Case Study Fibromyalgia

Case study for a forty-four-year-old male named Kevin diagnosed with Fibromyalgia (FM). The case study is to inform Kevin how yoga therapy can support him with his health concerns as well as persuade him to challenge some of his belief systems and lifestyle patterns. The purpose of this paper is to communicate how the Pancamaya Model can assist healing at multiple layers of his being and to outline clinical decision making and the rationale of the proposed treatment plan. The plan will also make suggestions of attitudes of behaviors the client may want to consider changing by growing their knowledge on specific topics. An attempt will be made to evaluate client outcome for subsequent sessions as well as a method of evaluation to measure these results. A sample summary of the proposed plan of care for the client’s primary care physician (PCP) is provided. The goal of the paper is to inform the reader concerning FM, to evaluate the written intake form and to persuade toward Yoga Therapy (YT) as a treatment plan. Given the written intake provided about Kevin, I conclude as a complement to his current care plan that Ayurveda and Pancamaya Model tools will change Kevin’s life and lead him on a healing journey.

Introduction

Can you imagine having a disease that causes widespread pain throughout your body, all conventional tests come back normal, and yet your entire life is being affected by this pain? Fibromyalgia (FM) is a disease that knows no gender, culture or age and affects over 10 million Americans a year, with a higher occurrence in women, according to the National Fibromyalgia Association (NFA). This paper will take you through a snapshot of Kevin’s life. Kevin was a security officer at a high-security government facility with “negative air flow” and high mental stress, frustration and anger which he found difficult to manage. He was a volunteer firefighter. He enjoyed socializing and participating in his community. It is estimated by NFA that FM affects 6% of the world population.  The individual patient on average spends $1,000 out of pocket per month above their health care program, while it costs the United States health care system upwards of $14 billion a year and an overall national productivity loss of two percent. What do you do when you are so ill it is affecting every area of your life? You appear healthy on the outside and you may be told you are making it all up. “Controlling the breath is the precursor to controlling everything about your life- the physical body, the emotions and the spirit.” – Sam Dworkis

While we are just beginning to untangle FM and its truths, one thing seems to be clear, it affects the central nervous system, and its symptoms can come on slow or quickly. FM on PubMed shows over nine thousand research studies have been done to date. Some of them are showing there is a difference in physiological abnormalities such as increased levels of Substance P in the spinal cord, decreased levels of blood flow to the thalamus, HPA axis hypofunction, low levels of serotonin and tryptophan and abnormalities in cytokine function. Given the written intake provided about Kevin, I conclude as a complement to his current care plan that Ayurveda and Pancamaya Model tools will change Kevin’s life and lead him on a healing journey

As a practicing mind-body practitioner for a decade and in school studying to receive my Masters of Science in Yoga Therapy, I have experienced first-hand the struggles of patients with FM and how mind-body modalities of movement including yoga therapy can enhance FM patients’ quality of life. This paper will first discuss a literature review concerning FM. Second, we will examine the Pancamaya model. Third, we will describe clinical decision making, treatment plan, client education and outcome evaluations. Finally, we will provide a summary of professional communication for Primary Care Physician (PCP).

Literature Review

YT can be applied to neurological and immune disorders such as pain and FM. In this literature review I will show that YT may have a role in the treatment of pain and FM by improving physical and psychological aspects as well as a quality of life. The Fibromyalgia Impact Questionnaire (FIQ) appears to be the gold standard for measuring outcomes during FM research. FIQ measures seven factors related to FM: pain, fatigue, anxiety, depression, morning stiffness, awakening unrefreshed and disability.

 Physiopathology may include the central nervous system (CNS) dysfunction related to pain modulation as well as neuroendocrine dysfunction and dysautonomia meaning a disorder of autonomic nervous system (ANS). (Bir, 2016) Researchers seem to agree thus far that FM is a disorder of central processing with neuroendocrine/neurotransmitter dysregulation.

FM is characterized as having a heightened sensitivity to sensory input. It has a complexity of symptoms such as widespread musculoskeletal pain, stiffness, fatigue, disturbed sleep, dyscognition, affective distress and reduced quality of life. (Bir, 2016) At this time there is no diagnostic lab test for FM, but there have been elevated levels of a pain mediator called Substance P found in spinal fluid in FM patients, indicating there is a problem in the processing of pain sensations in the spinal cord and brain which greatly amplifies pain. Their pain is real and can be debilitating even though the sensation is out of proportion to the actual damage or trauma. (McCall, 2007)

The majority of FM patients have four or more co-morbid pain or central sensitivity syndromes (CSS). Irritable bowel/bladder, headaches, pelvic pain, regional musculoskeletal pain syndrome, restless leg syndrome, and chronic fatigue suggest a shared pain processing. (Mist, 2013) FM and its common co-morbid diseases seem to have a central sensitization link. In a randomized, double-blind control study, pramipexole (dopamine agonist), a D3 agonist, has been shown to be effective in FM. Several studies have shown that the biology of depression is different in FM. Dexamethasone test shows no suppression in major depression compared with mostly normal suppression found in FM. The HPA axis is hyperactive with hypercortisolemia in major depression as opposed to relative hypocortisolemia in FM. The depression observed in CSS patients, including alpha-delta sleep has different characteristics. (Yunus, 2007)

Interventions with little side effects such as physical and behavior approaches may be valuable contributors for FM treatment. (Bir, 2016) An eight-week yoga program which included gentle poses, meditation, breathing exercises, coping methods and group discussions with a three-month follow-up showed significant reduction of symptoms of FM. Symptoms of FM that decreased were: pain, fatigue, stiffness, sleep problems, depression, memory, anxiety, tenderness, balance, vigor, and strength. Psychological improvements in coping with FM pain also improved by utilization of problem solving, acceptance, relaxation and activity engagement instead of using maladaptive strategies. (Bir, 2016). Female FM patients underwent an eight-week course in mindfulness-based-stress-reduction (MBSR) and found a modest reduction in anxiety symptoms but no decreased rates for pain or health-related quality of life indicators. However, when they took individuals and did an eight-week trial that included yoga, meditation and education there was a sizeable reduction in pain. These two eight-week programs suggest that a strategy of combining MBSR, yoga, and meditation may be more efficient than any of these techniques done singularly. (Bradshaw, 2012) A twenty-eight percent reduction in FIQ scores was noted after a two times per week eight week Hatha yoga research session. They included a blend of yoga styles including Hatha vinyasa, kundalini, and Iyengar. (Rudrud, 2012) The data seems to be consistent with earlier reports on ‘mindful’ meditation therapies reducing sleep disturbances, fatigue, and depression and improving the quality of life. Sub-analyses have found that only yoga also relieves pain. (Mist, 2013)

FM poses a financial burden on our society both in the use of health care costs and the result of an inability to work and lost income that FM patients face. (Rudrud, 2012)  Titrating practice to the patients’ energy level is critical and requires an understanding of relevant pathophysiology since FM is likely due in part to altered pain processing in the CNS and peripheral nervous system. Additional factors include genetic predispositions, autonomic dysfunction, and emotional, physical or environmental stressors. (Mist, 2013) FM, to our knowledge at this time, does not progress, cause death or do damage to joints, bones, internal organs and so on. (McCall, 2007)

Pancamaya Model

The following will be a snapshot of Kevin’s intake form using the Pancamaya model which will describe the full depth of how yoga therapy can impact his healing process.

Annamaya Kosha/ Physical Body:  Kevin explains his general health as “in pain and surviving.” He is forty-four years old. His physical body feels widespread pain. He has strong areas of pain in his feet, hands, elbows, and shoulders. He indicates symptoms such as heart palpitations, lower abdomen cramping, rashes, fatigue and so on. His current medical conditions include FM (2013) with co-morbid conditions of obesity, sleep apnea, insomnia, depressive symptoms, high blood pressure, glaucoma, gastrointestinal dysfunctions, borderline personality disorder and transforaminal lumbar interbody fusion and posterior instrumentation of L5-S1. He has debilitation for multiple days after engaging in physical activities such as mowing the lawn. He gets to bed at eight p.m. and wakes at five a.m. He does not rise rested, and it takes several hours to get moving. He relies on his furniture during this time. His dietary intake has been irregular, high caffeine, dairy, carbohydrates and nicotine (new to a cessation program) until recently. For work, he walks ten miles a day with heavy boots and carrying heavy cages on his shoulders. He currently takes Colace, Mirilax, Lumigan, Lisinopril, Bystolic, Nortriptyline and Piroxicam. (May want to ask your Dr. about SAM-e S-adenosyl-l-methionine and 5-HTP 5-hydroxytrypotophan as it may help improve tender points) He sees the following doctors: Rheumatologist, Ophthalmologist, PCP, Neurologist, Dentist and at times Psychotherapist. (Possible additional referrals may be: acupuncturist, massage therapist- not deep tissue, marma therapist and an osteopath) As a yoga therapist, I would be interested in observing the following in Kevin:

  • Muscle tension locations,
  • Guarding behaviors,
  • Posture,
  • Ease of casual movements, and
  • Testing limitations in ROM.
  • Also, what planes of motions cause him more or less discomfort?

I am curious to explore the following questions with Kevin to develop more clarity:

  • How long can you sit/stand before you want to sit/stand?
  • How is this affecting your life?
  • Is it getting better/worse/same?
  • Describe a twenty-four hour day in your life.
  • What do you do during your free time?
  • What health care practitioners/therapies have helped you the most? What worked? What did not?
  • Was it pedicle screws or cages?

Right now Kevin has a separation from his physical body and lacks awareness of his Ayurvedic constitution. The goal will be to build body awareness through asana, a standing practice on high energy days and a restorative practice on low energy days. Each practice should be done at 50%-60% of that day’s energy level-less is more, also look at developing an appropriate diet and lifestyle routine for him. Warm sesame oil self-massage before bathing and at bedtime, soothes vata and nourishes skin, joints and nervous system. A fifteen-minute oil massage then taking an Epson salts bath is preferred.

Pranamaya Kosha/ Energy Body: Kevin is having sleep apnea with breath cessation of over one hundred seventy-five times per night and wears a CPAP machine at night. Kevin is sleeping on average nine hours a day. He has significant fluctuations in appetite/diet with associated weight gain/loss. Kevin has gastrointestinal dysfunction with bleed fissures from the colon. His energy levels have been extremely low. Kevin left a high-stress job and his current job has significant physical demands and he must wear a ventilator the entire day. Kevin experiences energetic challenges. He has heart palpitations, anger and anxiety. As a yoga therapist, I would be interested in observing the following in Kevin:

  • Breathing pattern during discussions,
  • Breathing pattern while we did some movement,
  • Where does he breathe the best?
  • What is his self-report of his breath awareness and description?
  • Does he have the ability to calm body tension by calming breath?
  • Does he report that he feels his ability to calm the body with breath?

I would be interested in asking him the following questions:

  • How is your overall digestion?
  • What do you do to manage your stress?
  • How often do you suffer from insomnia and how long does it last? How is your immune system?

Kevin is showing signs of energy blocks especially in the lower chakras and lack of breath awareness. The goal will be to build breath awareness and to reconnect him with nature and other sources of prana. Apana vayu will help to ground the lower chakras and to help with nourishing the eliminatory systems, prana vayu to nourish the immune system and udana vayu to nourish the nervous and endocrine systems.

Manomaya Kosha/ Emotional Body: Kevin experiences headaches and has an informal diagnosis of depression and possible borderline personality disorder. He has very few memories before age seventeen. He feels let down by his health care team and describes his experiences as “shuffle him through too quickly.” His previous job had high mental stress, frustration and anger that he found difficult to manage. He is open to returning to psychotherapy in the future. He experiences mental and emotional challenges and has mental/verbal disturbances. He has experienced significant life events such as the death of sister (2006), recovery of a dismembered child’s body as a firefighter, loss of a job as a firefighter and social community due to his health. He lives near his parents but prefers solitude and therefore does not socialize much. I would be interested in observing the following:

  • Speed of speech
  • His ability to understand what is being taught and is he able to pick it up quickly or slowly
  • Do I see tamasic, rajasic or sattva qualities

Additional questions that I have are:

  • How is your short and long term memory?
  • How do you continue educating /feeding/exercising your mind as you age?
  • How is your mood? Positive/negative/ moody?
  • What does your pain mean to you? Why do you think your pain persists? How much of your life is impaired by pain?
  • How much better do you believe you can feel?
  • How would your life be different if you did not have widespread pain?
  • Is there anything you have discovered about yourself from having widespread pain?
  • Point to where it hurts most? What have you done for it? Does it radiate down the extremity? Numbness, tingling, weakness, dizziness, nausea, altered vision/hearing?
  • Can you tell me about the non-pain sensations you can feel in your body? In areas of pain, tension, or discomfort?

Kevin shows signs of awareness with his thought patterns and emotional reactions. Using Yoga nidra with eyes open, introspective asana, R.A.I.N. meditation and five-minute sprint or gratitude journaling, and introduction to Rosenberg style of nonviolent communication process may help him explore healthy emotional expression.

Vijnyanamaya Kosha/Wisdom Body: He has practiced paganism mostly on his own rather than in a community setting. He prefers solitude. I would like to observe his personality, values, ability to be self-reflective and how he interacts with the world around him. I would like to engage in conversations regarding these questions:

  • What motivates you to live a full life? What do you do every day to feed that interest or passion?
  • How do you view your life experiences? Glass half full or empty? Can you shift that perspective?
  • What old habits are you carrying around that are affecting your ability to be happy with your life?
  • How do you view your communication skills?
  • How open-minded are you?
  • Are you easy going or a perfectionist? Are you demanding of self and others?
  • Do you struggle with boundaries of speaking the truth in a way that can be received?

Kevin is struggling to see the big picture and to flow through the roller coaster of life with its painful ups and downs. The goal will be to teach Kevin to be the witness, to learn how to focus and stabilize the mind and access discriminating intuition which informs us, as he is whole and complete. Meditation, as part of sadhana (practice), quiets the mind (manomaya kosha) and frees us from misperceptions (vijnyanamaya kosha). Journaling this process is a tool for healing on the manomaya kosha and vijnyanamaya kosha by pacifying the mind and revealing wisdom.

Anandamaya Kosha/Bliss Body: Kevin can be prone to frustration, anger, anxiety and depression. His spiritual connection is strong and practices paganism.  His relationships are lacking due to his poor physical health. I would want to observe his level of joy, depressed, ability to be present, scattered, disassociated or connected. Questions that I would have for Kevin would be:

  • What brings you joy? What takes you away from joy?
  • Do you have personal relationships in your life? Do they connect you to your inner joy?
  • How does paganism connect to your inner joy?
  • Do you have a teacher/mentor/guide? What form does that take for you – a teacher, counselor, friend or parent?

Kevin appears to have a strong spiritual connection. I believe getting him to integrate the natural self into everyday living is the challenge. The goal may be to get him to read some spiritual books that align with his belief system and how what he reads aligns with the nature of the true self which is all aspects of life. Yoga Nidra can be used to relax the mind and the body, accessing stillness, peace and bliss as a reflection of our true self. Yoga nidra is a healing technique for all four lower koshas and a way to experience the bliss of the anandamaya kosha. Using meditation, as a method, allows the joy and bliss of anandamaya kosha to arise.

The primary dosha which is present in FM is Vata disease. Ayurveda views FM as having two leading causes. First, there is a disturbance in the nervous system function called vata and the second is an accumulation of toxins and blockages called ama through the physiology. Once these imbalances reach critical levels, the nervous system becomes less stable and aggravating impurities accumulating in the body is the breeding ground for fibromyalgia to be created. Indicating that there is a lack of trust in the universe and at a young age he was imprinted with thoughts of “I am not enough,” safety and security issues.  The kidney stones that he removed in 2014 indicate he is struggling with fear. (Lad, 2008) Vata imbalance expressed emotions that Kevin presents with are fear, anxiety, loneliness, emotional instability, and mood swings. He also shows signs of a Pitta imbalance with feelings of frustration and anger. Often Vata imbalances have ignored body signals or pushed through them. The metabolic fire is burnt out and as a YT we will want to get it moving again.

A difficult and insidious cycle that afflicts FM patients is the sedentary life because exercise is painful. The body feels like cement, the lack of exercise results in weight gain and fuels depression, which then makes it hard to overcome the lethargy of FM. The patient feels heavy, darkness around the eyes and has dullness to the skin. It is important to share with the client that at some point during their movement practice they will turn a corner. As you move your body, the “fuzz” (Fascia) will break up. The importance of movement and stretching is to maintain the sliding properties of the tissues in the body. Fascia seems to be tactilely tighter in pain points, learning to use your breath and stretch can help loosen fascia to make movement easier and more pain-free. Suggesting that the patient develops a movement routine that meets 50%-60% of their energy capacity that day, oil massage before or after their bath/shower, eating warm vegetables and working to learn to manage their stress response can help FM patients deal with a disease that is poorly understood medically and publicly.

Clinical Decision Making, Treatment Plan, Education and Evaluation

Titrating a practice that will match the patient’s energy level that day is important, a one size fits all program does not work because it must be able to flex and flow depending on energy levels. The more the patient practices with consistency, the more they will develop discernment of monitoring their body’s response and make better choices.   There are several contraindications to be aware of with Kevin with FM and the co-morbid diseases he is experiencing.

Contradiction Related Disease
Hot humid rooms Gastrointestinal Dysfunction, Insomnia
Transitioning to quickly FM, HBP, Depression
Full Inversions/ Strong Backbends Obesity, HBP, Glaucoma / Anxiety, Insomnia, HBP,
Strong breathing techniques/ left nostril breathing/ right nostril breathing Anxiety, HBP/ Depression/Anxiety
Strong Twists Gastrointestinal dysfunction (if struggling with diarrhea)
Vigorous repeated flow FM, Insomnia, HBP, Gastrointestinal dysfunction
Undo weight on particular joints (one-limb balances) Obesity
Careful with praise & corrections, avoid practicing near mirrors, eyes open and use grounding meditations Personality Disorder, Depression

Yoga therapy can help by teaching FM patients how to manage their stress response and learning breath techniques which will calm an agitated, nervous system and generate an inner sense of peace. Yoga Nidra and deep relaxation can help them to improve their sleep. Starting a meditation practice can help FM patients selectively focus their awareness and modulate the pain sensations down to a more manageable level. Consistent asana can improve posture and create better alignment of bones, and muscles. Introspective asana can help FM patients express what they are feeling as a huge emotional backlog may be lodged in the tissue causing pain. Sangha “community” therefore encourages patients to join an FM support group. Patients feel alone and misunderstood. A group can help them to share health care professionals, tips and facilitate connection with others.  “Let’s go into where in your body you feel that despair and that sadness, and let’s breathe into that, and release as much of it as we can.” Ana Forest

Kevin’s goal concerning YT is to establish a regular self-care routine to support a healthy life balance, ultimately decrease pain and improve physical functionality and overall quality of life.  Kevin’s home care plan will focus on establishing self-care mindfulness routines such as: creating good sleep hygiene routines, Yoga nidra before bedtime, walking meditation that he can use on his ten-mile walk, eating meditation, nature meditation, learning how to make driving, showering, tooth brushing and shaving a meditative routine as well as starting a journal practice. Eventually, we will build into developing a high energy day movement practice and a low energy day movement practice. We will start on the low energy practice first with a goal to use this as home practice. It is important to understand that FM patients only wake up with a certain quantity of spoonful’s of energy each day and they need to be able to have choices to modify for their needs that day. Other meditations that we may grow into are loving-kindness, separating two arrows and mudra meditations. An example of a good energy day practice may be: (vata reducing practice) mountain, wall push, chair, warrior 1, seated chair twist, low lunge, child’s pose, legs up wall, lotus, staff, one leg seated forward fold, seva pose, Savasana with a natural relaxed breath as they relax into stillness (3 blankets under knees, 1 blanket rolled for ankle, eye open, wrap a blanket around top of head, ears, neck and neck roll). An example of a low energy day practice may be: supported half dog an a table (1 or more folded blankets), supported relaxation pose (5 blankets, block, 2 pillows) towards the end adding some gentle arm movements, Seated Forward Fold leaning on a chair, Supine twist (1+ blankets), heal slides, cobra, and standing flowing twist, spinal movements at a table or counter. The goal for the first session is to go over the intake and create some additional clarity through conversation, set boundaries for our working relationship, to agree upon mutual goals between YT and client, to do a body scan and breath awareness techniques (an audio recording for client will be made and emailed to them).

It is important to teach Kevin that pain can be reduced, managed or eliminated if we move in a range-of-motion (ROM) that does not cause increased pain. If he does move into increased pain, the nervous system sees exercise as a stimulus and responds. If Kevin moves within his respected ROM his body will shift. Small steps make for significant change.  He may surprise himself. Kevin should try to move in as pure of a movement as he can and reduce compensation of which he may be aware. Those that move in their ROM improve faster than those who do not. Often the way the body unwinds and unravels tension and holding patterns is not the way we think it will go. A journaling suggestion for Kevin maybe to answer the following questions:

  • What did I do yesterday that left me feeling overdone today?
  • Do I have less pain than usual the day after YT session/ practice?
  • Am I relaxed and energetic?
  • If I practice YT sessions regularly does my mood improve? How about my sleep?

Realizing it may take longer to notice benefits than for the average person but in time he will continue to see the benefit of practicing. Journaling if he has less pain than usual the day after practice, recognizing if he is relaxed and energetic, as well as mood and sleep improvement will help track the progress that is being made for the mind. Also, using the FIQ and having the patient rate on a scale of 1 to 10 (1 = passive nothing going on and 10 = vigorous and painful) for a workout intensity level and asking that they workout at nothing above a 3-5 will help them learn to do subtle work, effort with ease, allowing for a steady practice of growth with less setbacks or injury.

See Appendix A for Home Plan of Care until the next YT

See Appendix B for PCP letter summarizing YT assessment with proposed plan of care (I would also enclose a YT FM brochure that had the latest research)

Conclusions and Future Study

Teaching FM patients to fully participate in CAM programs such as YT may produce long-term benefits and help erode self-defeating beliefs by taking control of their self-care. (Bir, 2016) A greater number of randomized control trials (RCT) are needed and current research supports YT as CAM for FM. Participants who completed weekly journals suggested increasing it to more than once a week because it did not capture the richness and variability of their experience. (Rudrud, 2012) Future research determining the role that a charismatic or caring YT plays rather than the intervention itself along with standardization of protocols, scripting mindfulness interventions, posture sequences and a range of modifications is needed. (Mist, 2013) CSS paradigm seems an important new concept with considerable significance that deserves further exploration. (Yunus, 2007) This growing body of research is proving that FM is not a made up disease and one that needs to be taken seriously.  Allopathic, Ayurveda, and Pancamaya model tools can lead to an incredible healing journey.

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