in a specified way on designated points on the body to relieve pain, produce analgesia, or regulate a body function.

  • Reflexology: A discipline that applies pressure to specific points on the feet, hands, or ears thought to correspond to different organs and systems of the body.

  • Simple Touch: Touching the patient in appropriate and gentle ways to make connection, display acceptance, and give appreciation.

• Hand-Mediated Biofield Therapy (Energy Therapies): Use of the hands on or near the body to manipulate energy fields or alter the biofield, to help or to heal.

  • Therapeutic Touch: Biofield therapy involving direction of a practitioner's balanced energies toward those of a patient; practitioner's hands lay on or close to a patient's body.

  • Healing Touch: Biofield therapy; uses gentle touch directly on or close to the body to influence and support the human energy system and bring balance to the whole body (physical, spiritual, emotional, and mental).

  • Reiki Therapy: Biofield therapy derived from ancient Buddhist rituals; practitioner places hands on or above a body area and transfers "universal life energy," providing strength, harmony, and balance.

  • Magnet Therapy: Bioelectromagnetic therapy; devices (magnets) applied to the body surface, producing a measurable magnetic field; used primarily to alleviate pain associated with musculoskeletal injuries or disorders.

• Mind-Body Therapies (Mind-Body Interventions): Honor connections between thoughts and physiological functioning, using emotion to influence health and well-being.

  • Yoga: Focuses on body musculature, posture, breathing mechanisms, and consciousness; goal is attainment of physical and mental well-being through mastery of the body, proper breathing, and meditation.

  • Meditation: Self-directed practice for relaxing the body and calming the mind using focused rhythmic breathing.

  • Hypnotherapy: A state of focused attention, often used to create changes in attitudes, behavior, and physiological reactions.

  • Imagery: A two-way communication between the conscious and unconscious mind and involves the whole body and all of its senses.

  • Guided Imagery: A state of focused attention, much like hypnosis, that encourages changes in attitudes, behavior, and physiological reactions.

  • Biofeedback: Uses electronic equipment to provide clients with visible or audible evidence that they are controlling their bodies' physical responses.

  • Qi Gong: Breathing and mental exercises combined with body movements.

  • T'ai Chi: Combines physical fitness, meditation, and self-defense.

  • Pilates: Physical movement and exercise designed to stretch, strengthen, and balance the body, in particular the core or center, including the abdominal region. It is also considered a movement therapy.

  • Art Therapy: Using art to reconcile emotional conflicts, foster self-awareness, and express unspoken (and often unconscious) concerns about disease.

  • Breathwork: Using a variety of breathing patterns to relax, invigorate, or open emotional channels.

  • Music Therapy: Using music to address physical, psychological, cognitive, and social needs; improves physical movement and/or communication, develops emotional expression, evokes memories, and distracts people in pain.

• Spiritual Therapy:

  • Faith: Refers to our beliefs and expectations about life, ourselves, and others.

  • Spiritual vs. Religious: While related, they are distinct concepts.

  • Prayer: Defined simply as a form of communication and fellowship with the Deity or Creator.

• Additional CAM Therapies:

  • Humor + Laughter Therapy: Used for mood elevation and stress reduction.

  • Bioelectromagnetics: Studies how living organisms interact with electromagnetic fields.

  • Detoxifying Therapies: Based on the belief that physical impurities and toxins must be cleared from the body to achieve better health. Examples include Hydrotherapy, Colonics/Colon Therapy, and Chelation Therapy.

  • Animal-Assisted Therapy: Involves animals as part of treatment.

  • Horticultural Therapy (Gardening or a Healing Garden): Stimulates the five senses, provides leisure activities, improves motor function, provides a sense of achievement, and improves self-esteem.

  • Movement Therapies:

    • Dance Therapy: Intimate and powerful medium because it is a direct expression of the mind and body; treats persons with social, emotional, cognitive, or physical problems.

    • Feldenkrais Method: A complementary therapy based on establishing a good self-image through awareness and correction of body movements.

CAM Safety Concerns

• Key Concept: "Natural" does not always mean better or safe.

• Very little research has been done on many CAM therapies.

• May have no effect, mild, or adverse reactions.

• Can delay or prevent healing.

• Toxicity: May occur and is likely underreported due to not being prescribed by a provider.

• Drug Interactions: May occur, especially in older adults and those with liver or kidney disease.

• Essential Oils: May cause issues.

• Supplements: May cause issues or become dangerous when mixed with other medications.

Safe or Effective Herbs (Determined by Non-US Regulatory Authorities)

• Aloe Vera:

  • Use: Skin disorders (burns, inflammation, acute injuries - topically); GI ulcerations (Crohn's disease, ulcerative colitis - orally).

  • Effects: Acceleration of wound healing (topical); Unknown mechanism, but known laxative effect (oral).

  • Potential Drug Interactions: Furosemide and loop diuretics; may enhance effects of laxatives (when taken orally).

• Chamomile:

  • Use: Inflammatory diseases of GI and upper respiratory tracts; Generalized anxiety disorder.

  • Effects: Anti-inflammatory; Calming agent.

  • Potential Drug Interactions: Drugs that cause drowsiness (alcohol, barbiturates, benzodiazepines, narcotics, antidepressants).

• Echinacea:

  • Use: Upper respiratory tract infections; Wound healing.

  • Effects: Stimulant of the immune system.

  • Potential Drug Interactions: Antirejection drugs and other drugs that weaken the immune system; may interact with antiretrovirals and other drugs used in HIV/AIDS treatment.

• Feverfew:

  • Use: Arthritis.

  • Effects: Anti-inflammatory; Inhibition of serotonin and prostaglandins.

  • Potential Drug Interactions: Warfarin and other anticoagulants; Aspirin and ibuprofen.

• Garlic:

  • Use: Elevated cholesterol levels; Hypertension.

  • Effects: Inhibition of platelet aggregation.

  • Potential Drug Interactions: Warfarin and blood thinners; Saquinavir and other anti-HIV drugs.

• Ginger:

  • Use: Nausea/Vomiting.

  • Effects: Antiemetic.

  • Potential Drug Interactions: Warfarin and anticoagulants; Aspirin and NSAIDs.

• Ginkgo:

  • Use: Alzheimer disease and dementia.

  • Effects: Memory improvement (though these effects are now in question given recent clinical trials).

  • Potential Drug Interactions: Warfarin and anticoagulants; Aspirin and NSAIDs.

• Licorice Root:

  • Use: GI disorders (gastric ulcers, hepatitis C).

  • Effects: Unknown.

  • Potential Drug Interactions: Corticosteroids and other immunosuppressive drugs; Digoxin; Antihypertensive drugs.

• Saw Palmetto:

  • Use: Benign Prostatic Hyperplasia.

  • Effects: Prevention of conversion of testosterone to dihydrotestosterone (needed for prostate cell multiplication).

  • Potential Drug Interactions: Finasteride and antiandrogen drugs; None known.

• Valerian:

  • Use: Chronic pelvic pain; Sleep disorders, mild anxiety, and restlessness.

  • Effects: Unknown mechanism; Central nervous system depression.

  • Potential Drug Interactions: Barbiturates and other sleep medications; Alcohol; Antihistamines.

Unsafe Herbs

• Calamus (Indian type most toxic): Contains varying amounts of carcinogenic cis-isoasarone. Documented cases of kidney damage and seizures with oral preparations.

• Chaparral: No proven efficacy; induces severe liver toxicity in some cases. Causes severe uterine contractions.

• Coltsfoot: Used for bronchitis in traditional healing systems; contains carcinogenic pyrrolizidine alkaloids; hepatotoxic.

• Comfrey: Used for wound healing and acute injuries; used for anti-inflammatory effects in osteoarthritis and rheumatoid arthritis. Contains carcinogenic pyrrolizidine alkaloids; may induce venoocclusive disease; hepatotoxic.

• Ephedra (ma huang): Found in "natural" weight-loss products; central nervous system stimulant, bronchodilator, cardiac stimulation, weight loss. Unsafe for people with hypertension, diabetes, or thyroid disease. Avoid consumption with caffeine.

• Life Root: Antirheumatic, menstrual flow stimulant. Hepatotoxic.

• Pokeweed: Used as anticancer; often used with folk remedies and in Native American healing. Do not use with children, though some websites claim safety with observation and monitoring and proper dosing.

Patient Education for CAM

• Always include questions on the use of CAM when obtaining medical histories.

• Ask the patient why they are taking a specific CAM therapy.

• Be aware of polypharmacy (the concurrent use of multiple medications).

• Consider special populations like pregnant or lactating women due to limited research on safety.

• Always apply age considerations as drug interactions and effects can vary significantly across the lifespan.