Page 1

Integrative Pain Management for Optimal Patient Care

The Pain Practitioner January / February 2017

Frida Kahlo Many historians agree she suffered

chronic widespread pain with symptoms that were identified as being typical of fibromyalgia.

+

Integrative Approaches to Fibromyalgia Empowered Pain Management Fibromyalgia Treatment at Brooke Army Medical Center Mindful Awareness Training for Persistent Pain


LET NOTHING STOP THEM.™

Alpha-Stim

When they’re in pain

®

Give your patients sustainable relief, quickly and safely. proVen: Alpha-Stim Significantly Reduces Pain

Through rigorous testing, the Alpha-Stim® M has been proven to effectively reduce acute, chronic, and post-traumatic pain by providing Microcurrent Electrical Therapy (MET). Additionally, the unique Cranial Electrotherapy Stimulation (CES) feature of the Alpha-Stim treats anxiety, depression, and insomnia in pain patients. Alpha-Stim is: • Cumulative in effectiveness, with most patients showing improvement after the first treatment • Safe, with no serious adverse events in over 35 years

In a study of severe pain patients, Alpha-Stim reduced pain by an average of 71% after only 5 treatment sessions1

Chronic pain patients using Alpha-Stim reported significantly improved functionality compared to the usual care and sham groups2

• Used as a first-line therapy, or as an adjunct to pharmacotherapy (without polypharmacy effects)

Help for your patients is Here. To get started and to see more clinical data, visit www.alpha-stim.com or call 1-800-for-pain (in USA) or +940-328-0788 (Outside USA). REFERENCES 1. Holubec JT. Cumulative response from Cranial Electrotherapy Stimulation (CES) for chronic pain. Practical Pain Management. 2009; 9(9):80-83. 2. Taylor AG, Anderson JG, Riedel SL, et al. Cranial Electrotherapy Stimulation improves symptoms and functional status in individuals with fibromyalgia. Pain Management Nursing. 2013 Dec; 14(4):327-335. Alpha-Stim and the Alpha-Stim logo are registered trademarks, and LET NOTHING STOP THEM is a trademark of Electromedical Products International, Inc. ©2017 Electromedical Products International, Inc. All rights reserved. Read a full disclosure of the minor and self-limiting risks here: alpha-stim.com/risk.


Academy of Integrative Pain Management

The Pain Practitioner JANUARY/FEBRUARY 2017

To access the virtual magazine, go to newsstand.aapainmanage.org

4 NOTES FROM THE FIELD Integrative Management: Not Just For Chronic Pain By Bob Twillman, PhD, FAPM, Executive Director PAGE 4

5 EDITORIAL Individual and Integrated By W. Clay Jackson, MD, DipTh, Editor-in-Chief 6 ANNUAL MEETING/EDUCATION A Patient Undergoing Rectal Surgery By Jeff Gudin, MD

PAGE 8x

7 PROFESSIONAL DEVELOPMENT Collateral Damage: Chronic Pain and the Family 8 ADVOCACY Advocacy Efforts Bring Positive Change By Katie Duensing, JD, SPPAN Assistant Director for Legislative and Regulatory Affairs 9 Research Research Recap

PAGE 12

10 PCORI: Enlisting the Brain in the Fight against Pain By Carl Sherman 12 Empowered Pain Management By Debra Nelson-Hogan 13 Integrative Approaches to Fibromyalgia By Melinda Ring, MD

PAGE 20

On the cover: Self Portrait 1943 by Frida Kahlo Getty Images

17 Fibromyalgia Treatment at Brooke Army Medical Center By Catherine A. Vriend, PhD 20 Mindful Awareness Training: A Promising Treatment Approach for Persistent Pain By Carolyn McManus, PT, MS, MA

And More, on the Web... Access the 2016 Archives Online! Did you know that we now have seven issues of The Pain Practitioner available online? Catch up on issues you may have missed by reading them on your desktop, mobile phone, or tablet. Plus, you can access extra interactive content like videos and slideshows and share them with your colleagues and team members!

Subscribe to The Pain Practitioner even if you are not a member... you can still get this bi-monthly publication for just $50 annually! Send your check to the Academy of Integrative Pain Management, 975 Morning Star Drive, Ste. A, Sonora, CA 95370

www.aapainmanage.org ACADEMY BOARD OF DIRECTORS President Joanna Katzman, MD, MSPH Past President Robert A. Bonakdar, MD, FAAFP Vice President W. Clay Jackson, MD, DipTh Secretary Paul Christo, MD, MBA Treasurer Kevin T. Galloway, BSN, MHA, Colonel, US Army (Retired) Directors-at-Large Alfred V. Anderson, MD, DC George D. Comerci, Jr, MD, FACP John Garzione, DPT Christian D. GonzĂĄlez, MD Michael Kurisu, DO, ABIHM Joseph Matthews, DDS, MSc Liaison to the Board Maggie Buckley

ACADEMY STAFF Executive Director Robert Twillman, PhD, FAPM Director of Professional Development Debra Nelson-Hogan Director of the State Pain Policy Advocacy Network (SPPAN) Amy Goldstein, MSW Assistant Director of Education Cathleen Coneghen SPPAN Assistant Director for Legislative and Regulatory Affairs Katie Duensing, JD Member Services Manager Whitney O’Donnell Account Managers Rosemary LeMay Professional Development Project Manager MacKenzie Davis Office Manager Karen Hebert

THE PAIN PRACTItiONER STAFF AND CONSULTANTS Editor-in-Chief W. Clay Jackson, MD, DipTh Editor Debra Nelson-Hogan Advertising and Sales Leslie Ringe Managing Editor Cathleen Coneghen Clinical Editor Christine Rhodes, MS Art Director Peter McKinley, Pak Creative Copy Editor Rosemary Hope

The Pain Practitioner is published by the Academy of Integrative Pain Management, P: 209-533-9744, F: 209-533-9750, Email: aapm@aapainmanage.org, website: www. aapainmanage.org. Copyright 2007 American Academy of Pain Management. All rights reserved. Send correspondance to: Debra NelsonHogan at dhogan@aapainmanage.org. For advertising opportunities, media kits, and prices, contact: Leslie Ringe, 209-288-2207, leringe@verizon.net The Pain Practitioner is published by the Academy of Integrative Pain Management solely for the purpose of education. All rights are reserved by the Academy to accept, reject, or modify any submission for publication. The opinions stated in the enclosed printed materials are those of the authors and do not necessarily represent the opinions of the Academy or individual members. The Academy does not give guarantees or any other representation that the printed material contained herein is valid, reliable, or accurate. The Academy of Integrative Pain Management does not assume any responsibility for injury arising from any use or misuse of the printed material contained herein. The printed material contained herein is assumed to be from reliable sources, and there is no implication that they represent the only, or best, methodologies or procedures for the pain condition discussed. It is incumbent upon the reader to verify the accuracy of any diagnosis and drug dosage information contained herein, and to make modifications as new information arises. All rights are reserved by the Academy to accept, reject, or modify any advertisement submitted for publication. It is the policy of the Academy to not endorse products. Any advertising herein may not be construed as an endorsement, either expressed or implied, of a product or service.


notes from the field

Integrative Pain Management: Not Just for Chronic Pain Any More By Bob Twillman, PhD, FAPM, Executive Director

Much is said in the media about the glut of opioid prescribing, with a focus on the treatment of both acute and chronic pain. My perception has been that, as clinicians, we tend to focus most heavily on providing integrative pain care for people with chronic pain, and tend to say relatively little about acute pain. I think that may be a mistake, and that we may have a great deal to offer people with acute pain. Along the way, we may also be able to make a sizeable dent in the excess prescribing of opioids for acute pain, sharply reducing the supply available for diversion, misuse, and abuse. Some of what we have to offer may be a common-sense approach to what I’ve begun calling opioid stewardship, but we may be able to tack on additional benefits by providing integrative pain care in an acute pain setting.

the hydrocodone tablets pre-operatively and three of the long-acting oxycodone tablets post-operatively, leaving 133 tablets in three different bottles. Why does this happen? How does this one family of three people wind up with 223½ opioid tablets they don’t need? I’ve proposed for some time now that the primary reason this happens is that no one ever follows up to find out how much medication patients actually need for acute pain. A new study (1) from researchers at Dartmouth Hitchcock did that follow-up and found that, for 642 patients undergoing five outpatient procedures, on average, only 28% of prescribed pills were taken. Further, if the number of pills prescribed was set at the 80th percentile

“Pills, pills everywhere…” Paraphrasing The Rime of the Ancient Mariner, it seems that we are surrounded by a sea of unused opioid medications that were prescribed for the treatment of acute pain. I often hear apocryphal stories about the teenager whose third molar extraction warranted a prescription for a month’s supply of hydrocodone tablets (interestingly, when I press people on this, I often find it was a prescription for 30 pills, not for a 30-day supply), or the day surgery patient who was discharged with enough medication to treat 10 patients. Most of us have stories like this. Consider one family’s experience: A teenager has all four third molars extracted, and is discharged with a prescription for 15 hydrocodone/acetaminophen tablets; two are used, leaving 13 in the medicine cabinet. The teenager’s middle-aged mother has an arthroscopic partial medial meniscectomy, and is discharged with 80 oxycodone/acetaminophen tablets; 2½ are used, and 77½ remain unused. The teenager’s middle-aged father falls, breaking his radial head; he is prescribed 30 hydrocodone/acetaminophen tablets in the emergency department, despite the fact that he is going to surgery in 13 hours, and is prescribed 20 controlled-release oxycodone tablets and 90 short-acting oxycodone tablets after having a prosthetic radial head installed, despite the fact that he has a nerve block in place that will render him pain-free for three days. He takes four of

4

of need for each procedure, nearly 10,000 fewer pills would have been prescribed to these 642 patients! Clearly, there is a common-sense solution here—do some follow-up, determine the actual needs for most patients, and prescribe (fewer pills) accordingly!

Integrative pain care FOR acute pain There may be additional ways in which we integrative pain care devotees can help with this problem, as well. At St. Joseph’s Medical Center in Paterson, New Jersey, Mark Rosenberg, DO, chairman of emergency medicine, has instituted a

| T HE PA I N P R AC T I TI O NE R | J A N U A R Y / F E B R U A R Y 2 0 1 7

robust integrative pain care program in his department. In five months, the hospital has reduced emergency department opioid use by 38%, according to an article in The New York Times (2). Patients who ordinarily would have been prescribed an opioid, instead, may receive trigger-point injections, be treated with non-opioid medications, have appropriate case management and post-discharge care arranged, or may even be visited by the resident harp player. Emergency department staff members are trained on how to talk to patients about non-opioid options for treating their pain, and often lead patients through basic relaxation techniques as their first intervention. Reportedly, both patients and staff usually walk away satisfied—and that’s an improvement, too! There really is no reason to think that the integrative approach we tout for chronic pain can’t also be effective for acute pain. In our efforts to teach people how to deliver optimal pain care by using a multimodal, multidisciplinary, patient-centered approach, we can’t just confine ourselves to those with chronic pain. If, as we believe, such an approach will reduce the need for opioids in people with chronic pain, shouldn’t we also believe that the same is true for acute pain patients? We know we have much to offer everyone with pain, so let’s get creative, like Dr. Rosenberg has, and see how much we can do to address the glut of opioids coming from emergency rooms and surgery centers—and make people a lot more comfortable in the bargain! ❏ References 1. Hill V, McMahon ML, Stucke RS, Barth RJ. Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Ann Surg. 2016. Sep. 14 [Epub ahead of print] 2. Hoffman J. An E.R. kicks the habit of opioids for pain. The New York Times. June 10, 2016. https://www.nytimes.com Accessed: January 17, 2017. Bob Twillman, PhD, is the executive director for the Academy of Integrative Pain Management. Dr. Twillman is responsible for overseeing federal and state pain policy developments and advocating for those supporting an integrative approach to managing pain. He also serves as Chair of the Prescription Monitoring Program Advisory Committee for the Kansas Board of Pharmacy.


Individual and Integrated The Pain Practitioner Is Your Source for Multimodal, Patient-centered Care

EDITORIAL

W. Clay Jackson, MD, DipTh, Editor-in-Chief

You’re holding in your hand—or scrolling through with your browser—an important tool in your therapeutic armamentarium. Do you believe that? I absolutely do, and it’s why I was thrilled when the Academy of Integrative Pain Management asked me to serve you as your next Editor-in-Chief. The Pain Practitioner is a way of connecting you to the latest scientific advances, clinical tips, professional trends, and a network of colleagues around North America and the world. We believe that you, the dedicated and informed clinician, constitute a key component of wellness in your patients’ lives, and we want to be your resource of choice in achieving your shared goals with your patients. As we approach what our Executive Director, Bob Twillman, has termed the “twin public health crisis” of undertreated pain and overprescription of opioids in the US, we believe that the Academy is uniquely positioned among professional organizations to serve as nexus for research, advocacy, and networking for those clinicians who are deeply motivated to serve their patients with excellence and compassion. You’ll find in this issue that engaging the power of the biopsychosocial-spiritual model is the focus of achieving quality outcomes in a classic chronic pain diagnosis, fibromyalgia. Integrative care works, because its multimodal approach brings to bear far more clinical power than a single focus on one way of treating the patient’s symptoms. In keeping with our focus on fibromyalgia in this issue, we are delighted to feature Mexican artist Frida Kahlo on our cover. When she was 18, Kahlo was in bus accident that left her with many broken bones and a deep abdominal wound. There has been some speculation that Kahlo may have suffered from symptoms of fibromyalgia, including pain and fatigue, and in fact, her work seems to align with the tender points of fibromyalgia. Whether her symptoms were indeed due to fibromyalgia or

from chronic post-traumatic arthritis (or a combination of both), the fact remains that her pain was a powerful influence on her art. One has only to look at her work to feel her suffering. If Kahlo shows us that art can come from pain, then member Maggie Buckley, patient liaison to the AIPM Board of Directors, is our inspiration for understanding that living with chronic pain is an art in and of itself. Her journey with chronic pain started when she was diagnosed with EhlersDanlos Syndrome at age 13 and in subsequent years she developed fibromyalgia and suffered migraines. In an interview in this issue, Maggie tells us how she has learned to listen to her body and manage her life through a body-mind-sprit approach that includes exercise, nutrition, and exquisite self-care. If her story underscores the idea that self-management is vitally important to our patients’ quality of life, then Catherine Vriend’s article describing the Fibromyalgia Treatment Program at Brooke Army Medical Center in San Antonio will point you to some ideas on how to implement such a program. Finally, Melinda Ring, MD, Executive Director of the Northwestern Medicine Osher Center of Integrative Medicine, has provided a fine overview of integrative approaches to fibromyalgia. I look forward to hearing from you regarding your response to the content of The Pain Practitioner. As you can see, it’s more than a magazine or journal— it’s a platform for interacting with your colleagues and partners in excellence from around the globe. If you have ideas, you’ll find that we’re approachable and welcome your input. Careful— you just may volunteer yourself into our next great advance in care! Our patients are paramount. The needs are great, but our resources—when we stand together— are equal to the task. Let’s do great things! ❏

Twitter: @mydocjackson Email: education@aapainmanage.org

Editorial Advisory Board

W. Clay Jackson, Editor-in Chief, is Clinical Assistant Professor of Family Medicine and Psychiatry at the University of Tennessee College of Medicine in Memphis, Tennessee, where he maintains a private practice in family and palliative medicine. He is also the Medical Director of Comprehensive Primary Care, and of Methodist Hospice and Palliative Services. Dr. Jackson is the Associate Fellowship Director of Palliative Medicine at the University of Tennessee College of Medicine. Michael Sprintz, DO, is the founder and Chief Medical Officer of Sprintz Center for Pain and Dependency in The Woodlands, Texas. He is triple board certified in pain medicine, addiction medicine, and anesthesiology. Jay Ginsberg, PhD, is a licensed clinical psychologist and neuropsychologist at the Dorn VA Medical Center, Columbia, South Carolina, where he is an advocate for integrative health and wellness using mind-body treatments for pain and PTSD. Alice Inman, PsyD, MSCP, is a clinical health psychologist in the Hematology/Oncology Clinic and director of Clinical Health Psychology Fellowship at the San Antonio Military Medical Center in San Antonio, Texas. She is also an Adjunct Professor in the School of Psychiatry, Department of Medicine, at the University of Texas Health Science Center, San Antonio, Texas. Bob Gatchel, PhD, is the director of the Center for Excellence for the Study of Health & Chronic Illness at the University of Texas at Arlington, as well as Director of Biopsychosocial Research, Osteopathic Research Center, University of North Texas Health Science Center. He also is clinical research program consultant at the Eugene McDermott Center for Pain Management at the University of Texas Southwestern Medical Center at Dallas. Brett Badgley Snodgrass, FNP-C, CPE, FACPP, is the director of clinical operations at LifeLinc Pain in Memphis, Tennessee. Alan Kaul, PharmD, MBA, FCCP, is the president at Medical Outcomes Management in Foxboro, Massachusetts. Nancy Cotter, MD, FAAPMR, FABIHM, FACN, is the founding medical director of the Integrative Medicine Program at Atlantic Health in New Jersey, and currently serves as the physician lead, Integrative Medicine, for VA New Jersey. Roger Mignosa, DO, is a physical medicine and rehabilitation physician, clinical professor of medicine, and exercise physiologist. He has taught at the University of Arizona-Center for Integrative Medicine for since 2011. Lucy Whyte Ferguson, DC, is a faculty member of the University of New Mexico Pain Center and a consultant with Project ECHO in New Mexico.

TH E PAIN PRACTITION ER

| VOLUME 27, NUMBER 1 |

5


Annual meeting/EDUCATION

Ask the Expert

A Patient Undergoing Rectal Surgery

By Jeff Gudin, MD

Pain relief must be tailored to the individual and the situation. There are times when it is not possible to give opioids, or it would be in the best interest of the patient to avoid opioids for postoperative pain, such as in the case below. Designing an analgesic regimen with little to no side effects can be challenging. We ask Jeff Gudin, MD, director of Pain Management and Palliative Care at the Englewood Hospital and Medical Center, Englewood, New Jersey, to comment.

Q:

A 42-year-old man is undergoing surgery for rectal cancer. He has a history of anal fissures, had a myocardial infarction at age 35, is overweight and continues to smoke cigarettes and use alcohol to a moderate degree. The patient was told that he must limit opioids postoperatively because of opioid-induced constipation with the danger of reopening his wound while straining to have a bowel movement. He is concerned about the pain, having undergone a previous painful procedure in the area (hemorrhoidectomy). What is your recommendation for an optimal postoperative pain regimen in this patient?

A:

As for any patient with pain, the goal is to provide adequate pain relief while minimizing complications. As we know, one of the main complications of opioids is constipation. As a pain specialist, when designing perioperative analgesics regimens, I always go back to basics: Optimize use of multimodal analgesic techniques to provide an opioid-sparing benefit. The use of a comprehensive, preemptive multimodal analgesic regimen has been shown to lower opioid requirements, minimize opioidrelated adverse side effects and complications, and reduce hospital length of stay.

Multimodal analgesia captures the effectiveness of individual agents in optimal dosages that maximize efficacy and attempts to minimize side effects from one analgesic (mainly opioids). This important concept employs the theory that agents with different mechanisms of analgesia may have synergistic effects in preventing or treating acute pain when used in combination. These regimens must be tailored to individual patients, keeping in mind the procedure being performed, side effects of individual medications, and patients’ pre-existing medical conditions (1). At our institution, we maximize the use of pre- and intra- operative analgesics and approaches. Our pain management team sees most spine and joint patients preoperatively, especially when pain or opioids are an existing issue. Preemptive regimens are individualized, including opioids and gabapentinoids. Regional anesthesia techniques are utilized when appropriate (including catheter techniques), and many surgeons have adopted the use of longacting liposomal bupivacaine injected into the wound and surrounding tissues. Our anesthesiologists regularly administer the first dose of intravenous acetaminophen or NSAID, which is continued for 24 to 48 hours postoperatively. Each of the above strategies has opioid-sparing properties, but may not completely obviate the need for opioids following surgery. Even small doses of opioids, combined with dehydration, immobility, bowel surgery and other factors, certainly predispose patients to constipation. At our institution, most patients are started on stool softeners and laxatives in the immediate postoperative period.

E FRE

Earn 5 CME Credits with our FREE Online Opioids Course!

Chronic Pain and Opioid Use: Best Practices in the Current Environment For more information, go to goo.gl/cclsib

This 5-hour program provides education on the optimal management of chronic pain, particularly using opioids appropriately and managing patients’ risk for harm. For more information, go to goo.gl/cclsib

6

| T HE PA I N P R AC T I TI O NE R | J A N U A R Y / F E B R U A R Y 2 0 1 7

For patients with a clear diagnosis of opioid-induced constipation (OIC), especially if they are maintained on opioids chronically, l would consider one of the novel peripherally acting mu-opioid receptor antagonists (PAMORAs), which decrease the constipating effects of opioids. We recognize that traditional laxatives are often not effective at controlling OIC. However, clinicians must recognize the contraindications to PAMORAs, including avoiding use in patients with known or suspected gastrointestinal (GI) obstruction and patients at increased risk of recurrent obstruction, due to the potential for GI perforation. It is obviously not for use in patients with a fresh anastomosis. In addition, a hydrating postsurgery diet with gradual addition of raw fruits, vegetables, and fiber are helpful to keep regular bowel movements. Another option is to repopulate the gut with beneficial bacteria by eating yogurt and foods that naturally contain probiotics, or even by supplementing with a probiotic. Exercise will also help stimulate bowel movements. It is believed that the more you move, the more food moves through your body. If possible, exercises that stimulate the abdominal wall muscles are likely more beneficial, but even walking is helpful to increase movement. The use of opioids has long been viewed as the standard of care for treating postoperative care for most surgeries, including abdominal surgery. Although opioids are the mainstay for acute postoperative pain, their many adverse effects such as respiratory depression, nausea, vomiting, and bowel dysfunction, limit their use. A safe, effective multimodal, opioid-sparing pain management plan can optimize patient outcomes following most surgery. â??

Jeff Gudin, MD, is director, Pain and Palliative Care, at Englewood Hospital and Medical Center, Englewood New Jersey, and clinical instructor, Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York. He is board certified in pain management, anesthesiology, palliative care, and addiction Medicine.

Reference 1. Buvanendran A, Kroin JS. Multimodal analgesia for controlling acute postoperative pain. Curr Opin Anesthesiol. 2009;22:588-593.


PROFESSIONAL DEVELOPMENT

Collateral Damage: Chronic Pain and the Family Alfred V. Anderson, MD, former Academy board president, is not a stationary kind of guy. In addition to being a physician and a chiropractor, he is a musician (a drummer, of course), a biker, an RV enthusiast, and a general lover of outdoor activities. He enjoyed these activities with his wife, Carol, until surgery to remove a lymph node damaged her pudendal nerve. Thus began the downward spiral that has left Carol in intractable pain and Anderson, who has specialized in pain management for 32 years, feeling helpless and, sometimes, even hopeless. Dr. Anderson explained that initially the damaged nerve did not interfere with Carol’s activity, but as time passed she could not sit. “It is amazing how much we sit in our daily life,” Dr. Anderson said, “This impacted even simple things, like going out to dinner or going to the movies. She was fine standing and walking, but you can’t stand and walk all the time.” Ultimately the cascade that takes place with chronic, intractable pain can limit function; in Carol’s case, it got worse as time went on. Since there is an ethical issue regarding treatment of a family member, she was referred to a pain specialist who performed various injections and placed her on medication. “Carol was on high doses of schedule II opioids. Even though she could tolerate the pain, she still could not sit for protracted periods of time,” Dr. Anderson explained. It was decided that a trial with a spinal cord stimulator might be helpful. And although CE OUR RES

she did very well with the trial, five or six days after the the leads were implanted, the pain relief stopped. Radiographs showed the leads had slipped; this subsequently required another surgical procedure to remove those leads and to put a paddle electrode into the spine. This involved doing a hemilaminectomy, which is a surgical procedure required for placement of the electrodes. Finally, she didn’t get the charging mechanism done properly with the unit, so the first two weeks she endured pure agony. Subsequently, she has gone through all manner of therapies, but ultimately the nerve damage translated to chronic widespread pain. Her only minimal relief is exercise programs such as yoga and other integrated systems. Dr. Anderson is learning what is like to be part of his loved one’s pain. “This collateral damage—the impact on the family—is devastating. It is more than just asking families to change their lifestyle to accommodate a loved one’s pain; the foundation of the family changes and too often results in divorce and/or financial ruin. Fortunately this situation has brought us closer together.” Dr. Anderson admits that his personal situation has prompted him to look more carefully at the families of his own patients. “The family members are showing as much strain and stress in their facial expressions as the patient. It is agonizing for the family members. I think we should spend some time thinking about the secondary effect on the family.” The family, much like the highimpact pain patients, are now considered “collateral damage” by many experts who are observing inadequate access to highquality, integrative treatment of pain. ❏

S

Family Support

Several patient advocacy groups have resources, including support groups, to help families of those with chronic pain, including: The American Chronic Pain Association (ACPA): https://theacpa.org/coping-within-the-family Interstitial Cystitis Association: http://www.ichelp.org/support/caregiver-support/ National Fibromyalgia & Chronic Pain Association: http://www.fmcpaware.org/community/nfmcpa-education-and-support-groups.html Pain Connection: http://www.painconnection.org/ PAINS: http://www.painsproject.org/ and https://www.theacpa.org/uploads/chronicle_ march2012_ONLINE.pdf Reflex Sympathetic Dystrophy Syndrome Association (Complex Regional Pain Syndrome [CRPS]): http://rsds.org/caregivers/ The Foundation for Peripheral Neuropathy: https://www.foundationforpn.org/ The Pain Community Caregiver forum: http://paincommunity.org/forums/forum/caregivers/ TMJ Association: http://tmj.org/ US Pain Foundation: http://www.uspainfoundation.org/support-groups/

Contributors

Donations support the vital work of the Academy’s policy and advocacy efforts. We would like to thank the following contributors: Raman Kapur, MD Petra Burke-Ramirez,MD Johnny L. White, Jr., MD, MBA Lillian Matthews, DPM Lesslie G. Moore, DDS, DN, PhD Anne R. Wolfe, PhD Donations may be tax deductible as an ordinary business expense. If you would like to donate in support of our policy and advocacy please contact the Academy at 209-5339744 or aapainmanage.org.

Newly Credentialed Members

Advanced Diplomate Boris Leybel, MD, Saddle River, New Jersey Mark A. King, MD, Roseville, California John Patrick Maye, PhD, CRNA, Tampa, Florida Diplomate Zhaoxue Lu, PhD, LaC, Lake Oswego, Oregon Mark Mulak, DC, Cranston, Rhode Island

In Memory We honor the memory of the following deceased members: Richard B. Garver, EdD Martin M. Becker, DPM

TH E PAIN PRACTITION ER

| VOLUME 27, NUMBER 1 |

7


ADVOCACY

Advocacy Efforts Help Bring Positive Change across the Nation By Katie Duensing, JD, SPPAN Assistant Director for Legislative and Regulatory Affairs

For more than five years, AIPM’s State Pain Policy Advocacy Network has been working to improve the state of pain care across the country, advocating for policies that allow pain care providers to deliver optimal care to their patients and that improve access to, and affordability of, that optimal care. During those years, we have seen a spotlight turned upon the practice of pain management unlike ever before, which has brought many challenging changes—but with these challenges also comes great opportunities to improve the care for people with pain. The theme of change has already carried into 2017, as we saw the New Year rung in with the adoption of four policies across the nation that we have been working on for months—even years in one case. Our hard work and diligence, in concert with many other organizations and advocates has paid off, and we couldn’t be more excited to share these positive results with our AIPM members!

Delaware The state has been considering adoption of the Division of Professional Regulation’s Safe Prescribing of Opioid Analgesics since 2015, and we have been working to improve this regulation at every opportunity, submitting extensive comments in 2015 and twice in 2016. As originally proposed, this regulation would have merely been intended to “address potential prescription drug overdose, abuse, and diversion.” At our suggestion, the regulation now also intends to “encourage the proper and ethical treatment of pain.” Also at our suggestion, documentation requirements for prescribers were clarified so that they don’t inadvertently leave skilled and well-intentioned practitioners open to unjust and unintended liability. Many of our other suggestions were also adopted verbatim or nearly verbatim, addressing concerns related to treatment agreements, definitions, referral to a pain or addiction specialist, and more. While this regulation is not perfect, we are relatively happy with its final state and thrilled with the changes we were able to effect along the way.

8

New York The state of New York welcomed 2017 by passing legislation to reform step therapy. After years of patients’ rights groups advocating for this type of reform, Governor Andrew Cuomo has signed a law that requires health insurers to respond to step therapy appeal requests with 72 hours in normal circumstances and 24 hours in emergency situations in order to prevent unnecessary delays in critical care for patients. All too often, the utilization of step therapy forces patients with serious and degenerative medical conditions to undergo an indefinite, painful, and often dangerous, process of trial and error before finally receiving the treatment originally recommended by their health care provider. We believe passage of this legislation will help to ensure that patients are able to receive the optimal medication for their particular situation, as determined by their health care provider, and will also result in an overall financial savings to the patient and the health care system.

Michigan Michigan took steps to reduce fatalities related to opioid overdoses when they recently approved legislation that allows Michiganders to obtain and carry the life-saving opioid overdose reversal drug naloxone without a prescription. We have long supported this legislation that allows Michigan’s Chief Medical Executive to issue a statewide standing order for naloxone, as we believe that passage of this bill is a vital step in improving the public health and preventing tragic, unintended, and avoidable deaths from opioid overdoses.

Federal level Passage of the ECHO Act requires specified federal agencies to study technologyenabled collaborative learning and capacity building models and the ability of those models to improve patient care and provider education. These programs, known as ECHO programs, link expert specialist teams at an academic medical center with primary care clinicians in local communities in order to share expertise. Essentially, the

| T HE PA I N P R AC T I TI O NE R | J A N U A R Y / F E B R U A R Y 2 0 1 7

federal government will conduct a study that analyzes ECHO programs from across the country to determine their effectiveness. We at AIPM have been supportive of ECHO programs for years, as we see them as an incredibly effective way to bring high quality pain care to rural and/or underserved areas, expanding the number of clinicians that are trained to provide care to those living with complex pain conditions. In fact, AIPM’s current Board President and Executive Director participate in ECHO programs in New Mexico and Kansas, respectively. We look forward to this study’s findings, as positive findings would likely result in expansion of, and increased funding for, ECHO programs across the country. To see currently active legislation and regulations that need your support or opposition, visit http://www.sppan.aapainmanage.org. To talk about ways to get involved in advocacy efforts in your state, contact SPPAN’s Director, Amy Goldstein, at agoldstein@aapainmanage.org. If you have a question about specific legislation or regulations, contact Katie Duensing, SPPAN’s Assistant Director for Legislative and Regulatory Affairs, at kduensing@aapainmanage.org. ❏ Katie Duensing, JD, is the Assistant Director for Legislative and Regulatory Affairs for the State Pain Policy Advocacy Network, a project of the Academy of Integrative Pain Management. She monitors, analyzes, and works to improve pain-related policies from every jurisdiction across the nation, actively engaging with policymakers to help shape optimal, person-centered pain policies.


RESEARCH

Research Recap Every other week, Currents, the AIPM’s e-newsletter, publishes research and guidelines on issues related to chronic pain. You can subscribe to Currents and the digital version of The Pain Practitioner from this link: http://blog. aapainmanage.org/notifications-the-pain-practitioner/

consumers, patients, and physicians more aware of its potential. A program to increase the visibility of camu camu can contribute substantially not only to the management of inflammatory conditions and its positive contribution to overall good health but also to its potential role in many disease states. Read more: http://www.ncbi.nlm.nih.gov/pubmed/25275221

Neuropeptides CRH, SP, HK-1, and inflammatory cytokines IL-6 and TNF are increased in serum of patients with fibromyalgia syndrome, implicating mast cells.

Are strong opioids equally effective and safe in the treatment of chronic cancer pain? A multicenter randomized phase IV ‘real life’ trial on the variability of response to opioids.

This study shows that neuropeptides corticotropin-releasing hormone (CRH), substance P (SP), and SP-structurally-related hemokinin-1 (HK-1) were significantly elevated in the serum of patients with FMS compared with healthy controls. Moreover, SP and HK-1 levels were positively correlated in fibromyalgia syndrome (FMS). The serum concentrations of the inflammatory cytokines interleukin (IL)-6 and tumor necrosis factor (TNF) were also significantly higher in the FMS group compared with healthy subjects. In contrast, serum IL-31 and IL-33 levels were significantly lower in the FMS patients in comparison with healthy controls. The current results indicate that neuropeptides could stimulate mast cells to secrete inflammatory cytokines that contribute importantly to the symptoms of FMS. Treatment directed at preventing the secretion or antagonizing these elevated neuroimmune markers, both centrally and peripherally, may prove to be useful in the management of FMS. Read more: https://www.ncbi.nlm.nih.gov/pubmed/26763911 Adjunctive acupuncture for pain and symptom management in the inpatient setting: protocol for a pilot hybrid effectiveness-implementation study. Common pharmacologic approaches for pain have serious side effects and are not appropriate for all patients. Results from randomized controlled trials support the efficacy of acupuncture to manage symptoms such as postoperative pain, cancer-related pain, nausea and vomiting, and withdrawal from narcotics. A pilot study using a hybrid effectiveness-implementation design will assess the effectiveness of acupuncture to manage pain and other symptoms and improve patient satisfaction; and evaluate the barriers and facilitators to implement an on-going acupuncture service for inpatients. Read more: http://www.ncbi.nlm.nih.gov/pubmed/27181130 Craniosacral therapy for the treatment of chronic neck pain: a randomized sham-controlled trial. With growing evidence for the effectiveness of craniosacral therapy (CST) for pain management, the efficacy of CST remains unclear. This study aimed at investigating CST in comparison with sham treatment in chronic nonspecific neck pain patients. Read more: http://www.ncbi.nlm.nih.gov/pubmed/26340656 Antioxidant and associated capacities of camu camu (Myrciaria dubia): a systematic review As patient-centered care is embracing a multimodal, integrative approach to the management of disease, patients and physicians are increasingly looking to the potential contribution of natural products. Camu camu, a well-researched and innovative natural product, has the potential to contribute, possibly substantially, to this management paradigm. The key issue is to raise camu camu’s visibility through increased emphasis on its robust evidentiary base and its various formulations, as well as making

Guidelines tend to consider morphine and morphine-like opioids comparable and interchangeable in the treatment of chronic cancer pain, but individual responses can vary. This study compared the analgesic efficacy, changes of therapy, and safety profile over time of four strong opioids given for cancer pain. Read more: http://www.ncbi.nlm.nih.gov/pubmed/26940689 Comparative effectiveness of Tai Chi versus physical therapy for knee osteoarthritis: a randomized trial. Studies have suggested that Tai Chi alleviates the symptoms of knee osteoarthritis but there have been no trials that directly compared Tai Chi with standard therapies. 204 participants with symptomatic knee osteoarthritis (mean age: 60 years; 70% women, 53% white) did either Tai Chi twice a week for 12 weeks or physical therapy twice a week for six weeks followed by six weeks of monitored home exercise. The primary outcome was Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at 12 weeks and the score was substantially reduced in both groups. Both groups significant improvement in most secondary outcomes and were maintained up to 52 weeks although the Tai Chi group had greater improvements in depression and the physical component of quality of life. Read more: http://annals.org/article.aspx?articleID=2522435 A quasi randomized-controlled trial to evaluate the effectiveness of clown therapy on children’s anxiety and pain levels in emergency department. This study investigated whether using medical clowns during painful procedures in the emergency department (ED) affects children’s anxiety and pain. Forty children (4-11 years) admitted to the ED for pain procedures were enrolled and assigned to the clown group or to the control groups in which they were entertained by parents and ED nurses. Anxiety was assessed by the Children’s Anxiety and Pain scales and pain was evaluated with the Numerical Rating Scale and Wong-Backer Scale. Children’s anxiety levels were significantly lower in the clown group than those in the control group, but pain levels were the same in both groups. Read more: http://www.ncbi.nlm.nih.gov/pubmed/26755209 Integrative therapies for low back pain that include complementary and alternative medicine care: a systematic review. This review demonstrated support in the literature for integrated CAM and conventional medical therapy for the management of chronic low back pain (LBP). The combined therapies were more effective for the management of LBP than single modalities. Further research into the integrated management of LBP is clearly needed to provide better guidance for patients and clinicians. Read more: http://www.ncbi.nlm.nih.gov/pubmed/25568825 TH E PAIN PRACTITION ER

| VOLUME 27, NUMBER 1 |

9


PCORI

This article was originally published in October 2016 as a Research in Action feature on the PCORI website (www.pcori.org). It is published here with the permission of the Patient-Centered Outcomes Research Institute.

PCORI: Enlisting the Brain in the Fight against Pain

Reducing Disparities with Literacy-Adapted Psychosocial Treatments for Chronic Pain: A Comparative Trial By Carl Sherman

A project in Alabama takes a down-to-earth approach in teaching patients to think differently and cope more effectively with chronic pain. It may alleviate depression, too. Chronic pain is a major health problem, particularly among economically disadvantaged people. Compared with the general population, they have not only a higher incidence of chronic pain but also less access to pain treatment. Preliminary results of “Reducing Disparities with Literacy-Adapted Psychosocial Treatments for Chronic Pain: A Comparative Trial,” a Patient-Centered Outcomes Research Institute-(PCORI)-funded project suggest that group sessions of both cognitive behavioral therapy (CBT) and education about pain can help disadvantaged people deal with chronic pain. Certain pain education interventions and CBT have previously been shown to reduce chronic pain’s intensity and impact. But these interventions have mainly been tested on literate, middleclass patients. A PCORI-funded team wanted to know whether economically disadvantaged people can benefit from the methods when tailored to reduce reading and writing demands, as well as complexity, and adapted to be culturally appropriate. If the revised methods are effective, health care providers may be able to offer evidence-based pain management approaches that don’t require advanced technology.

Preliminary Findings The study divided its 300 participants—most of whom live below the poverty threshold and have poor reading ability—into three sets (medical treatment only; medical treatment plus group pain education; and medical treatment plus group CBT that includes pain education). The study’s principal investigator, Beverly E. Thorn, PhD, of the University of Alabama, had adapted standard CBT practices and patient materials, as well as the group education materials, for this population. The research team evaluated the participants immediately before and after 10 weeks of group treatments, and six months after those treatments ended. “The preliminary analyses of the resulting data indicate that immediately after the treatment period, patients who received pain education, with or without CBT, experienced less pain and fewer symptoms of depression, and functioned better than those with medical care only,” Dr. Thorn says. These are preliminary findings, Dr. Thorn emphasizes. Her team will now examine the data more closely to see whether certain factors have a significant influence on the results. They will consider, for example, the number of sessions a participant attended, group cohesion, and the participant’s relationship with the group leader. The researchers will also analyze the six-month results. “Pre- and immediately posttreatment data tell you if the treatment had an effect,” Dr. Thorn says. “Six-month data tell you whether the effect lasted. Particularly in multiply disadvantaged populations, such as the one we studied, it may be critically important to continue behavioral monitoring and add booster or maintenance interventions, such as continuing support groups, to help patients maintain treatment effects.”

10

| T HE PA I N P R AC TI TI O NE R | J A N U A R Y / F E B R U A R Y 2 0 1 7

Dr. Thorn also expects her data to provide insights beyond indicating which of the treatments works best on average. The team will assess whether existing depression, cognitive habits, educational attainment, or other patient factors make a difference in individuals’ experience of pain or response to therapy.

People Take Notice Dr. Thorn’s team has not yet published results in a scientific journal, but the research has attracted attention: a New York Times article about disparities in chronic pain treatment described the preliminary findings. The local medical community has taken note, too. “Early on, when I visited one of the pain clinics where we conducted the study, the head physician said to me, ‘Dr. Thorn, what are you doing to my patients? They’re coming in, smiling at me, teaching me about chronic pain. This is magic!’” Dr. Thorn says. “That was so gratifying to hear.” The study itself had intriguing aspects. Fewer than 15 percent of patients in all three groups dropped out during treatment—a lower dropout rate than typically seen in behavioral treatment studies of people with chronic pain, Dr. Thorn says. In particular, the researchers were surprised that so many patients who received only standard medical care stuck with the study. Dr. Thorn says, “More than a handful said they got something therapeutic out of our repeated assessments of their pain and experiences.” She gives an example: “One woman said, ‘You asked me four times, What am I doing to help myself manage my pain? It started me thinking, What am I doing?’ And so she joined a yoga class.” Dr. Thorn hopes her results will help “get treatment into the hands of people who can use it.” If findings are positive, she plans to develop a free toolkit to train clinicians in low-income areas in pain education or CBT. The study’s findings may also shed light on the nature of chronic pain—and effective treatment—particularly among economically disadvantaged people. ❏ Carl Sherman is freelance medical writer.

About PCORI The Patient-Centered Outcomes Research Institute (PCORI), authorized by Congress in 2010, is an independent nonprofit, nongovernmental organization located in Washington, D.C. Its mission is to “help people make informed health care decisions, and improve health care delivery and outcomes, by producing and promoting high-integrity, evidence-based information that comes from research guided by patients, caregivers, and the broader health care community.” Its mandate is to improve the quality and relevance of evidence available to help patients, caregivers, clinicians, employers, insurers, and policy makers make informed health decisions. PCORI funds comparative clinical effectiveness research (CER) and supports work that will improve the methods used to conduct such studies. For more information, visit http://www.pcori.org/


Fibromyalgia and PTSD

This issue of The Pain Practitioner features

Fibromyalgia and Posttraumatic Stress Disorder

F

ibromyalgia has afflicted sufferers throughout recorded history, long before there was a name for the painful condition. Job describes his pain in the Bible: ”Days of pains are my life and at night my bones are pierced and the pains that make me suffer do not let me any rest.” Florence Nightingale, Charles Darwin, and many others also suffered from conditions that cause pain and fatigue, the hallmarks of fibromyalgia. Trauma, including car crashes and sexual or physical abuse, seems to correlate with fibromyalgia. Frida Kahlo, the artist who made her mark in the early 20th century in Mexico, might have suffered from fibromyalgia symptoms, including pain and fatigue. Kahlo was 18 when she suffered numerous broken bones and a deep abdominal wound in a serious bus accident. After frequent surgeries, she still suffered from severe, widespread pain and chronic fatigue. Despite her pain and disability, Kahlo engaged in an active life. She had a tempestuous marriage to the famous Mexican muralist Diego Rivera. She traveled extensively and knew the world leaders and artistic personalities of her time. Kahlo began painting after her accident. During periods of immobilization in a plaster corset, she used a special easel with a mirror that was attached to the canopy of her bed so that she could focus on herself. The theme of Kahlo’s chronic pain runs through her art, and she often depicted her own body bound, broken, or covered with nails. Kahlo’s work seems to line up with the tender points of fibromyalgia. Indeed, her self-portraits depicting barbed wire around her neck and nails in her body may strike a chord in others all too familiar with fibromyalgia pain. But just as some experts believe in the possibility that Kahlo had fibromyalgia, some argue that Kahlo’s pain was due purely to her accident and subsequent surgeries, and others raise the possibility of chronic back pain. The question of whether physical trauma can lead to fibromyalgia is one being explored in the Armed Forces. Research published by H. Cohen and colleagues in 2002 shows a significant overlap between posttraumatic stress disorder (PTSD) and fibromyalgia. This finding has led some to suggest that optimal care for fibromyalgia patients should include investigation for a component of PTSD. In an exploratory STRONG STAR study, Col. Jay B. Higgs, MD, (USAF, Ret.) of San Antonio Military Medical Center, and his team are taking the opposite approach. They are conducting research on the prevalence and impact of fibromyalgia in active-duty members of the military suffering from PTSD. As part of this novel research effort, patients with PTSD who are enrolled in STRONG STAR clinical trials at Fort Hood will be asked to consent to an additional study in which they will be screened for fibromyalgia. Investigators will then calculate the prevalence of fibromyalgia among PTSD patients and observe its influence on their prognosis by comparing treatment-outcome data between groups that do and do not meet criteria for fibromyalgia. The prevalence of fibromyalgia among patients’ spouses who are willing to consent to screening will also be investigated, as researchers look for secondary familial consequences of PTSD. Research findings could shed light on yet another painful effect of PTSD and reveal additional complications for health care professionals to consider when treating PTSD or fibromyalgia. ❏ TH E PAIN PRACTITION ER

| VOLUME 27, NUMBER 1 |

11


Empowered Pain Management

Empowered Pain Management

A Patient Shares Her Self-care Regimen along with Some Advice to Providers by Debra Nelson-Hogan

Maggie Buckley, patient liaison to the AIPM Board of Directors, was diagnosed at the age of 13 with Ehlers-Danlos syndrome (EDS), a group of genetic tissue disorders that share a core set of symptoms, including joint hypermobility, vessel fragility, skin fragility, and in more severe cases, organ or vessel rupture. In addition, she has been diagnosed with fibromyalgia and has experienced migraines and widespread pain. Over the years, Maggie has learned to listen to her body and manage her life though a body-mind-spirit approach, exercise, nutrition, and exquisite self-care. Although pain management is important, for Maggie, sleep is the key element to maintaining good health. Sleep is a constant challenge for people in pain, and inadequate sleep particularly exacerbates Maggie’s fibromyalgia symptoms and her migraines. Her sleep hygiene regimen includes appropriate exercise, a nutrition regimen to keep her adverse symptoms at bay, massage, and acupuncture. She also manages her “screen time,” using TVs, computers, and phones sparingly and using special orange-tinted glasses to cut out blue light. Then, she has a disciplined sleep routine of “going to bed at the same time every day, going through the same exact routine, so that your brain keeps getting these reinforced signals that bed is coming up,” she says. Acupuncture has helped reduce her migraine days (from 21 to three per month) and increase her sleep (from three to fiveand-a-half hours per night). With appropriate sleep, she notes, “Everything else has come under control. I have a lot less pain and depression. I can get through the day.” Maggie also works with a massage therapist who knows how to work with the sensitivity and painful areas. “Human touch is valuable; the warmth and gentle massage distracts your brain,” she says. Maggie also follows a fairly restrictive diet. She has celiac disease, so avoids gluten, and is allergic to dairy. She avoids both caffeine and alcohol. Primarily, she eats a plant-based diet, with weekly servings of fish and poultry. She has had success with some supplements, such as increasing her intake of omega-3 fatty acids and avoiding foods with omega-6. “It’s been 55 years of trial and error discovering whether foods make me feel good or bad,” she says. Exercise is important to overall good health and sleep. She has done some yoga, modified for both EDS and fibromyalgia, and has enjoyed therapy pools. And her favorite exercise? Walking the dog. “I’ve had a power wheelchair since 1995. My current dog actually prefers if I’m in the wheelchair because then we go and go and go until he’s tired and then he gets in my lap and we go home.” Meditation and guided imagery have also been important tools. “Having grown up in California, in the Bay Area, and then diagnosed with a chronic pain condition in the early ’70s, I was blessed by the cultural anomaly of meditation. I went to a Stanford eight-week study where I learned to sit still, and to breathe. They taught us to do a body scan, and still I do a body scan first thing in the morning and at any point during the day if I have an awareness of something that’s not right,” she says. “The idea is

12

| T HE PA I N P R AC TI TI O NE R | J A N U A R Y / F E B R U A R Y 2 0 1 7

to slow your breathing. Just breathe and calm down, and assure yourself that you are safe, you’re going to be okay, you are cared for. That’s the mantra that goes through my mind when I’m doing those meditations and they’re very comforting. Also, I was taught these exercises at the age of 13 and 14, when my brain was still forming, I was young enough that it became second nature. If something becomes overwhelming, I can do a quick two-minute guided meditation. Maggie has had a rich and full life while being so ever vigilant in managing her health. She has learned to do “a cost-benefit analysis” on certain activities to determine their worth to her. For example, although she skied from ages four to 34, she stopped when the physical cost was such that she would be flat on her back for 48 hours to recover. She stopped skiing altogether when the cost of even going out for an hour-and-a-half to two hours was five days of recovery. The quality of her life depends on careful planning and execution. With her many years managing serious pain issues, and working as an advocate for the chronic pain community, what would she like to tell health care providers? “I want them to know that listening to the patient and making a supportive connection is so important because the patient is afraid of you. She has likely been in the system so long and has been told that she is crazy and is doing something wrong and that she is responsible for her pain. People have been told that they’re not believable, or trustworthy,” she says. “Then, from there, the provider can recognize that there are a multitude of things that need to be done, that should be done to help support this person. There’s no single thing that will fix the problem. There have to be several things and you cannot start one, wait for that to work, and then, start another sort of thing. Find a way to support the patient in making a mind/body connection, support the patient in finding and redefining exercise for them and providing nutritional support,” she adds. Perhaps others with fibromyalgia and other co-morbid conditions could learn from Maggie that managing the EDS, fibromyalgia and other conditions has been a lifelong journey of trial, error, research and commitment not only to good health but to living a good and productive life. ❏


Integrative Approaches to Fibromyalgia

Integrative Approaches to Fibromyalgia By Melinda Ring, MD

than tramadol, muscle relaxants, and stimulants, but there is The goal of fibromyalgia treatment is to develop an individualized insufficient evidence for their efficacy or safety (5). Several invesapproach that addresses the severity of the patient’s pain, the tigational medications have shown promise in reducing pain and presence of comorbidities, and the degree of the patient’s improving patients’ satisfaction. These include low-dose naltrexone functional impairment. In most cases, effective management (6), memantine (7), and intravascular immune globulin (8). Sodium involves patient education as well as a variety of treatments, oxybate, a potent sedative, demonstrated improvements in sleep including neuromodulatory medications and nonpharmacologic as well as pain in clinical trials, but was not approved for use in measures such as physical activity, cognitive behavioral therapy fibromyalgia because of concerns about its potential for abuse. and integrative medicine approaches. Because of the heterogeneous nature of fibromyalgia, treatment with pharmacologic agents may be effective only for some patients and sometimes only to a partial extent, especially if used as monotherapy (1). Thus, a patient on Table 1. Pharmacologic Treatment of Fibromyalgia pharmacotherapy may experience insufficient reduction in pain or other symptoms and seek additional treatment soluFDA Drug Dose Precautions tions for greater relief. In an integrative practice, education Approved and pharmacologic therapies, together with lifestyle approaches, are the foundation of fibromyalgia treatment. In Alpha-2-delta ligands the management of fibromyalgia, the clinician embarks on a journey with the patient, selecting from the variety of treat50 mg three ment options available. Successful treatment depends on Pregabalin times daily, then Yes matching the right therapy to the appropriate patient. (Lyrica®) increased up to As many as 90% of patients with fibromyalgia use at least 600 mg per day one nonpharmacologic treatment (2). Even clinicians who 300 mg once daily do not offer these treatments themselves must be become initially, increase a knowledgeable source on their effectiveness and safety, in to twice daily, then No Gabapentin three times daily order to provide individualized counseling to their patients. to maximum of 3600 mg daily

Pharmacologic Treatment Treatments for fibromyalgia address either the increased excitation or decreased inhibition of ascending pain pathways. Medications that reduce the release of pronociceptive transmitters or neuromodulators substance P and glutamate, such as the alpha-2-delta ligands pregabalin and gabapentin, are thought to reduce pain facilitatory mechanisms, or ascending pain signals to the brain. Medications that enhance serotonin and norepinephrine by blocking the reuptake of these neurotransmitters seem to enhance the pain inhibitory effects in the descending inhibitory pathways (Table 1). In clinical practice, treatment with a single drug at the maximum dose is often insufficient; in such cases, combination therapy may be warranted to take advantage of multiple mechanisms of action for reducing pain or to target different symptoms. For example, combining a low dose of a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine, or a dual norepinephrine and serotonin reuptake inhibitor (SNRI), in the morning with a low dose of tricyclic antidepressant, such as amitriptyline, in the evening has been shown to result in greater improvement in pain than using either drug alone (3). Similarly, adding the SNRI milnacipran to the anticonvulsant pregabalin has been shown to produce greater pain reduction and global improvement compared to pregabalin alone (4). In patients with temporary flare-ups of otherwise wellcontrolled pain, analgesic agents such as acetaminophen, tramadol, and nonsteroidal anti-inflammatory drugs (NSAIDs) may be helpful. Other medications have been used in patients with fibromyalgia, including opioid analgesics other

Serotonin/norepinephrine reuptake inhibitors Duloxetine (Cymbalta®)

30 mg daily for 1 week, then increasing to 60 mg daily

Milnacipran (Savella®)

12.5 mg daily, then titrated daily until 50 mg twice daily

Activation or sedation, hot flushes and sweating, weight gain, sexual dysfunction, anticholinergic effects, hypotension

Yes

Yes

Selective serotonin reuptake inhibitors Fluoxetine

5 to 20 mg initially, titrating upward as needed

Activation or sedation, hot flushes and sweating, weight gain, sexual dysfunction

No

Paroxetine

10 to 20 mg initially, titrating upward as needed

Activation or sedation, hot flushes and sweating, weight gain, sexual dysfunction; withdrawal syndrome

No

Tricyclic Antidepressants and Analogues Amitriptyline

5 to 10 mg nightly, titrating upward as needed

Excessive sedation, anticholinergic effects, and hypotension

No

Nortriptyline

50 mg nightly, titrating upward as needed

Excessive sedation, anticholinergic effects, and hypotension

No

TH E PAIN PRACTITION ER

| VOLUME 27, NUMBER 1 |

13


Integrative Approaches to Fibromyalgia

Nonpharmacologic Therapies Among the nonpharmacologic options, the evidence for education, physical activity, and cognitive behavioral therapy is most consistent. Other therapies that focus on dietary supplementation and complementary and integrative healing disciplines are also frequently used, but rigorous evidence for their effectiveness is often lacking. Education Education is an important component of treatment with measurable benefits when combined with other approaches. A recent study showed that self-management education enhanced the benefits of a supervised exercise program that included strength, aerobic, and flexibility training in patients who were also receiving medication (9). In this program, the addition of the Arthritis Foundation’s fibromyalgia self-management course led to a reduction of the impact of fibromyalgia on physical, social, and emotional function over a period of six months.

Food sensitivities may contribute to fibromyalgia symptoms, and an elimination diet can identify those foods that exacerbate pain, fatigue, or mood. In an elimination diet, the most common offending foods, such as sugar, alcohol, dairy products, wheat, eggs, citrus, soy, chocolate, coffee, and artificial sweeteners and additives, are eliminated for at least three weeks, then added back one at a time every four days. Even if the elimination diet proves too challenging for patients to maintain, it is important to eliminate additives such monosodium glutamate (MSG), which is metabolized into glutamate, and aspartame, which is converted to aspartate (16). Both can activate pain-amplifying receptors in the central nervous system (17). Dietary Supplements Dietary supplements are often an integral part of an integrative medicine treatment plan, particularly for those patients who do not respond well or have difficulty tolerating prescription medications. A summary of the supplements most often used for fibromyalgia is detailed in Table 2.

Physical Activity Physical activity may significantly reduce pain for some patients with fibromyalgia, as well as improve depression, fatigue, global health, and other aspects of overall patient care (10). Patients with chronic pain often become sedentary, which leads to Table 2. Summary of Dietary Supplements for Fibromyalgia deconditioning and contributes to other symptoms. Exercise can reduce the impact of deconditioning, but the exact Supplement Recommended Dose Effects Potential Adverse Effects mechanism by which movement activities improve fibromyalgia is still unknown. Research has shown that aerobic training at moderate intensity improves patients’ overall sense of well-being and physical function. In addition, strength and flexibility training also shows evidence of decreases in pain and tenderness as well as improvements in mood, function, and overall well-being (9, 10). Patients with difficulties with exercise or physical functioning should be referred to a physiatrist for further evaluation and management. Cognitive Behavioral Therapy Cognitive behavioral therapy (CBT) has been shown to be a cost-effective therapy that can help patients with fibromyalgia reduce symptoms, increase their ability to cope with the disease, and identify and limit maladaptive illness behavior (11-14). For example, certain cognitions have been identified that seem to perpetuate patients’ pain. Catastrophizing, or the tendency to rate everything in an overly negative or overwhelming way, can be addressed successfully with CBT. Patients who are said to have an external locus of control, meaning that they externalize their problems and tend to feel a lack of control over their symptoms, seem to have more problems with pain. CBT can help such patients develop more of a sense of internal control, and this can result in lasting improvement in physical function (12).

S-adenosylmethionine (SAMe)

400 mg twice daily

Improves depression and tender point severity

Nausea, mania

5-Hydroxytryptophan (HTP)

100 mg three times a day

Improves tender points, anxiety, sleep, and pain

Mild digestive distress, possible allergic reaction

Magnesium glycinate or magnesium citrate or magnesium malate

100-200 mg twice daily

Improves tender points, depression

Nausea, vomiting, diarrhea

D-ribose

5 g two- to threetimes daily

Improves energy, sleep, mental clarity, pain intensity, well being

Diarrhea, gastrointestinal discomfort, nausea, and headache

Coenxyme-Q10

100-300 mg daily

Improves pain fatigue, morning tiredness, and tender points

Nausea, possible drug interactions, low blood pressure

Acetyl l-carnitine (LAC)

1,000-2,000 mg daily

Improves pain, depression

GI side effects, agitation, fishy odor in urine, sweat, hypothyroid, increase warfarin levels

B vitamins

Thiamine (B1) 50-100 mg daily, pyridoxine (Vitamin B6) 50-100 mg daily, 0.5-2mg daily of folic acid and vitamin B12.

Additional Nonpharmacologic Therapies

Nutrition Several small studies of various nutritional practices have shown benefit in regulating fibromyalgia symptoms. For example, a three-month study in Finland assessed the effects of a vegan diet on pain, sleep, and wellness in fibromyalgia patients. Patients ate fruits, legumes, seeds, nuts, and vegetables, but were not allowed to eat animal products, coffee, tea, alcohol, sugar, or salt. Symptoms improved during the three months of the diet, but returned to baseline with resumption of a full diet (15).

Melatonin

1.5 - 5 mg nightly

Excess B vitamin supplementation can be associated with neuropathy

Improves pain, sleep quality, and depression

Headache, shortterm feelings of depression, daytime sleepiness, dizziness, stomach cramps

Source: Cederquist, L Integrative Approaches to Fibromyalgia. In: Bonakdar and Sukiennik, eds. Integrative Pain Management. New York, NY. Oxford University Press; 2016:660.

14

| T HE PA I N P R AC TI TI O NE R | J A N U A R Y / F E B R U A R Y 2 0 1 7


Integrative Approaches to Fibromyalgia

Yoga and Tai Chi The benefits of yoga have been studied; one pilot study showed that nine weekly sessions of relaxing yoga showed improvements in pain and function (18). A specific form of yoga, Yoga of Awareness, has also been shown to improve pain, fatigue, and mood, as well as fibromyalgia coping strategies (19, 20). Tai chi, a traditional Chinese movement approach, has also been shown in a randomized trial to have a positive impact on fibromyalgia symptoms and quality of life both during the study; notably, these benefits were maintained at six months (21). Acupuncture Acupuncture is often recommended for fibromyalgia and is generally safe when performed by a well-trained practitioner. However, systematic reviews of acupuncture therapy have found inconsistent results for relieving pain in patients with fibromyalgia (22,23). Given the relative low risk, a trial of acupuncture with weekly sessions for eight weeks may be a reasonable consideration for many patients. Manual Therapies (Massage, Osteopathic Manipulation) A systematic review evaluating the effectiveness of massage in fibromyalgia showed that multiple styles of massage therapy consistently improved the quality of life of people with fibromyalgia. Myofascial release had large, positive effects on pain and medium effects on anxiety and depression and also improved fatigue, stiffness, and quality of life; connective tissue massage improved depression and quality of life; manual lymphatic drainage was better than connective tissue massage in stiffness, depression, and quality of life; Shiatsu improved pain, pressure pain threshold, fatigue, sleep, and quality of life; only Swedish massage did not improve outcomes (24). A pilot study on osteopathic manipulative treatment (OMT) in conjunction with medication for fibromyalgia showed evidence for efficacy of OMT in improving tender point pain thresholds and activities of daily living (25). Craniosacral therapy was shown in one study to result in a significant reduction in tender points with persistent benefits at one year post-therapy (26).

Thank you to our Corporate Council Members!

Mindfulness-Based Stress Reduction (MBSR) Mindfulness-based stress reduction (MBSR), the eight-week meditative program developed by Jon Kabat-Zinn for people who suffer chronic pain, has been studied in fibromyalgia patients with mixed results. Although further research is needed, a 2015 study of MSBR used to treat women with fibromyalgia showed a significant reduction in perceived stress, sleep disturbance, and symptom severity (27).

Conclusion There are several steps to helping patients with fibromyalgia, and they can be summarized by the acronym ACCEPT: Acknowledge their pain is real, and inform them that fibromyalgia is a Chronic condition with Challenges in treatment and management. In addition to utilizing the medications and nonpharmacologic therapies shown to have benefit, Educating them, being their Partner, and fostering a Trusting relationship, are all important steps for the clinician to help their patients in the healing journey. â?? Melinda Ring, MD, serves as the Executive Director of the Northwestern Medicine Osher Center of Integrative Medicine, and is a clinical associate professor of medicine at the Northwestern University Feinberg School of Medicine, Chicago, Illinois. In her roles at Northwestern, she oversees the clinical programs, medical trainee education, and research in the emerging field of integrative medicine. Her expertise is reflected in her contribution to textbooks, lectures, and research articles and her first book on integrative women’s health, The Natural Menopause Solution. Her interests include bioidentical hormones, food as medicine, dietary supplements, mindfulness, and the healing power of nature. She is passionate about raising awareness of the power of integrative medicine to heal ourselves and our health care system.

Academy of Integrative Pain Management Corporate Council Membership

Contact Leslie Ringe, (209) 288-2207, leringe@verizon. net to become a Corporate Council Member today!

TH E PAIN PRACTITION ER

| VOLUME 27, NUMBER 1 |

15


Integrative Approaches to Fibromyalgia References 1. Noller V, Sprott H. Prospective epidemiological observations on the course of the disease in fibromyalgia patients. J Negat Results Biomed. 2003;2:4. 2. Pioro-Boisset M, Escaile JM, Fitzcharles MA. Alternative medicine use in fibromyalgia syndrome. Arthritis Cure Res. 1996;9(1):13-17. 3. Goldenberg D, Mayskiy M, Mossey C, Ruthazer R, Schmid C. A randomized, double-blind crossover trial of fluoxetine and amitriptyline in the treatment of fibromyalgia. Arthritis Rheum. 1996;39(11):1852-1859. 4. Mease PJ, Farmer MV, Palmer RH, Gendreau RM, Trugman JM, Wang Y. Milnacipran combined with pregabalin in fibromyalgia: a randomized, open-label study evaluating the safety and efficacy of adding milnacipran in patients with incomplete response to pregabalin. Ther Adv Musculoskelet Dis. 2013;5(3):113-126. 5. Boomershine CS, Crofford LJ. A symptom-based approach to pharmacologic management of fibromyalgia. Nat Rev Rheumatol. 2009;5(4):191-199. 6. Younger J, Noor N, McCue R, Mackey S. Low-dose naltrexone for the treatment of fibromyalgia: findings of a small, randomized, doubleblind, placebo-controlled, counterbalanced, crossover trial assessing daily pain levels. Arthritis Rheum. 2013;65(2):529-538. 7. Olivan-Blázquez B, Herrera-Mercadal P, Puebla-Guedea M, et al. Efficacy of memantine in the treatment of fibromyalgia: a doubleblind, randomized, controlled trial with 6-month follow-up. Pain. 2014;155(12):2517-2525. 8. Caro XJ, Winter EF, Dumas AJ. A subset of fibromyalgia patients have findings suggestive of chronic inflammatory demyelinating polyneuropathy and appear to respond to IVIg. Rheumatology (Oxford). 2008 Feb;47(2):208-211. 9. Rooks DS, Gautam S, Romeling M, et al. Group exercise, education, and combination self-management in women with fibromyalgia: a randomized trial. Arch Intern Med. 2007;167(20):2192-2200. 10. Busch AJ, Webber SC, Brachaniec M, et al. Exercise therapy for fibromyalgia. Curr Pain Headache Rep. 2011 Oct; 15(5): 358–367.

11. Luciano JV, D’Amico F, Cerdá-Lafont M, et al. Cost-utility of cognitive behavioral therapy versus U.S. Food and Drug Administration recommended drugs and usual care in the treatment of patients with fibromyalgia: an economic evaluation alongside a 6-month randomized controlled trial. Arthritis Res Ther. 2014;16(5):451. 12. Williams DA, Cary MA, Groner KH, et al. Improving physical functional status in patients with fibromyalgia: a brief cognitive behavioral intervention. J Rheumatol. 2002;29(6):1280-1286. 13. Glombiewski JA, Sawyer AT, Gutermann J, Koenig K, Rief W, Hofmann SG. Psychological treatments for fibromyalgia: a meta-analysis. Pain. 2010;151(2):280-295. 14. Bernardy K, Klose P, Busch AJ, Choy EH, Hauser W. Cognitive behavioural therapies for fibromyalgia. Cochrane Database Syst Rev. 2013;(9):CD009796. 15. Kaartinen K, Lammi K, Hypen M, Nenonen M, Hanninen O, Rauma AL. Vegan diet alleviates fibromyalgia symptoms. Scand J Rheumatol. 2000;29(5):308-313. 16. Smith JD, Terpening CM, Schmidt SO, Gums JG. Relief of fibromyalgia symptoms following discontinuation of dietary excitotoxins. Ann Pharmacother. 2001;35(6):702-706. 17. Skypala IJ, Williams M, Reeves L, Meyer R, Venter C. Sensitivity to food additives, vaso-active amines and salicylates: a review of the evidence. Clin Transl Allergy. 2015; 5:34. 18. da Silva GD, Lorenzi-Filho G, Lage Lv. Effects of yoga and the addition of Tui Na in patients with fibromyalgia. J Altern Complement Med. 2007;13(10):1107-1113. 19. Carson JW, Carson KM, Jones KD, Bennett RM, Wright CL, Mist SD. A pilot randomized controlled trial of the Yoga of Awareness program in the management of fibromyalgia. Pain. 2010;151(2):530-539. 20. Carson JW, Carson KM, Jones KD, Mist SD, Bennett RM. Follow-up of yoga of awareness for fibromyalgia: results at 3 months and replication in the wait-list group. Clin J Pain. 2012;28(9):804-813. 21. Wang C, Schmid CH, Rones R, et al. A randomized trial of tai chi for fibromyalgia. N Engl J Med. 2010;363(8):743-754. 22. Deare JC, Zheng Z, Xue CC, et al. Acupuncture for treating f ibromyalgia. Cochrane Database Syst Rev. 2013;(5):CD007070. 23. Yang B, Yi G, Hong W, et al. Efficacy of acupuncture on fibromyalgia syndrome; a meta-analysis. J Tradit Chin Med. 2014;34(4):381-391. 24. Yuan SL, Matsutani LA, Marques, AP. Effectiveness of different styles of massage therapy in fibromyalgia: a systematic review and metaanalysis. Man Ther. 2015;(2):257-264. 25. Gamber RG, Shores JH, Russo DP, Jimenez C, Rubin BR. Osteopathic manipulative treatment in conjunction with medication relieves pain associated with fibromyalgia syndrome: results of a randomized clinical pilot project. J Am Osteopath Assoc. 102:321-325. 26. Matarán-Peñarrocha GA, Castro-Sáchez AM, Carballo García GM, Moreno-Lorenzo C, Parrón Carreño TP, Onieva Safra MD, Influence of Craniosacral Therapy on Anxiety, Depression and Quality of Life in Patients with Fibromyalgia. Evidence-Based Complementary and Alternative Medicine. 2011;1-9. http://dx.doi.org/10.1093/ecam/nep125 27. Cash E, Salmon P, Weissbecker I, et al. Mindfulness meditation alleviates fibromyalgia symptoms in women: results of a randomized clinical trial. Ann Behav Med. 2015;49(3):319-330.

Learn More About Integrative Pain Management Earn FREE CME/CEU for Members at The AIPM’s Pain Care Learning Center Integrative Pain Management: Global Perspectives on How we can Improve Pain Care, Robert A Bonakdar, MD (1 credit) For more information, go to goo.gl/WgjNtv

16

| T HE PA I N P R AC TI TI O NE R | J A N U A R Y / F E B R U A R Y 2 0 1 7


Fibromyalgia Treatment at BAMC

Fibromyalgia Treatment at Brooke Army Medical Center

Eight-week program employs CBT, psychoeducation, and hypnosis to relieve symptoms and improve quality of life By Catherine A. Vriend, PhD

sible loss of career and the often significant expectations of that career can be devastating. By and large, these service members had been advancing in rank as the go-to person in their unit and likely in their family as well. Acknowledging the reality of the situation and working toward finding the new person who can succeed in civilian life has become an important part of the program.

Intake Session

Over its 18-year hstory, the Fibromyalgia Treatment Program at Brooke Army Medical Center (BAMC) has evolved to meet the needs of a dramatic shift in patient population by incorporating the helpful strategies coming out of research and in response to patient outcomes. At present, the program consists of a twohour intake session and eight weekly 2.5 hour sessions. The information and specific strategies to mitigate symptoms and impact of the disorder on function and quality of life are couched within a Cognitive Behavioral Therapeutic (CBT) framework with specific strategies to mitigate symptoms, some components of Acceptance Commitment Therapy (ACT) and hypnosis in support of cognitive and behavior change. I refer to the program as a treatment program designed to enable patients to develop an individual self and pain management program. BAMC, located at Fort Sam Houston, San Antonio, Texas, is the largest tertiary medical facility with patients from all branches of the service. Over time, the demographics of my patient population have changed dramatically and the program has evolved to meet the specific needs of these patients. Initially, my groups were mostly female and non-active duty with a sprinkling of veterans from Vietnam, Bosnia, and Desert Storm operations. There were always a number of patients who had been Airborne, Special Ops, or injured in the field. Now with major combat action in the Middle East over several years, the military and VA are seeing more chronic pain conditions, including fibromyalgia, in both male and female active duty and prior service members. Most are active duty, in the process of medical retirement, or recently retired, and they bear little resemblance to what one thinks of as typical fibromyalgia patients. At least a third of patients are male, and all service members utilize components of CBT and ACT from intake on to address anxiety and denial and to acknowledge the grief resulting from the loss of the person they knew themselves to have been. The pos-

I have found an intake evaluation to be essential. Some patients are so distressed by interpersonal issues that they cannot benefit from the program without individual work first, or they have comorbidities that render group treatment inappropriate. I also have patients who are leaving the area or separating from the service, or who cannot participate in the group because of duty or family circumstances. The intake gives me an opportunity to identify those patients and offer alternate care. Importantly, the intake allows me to characterize the patient’s expression of fibromyalgia and validate their experience. Included in the intake is administration of the Fibromyalgia Impact Questionnaire-R (FIQ-R). Although I do not expect big changes in this measure over eight weeks, the FIQ-R provides a lot of information that I include in my chart note in addition to the score. What I do expect to alter within eight weeks is measured by the Pain Catastrophizing Scale (PCS) and the Fibromyalgia Self Efficacy Scale (FSES). Based on analysis of previous groups, the goal is a 30% improvement in the FSES and movement from clinically relevant to non-clinically relevant scores on the PCS. Following the information gathering and premeasurements, I provide an extensive overview of the disorder and the hypotheses regarding development, neurobiology, and interaction with psychological status. For many active duty patients, this initial overview provides enough information to reduce their anxiety and begin to manage the condition. Butler and Moseley refer to this approach as “information therapy” (1). This session also exemplifies my three guiding principles that have evolved in working with this patient population and as a clinical health psychologist in general. These patients often have had a rough time of it with other providers, so “first do no harm.” 1.) You must validate the experience of the patient. 2.) It helps to be interested in fibromyalgia to develop a coherent but flexible conceptualization of the disorder. You should be comfortable reviewing the research, which is spread across rheumatology, neurology, pain, GI, sleep medicine, and neuroscience literature, so that you are well acquainted with the symptoms and have the latest information regarding etiological hypotheses and management strategies. 3.) Use your knowledge to establish and maintain your credibility with your patients and with your medical treatment colleagues.

Weekly Sessions Each session of the program includes CBT, breathing exercises, and meditation practice leading to hypnosis, and contracts developed by each patient designed to promote cognitive or behavior change during the week. Contracts are based on information covered in the session and the patient’s related goals.

TH E PAIN PRACTITION ER

| VOLUME 27, NUMBER 1 |

17


Fibromyalgia Treatment at BAMC Each contract is reviewed at the beginning of the next session. Handouts are provided after an area is covered. I use a white board so that I can bring the patients along in the presentation and hold their interest in a way that does not occur with PowerPoint. I use a lot of humor, concrete examples, metaphors and “show and tell” items. There are three specific goals for the eight weeks: that patients will begin to get a handle on their sleep disorder, that they will develop their personal daily stretching program, and that they will alter their self-talk to acknowledge their experience while assuring themselves that they are “okay”. No more “this pain is killing me!” These are significant tasks that involve eliminating habitual behaviors and developing new behaviors. Patients are encouraged to experiment with various management strategies based on their experience of fibromyalgia and adopt what is most helpful to them.

Understanding Fibromyalgia Week One. The first session of the program focuses on sleep, using the principles of Cognitive Behavioral Therapy for Insomnia (CBT-I) and general concepts of sleep medicine, such as dealing with the pressure to sleep and the role of melatonin. Aspects specific to fibromyalgia are explained along with specific management strategies. For example, patients tend to wreck their sleep cycle as they try to get more sleep or shift their sleep cycle. Or they may overly depend on caffeine to function during the day, finally hitting their caffeine nadir as morning approaches, only to repeat the cycle. Just as fibromyalgia patients experience augmented sensory stimuli during the day, the same may occur at night with sounds, light, and pain with pressure resulting in frequent arousals. Thus, stimuli must be controlled prior to bedtime and during the night as well. Sleep restriction is employed as necessary. Week Two. The second session focuses on a review of medications that have been or could be prescribed. I try to get patients’ preoccupation with medication out of the way early in the program. Patients need to be informed consumers of both prescription and over-the-counter medications, including herbs and supplements. They often need to learn how to take medication for the best outcome, and to be aware of the most likely side effects and realize that just as other stimuli are augmented, side effects may be amplified as well. They need to be cautioned about NSAIDS and acetaminophen. It is the nature of many people’s response to pain that if a recommended dose does not work, more should be taken. Acute pain is a survival mechanism, the purpose of which is to make you stop it. It is supposed to really bother you if it is acute and related to impending or threat of body damage by injury or disease. The problem with chronic pain is that it is perceived as an acute threat to bodily integrity, and the naïve patient will respond to it in the same way as acute pain. Week Three. The third session addresses the brain’s processing of that threat and of pain. CBT is generally used to help patients get past the natural response to pain of ceasing movement by addressing the benefits of activity and exercise in managing pain. Our program seeks to change the way the pain signal is processed in the brain by changing the threat level of the signal. It closely resembles CBT for depression and anxiety by changing the maintaining cognitions. Strategies are provided for altering the process either behaviorally, cognitively, or with medication at each level. As many patients also have symptoms of Post Traumatic Stress Disorder (PTSD), we look at the interaction between PTSD associated-threat and threat associated with pain. At this point, patients with severe PTSD who may have avoided treatment or dropped out of treatment realize they need

18

| T HE PA I N P R AC TI TI O NE R | J A N U A R Y / F E B R U A R Y 2 0 1 7

to complete it if they are going to be able to manage fibromyalgia well. Show and tell includes topical formulas, such as L-menthol, which have specific direct and indirect effects on pain transmission early in the pain pathway (2). Week Four. The fourth session addresses headache including migraine, a central sensitization syndrome whose symptoms, including stimulus sensitivity, overlap with those of fibromyalgia. I rely heavily on the work of Robert Bonakdar, MD, at the Scripps Center for Integrative Medicine. As I have by then discussed herbs such as butterbur, the second half of the session continues with other complementary therapies, such as acupuncture and massage, for which there is some evidence of efficacy. Patients are cautioned to make sure their medical providers know everything they are taking, that because a therapy is “natural” or over-thecounter it is not automatically benign. They are encouraged to discuss medication interactions with a pharmacist and are provided with websites to look up supplements, herbs, and food interactions with medications. Therapies include proper use of cold and proactive use of heat to combat myofascial pain disorder.

Stress Management Week Five. The fifth session begins formal stress management as patients are already enduring a high baseline level of sympathetic drive, and additional stress results in flare-ups of all symptoms. The three components of stress management are 1.) changing the situation: problem solving or altering the situation such that it is less stressful; 2.) changing the body’s response: strategies to increase parasympathetic drive, such as paced deep abdominal breathing and exercise; and 3.) changing the mind. The entire presentation on exercise is placed within the context of reducing stress and the physiological impact of stress on the body. Patients are provided with a handout on stretching and instructions on developing their personal stretching program. I also review strategies for prevention of common pain issues such as trochanteric bursitis and patella-femoral syndrome. I recommend moderate aerobic exercise for reducing the physiological effects of stress using a gradual plan for advancement to encourage patients to focus on the process (3). As with aerobic exercise, patients benefit from resistance training when they can develop a personalized program and understand why they experience fatigue and pain. They may learn to tolerate the fatigue and pain if they have a strategy for advancing slowly without a crash. My preference for patients is water exercise beginning with building tolerance for walking in chest high water. Patients are encouraged to experiment with a variety of forms of exercise including Tai Chi (4). They are advised to go slow, watch for their limit, and focus on process. This is a difficult adjustment for highly disciplined service members who are used to hard exercise. But as they are likely not doing any exercise at this point, we use motivational strategies that align with the military mission concept. Military service members are expected to function as athletes, and, in many cases, as elite athletes. When they struggle and no longer see themselves as a strong and competent resource to their unit but rather as a burden, their risk for depression increases. Service members may repeatedly crash, becoming demoralized as well as deconditioned. In this session, the first of three hypnotic inductions is presented, which focuses on suggestions for improved health and wellbeing. Week Six. The sixth session continues stress management and addresses ways of changing a stressful situation. We work on altering daily situations containing low level stressors and proceed to formal problem solving for more serious issues. Critical aspects of problem solving approaches are reviewed, and patients volunteer longstanding and thorny problems for the group


Fibromyalgia Treatment at BAMC to work through. They come to appreciate the benefits of having more than one person working on a problem and the amount of pertinent information the group can generate, as well as the benefit of problem solving during the day on paper rather than ruminating on an issue when trying to sleep. The second hypnotic induction is presented and the second suggestion added. Week Seven. The seventh session addresses the last part of stress management, which is changing the mind, or dealing with depression, anxiety, and anger. Principles of CBT are reintroduced with an emphasis on becoming aware of the thoughts, beliefs, and expectations that generate negative affect, and then challenging and altering these cognitions. Patients report situations from the previous week that are frequently stressful and the group works through the situation with regard to the immediate self-talk, resulting emotional and physical response, core problematic cognition, and challenge. The third hypnotic induction is presented and the last suggestion added.

References 1. Butler DM, Moseley L. Explain Pain. 2nd Ed. 2013 Adelaide, Australia: NOIGROUP Publications; 2013. 2. Anderson H.H., Gazerani P, Arendt-Nielsen L. High concentration of Lmenthol exhibits counter-irritancy to neurogenic inflammation, thermal and mechanical hyperalgesia caused by trans-cinnamaldehyde. J Pain. 2016;17(8):919-929. 3. Bote ME, Garcia, JJ, Hinchado MD, Ortega E. Fibromyalgia: anti-inflammatory and stress responses after acute moderate exercise. Plos ONE. 2013; 8(9):e74524.doi:10.1371/journal.pone.0074524. 4. Jones KD, Sherman CA, Mist SD, Carson JW, Bennet RM, Li F. A randomized controlled trial of 8-form Tai chi improves symptoms and functional mobility in fibromyalgia patients. Clin Rheumatol. 2012;31(8):1205-1214. 5. Peeke P. Fight Fat After Forty. New York:Penguin Putnam; 2000.

Ongoing Management Week Eight. The eighth session covers stress resilient eating and weight management with fibromyalgia. The problem of metabolic syndrome and its progression to diabetes and fatty liver disease is illustrated along with the role of the interaction of the inclination to self-comfort and inactivity, poor sleep, and chronic pain with autonomic dysfunction and the typical American lifestyle. I utilize Pamela Peeke’s approach (5) with the exception of using reasonable caution with resistance exercise. The second half of the session reviews GI difficulties and strategies to mitigate dysfunction. Patients often experience a variety of GI symptoms including irritable bowel syndrome. Patients then complete the post session outcome assessments, and I provide them with a number of other additional resources. They are invited to work on their own for a time and then feel free to return to the BAMC program for a booster, to address aspects of self-management they have found difficult, or to address the disruption of their management program by the onset of a new comorbidity. Active duty patients are encouraged to return once out of uniform when they are able to initiate certain changes that prior service prevented. ❏ The views expressed in this article are solely those of the author and do not reflect an endorsement by or the official policy of the Brooke Army Medical Center, the U.S. Army, the U.S. Air Force, the Department of Defense, the Department of Veterans Affairs, or the U.S. Government. Catherine Vriend, PhD, is the chief of the clinical health psychology service, department of behavioral medicine at Brooke Army Medical Center (BAMC), San Antonio, Texas. As a subject matter expert on complementary medicine to reduce reliance on medication, she contributed to the development of the DOD-VA Integrated Pain Management initiative. She has been the director of the BAMC Fibromyalgia Treatment Program for the past 17 years.

Learn More About Fibromyalgia at the AIPM’s Pain Care Learning Center Earn FREE CME/CEU for Members at The AIPM’s Pain Care Learning Center · Fibromyalgia: Diagnosis and Treatment of a Prototypical Mind-body Disorder, Catherine Vriend, PhD (1 credit) For more informations, go to goo.gl/BRjLm1

5 REASONS

To Apply for AIPM’s Advanced Pain Management Practitioner (APMP) Certificate – Prescriber Edition ➊ ➋ ➌

Document your knowledge and use of best practices in pain care.

Gain visibility in AIPM’s online directory as an APMP certificate-holder.

Conveniently schedule your exam when and where you want it.

Demonstrate your extensive experience treating people with pain. Show your patients and peers you’ve gone above and beyond to provide safe and effective pharmacologic pain care.

Plus, when you bundle this certificate with our optional Curriculum Overview Course, you’ll receive $500 off!

· The Evolution of Fibromyalgia, Jay B. Higgs, MD (1 credit) For more informations, go to goo.gl/2rf9lP

TH E PAIN PRACTITION ER

| VOLUME 27, NUMBER 1 |

19


Mindful Awareness Training

Mindful Awareness Training: A Promising Treatment Approach for Persistent Pain Carolyn McManus, PT, MS, MA

The National Pain Strategy identifies the biopsychosocial model and pain self-management approaches as important components of chronic pain treatment and prevention (1). Mindfulness training actively engages patients in pain selfmanagement within a biopsychosocial framework consistent with these national recommendations. Mindful awareness has been defined as “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding experience, moment by moment” (2). It includes the observation of thoughts, emotions, and sensory experiences. Whether the object of one’s attention is pleasant, unpleasant, or neutral, all perceptions are met with acceptance, friendliness, and curiosity. No effort is made to suppress, eliminate, or change the experience. Jon Kabat-Zinn pioneered the training of clinical populations in mindful awareness when he developed and taught MindfulnessBased Stress Reduction (MBSR) at the University of Massachusetts Medical Center in 1979. This initial program has expanded over the years to become the University of Massachusetts Medical School Center for Mindfulness in Medicine, Health Care, and Society and its success has led to the establishment of MBSR programs throughout the United States and around the world. The program is not limited to patients with chronic pain conditions. It meets weekly for 2.5 hours for eight consecutive weeks and includes a six-hour day of mindfulness. Class size is 20 to 30 participants. As the program requires a commitment to daily meditation and the integration of mindfulness into life circumstances, MBSR draws self-motivated individuals ready to take an active role in managing their symptoms. Mindful awareness is cultivated through instruction in and practice of sitting meditation, the mindful observation of body areas also known as the body scan, walking meditation, and gentle yoga. Periods of group discussion promote the exploration of participants’ experiences of mindfulness practices and their application to symptom management and daily life. A structured home program includes a workbook that covers class material and weekly home assignments, instructions to incorporate mindfulness into neutral, pleasant, and unpleasant experiences and guided audio recordings for daily practice. An expanding body of medical literature has identified physical and mental health benefits for patients with persistent pain who receive training in mindful awareness (3-8). In a recent randomized, interviewer-blind, clinical trial, Cherkin and colleagues randomly assigned 342 adults aged 20 to 70 years with chronic low back pain to receive MBSR (n = 116), an 8-week cognitive behavioral therapy program (CBT) (n = 113), or usual care (n = 113) (5). At 26 weeks from trial entry, follow-up assessments demonstrated the percentage of participants with clinically meaningful improvement in disability was significantly higher for those who received MBSR or CBT than for those who received usual care (see Figure 1). The MBSR group showed continued improvements in disability between follow-up assessments at weeks 26 and 52, suggesting MBSR provides patients with lasting skills effective for managing pain.

In addition to the MBSR program model, mindful awareness instruction can be integrated into individual patient care. With individual mindfulness training, instruction is tailored to a patient’s specific goals and needs. As with the group model, patients are taught mindful breathing, body scan, and walking. They are instructed to bring mindful awareness to movement during exercise. A home program can include such mindful practices as: • Pausing and practicing mindful breathing throughout the day • Meeting the experience of pain with mindful awareness • Labeling pain as “sensation” • Integrating mindful awareness into routine activities such as handwashing • Planning a pleasant activity and being mindful of the experience • Practicing 10 minutes of a mindful meditation daily

Figure 1. Mindfulness-Based Stress Reduction vs. cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain (5).

Percentage of Participants With Clinically Meaningful Improvement on Roland Disability Scale

80 60 40 20

4 Weeks

8 Weeks Usual Care

20

| T HE PA I N P R AC TI TI O NE R | J A N U A R Y / F E B R U A R Y 2 0 1 7

26 Weeks

52 Weeks

MBSR

CBT


Mindful Awareness Training

What Patients Learn I have taught mindfulness in a clinical setting for more than 20 years and was one of the MBSR instructors for the Cherkin study. With training in mindful awareness, patients learn to observe the sensation of pain as distinguished from their additional physical, cognitive, and emotional reactions to the sensation. With stable, kind, and curious attention, they witness the constant flow of sensations, thoughts, and emotions and uncouple the immediate sensory experience of pain from secondary reactions to the sensation. This calm observation of the component parts of the pain experience makes available the possibility of new choices. Patients frequently have automatic, unconscious habitual reactions to the experience of pain that exacerbate their distress. These include shallow breathing, muscle guarding, catastrophic thinking, worry, fear, and anger. By observing the sensation of pain and these reactions with mindful awareness, patients gain insight into how these reactions escalate pain and suffering. They experiment with new choices that include diaphragmatic breathing, muscle relaxation, and self-compassion. They learn to recognize that fear and worry are often about the future and can shift their focus from fruitlessly stressing about the unknowns of tomorrow to making healthy choices today. Through mindful breathing, body scan, and movement, patients build body awareness and learn to sense and interpret bodily sensations in new, non-threatening ways. For those alienated from their body due to pain, mindful practices can help them learn to feel more at home and at ease in their body, even while experiencing pain. Improved body awareness can help patients perform exercises correctly, pace their activities, and appropriately adjust posture and body position as a means to prevent pain and tension escalation. Body awareness is also necessary for the awareness and regulation of emotions. I frequently hear patients describe many themes identified in a qualitative study by Doran that examined the role of mindfulnessbased therapy in chronic back pain (6). Patients reported they: • Became familiar with the pattern of pain and their habitual reactions to pain • Recognized the difference between being tense and being relaxed in relation to pain • Identified early warning signs that precede a pain flare-up • Stopped the cycle of projecting past experience of pain onto a fear of future pain • Changed maladaptive attitudes and approaches to pain • Reduced identification with the diagnostic label or story about pain • Became more flexible in their attitude toward pain • Reduced self-blame and inner conflict • Felt less “fragmented” and experienced a greater integration of mind and body

CASE STUDY Tom was a 58-year-old man with a 39-year history of back pain following a lifting injury. He managed his pain successfully with exercise until two years prior to participating in MBSR. His pain had grown constant and became more intense, which significantly limited his ability to perform household chores and participate in social activities. His MRI was normal. Tom’s previous treatment included various medications, chiropractic manipulation, several physical therapy approaches and exercise. After reading Back in Control by David Hanscom, MD (9), he was inspired to take a

more active role in his pain management and enrolled in MBSR training at Swedish Medical Center, Seattle, Washington. He describes his experience: “I had reached a crisis of pain and anxiety. I decided I needed to take action as my life was being seriously degraded, and at 58, I saw that it was likely going to get worse in the years to come unless I took control. The transformation that this course and the larger engagement in mindfulness has had on me is quite remarkable. I cannot say my pain is gone, but it is substantially diminished. My experience of my own body and mind has begun to shift in fundamental ways. I now appreciate that I can control anxiety by slowing down, breathing, and ‘stepping back’ from it, realizing that the anxious state is just that—a state—and a transient one. That pain is a sensation, not my life, and not even in all of my body. Pain is also often transient, if I step back, move to a different position, and breathe. “But perhaps most important, the process of focusing my awareness and being present in my body has begun to teach me to sense, discriminate, and control my muscles in ways I had never thought I could before. This allows me to change my muscle engagement and the feelings in them and, in many cases, substantially alleviate pain. This has enabled me to increase my activity and return to doing things I enjoy. “I am just beginning this exploration of mindfulness, and I guess, based on what I read and hear, I may look forward to always be ‘just beginning.’ All I can say for certain is that this beginning feels very encouraging, much like the spring renewal I’m seeing all around me in this month of March, after just a few weeks of practice.”

Integrating Mindfulness into Pain Treatment Pain professionals have an opportunity to include mindfulness principles and practices in the care of patients with subacute and persistent pain conditions. Prior to introducing mindfulness to patients, pain professionals need personal experience practicing mindfulness meditation and integrating mindfulness into daily life. Trying to teach mindfulness to a patient without personal experience of the practice is like trying to teach someone to swim without having ever been in the water. Those interested in integrating mindful awareness into patient care can read Full Catastrophe Living by Jon Kabat-Zinn (2), participate in an MBSR program, more deeply engage in the practice in a meditation retreat, and take relevant continuing education courses. They can explore applying mindful attitudes to daily life and when in pain or distress. If a pain professional is inspired to teach MBSR, a dedicated study of mindful principles and practices, commitment to a daily meditation practice, participation in several meditation retreats, and a professional training program would be required.

Summary Mindful awareness offers an innovative treatment approach to patients in pain. A growing body of evidence suggests mindful awareness training contributes to improved outcomes on physical and mental health measures in patients with persistent pain. Through improved body awareness and cognitive and emotional regulation, patients can learn to relate to the sensation of pain in new ways and make choices that improve well-being and function. Pain professionals have the opportunity to train in mindful awareness and integrate attitudes, principles, and practices of mindful awareness into the treatment of patients in pain.

TH E PAIN PRACTITION ER

| VOLUME 27, NUMBER 1 |

21


Carolyn McManus, PT, MS, MA, is a physical therapist on staff in the Rehabilitation Department at Swedish Medical Center in Seattle,WA where she has taught Mindfulness-Based Stress Reduction since 1998. In addition, she is a research associate at the VA Puget Sound where she participates in clinical trials examining the role of mindfulness and kindness meditation training in veterans. She is an author, professional trainer, and national speaker.

Where to Learn about Mindfulness Books Burch V, Penman D. You Are Not Your Pain: Using Mindfulness to Relieve Pain, Reduce Stress, and Restore Well-being. New York, NY: Flatiron Books; 2015. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness. New York: Bantam; 2013. Salzberg S. Real Happiness: The Power of Meditation: A 28-Day Program. New York, NY: Workman Publishing Company; 2010. Online Resources Some reflections and guidance on the cultivation of mindfulness with Jon Kabat-Zinn, PhD: www.youtube.com/watch?v=dd6ktroFf8Q Brief guided meditations: www.carolynmcmanus.com/guided-meditations-free-downloads/ Mindfulness apps: Headspace, Smiling Mind, iMindfulness Professional Training Center for Mindfulness in Medicine, Health Care, and Society, UMass Medical School, Worcester, MA: www.umassmed.edu/cfm/ UC San Diego Center for Mindfulness, San Diego, CA: mbpti.org Mindfulness-Based Pain Treatment: www.carolynmcmanus.com/professionals/

References 1. https://iprcc.nih.gov/docs/HHSNational_Pain_Strategy.pdf 2. Kabat Zinn J. 2013. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness. 2nd ed. New York: Bantam; 2013. 3. Reiner K, Tibi L, Lipsitz JD. Do mindfulness-based interventions reduce pain intensity? A critical review of the literature. Pain Med. 2013;14(2):230-242. 4. Veehof MM, Trompetter HR, Bohlmeijer ET, Schreurs KM. Acceptance- and mindfulnessbased interventions for the treatment of chronic pain: a meta-analytic review. Cogn Behav Ther. 2016;45(1):5-31. 5. Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: A randomized clinical trial. JAMA. 2016;315(12):1240-1249. 6. Doran NJ. Experiencing wellness within illness: Exploring a mindfulness-based approach to chronic back pain. Qual Health Res. 2014;24(6):749-760. 7. McCubbin T, Dimidjian S, Kempe, Glassey MS, Ross C, Beck A. Mindfulness-based stress reduction in an integrated care delivery system: one-year impacts on patient-centered outcomes and health care utilization. Perm J. 2014;18(4):4-9. 8. Garland EL. Disrupting the downward spiral of chronic pain and opioid addiction with mindfulness-oriented recovery enhancement: a review of clinical outcomes and neurocognitive targets. J Pain Palliat Care Pharmacother. 2014;28(2):122-129. 9. Hanscom, D. Back in Control: a Surgeon’s Roadmap out of Chronic Pain. 2nd ed. White River Junction, VT: Vertus Press; 2016.

ADVERTISING DIRECTORY To advertise LESLIE RINGE (209)288-2207, leringe@verizon.net

Electromedical Products International, Inc Alpha-Stim www.alpha-stim.com 800-FOR-PAIN (367-7246) INSIDE FRONT coveR Transition Consultants Medical Practice Sales, Appraisal and Financing www.TransitionConsultants. com 800-416-2055 PAGE 22 Micro Format, Inc. Secure Prescription Paper: Rx Pads, Laser Rx Paper, Thermal Rx Paper Rolls www.RxPaper.com, www.PrescriptionPaper.com 800-333-0549 Page 22

PRACTICES WANTED: PAIN MANAGEMENT, PM&R, & PT Considering Selling your Practice? We are seeking practices on behalf of qualified buyers. Flexible deal structure, all-cash, with favorable terms. Option for sellers to remain post-sale as employed providers. Contact: Mo Majdi 800-416-2055 http://TransitionConsultants.com

22

Join AIPM Now! WHY JOIN?

• We are the FUTURE in integrative pain management

The only professional organization dedicated to Integrative Pain Management.

• We are a multidisciplinary pain organization: Acupuncturists, Chiropractors, MDs and DOs, Nurses, Physical Therapists, Behavioral Health specialists, and the list goes on!

For more information, go to http://www.aapainmanage.org/membership/.

| T HE PA I N P R AC TI TI O NE R | J A N U A R Y / F E B R U A R Y 2 0 1 7

For more information, go to www.aapainmanage.org/membership


The education you need, when you want it.

• AIPM’s Pain Care Learning Center offers comprehensive, on-demand, integrative pain management education with CME/CEU provided for physicians, nurses and psychologists and documentation of attendance for other disciplines. • Basic content offered free for AIPM members. New programs are offered monthly. • 14-hour Curriculum Overview Course for those taking the APMP. To get started, go to: education.aapainmanage.org or For more information: contact Cathleen Coneghen at cconeghen@aapainmanage.org

Earn 5 CME Credits for FREE! Chronic Pain and Opioid Use: Best Practices in the Current Environment For a limited time, this 5-hour online program is available FREE to all clinicians who treat people with pain.

You will learn: •

Strategies for assessing a patient’s risk for opioid misuse, abuse, and addiction.

How to select an opioid and alternative treatment options.

Safe prescribing and ongoing monitoring such as urine drug testing and prescription databases

Legal and regulatory perspectives on opioid prescribing

… and more!

Led by our distinguished faculty, including Paul Christo, MD (chair), Brett Badgley Snodgrass, FNP-C, CPE, FACPP, Gary Reisfield, MD, and Jennifer Bolen, JD. For more information, go to goo.gl/CCLSIB


Nonprofit Org US Postage Paid Burl VT 05401 Permit #19 975 Morning Star Drive #A Sonora, CA 95370

The 28th Annual Meeting

The ONLY Clinical Meeting Dedicated to Integrative Pain Management

San Diego, California October 19-22, 2017 Hilton San Diego Bayfront Over 3+ days, you’ll earn up to 30.5 hours of CEU/CME – plus you will:

• Learn about the newest, evidence-based,

integrative approaches to pain management.

Immerse yourself in the latest techniques for pain management at the year’s largest meeting for all members of the pain care team!

Get best practices of team-based care for the most commonly encountered and challenging painful conditions.

Participate in interactive discussions about case studies and lessons learned from other members of the pain care team and experts in the field.

Be at the forefront of the biggest policy and advocacy issues affecting access and reimbursement for integrative pain care.

Join the largest network of pain care professionals at this once-a-year opportunity! Secure your spot now at the lowest rates all year: aipm28.eventbrite.com

Program Chairs

Robert A. Bonakdar, MD, FAAP

Michael Kurisu, DO

Roger Mignosa, DO

The Pain Practitioner - Fibromyalgia  

The Pain Practitioner is the official magazine of the Academy of Integrative Pain Management (http://www.integrativepainmanagement.org). Thi...

The Pain Practitioner - Fibromyalgia  

The Pain Practitioner is the official magazine of the Academy of Integrative Pain Management (http://www.integrativepainmanagement.org). Thi...