2. 7 Guiding Principles
- First, Do No Harm
- Healing Power of Nature
- Address the Fundamental Causes of Disease
- Heal the Whole Person
- Doctor as Teacher
- Principles of Healthy Living & Preventive
Medicine
- Constitutional Health of the Individual (balance)
3. Disease Issues
- Previously medically diagnosed with :
- Fibromyalgia
- Asthma and environmental allergies
- Osteoporosis
- Chronic fatigue depression and anxiety
- Crohn's disease
- Incontinence with exercise
- Chronic headaches
- Gallbladder attacks
4. Disease Issues
- Primarily environmental allergies (ex: pollen, mold, scents trees)
that worsen her asthma and cause headaches and sinusitis.
● Red pinpoint rash on her upper body 3-4x/year at any time of the year
(non-specific allergic reaction)
● Exposed to many chemicals (topical and inhalants) in the operating room
with poor ventilation system
- Fibromyalgia:
● Has never been without pain since her late 20’s
5. Disease Issues
- Chronic constipation:
● Severe pain in right upper quadrant of the abdomen blood and mucous in
the stool almost every week.
● Persistent bloating primarily in transverse colon + right upper quadrant of
abdomen.
- Medication:
● Ativan 4-5x/week depending on the situation (anxiety)
● Tylenol 3 approx 4x/week and Advil approx 2x/week
- Recovering from serotonin syndrome
6. Disease Issues
- Fatigue
● Recurrent nightmares and restless leg syndrome, exhausted all the
- Pneumonia 6 times in the past 5 years and gets bronchitis at least 2x/year
that lasts for 3-4 weeks body is freezing cold any time of the year
- Diet:
● Gallbladder attacks lasting approx. 8 hours when fatty, greasy foods are
eaten
7. Hereditary Susceptibility
Depression: siblings, both parents, maternal grandmother
Fibromyalgia: sister, brother and mother
Glaucoma: father
Myocardial infarctions: paternal and maternal grandparents and
mother
Bipolar disorder: sister
Rheumatoid arthritis: brother
Alcoholism: brother
Alzheimer’s: maternal grandparents
Already presenting with depression, fibromyalgia, early signs of
Alzheimer’s
8. Susceptibility to Other Conditions
Bone Breakage
Immunity Problems
Slipping of TMJ disk
Suicide
9. Root Cause of Health Issues
Fibromyalgia: is a disorder
characterized by widespread
musculoskeletal pain
accompanied by fatigue, sleep,
memory and mood issues.
People with fibromyalgia also
are more susceptible to tension
headaches, temporomandibular
(TMJ) joint disorders, irritable
bowel syndrome, anxiety and
depression
http://www.mayoclinic.org/diseases-conditions/fibromyalgia/basics/definition/con-20019243
10. Fibromyalgia Due to Severe
Emotional Trauma
Traumatic childhood events:
1) When she was six years old, she witnessed a
classmate get hit by a car and killed
2) Both her parents contemplated suicide frequently during
her childhood and she found her father’s suicide note
when she was 13 years of age
3) Her brother was physically abusive and she was afraid
of him until she was 17
11. Acupuncture Therapy for Pain
Stival and colleagues (2014) conducted a double-blind study
to evaluate the effectiveness of acupuncture as pain
treatment
In this study some patients were administered acupuncture
adhering to traditional Chinese Medicine while others were given sham
acupuncture
The study concluded that acupuncture done by traditional Chinese Medicine can
result in the immediate reduction of pain in fibromyalgia patients.
Acupuncture interferes with the neurotransmitters related to pain and depression
making it an effective therapy for chronic pain patients.
12. Alternative Ideas
Mind-body work: Qigong, yoga, massages
Qigong: is said to help with insomnia, restless leg syndrome and
fibromyalgia
Yoga: focuses on stretching, relaxation and low impact
movements that will ease joint and muscle pain
Massage Therapy: help reduce inflammation and ease muscle
tension/stiffness
Detoxification: steam baths, saunas, mineral baths and low-
intensity exercise to induce sweat
13. Exercise as Fibromyalgia Treatment
Bote et al., (2013) conducted a study to determine if single
sessions of moderate cycling would relieve
the inflammatory response experienced by
fibromyalgia patients.
Following the completion of the study, it was
found that cycling caused a decrease in the
release of inflammatory cytokines by the patients monocytes
“Modified habitual exercise” is considered an effective non-
pharmacological therapeutic aid in the treatment of fibromyalgia
inflammation
14. Alternative Exercise
Aqua fitness and aerobics: water buoyancy
will reduce strain on bones and muscles
making it easier to exercise
Whole body vibration:
Can help reduce pain and fatigue of
fibromyalgia
Increasing bone density
Reduce the stress hormone cortisol and
elevate serotonin
15. Mindfulness Training for
Fibromyalgia Patients
Study to determined whether the implementation of a
mindfulness-based training program is effective in reshaping
anger, anxiety, and depression levels in a group of women
diagnosed with fibromyalgia.
7 week mindfulness training program consisting of acceptance
and commitment therapy, explanations and discussions, tales
from Zen philosophy and Vipassana
Teach participants to let their thoughts flow without any
judgement and without trying to change them. Learning to
think and not react to situations. Learning to not let emotions
control them (not dwelling or holding onto negativity)
Significant reduction of anger levels, internal expression of
anger, state anxiety and depression was revealed in statistical
analysis.
(Amutio et al., 2015)
16. Other Treatment Options
- Gallbladder attacks: cut out
greasy and fatty foods out of diet
- Restless Leg Syndrome: leg
massages, heat/ice packs,
Relaxis pad
- Appetite: not consuming enough
water, (7-8 glasses)
- TMJ: heat/ice packs, massages,
soft foods, dentist
http://www.webmd.com/oral-health/guide/temporomandibular-disorders-tmd?page=3#1
17. Patients Goals & How Treatment
Plan Works With Them
- Wants to slow down the
progression of illness and diseases
and wants to prevent other
illnesses from occurring
- Health Promotion: want to strive
towards healthier living
- Wants a better quality of life.
18. Possible Problems With
Treatment Ideas
- Fatigue and Muscle Pain
- Sedentary Lifestyle
- Urinary incontinence
- Lack of self-efficacy
- Depression
- Anxiety
19. Integration With Existing Practitioners
➮ Psychiatrist
➮ MD and Chiropractictor
➮ Gynecologist
➮ Naturopathic doctor
➮ Massage Therapist
21. References
Amutio, A., Franco, C., Pérez-Fuentes, M. de C., Gázquez, J. J., & Mercader, I. (2014). Mindfulness training for reducing anger,
anxiety, and depression in fibromyalgia patients. Frontiers in Psychology, 5, 1572. doi:10.3389/fpsyg.2014.01572
Bote M. E., Garcia J. J., Hinchado M. D. & Ortega E. (2013). Fibromyalgia: anti-inflammatory and stress responses after acute moderate exercise.
Public Library of Science 8 (9). 1-6.
http://diet.lovetoknow.com/wiki/Detox_Diet_to_Cure_Fibromyalgia
http://www.drweil.com/drw/u/WBL02312/Qigong-Eases-Fibromyalgia-Pain.html
http://www.massagetherapy.com/articles/index.php/article_id/644/Treating-Fibromyalgia
http://www.mayoclinic.org/healthy-living/womens-health/in-depth/kegel-exercises/art-20045283
http://www.medicaldaily.com/fibromyalgia-symptoms-may-be-reduced-whole-body-vibration-exercise-285446
Stival R. S. M., Cavalheiro P. R., Stasiak C., Galdino D. T., Hoekstra B. E. & Schafranski M. D. (2014). Acupuncture in fibromyalgia: a randomized,
controlled study addressing the immediate pain response. Revista Brasileira de Reumatologia. 54 (6). 431-436
http://www.yogajournal.com/article/health/pain-reliever/
http://www.webmd.com/fibromyalgia/features/water-exercise-for-fibromyalgia-easing-deep-muscle-pain
Editor's Notes
Amira:
Hello everyone. The following presentation is an overview of the results in which my fellow colleagues (everyone say name) and I, Amira, have concluded after examining this case study at a closer look.
Amira:
First of all, I’d like to start off by listing the 7 guiding principles because we as a group feel that they’re important for not only the patient’s safety and security, but also for our own morals and integrity as doctors overlooking this case study. They are:
1. - To do no harm
2. - The Healing Power of Nature
3. - To address the fundamental causes of diseases
4. - Heal the whole person
5. - Doctor as Teacher
6. - Demonstrate the principles of healthy living and preventive medicine
7. - And give a balance to the individual’s health
Amira:
As we know, this patient has been previously diagnosed with several health concerns such as:
· Fibromyalgia –Which we know is the main contributing factor to the majority of her pain. Both of her siblings and mother suffered from it as well.
· Asthma and environmental allergies
· Osteoporosis
· Chronic fatigue depression and anxiety—This could be due to the fact that she doesn’t get much sleep due to recurrent nightmares of tornados and people drowning resulting in no more than 4 hours of sleep per night. Also, her energy is severely low
· Crohn’s disease
· Incontinence with exercise—previously to this, she was a very active woman who would exercise for about 1.5 hours about 6 times per week. She hasn’t been without pain since her late 20’s and hasn’t exercised since having her first baby
· Chronic headaches
Amira:
Notably, with regards to her Asthma and environmental allergies, we know she is sensitive to pollen, mold, and the scent of trees. These environmental allergies seem to worsen her asthma and provoke headaches and sinusitis. While working as a nurse she was exposed to many chemicals and poor ventilation systems which we believe contributed to the onset of her asthma and allergies. In addition, she has red pinpoint rash on her upper body approximately 3 to 4 times per year that has not been attributed to any specific allergic reaction.
As
Amira:
Taking into consideration her chronic constipation, she has severe pain in the right upper quadrant of the abdomen coupled with the frequent presence of blood and mucous in the stool. Speaking of this, she has persistent bloating primarily in the transverse colon and right upper quadrant of the abdomen. She is currently recovering from serotonin syndrome and has been given a prescription of Ativan 4-5 times a week for her anxiety, Tylenol 3 approximately 4 times a week, and Advil 2 times a week.
Amira:
As I mentioned earlier, her fatigue is most likely due to lack of sleep that encompasses her recurrent nightmares and restless leg syndrome. With that, she has also been diagnosed with pneumonia 6 times in the past 5 years and gets bronchitis at least twice a year that lasts 3-4 weeks. Her body temperature is freezing cold regardless the time of year. As for her gallbladder attacks, they last approximately 8 hours but are only present when fatty and greasy foods are eaten.
Jackie:
Hereditary Susceptibility in a medical sense is a term used to describe a state of being especially sensitive to experiencing a particular condition based on genetics.
In this case, we know from the patient’s family history that she is susceptible for the following conditions/diseases:
Depression: This mental illness has been reported by her siblings, both parents, as well as her maternal grandmother, making her especially vulnerable to experience this condition.
Fibromyalgia: Based on family history alone, the patient is already susceptible to this disease as you may be more likely to develop fibromyalgia if one relative also has the condition. In this case, her sister, brother, and mother all have this disease
She is also susceptible to Glaucoma from her father; myocardial infarctions from both sets of grandparents as well as her mother; Bipolar disorder because of her sister; Rheumatoid arthritis and alcoholism because of her brother; and Alzheimer's from her mother’s parents.
Jackie:
Not only is she more susceptible to genetically passed on conditions, but because of the illnesses that she is already experiencing, she is susceptible to a number of secondary conditions due to the negative influences of each disease.
Individuals that suffer from poor absorption due to a substandard diet are at risk for bone breakage. A lack of resistance and strength training can also contribute to a higher likelihood of experiencing damage to her bones.
The lack of nutrients that the patient gets from her diet can also impact her body’s natural immune response. The strength of our immune system determines our body's ability to resist infection. Chronic fatigue is a good indicator that her immune system is weak. The immune system absolutely needs optimum nutrition in order to function well. Since she’s not consuming adequate amounts of vitamins and minerals, her immune system will be compromised.
A major symptom that people with fibromyalgia often experience is a slipping of the TMJ disk. This would require jaw surgery, and the need to have the jaw wired shut. And finally, suicide is always a worry for anyone that is experiencing depression. The risk of suicide is especially increased with the mental fatigue as a result of her poor diet, her family’s history of depression and attempted suicide, and the feeling of exhaustion and hopelessness that she will find no relief of her pain.
Vic:
We believe the main root cause of her health issues is the fibromyalgia is defined as a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues.
People with fibromyalgia also are more susceptible to tension headaches, temporomandibular (TMJ) joint disorders, irritable bowel syndrome, anxiety and depression
Vic:
Severe emotional trauma can contribute to fibromyalgia and the client has been been through a few traumatic events:
1)When she was 6 years old, she witnessed a classmate get hit by a car and killed
2) Both her parents contemplated suicide frequently during her childhood and she found her father’s suicide note when she was 13 years of age
3) Her brother was physically abusive and she was afraid of him until she was 17
We believe it is important to evaluate a wide variety of treatments to aid the patient and allow the natural healing of the body. To do this we believe that the patient should receive acupuncture treatment for pain, exercise therapy for inflammation and mindfulness training for emotional and spiritual healing. First we’ll look at acupuncture and alternative therapies as treatments for fibromyalgia.
http://www.mayoclinic.org/diseases-conditions/fibromyalgia/basics/causes/con-20019243
Jess:
Since acupuncture is known to interfere with the neurotransmitters related to pain and depression, it is considered an effective therapy for chronic pain patients
Stival and colleagues (2014) conducted a double-blind study using 36 fibromyalgia patients to evaluate the effectiveness of acupuncture as an alternative pain treatment. In this study some patients were administered acupuncture that adhered to traditional Chinese Medicine while others were given sham acupuncture. The study then concluded that, when compared to sham acupuncture, acupuncture performed in accordance with traditional Chinese Medicine can result in the immediate reduction of pain felt by those with fibromyalgia.
Stival R. S. M., Cavalheiro P. R., Stasiak C., Galdino D. T., Hoekstra B. E. & Schafranski M. D. (2014). Acupuncture in fibromyalgia: a randomized, controlled study addressing the immediate pain response. Revista Brasileira de Reumatologia. 54 (6). 431-436
Jess:
Other alternative therapies she can consider include mind-body work such as Qigong, yoga, massages
Qigong is referred to as meditative movement used to align body, breath, and mind-and is said to help with insomnia, restless leg syndrome and fibromyalgia. In addition, yoga focuses on stretching, relaxation and low impact movements that will help to ease joint and muscle pain. Also massage therapy can help reduce inflammation and ease muscle tension/stiffness.
Along with mind-body work, detoxification can be accomplished through steam baths, saunas, mineral baths and low-intensity exercise to induce sweat
Qigong: http://www.drweil.com/drw/u/WBL02312/Qigong-Eases-Fibromyalgia-Pain.html
Detoxification: http://diet.lovetoknow.com/wiki/Detox_Diet_to_Cure_Fibromyalgia
Yoga: http://www.yogajournal.com/article/health/pain-reliever/
Massage therapy: http://www.massagetherapy.com/articles/index.php/article_id/644/Treating-Fibromyalgia
Jess:
We believe it would be beneficial for her to begin low impact exercise in her home so she can become comfortable with her surroundings and be able to reach a washroom should her exercise induced incontinence begin. We also think that in an effort to combat her incontinence she should participate in Kegel exercises daily to strengthen her pelvic floor muscles and allow her to eventually exercise outside the home.
http://www.mayoclinic.org/healthy-living/womens-health/in-depth/kegel-exercises/art-20045283
To support this decision, Bote et al., (2013) conducted a study to determine if single sessions of moderate cycling would relieve the inflammatory response experienced by fibromyalgia patients. Following the completion of the study it was found that the cycling did cause a decrease in the release of inflammatory cytokines by the patients’ monocytes however it was noted that this response differed according to each individual. Based on this study “modified habitual exercise” is considered to be an effective non-pharmacological therapeutic aid in the treatment of inflammatory pathologies such as fibromyalgia and that is why we believe it would be an important step towards her healing.
Bote M. E., Garcia J. J., Hinchado M. D. & Ortega E. (2013). Fibromyalgia: anti-inflammatory and stress responses after acute moderate exercise. Public Library of Science 8 (9). 1-6.
Jess:
Some alternative exercise options include aqua fitness or aerobics and whole-body vibration which we believe may improve her exercise experience through variation in routine. In aqua fitness and aerobics the buoyancy of the water will reduce the strain on her bones and muscles making it easier for her to exercise. Whole body vibration can help reduce the pain and fatigue of fibromyalgia, help with osteoporosis by increasing bone density, and can reduce the stress hormone cortisol and elevate serotonin resulting in improved mood and increased energy.
Whole body vibration: http://www.medicaldaily.com/fibromyalgia-symptoms-may-be-reduced-whole-body-vibration-exercise-285446
Aqua fitness: http://www.webmd.com/fibromyalgia/features/water-exercise-for-fibromyalgia-easing-deep-muscle-pain
Vic:
Another study looking to alleviate the pain of fibromyalgia was a study that focused on the effects of mindfulness training on women suffering from fibromyalgia to help emotional and spiritual healing. This study was looking to determine whether the implementation of a mindfulness-based training program was effective in reshaping anger, anxiety, and depression levels in a group of women diagnosed with fibromyalgia. The program was 7 weeks and consisted of acceptance and commitment therapy, explanations and discussions, tales from Zen philosophy and Vipassana. The goal was the teach participants to let their thoughts flow without any judgement and without trying to change them. They were learning to think and not react to situations - so not dwelling or holding onto negativity. There was found to be a significant reduction of anger levels, internal expression of anger, state anxiety, and depression.
Amutio, A., Franco, C., Pérez-Fuentes, M. de C., Gázquez, J. J., & Mercader, I. (2014). Mindfulness training for reducing anger, anxiety, and depression in fibromyalgia patients. Frontiers in Psychology, 5, 1572. doi:10.3389/fpsyg.2014.01572
Nat:
In terms of her gallbladder attacks, the best solution for her would be to cut all greasy foods out of her diet. Cutting out greasy foods will not only improve the state of her gallbladder, but it will allow for her transition towards healthier living. For restless leg syndrome numerous methods are available. The use of heat pads and ice packs have proven to help reduce pain, as well as daily leg massages prior to sleeping. The best method that we have found to improve her condition would be the use of a Relaxis Pad. The Relaxis Pad, once placed under the patient’s legs, provides counterstimulation to the naturally occurring restless leg sensation allowing the patient to sleep. It was noted that she drinks about 3-4 glasses of water per day, when in reality, she should be drinking 7-8 glasses. To dissipate the pain from her TMJ disorder, heat and ice packs should be applied to sensitive areas and soft foods should be eaten to reduce jaw strain. If pain persists we suggest that she visit a dentist to address the problem.
Restless leg syndrome: http://www.webmd.com/brain/restless-legs-syndrome/restless-legs-syndrome-rls?page=2#2
Gallbladder attacks: http://gallbladderattack.com/#gallbladderdiet
Nat:
As stated previously, many of the illnesses and symptoms that she is diagnosed with are related to fibromyalgia. By addressing her fibromyalgia, it will aid in the degression of the ailments she currently has. Our treatment plan is designated to treat the root causes that are related to this, which will in turn, slow down the progression of the illnesses. Many of the techniques we have suggested revolve around the well-being of the whole individual, thus improving her quality of life. One example of this would be yoga which allows for her to de-stress, as well as having a sound mind.
Nat:
If you have fibromyalgia, it may be difficult to consider beginning exercise due to fatigue and muscle pain, resulting in a primarily sedentary lifestyle. In terms of being more active, she may be hesitant to begin an exercise regimen due to her urinary incontinence. The main problem with this would be the lack of her self-efficacy regarding exercise which will have a negative effect on her motivation and further add to her insecurities. Also, due to her depression, it will be difficult for her to find motivation to implement this new lifestyle and abandon her old one. Since thoughts of suicide run in her family, she may not find this lifestyle change to be beneficial for her. Finding the right motivation will be the key to living the rest of her life to the fullest. Her anxiety may be a barrier when she has to try new things, such as yoga and Qigong. It also may come into play when she has to return to exercise such as aerobics and swimming.
Jackie:
In order to implement our treatment ideas, we will need to discuss the options with all of her existing practitioners. This includes:
Her psychiatrist to make sure she attends consistent appointments, as this will help with her mental state and hopefully lower her risk of suicide.
Her current medical doctor and chiropractor to help her with strengthening exercises and to watch for any improvements (or deterioration)
We would like to encourage her to have another discussion with her gynecologist about the importance of a hysterectomy, to hopefully schedule an appointment for said surgery.
Try acupuncture with her naturopathic doctor as well as meditation
And also continue with massage therapy to help with relaxation and sleep
Jess:
In closing we think it’s very important that we avoid pharmacological interventions and assist the patient in healing the body naturally and slowly. By introducing her to alternative forms of pain management we hope to see a change in her sleep patterns and as a result her mood. We believe by improving upon the main causes of her current illness state we can prevent further damage to the body and reduce susceptibility to other diseases. We also hope that once it is possible to move her exercise activities outside of the house, she will be able to expand her social network and find new friendships that will aid in her journey to well-being.
