This case looks at a 48 year old female who has had TMJ and migratory pains in multiple joints for two years and has had four different providers.  Her latest provider has diagnosed her as having fibromyalgia and despite multiple medication regimens, her pain is still making it difficult to perform her daily work duties.
The case was presented by faculty from Pharmacy, Professional Psychology, Occupational Therapy, Physical Therapy, Physician Assistant Studies and Dental Health Science

Antick, Jennifer

Buhler, Amber

Fuentes, David

Jobst, Erin

Randolph, Randy

Rohner, Shawna

English

CommonKnowledge

Fibromyalgia ICC Sept. 10, 2009  
Case study: 
Patient is referred by her PA to an interprofessional specialty clinic.  
1. Physician Assistant’s initial referral: Our case is a 48 year old female, Judy, divorced mother of two, who works for a local nursery as an account receivable administrator.  She has had TMJ and migratory pains in multiple joints for two years and has had four different providers.  Her latest provider has diagnosed her as having fibromyalgia and despite multiple medication regimens, her pain is still 4-6 on a 10 point scale most of the time making it difficult to perform her daily work duties.  Her current medications are Fluoxitine 40 mg AM daily, Amitryptiline 20 mg at night, cyclobenzapine 10 mg twice daily, Tramadol 75 mg QID, Zolipdem 5 mg at bedtime for sleep, Calcium carbonate 1500 mg daily.  Her provider is frustrated and so is she.  The provider notes that the patient is adjusting medications on her own and is not engaged in her treatment plan. She comes to the clinic today for her first visit. 
 
QUESTIONS:  1. What is the first question you would ask one of the other providers?   
 2: Physical Therapist’s rounds presentation Initial physical examination by the physical therapist revealed: 
o Vitals (seated, at rest): BP: 134/82 mm Hg, HR 84 bpm, RR 19 
o Posture: “forward-head” position, shoulder protraction, exaggerated anterior pelvic tilt 
o Pain with palpation in suboccipital region and several more “tender points” in trapezius muscles, scapular region, and posterior iliac crests 
o Decreased cervical range of motion (ROM) in all directions  
o Mild weakness in trunk musculature and bilateral upper and lower extremities (3+/5 or 4/5) 
o Shortened hamstring, gastrocnemius/soleus, and pectoralis muscles and lengthened middle/lower trapezius muscles 
o 6-minute walk test (6MWT): decreased gait speed (for age) with c/o increasing neck, lower extremity, and trunk pain. Vitals (immediately after) indicate decreased aerobic conditioning.   Physical therapy evaluation: Patient presents with poor posture, muscle length imbalances, pain with palpation in multiple body regions, decreased cervical ROM, generalized weakness, decreased aerobic conditioning, and pain with aerobic exercise.   
QUESTIONS: 1. How would PT intervene?  2. How could the PT improve the patient’s ability to participate in the PT treatment plan within her pain tolerance?   3. What is the first question you would ask one of the other providers at this point?  
 
3: Pharmacist’s Rounds presentation The patient reports that she has received no benefit from the pain medications she has used in the past. She is currently taking combinations of traditional antidepressant agents, muscle relaxants and neurotransmitter-modulating agents in an attempt to reduce her pain, but with little benefit. She has a medical history of generalized pain and constant sleep disorders. Various physicians have excluded countless diagnoses including, but not limited to, sciatica, various types of back, central and peripheral pain, temporal artheritis, polyarthralgia rheumatica, osteoarthritis, etc. During the process of reaching her diagnosis of fibromyalgia, physicians have also referred her to psychiatrists in hopes of exploring and identifying other possible disorders. She has had consults with various health care providers and has, simply due to her use of prescribed opiates, felt judged on many occasions. She reports having difficulty discussing her pain with family and friends due to the stigmas associated with “pain killers.” She admits to having poor medication adherence.  The patient complains of xerostomia.  She also reports experiencing “flu-like symptoms” on several occasions when she has missed Rx doses due to self-medicating with alcohol.  
QUESTIONS:  1. Could any of the patient’s medications be adversely affecting her balance/motor coordination?   2. What medication management changes might the Pharmacist implement with this patient?   3. What is the first question you would ask one of the other providers at this point?   
 4. Clinical Health Psychology Rounds presentation  As the client presented with issues with medication adherence and frustration with functional losses, she was assessed with several measurement instruments to help determine the relationship between her physical symptoms and her psychological functioning.   Assessment: 1. Are there psychological considerations that exacerbate, initiate or maintain this client’s pain condition? Are psychological conditions being exacerbated by her pain condition?   Clinical Interview, Personality Assessment Inventory, Hamilton Depression Scale 2. What patterns (behavioral, emotional, and functional) do we see with this client’s pain?   Multidimensional Pain Inventory, Pain Ratings Scales   
Test Results/Conclusions: 
 The pharmacist has reported concerns about medication adherence and statements of client frustration regarding her medical providers. Through clinical interview, the client clarified that she had no history of depression or other mood disorder and results of the PAI did not indicate evidence of any other major mental health concerns with the exception of depressive symptoms consistent with her self-report. Although the client is currently endorsing depressive symptoms, it appears that her pain condition may be exacerbating her symptoms of irritability, fatigue, insomnia, feelings of hostility, depressed mood, difficulty concentrating, and feelings of worthlessness. The client stated that much of her frustration occurs because she is not able to perform her work functions the way that she used to. She tires more easily but feels that she must continue to “push through” the pain; she is worried about the welfare of her children if she loses her only source of income. She feels that none of the medical providers have taken the time to listen to her and stated that her friends have “stopped talking to me because they think I’m too negative.” She stated that she feels “overwhelmed and stressed” by the medication and exercise regimens that have been prescribed to her.  Diagnosis Axis I: 307.89 Pain Disorder Associated with Both Psychological Factors and a General Medical Condition, Chronic Axis II: 799.9 Diagnosis Deferred Axis III: Fibromyalgia (per medical report) Axis IV: Occupational Problems, Problems related to Social Environment, Economic Problems Axis V: GAF: 50-55 
 
QUESTIONS: 1. What have we learned about this patient that may help answer why the initial provider felt the patient was “not engaged in her treatment plan?”  2. What interventions might a clinical health psychologist implement with this patient?   3. What is the first question you would ask one of the other providers at this point? 
5. Occupational Therapist’s Rounds presentation    Client filled out the Occupational Self Assessment (OSA) form.  Client noted having “a lot of problem” concentrating on her tasks, physically doing what she needs to do, doing activities she likes, being involved as a worker and family member and relaxing and enjoying herself.  Client noted general fatigue, pain and forgetfulness to be the primary barriers to these daily occupations.  Client tends to push herself through activities and then finds that she is laid up in bed for a day or more because of the increase in levels of fatigue and pain.  Client is no longer involved in those “fun” activities due to her fear in increasing her fatigue and pain levels.  Client finds that she is quite forgetful; not remembering for instance what is discussed during her medical appointments.  Client states that her life is very stressful.  How she deals with stress is through avoidance. 
 
QUESTIONS:  1. How would OT intervene?  2. How would you address this client’s “problem” with relaxation?   3.    What is the first question you would ask one of the other providers at this point? 

 
6: A visit to the Dental Hygiene Clinic  Patient complains of frequent headaches, jaw pain with limited opening (is painful to yawn), and frequency of dental decay on the increase.  She also complains of a constantly dry mouth.  Because it is sometimes difficult for the patient to chew, she finds that she is losing weight due to not eating enough.    Her mouth seems to be dry all the time.  She seems to be in a vicious circle of pain with her TMJ.  She finds herself clenching/grinding more frequently which in turn sets off facial and TMJ pain.   
 
QUESTIONS:  1. What is the relationship between the patient’s headaches and fibromyalgia?  Which came first?  2. Is the patient’s dry mouth a symptom of fibromyalgia or medications?  3. What can be done to decrease the rate of caries she is experiencing?  


Fibromyalgia: A visit to the interdisciplinary pain clinic

https://commons.pacificu.edu/cgi/viewcontent.cgi?article=1018&amp;context=icc

Fibromyalgia: A visit to the interdisciplinary pain clinic

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