AN ADVANCED PRACTICE NURSING APPROACH UTILIZING;

. - . .

EXERCISE IN THE TREATMENT OF FIBROMYALGIA

A PATIENT EDUCATION BROCHURE

. I Schoiarly Prolectfor the Degree (MA 8 N
MICHIGAN STATE UNIVERSITY
SUSAN SUGDEN

.....

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AN ADVANCED PRACTICE NURSING APPROACH UTILIZING
EXERCISE IN THE TREATMENT OF FIBROMYALGIA:
A PATIENT EDUCATION BROCHURE
BY

Susan Sugden

A SCHOLARLY PROJECT
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
MASTER OF SCIENCE
College of Nursing

1999

ABSTRACT

AN ADVANCED PRACTICE NURSING APPROACH UTILIZING
EXERCISE IN THE TREATMENT OF FIBROMYALGIA:
A PATIENT EDUCATION BROCHURE
BY

Susan Sugden

Fibromyalgia (FM) is a chronic widespread
musculoskeletal pain syndrome that consists of generalized
pain, stiffness, fatigue and poor sleep. Personal
suffering and significant consumption of societal resources
makes FM worthy of holistic treatment that will preserve
functioning and personal dignity. The Nightingale theory
of nursing was the conceptual framework for development of
a patient education brochure about the benefits of exercise
as an intervention for FM. Review of current literature
provided the foundation of the advanced practice nursing
approach to this problem. Research implications of the
project are considered from both qualitative and
quantitative perspectives. Exercise has both physical and
psychological benefits for people with FM, as an
intervention that may improve quality of life and limit

disability.

ACKNOWLEDGMENTS

I wish to express my gratitude to Dr. Louise Selanders
for her academic guidance through this project. Dr.
Selanders handed me my first stethoscope twenty years ago,
introduced me to the genius of Florence Nightingale, and
was a source of personal and professional support during
this evolution in my nursing career.

True appreciation for their time and guidance is also
owed to Catherine Lein, M.S.N. and Dr. Cynthia Gibbons who

served on the project committee, and to Dr. Claire Collins

who guided this project through the formative stage. Thank

you for your knowledge, leadership and moral support.

iii

TABLE OF CONTENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIST OF FIGURES v
INTRODUCTION 1
Statement of the Problem 1
Purpose of the Project 3
CONCEPTUAL FRAMEWORK 5
Person 7
Environment 8
Health 9
Nursing 10
REVIEW OF LITERATURE 13
Fibromyalgia 13
Theories of Etiology 17
Muscle Pathology 21
Deconditioning 22
Pain Control 23
Mental Health 25
Barriers 27
PRODUCT OF THE SCHOLARLY PROJECT 30
RESEARCH IMPLICATIONS 35
SUMMARY 38
REFERENCES 40

 

iv

LIST OF FIGURES

FIGURE 1. Nightingale's Model for Nursing Practice ..................... 12

INTRODUCTION

Patients with chronic pain patients live with the
uncertainty of finding a cure. For people living with the
chronic pain of fibromyalgia the journey toward diagnosis
does not always result in a positive outcome. In the
process of seeking relief many fibromyalgia (EM) patients
have encountered frustration with the health care system as
their mental health and credibility are questioned. Health
care providers become frustrated with these patients
because they cannot find a cure for people with FM.

This paper will explore the use of exercise as one
intervention modality that, along with medication, coping
skills training and lifestyle change, may help patients
live better with fibromyalgia. Nursing offers a bridge
from the mind-body dichotomy of the medical model to a more
holistic treatment of the bio-psycho-social-spiritual
person. If we change the goal from cure to care, we can
help people with FM learn ways to feel better while living
with this chronic benign pain.

Statement of the Problem

Chronic benign pain is defined as any pain lasting
longer than six months duration that occurs daily and is
nonmalignant (McCaffery and Beebe, 1989). It is not life
threatening, and it is not always responsive to current

1

methods of pain relief. Chronic benign pain differs from
acute pain in that there are no objective signs of tissue
injury-no bruises or broken bones to lend credibility to
the patient’s complaint (Meilman, 1984). Chronic benign
pain has a gloomy prognosis and may continue the rest of
the patient’s life. Treatment of chronic pain usually does
not involve narcotics, but does use pain management
techniques and skills training to help patients cope with
pain. The goals of chronic pain treatment are to improve
quality of life and prevent disability. Fibromyalgia is a
form of chronic benign pain.

Fibromyalgia patients are intensive users of healthcare
resources, averaging ten outpatient medical visits per year
and one hospitalization every three years (Wolfe, Anderson,
Harkness et al., 1997). The average yearly cost for
service utilization among fibromyalgia patients is $2,274
(Wolfe et al., 1997) meaning fibromyalgia costs as much or
more than other rheumatic conditions (Solomon and Liang,
1997).

Personal costs are high for FM patients who search for
a healthcare provider who believes them: “Sooner or later,
most patients with pain realize that they cannot prove
their pain” (McCaffery and Beebe, 1989, p.7). Trust may be
destroyed and the therapeutic relationship may become
adversarial when the provider does not believe the patient.
Most EM patients experience psychological distress as a

2

consequence of chronic pain and its effects on the quality
of life (Bennett, 1996). One study found that chronic
musculoskeletal pain was a benchmark diagnostic feature of
FM and a predictor of disability and depression (Nicassio,
Schuman, Kim, Cordova and Weisman, 1997). Research
describing the prevalence and characteristics of FM in the
general population found that 19.7% of persons with FM had
applied for, and 7.3% had received disability benefits
(Wolfe et al, 1995, p.26). Personal suffering and
significant consumption of societal resources makes EM
worthy of holistic treatment that will preserve functioning
and personal dignity.
Purpose of the Project

The purpose of this scholarly project is to develop a
patient information brochure on the benefits of exercise
for people with FM. The proposed project will be based on
review of pertinent literature and actual experience in a
practice where FM patients are evaluated and treated. EM
management involves many aspects of Advanced Practice
Nursing (APN) care: pharmacology, non—narcotic pain control
modalities, stress management, lifestyle modifications,
counseling and education. Exercise was chosen as a
treatment intervention which can be self-managed and have
positive effects on mental and physical health. The focus
in FM is not to cure, but care, as it is in so many chronic
conditions that APNs treat. Improving quality of life and

3

preventing disability are strong nursing goals relevant to
patients with FM.

APNS focus on health promotion both for persons who
have no disease and for those with chronic health problems
(Snyder and Mirr, 1995). Holistic assessments that
encompass physiological, psychosocial, behavioral and
spiritual elements are an integral part of the APN role.
Nursing has a tradition of placing emphasis on education
and counseling, and since APNs function on the expanding
boundaries of nursing’s scope of practice, they bring an
armamentarium of nursing interventions to the management of
health problems. Nursing is eclectic in drawing knowledge
from the other helping professions including medicine,
psychology, and sociology. APNs apply scientific knowledge
to the processes of diagnosis and treatment; and just as
important, they provide a caring relationship that
facilitates health and healing (Snyder and Mirr, 1995).
APNs are versatile and capable of caring for the
multifaceted problem of fibromyalgia.

Many role characteristics of APNs commend them as
appropriate primary caregivers for patients with FM. As an
assessor the APN systematically collects subjective and
objective data to formulate a clinical judgment about the
care needed by the patient with FM. Using theory and
advanced clinical judgment, the APN in the role of
clinician promotes self-care abilities to help the patient

4

dealing with FM maintain health, cope with their illness
and manage disabilities. This may involve the APN
functioning as a case manager, coordinating care amongst a
team of health care professionals including Rheumatology
specialists, physical or occupational therapists, and
psychologists. In a chronic illness such as FM the role of
educator is key to helping the person with FM understand
their condition and learn a variety of treatment and coping
skills. The APN functioning in the role of counselor
provides the stabilizing human support that allows clients
to express concerns and use problem solving skills. This
role is important for the FM patient who faces an
indefinite future of pain and may suffer depression.
Providing hope through scientific research is another role
of the APN as an investigator of clinical problems and
tester of nursing theories. People living with FM have much
to gain from the holistic care of an APN.
CONCEPTUAL FRAMEWORK

The conceptual model for this paper will be based on
the work of Florence Nightingale. Nightingale’s nursing
focused on persons and their response to health problems
rather than specific illnesses. The American Nurses
Association defines nursing as the “diagnosis and treatment
of human responses to actual or potential health problems”
(American Nurses Association, l995,p.6). This contemporary
definition can be seen as an evolution of the Nightingale

5

theory of nursing. Florence Nightingale believed in the
essential unity of mind, body and spirit. She maintained
that the presence of pathology was not a prerequisite for
nursing care (Fitzpatrick and Whall, 1996). This concept
of nursing is consistent with contemporary definitions
which pay attention to the range of human experiences
across the health continuum without restriction to a
problem-focused orientation (American Nurses Association,
1995). An integrated approach is essential in nursing,
blending objective data with an understanding of the
patient’s subjective experience.

Florence Nightingale suffered years of chronic pain and
illness following her service in the Crimean war as a
result of contracting chronic brucellosis (Dossey, 1998).
Despite her chronic pain she was a prolific writer, a
leader in nursing education and administration, a public
health advocate and a superb statistician (Selanders, 1998
and Kopf, 1978). Nightingale utilized traditional medical
therapies and explored types of nonmedical therapies during
her illness—including massage, pets, nature and prayer
(Dossey, 1998 and Light, 1997). Given this historical
context, applying the Nightingale model of nursing to FM is
especially appropriate.

Nursing has evolved greatly since the time of Florence
Nightingale, and yet her ideas are the basis of modern
nursing theory. The concepts of person, environment,

6

health and nursing are known as nursing's metaparadigm
(Fawcett, 1995). Many variations on the theory of nursing
exist, yet theorists return to these four essential areas
to define our practice. Nursing's metaparadigm is a
contemporary tool used to organize and compare the various
nursing theories (Lobo, 1995). Nightingale preceded modern
nursing theory development by one hundred years, but she
was a prolific author who left the essence of nursing's
conceptual base in her writings (Meleis, 1997; Selanders,
1993). Nightingale's interpretations of the four concepts
have contemporary relevance and will be applied to the use

of exercise as an intervention in fibromyalgia.

Person

Nightingale asserted that medicine treated the sickness
and nursing cared for the sick (Nightingale, 1992). Person
is defined as the recipient of nursing care, an individual
who is referred to as the patient in Nightingale’s writings
(Selanders, 1993). People are seen as holistic blends of
the biological, psychological, social and spiritual
elements (Dossey and Dossey, 1998). Holism means that the
individual is more than the sum of its parts (Dossey,
Guzzetta, Keegan and Kolkmeier, 1995). Utilizing this
concept of person, the pathology and disability of EM
become less important than the effect they have on the
patient. Nightingale believed people had control of their

7

destiny and could make choices that would lead them toward
perfection-and ultimately toward God (Widerquist, 1992).
She viewed patients as active participants in care, with
the ability to help themselves heal using their “reparative
powers” (Selanders, 1993, p.15; Dennis and Prescott, 1985,
p.75).
Environment

Nightingale’s work has been called an environmental
adaptation theory because of the pivotal role environment
plays in her view of nursing intervention (Selanders,
1993). The environment was defined in the physical sense
in Victorian England and it left a lot to be desired.
Sanitation issues were a major focus of Nightingale’s
reforms in England, the Crimea and India (Smith, 1982).
Basic issues such as the disposal of human waste and purity
of water sources were fundamental to her efforts to reduce
disease and suffering. Nightingale also addressed the
psychological and social needs of patients in an effort to
remove obstacles to the natural healing force “by attending
to all dimensions of a person” (Light, 1997, p.34). The
essence of environmental adaptation is to help people
organize their internal and external environment to
facilitate their innate healing capacity (Light, 1997).

Selanders compels nurses to consider Nightingale's
environmental adaptation concept in a contemporary context,
comparing Maslow's hierarchy of needs to the strategies

8

Nightingale advocated to promote health (Selanders, 1998).
In her practical, logical way Nightingale started with the
basic physiological needs, then advanced to psychological
care. Nightingale would treat both mind and body through
manipulation of the environment, putting the patient in the
best possible condition for nature to act (Selanders,
1998).

Exercise impacts the physiologic and psychological
well-being of people with FM. In her Report of the Indian
Sanitary Commission in 1863, Nightingale recognized “lack
of suitable occupation and exercise” as a factor in camp
disease rates (Kopf, 1978, p.100). Despite debate
regarding the cause of FM, there are positive interventions
to offer these patients. Exercise changes the physical
environment by increasing muscle blood flow, flexibility
and efficiency. The psychological environment is altered
by exercise through increased sense of control and
decreased susceptibility to pain. Exercise can be a social
activity, decreasing isolation and disability.
Nightingale's theory of environmental adaptation applies to
this intervention's use in the treatment of FM.

Health

Nightingale was ahead of her time when she
conceptualized health as more than the lack of illness.
“Health is not only to be well, but to use well every power
we have to use” (Nightingale, 1859/1949, p.26).

9

Contemporary definitions of health include the ideas of
stability and self-actualization, which are compatible with
the Nightingale conception of health (Pender, 1996).
Natural laws were thought to govern health and Nightingale
believed that altering the environment would fulfill these
laws, resulting in health (Selanders, 1993). Disease was
seen as a reparative process that could restore a person to
wholeness (Light, 1997).

By definition, chronic pain_has not resolved-that is
what defines it as chronic in the first place. To live
with chronic pain and be as healthy as possible means
maximizing abilities and working toward an improved quality
of life. By not letting pain control choices, activity and
attitude, people with FM can use every power they have to
optimize their lives. Each symptom of FM can be Viewed as
“dys-ease”, or a lack of comfort that leads the patient to
seek nursing care to restore health. Therefore, the
discomfort of FM may rouse a patient to pursue health and
in this way function as a reparative process.

Nursing

Nightingale was a devoutly religious woman who did not
take credit for curing the sick. Instead, her View was
that nursing “put the patient in the best condition for
nature to act upon him” (Nightingale, 1859/1992, p.74).
Nursing was seen as an art and a science: a goal-directed,
research-driven process that restored a patient to health

10

(Reed and Zurakowski, 1996). Nursing could encompass
health promotion, maintenance or restoration and was not
limited to care of the sick or injured (Selanders, 1993).
Whether nursing the individual or a population, the action
of the nurse was to alter the environment so that nature
could heal the patient.

Nursing in Nightingale’s time consisted of a nurse
acting on a patient’s environment to facilitate a change.
This should be understood in an historical context as
typical thinking about illness in the nineteenth century.
The patient was not seen as an equal partner in health care
(a concept popular today), but as recipient of the
administrations of the nurse who is the active participant
in the relationship (Selanders, 1993). The nursing process
consists of observation, documentation, and environmental
alteration performed to benefit the health of the patient.
Evaluation of the resulting state of health provides the
nurse with feedback and then the process of
assessment/observation begins again.

In a model specific to FM, the APN observes the
patient's health status and identifies the discomfort or
“dys-ease” of the person with FM (see Figure 1). The APN
then identifies the need for environmental alteration and

the desired outcome of nursing intervention.

11

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Desired outcomes in FM are to decrease pain, increase
quality of life and limit disability. Exercise is named as
the environmental alteration to be accomplished, then the
intervention of education is performed including the use of
a patient information brochure about the benefits of
exercise for people with FM. The patient is treated
holistically, with attention given to the biological,
psychological, social and spiritual aspects of their life.
After documentation, the nurse analyzes the impact of the
environmental alteration on the patient's health status;
this becomes feedback for the patient observation step of
the model.
REVIEW OF LITERATURE
Fibromyalgia

Fibromyalgia is a chronic pain syndrome and is the
most common cause of widespread pain seen in medical
practice, (Bennett, 1995) affecting an estimated three to
six million people in the United States (Wolfe, Ross,
Anderson, et al., 1995, p.19). Although anyone across the
age span may have fibromyalgia, women are twenty times more
likely to be affected than men (Ryan, 1995, p.25) with the
typical patient diagnosed between the ages of thirty and
fifty (Krsnich-Shriwise, 1997, p.68).

Controversy surrounds fibromyalgia as to whether it is
a disease, a syndrome or a psychosomatic illness. Diseases
usually have known causes and well-understood mechanisms

13

for producing symptoms. Syndromes are collections of signs
and symptoms that occur together and paint a clinical
picture (Starlanyl and Copeland, 1996). Syndromes are
serious problems that cause suffering and disability.
Fibromyalgia was defined by the American College of
Rheumatology (ACR) in 1990 as a syndrome including
widespread musculoskeletal pain, multiple tender points,
dysfunctional sleep, persistent fatigue and paresthesias
(Yunus, 1996). The etiology and the pathology of
fibromyalgia are not well understood. “The absence of an
obvious physical cause, therefore, can lead to a labeling
of the entire pain experience as psychopathology” (King and
Goddard, 1994, p.S-9).

Fibromyalgia (FM) is not a new phenomenon. A condition
known as muscular rheumatism lead Ralph Stockman to perform
muscle biopsy studies in 1904(Simms, 1996). The term
fibrositis was used to denote a syndrome of generalized
muscular pain, tender points at multiple sites, poor sleep
and fatigue until 1981 when Yunus published a study of the
clinical characteristics of this syndrome (Rachlin, 1994).
Fibrositis was abandoned in favor of the term fibromyalgia
because research does not support inflammatory changes in
muscle tissue as the source of the generalized pain
(Rachlin, 1994 and Simms, 1996). In 1990 the American

College of Rheumatology published Criteria for the

 

Classification of Fibromyalgia to propose diagnostic

 

14

criteria that define the syndrome (Wolfe et al., 1990).
Those criteria include:
o Widespread pain in combination with
0 Pain at 11 or more of 18 specific tender point sites.
Widespread pain is further defined as pain on the right and
left sides, pain above and below the waist, and axial
skeletal pain (cervical spine, anterior chest, thoracic
spine or low back)(Bennett, R. and McCain, G., 1995).

Tender points are generally areas where muscle attaches
to ligaments or bone and these areas localize pain when
stimulated (Krsnich-Shriwise, 1997). That is one way to
differentiate between a tender point and a trigger point.
Trigger points radiate or refer pain when stimulated.
Tender points are localized areas of pain associated with
fibromyalgia; trigger points are dense areas of tightness
within a muscle and they are associated with the myofascial
syndrome (Maurizio and Rogers, 1997). Patients with FM have
a generalized increase in pain sensitivity compared to
unaffected individuals (Mikkelsson, Latikka, Kautiainen,
Isomeri, and Isomaki, 1992). What is unique about FM is
reproducible pain at specific tender points. This pain is
qualitatively and quantitatively different from the pain of
other chronic conditions like rheumatoid arthritis (Yunus,
1996).

Examination of tender points requires knowing where to
palpate, how much pressure to apply, and how to judge a

15

pain response in the patient. The diagnosis requires that
the patient feel pain, not just tenderness, when the
examiner applies four kg of pressure to the tender point
(Bennett and McCain, 1995). To meet the ACR criteria, the
pain must be present for at least three months (Maurizio
and Rogers, 1997). Tender points may be assessed by manual
palpation or by a pressure pain meter called a dolorimeter
(Mikkelsson et al., 1992). A criticism of the ACR criteria
is that the evaluation of tender points is not objective
(Hadler, 1997) and this is a legitimate claim since the
sensation of pain is a completely subjective experience.
“Pain is whatever the experiencing person says it is,
existing whenever the experiencing person says it does”
(McCaffery and Beebe, 1989, p.7). Research has shown that
the presence of tender points in combination with
widespread pain provides the most sensitive, specific and
accurate criteria for the diagnosis of FM (Wolfe et al.,
1990).

The most common symptoms of FM are generalized pain,
stiffness, fatigue and poor sleep (Rachlin, 1994).
Feelings of swelling without objective signs of edema, and
paresthesia are present in half the patients who have
fibromyalgia (Yunus, 1996). Associated symptoms include
headaches, irritable bladder and irritable bowel syndromes,
dysmenorrhea, Raynaud's phenomenon, difficulty
concentrating, anxiety and depression (Bennett and McCain,

16

1995).
Theories of Etiology

There are multitudes of theories in the literature yet
the etiology of FM is unclear. Fibromyalgia has many
symptoms that overlap with other disorders, such as chronic
fatigue syndrome, temporomandibular syndrome and
dysfunctional pain syndrome (Yunus, 1996). These syndromes
occur most often in women and lack laboratory tests or
pathological tissue changes that might provide verification
of the patient’s complaints (Rachlin, 1994). Perhaps the
most controversial theory of etiology of FM is the
psychosomatic postulation. Hadler declared that “these are
normal people whose individual personality traits and
vulnerability predispose them to learning to lead a life of
somatizing” (1997, p.176). The fact that somatization is
five to ten times as common in women as it is in men and
correlates with high levels of depression would seem to
support this line of reasoning (Eisendrath and Nye, 1997,
p.50). Approximately thirty percent of FM patients have
significant psychological problems—the most common
diagnosis being depression (Bennett, 1995, p.271). This
thirty-percent co-morbidity of depression with FM does not
mean that FM is a variant of depression. “Anxiety is
usually associated with brief pain, whereas depression
tends to accompany prolonged pain; an element of both is
usually present with all pain” (McCaffery and Beebe, 1989,

17

p.9). An emotional reaction to pain does not mean that
pain is caused by an emotional problem. The psychosomatic
theory may simplify the complex relationship between pain
and depression.

Fibromyalgia may be related to a sleep disorder in
which non-rapid eye movement (NREM) sleep is disrupted.
Moldofsky found a pattern of alpha wave intrusion in stage
three and stage four sleep during electroencephalogram
(EEG) studies of patients with fibromyalgia (Moldofsky,
1993). .Alpha waves are “awake” type of brain waves and
are not normally present during deep sleep. He also was
able to demonstrate that disrupting NREM sleep in healthy
volunteers resulted in development of musculoskeletal and
mood symptoms similar to those seen in FM. When compared
to normal or insomniac patients, the fibromyalgia group
spent thirty-five percent more time in alpha wave anomaly
sleep (Rachlin, 1994, p.68). Neurochemical alterations,
such as lack of serotonin may be responsible for alpha wave
anomaly sleep disruption (Millott and Berlin, 1997). Other
causes of alpha wave intrusion are stress, trauma, biologic
illness and environmental influences (Rachlin, 1994).
Exercise improves sleep by increasing the amount of time
spent in slow-wave or deep sleep. Slow-wave sleep is
associated with a well-rested feeling upon awakening, and
many FM patients wake up feeling unrefreshed (Dishman,
1992). Fatigue may contribute to complaints of memory

18

loss, poor concentration, forgetfulness and confusion by
patients with FM (Slotkoff and Clauw, 1996). Critics of
this theory point out that alpha wave intrusions occur in
healthy persons, and that many patients with fibromyalgia
have normal EEG patterns during sleep (Slotkoff and Clauw,
1996).

Central nervous system structural changes may account
for the pain perception of FM patients. The thalamus is
important in integration and perception of pain signals,
and sends output regulatory messages to the hypothalamic-
pituitary—adrenal axis. The caudate nucleus signals the
occurrence of noxious events and can produce analgesic
effects (Koopman, 1997). Researchers have used single
photon emission computed tomographic imaging (SPECT) to
show that patients with FM have low regional cerebral blood
flow to both the thalamus and the caudate nucleus (Mountz,
Bradley, Modell et al., 1995). The theory is that the
brain is compensating for prolonged exposure to noxious
stimulation flowing up the spinal pathways. Neuroendocrine
theories may also decipher the multifaceted symptoms seen
in FM. Changes in the hypothalamic-pituitary-adrenal axis
and the sympathetic nervous system occur in response to
stress. People with FM have a hyporesponsive stress system
with high levels of substance P, and low levels of
serotonin availability. Substance P is a nociceptive
neurotransmitter that along with dynorphin and calcitonin

19

gene-related peptide causes hyperexcitability and
hyperalgesia in the dorsal horn of the spinal cord
(Pillemer, Bradley, Crofford, Moldofsky and Chrousos,
1997). Hyperalgesia is a normal stimulus such as light
touch being perceived as painful. Less serotonin means
less down-regulation of nocioception (Pillemer et al.,
1997) and when serotonin is depleted there is a decrease in
restorative NREM sleep, an increase in depression and pain
(Krsnich-Shriwise, 1997). Another endocrine theory
proposes that the hormonal changes of menopause may cause
sleep disorders and decreased secretion of growth hormone
which is necessary for repair of muscle microtrauma
(Crofford and Demitrack, 1996). Hormones then, may impact a
patient's ability to sleep and repair daily stresses
suffered by the body and influence a person's ability to
cope with pain.

A theory of muscle deconditioning weaves together the
symptoms of FM in a multicausal model. Sleep deprivation
leads to fatigue and inactivity, which results in unfit
muscles. Muscle is thixotropic: if it is not used, it
becomes shorter, stiffer and weak (Bennett, 1995). This
leaves the muscle at risk for microtrauma-disruption of
muscle fibers and abnormal permeability of the sarcolemmal
membrane that occurs during activity (Bennett, 1989).
Deconditioning leads to loss of flexibility, easy muscle
strain and soreness; this pain contributes to inactivity

20

and the feedback loop continues (Caudill, Holman and Turk,
1996).

Fibromyalgia treatment is aimed at symptoms, using
concepts from proposed etiologies for direction. This is a
complex syndrome offering rich opportunity for research.

Muscle Pathology

Many researchers have looked for the source of FM pain
by examining the muscle tissue for signs of pathology. In
Sweden studies assessed muscle morphology, metabolism and
physiology attempting to explain the pain, fatigue and
stiffness that accompanies FM (Bengtsson and Henriksson,
1989). They found changes indicating disturbances in
microcirculation, mitochondrial damage and reduced high
energy phosphates, leading to the conclusion that muscle
hypoxia might be a cause of FM pain. Criticism of the
Bengtsson studies include the pathologic changes found were
located in only one of the sites biopsied, and changes were
not replicable in multiple alternate sites on the same
patients (Simms, 1996). .Also, the types of muscle changes
described as moth-eaten and ragged red have been found in a
variety of disorders (not just FM) and can be induced in
experiments that cause muscle ischemia (Heffner and Barrow,
1978).

Research by Yunus and Kalyan-Raman found no more muscle
abnormalities in people with FM than in pain-free control
subjects (Yunus and Kalyan-Raman, 1989). This was a well-

21

designed, blinded, controlled study done at the University
of Illinois in 1986. Simms critically reviewed thirty-
three studies in an attempt to answer the question of
muscle pathology in FM syndrome, concluding that the
studies failed to confirm muscular pathology (Simms, 1996).
Changes in blood flow and muscle metabolism were consistent
with the effects of muscle deconditioning. There is not
sufficient evidence in the literature to support the
presence of muscular pathology in the syndrome of FM.
Deconditioning

When muscles are not used they become tighter, stiffer
and less efficient (Rosen, 1994). This concept of
deconditioning as a source of the symptoms of FM surfaces
in the literature with the sleep deprivation studies of
Moldofsky and Scarisbrick (1976). After noting during an
initial study that FM patients suffered from a
characteristic pattern of sleep disruption in stage four, a
second study was performed in which FM symptoms were
induced by selectively interrupting the stage four sleep
cycles of healthy volunteers (Moldofsky and Scarisbrick,
1976). The more aerobically fit subjects were less
susceptible to developing FM symptoms. This study was the
basis for much research into the fitness levels of FM
patients.

Research on physical fitness has found that people with
FM are less aerobically fit than average control groups.

22

One research team studied aerobic fitness of patients with
fibrositis at The Oregon Health Sciences University at
Portland. Over eighty percent of the fibrositis patients
in this study were below the average level of aerobic
fitness (Bennett, Clark, Goldberg, Nelson, Bonafede, Porter
and Specht, 1989, p.457). This study found low clearance
of a marker for muscle blood flow, lending support to the
deconditioning model of etiology in FM. Another study of
physical performance characteristics of women with
fibromyalgia (Mannerkorpi, Burckhardt and Bjelle, 1994)
found FM subjects were significantly below average in
physical performance measures on muscle strength and
endurance tests when compared to the healthy control group
or to average age-specific norms. Thus, studies indicate
that FM patients are less aerobically fit than average
persons are.
Pain Control

While there are many strategies used to control pain,
regular physical exercise is noted to be of great benefit
for patients with FM. A two year study following forty-
four FM patients discovered that time spent in exercise and
aerobic activity inversely correlated with the severity of
the FM symptoms (Granges, Zilko and Littlejohn, 1994). The
study interventions consisted of verbal explanation and
reassurance about FM, and a standardized written
information sheet provided to patients. Special emphasis

23

was given on the importance of regular physical exercise
for the management of their condition. Patients also had
individualized drug regimens of analgesics and
antidepressants. Even though causality cannot be assumed
on the basis of correlation, it is interesting that
physical exercise (rather than drugs, coping skills, or
specific physical therapies) was the variable correlating
with better health. No specific prescribed physical
activity intervention was included in this study, but the
authors did advocate physical activity as a major component
of the management of EM patients. When considered in
conjunction with the Moldofsky (1976) studies on sleep
deprivation, this study seems to support the role of
physical fitness in EM symptom prophylaxis.

Other research studies confirm the benefits of exercise
for the FM patient. Comparison of flexibility exercises
with cardiovascular fitness training in a randomized,
controlled study of forty-two FM patients showed
improvements in both pain threshold scores and global
assessment scores for the fitness training group vs a
control group receiving flexibility exercises (McCain,
Bell, Mai, and Halliday, 1988). This study also found
lowered levels of psychological distress in both groups,
but concluded the improvements in FM were not the result of
this decrease in psychological distress. The authors
attribute improvements to expected increases in beta-

24

endorphins, ACTH, prolactin and growth hormone that
accompany strenuous exercise (Mccain et al, 1988). These
hormonal responses to exercise are well documented
elsewhere (Masironi and Denolin, 1985; and Morgan, 1997).
Whatever the mechanism, these patients demonstrated less
pain and felt better when they exercised.

Pain control as an effect of aerobic exercise is
documented in a controlled study comparing exercise with
stress management (Wigers, Stiles and Vogel, 1996). FM
patients were randomly assigned to fourteen weeks of
aerobic exercise, stress management or treatment-as-usual
group interventions. Measurements of pain, fatigue and
depression decreased for patients assigned to the aerobic
exercise group; these people also experienced increased
work capacity and global subjective improvements (Wigers,
Stiles and Vogel, 1996). Research supports the beneficial
effects of exercise on several aspects of FM including pain
control, feelings of well being and reduced fatigue.

Mental Health

Exercise may be advantageous in treating depression
that often accompanies chronic pain. Several studies have
shown that even a moderate amount of physical exercise has
an antidepressant effect on FM patients (Martinsen, Medhus
and Sandvik, 1985; Clark, Burckhardt and O'Reilly, 1991;
Gowans, Voss, deHueck ET al, 1996). The mechanisms
proposed for this link between mind and body include

25

psychological and physiological responses. Biological
hypotheses for improved mood include increases in beta-
endorphin, serotonin, and norepinephrine production
associated with the stress of aerobic activity (Morgan,
1997). Mentally, exercise can be a mastery experience that
boosts a person’s sense of self-efficacy--the belief that
one can manage a specific challenging situation (Bandura,
1977). Higher self-efficacy was associated with less pain
and less impairment of physical activities in research
involving seventy-nine FM patients (Buckelew, Murray,
Hewett, Johnson and Huyser, 1995). Other psychological
models point out that exercise provides therapeutic
distraction; exercise and pain behaviors are mutually
exclusive (Martinsen and Morgan, 1997). There seems to be
a mind-body connection whereby exercise improves
depression.

One study found approximately thirty percent of FM
patients had psychological problems with the most common
diagnosis being depression (Bennett, 1995, p.271). The
mental health benefits of exercise are also available for
the majority of FM patients who are not depressed.
Secondary analysis of four population surveys of physical
activity and mental health in the United States and Canada
found level of physical activity was positively associated
with general well-being, and lower levels of anxiety and
depression (Stephens, 1988). Physical activity related

26

strongly to mental health and “more important than the size
of the treatment effect, however, is the generality of this
relationship: it not only applies to the superfit and to
neurotics but also extends to the general population”
(Stephens, 1988, p.43).

Research studies on FM have demonstrated the benefit of
promoting internal locus of control for patients who suffer
chronic pain (Wells, 1994). FM patients who had a sense of
coherence-confidence their environment was predictable and
that they had resources to cope with life's challenges—
reported they felt well despite high symptom levels
(Soderberg, Lundman, and Norberg, 1997). Feelings of lack
of control produced pessimism, anxiety and decreased pain
tolerance in FM patients who were compared to rheumatoid
arthritis patients in a study of locus of control
(Gustafsson and Gaston-Johansson, 1996). Aerobically fit
subjects demonstrated resistance to psychosocial stressors
in a meta-analysis of thirty-four studies conducted by
Crews and Landers (1987). Exercise may be an opportunity
for FM patients to be active in their treatment, charting a
course toward control over their symptoms that results in
improved mental and physical health.

Barriers

A major problem with exercise interventions is the
reversibility of the benefits associated with activity.
Aerobic exercise increases blood flow to muscles and

27

increases the ability of the mitochondria to produce ATP-
the fuel for muscle activity. Within eight weeks of
exercise cessation detraining occurs, and gains of exercise
are not retained (Coyle, 1988). Wigers, Stiles and Vogel’s
research confirmed this reversibility: at four year follow—
up ”a considerable compliance problem may explain the lack
of long-term effects on symptom severity in the aerobic
exercise group as a whole” (1996, p.83). Aerobic exercise
appears to be an effective treatment of FM symptoms when
patients adhere to it.

Because of the reversibility of exercise's benefits and
the chronicity of the pain of FM, patients may see exercise
as an insurmountable project. Several studies document an
initial deterioration with postexertional pain, stiffness
and fatigue when these people begin aerobic activity
(Martin ET a1, 1996; McCain, Bell, Mai and Halliday, 1988;
and Mengshoel, Vollestad and Forre, 1995). While transient
in nature, this initial worsening may have a negative
effect on adherence to new activity. The presence of pain
is not a contraindication to exercise (Rosen, 1994;
Meilman, 1984). This is a very different mindset from
acute pain management where patients are often encouraged
to rest. Returning the patient to a quality life and
preventing disability may require the patient to exercise
through the pain. The patient needs to understand that
“pain relief, if it comes at all, will likely occur after

28

the disability is alleviated” (Meilman, 1984, p.313).
Exercise is a long-term commitment for people with FM that
requires significant motivation both to start and to
maintain new behaviors.

Factors affecting adherence to rehabilitation
interventions for individuals with FM were studied and
found to be multifaceted (Huyser, Buckelew, Hewett and
Johnson, 1997). The highest predictors for adherence
included lower levels of depression, increased outcome
expectancy, higher levels of education and self-efficacy,
and younger age. They concluded “general difficulties in
exercise and increases in pain secondary to exercise may
have mitigated adherence” (Huyser, Buckelew, Hewett and
Johnson, 1997, p.84). Adherence may rest on the patient's
education about pain and symptom control, supporting the
expectancy the patient will have the resources to influence
the course of their life. Given that the benefits of
exercise are quickly reversible, adherence may be the
largest stumbling block in the use of exercise in the
treatment of FM.

In conclusion, FM is a pain syndrome of unclear
etiology. There is no reliable evidence in the literature
of muscle pathology in FM. There is evidence that
aerobically fit individuals are less susceptible to
developing symptoms of FM in sleep deprivation studies, and
FM patients are less aerobically fit than average people

29

are. Exercise offers the benefits of improved mental
health, improved pain control and the opportunity for
patients to be active participants in their care.
Lifestyle change can be difficult, but the incentive to
exercise includes improved quality of life and prevention
of disability for people who live with FM.
PRODUCT OF THE SCHOLARLY PROJECT

The outcome of this scholarly project is a patient
education brochure about exercise for people newly
diagnosed with FM. Searching the literature dealing with
FM revealed many scholarly journal articles and a few books
written about FM that included chapters on exercise, but
there was a lack of patient information specifically
addressing exercise and FM on an introductory level. Given
the potential benefits of physical activity in this
population and the lack of available, easily accessible
information for patients, there is a need for a brochure of
this type. This educational brochure may function as an
adjunct teaching supplement, as a motivational aid or as a
source of referral to organizations offering more
information. Appropriate settings for use of a brochure on
exercise and FM might include primary and specialty care
offices, pain management centers, community sites offering
fitness programs for FM patients and in Arthritis
Foundation FM classes.

APNs emphasize health promotion and have much to offer

30

the person with FM. Exercise is an effective adjunct
therapy to cognitive-behavioral therapy, medications or
coping skills training. Exercise is also appropriate for
the patient who may not wish to take antidepressant
medication and who desires a non-pharmacologic approach to
treatment. Nursing is an advocate for patient choice and
education in the alternative therapies. The APN is prepared
to make a holistic assessment, prescribe a course of action
and coordinate the care of the person with FM. APNs take
the time to educate patients, drawing on their scientific
knowledge. They utilize concepts from the social and
psychological sciences to address motivation and adherence
issues. By maintaining an ongoing, caring relationship the
APN in primary care provides an empowering environment for
the FM patient who may need that stabilizing human support
before they can contemplate any lifestyle change.

The Nightingale conceptual framework guides design and
content of the pamphlet. In keeping with Nightingale's
environmental adaptation theory which helps the patient
organize the internal and external environment to
facilitate their inner healing capacity, the brochure
presents exercise as a way to alter both the physical and
psychological environment of the person with FM. Patients
will be addressed as an active participants in their own
care, consistent with Nightingale’s belief that all people
have reparative powers and the ability to help themselves

31

heal. The goal of this presentation is to improve the
health of the person with FM, which in the Nightingale
philosophy includes more than a lack of illness but self-
actualization and stability. Stated in chronic pain
terminology, the goal is to improve quality of life and
limit disability.

Methods used to achieve this goal include education,
motivation and offering resources in the community.
Education begins with the title, ”Fibromyalgia: feeling
better with exercise” which does not imply a cure for FM,
but instills the expectation that exercise can help
patients improve their health. Butterfly graphic images on
the title page are meant to portray the ideas of well being
and optimism. Moving into the written content of the
brochure, the person with FM is welcomed and then
introduced to the definition of FM. This definition is
taken from the American College of Rheumatology (Wolfe et
al., 1990) diagnostic guidelines and has been summarized
without medical terminology to be understandable for a
reader in the general public. Incidence rates are given to
help the person with FM see that other people share their
problem and decrease their sense of isolation.

The second section of the brochure summarizes current
knowledge of chronic pain and its relationship to
depression, and introduces motivating factors for exercise.
Chronic pain is differentiated from acute pain and the

32

foundation is laid for the introduction of the exercise
intervention. Especially important is the concept that FM
is not caused by a current tissue injury or an inflammatory
process (Simms, 1996; Yunus and Kalyan-Raman, 1989). The
implication is to dispel the fear of harming their body by
being active. Several motivating factors are introduced
such as pain is made worse by immobility, improving sleep
may ease the symptoms of FM, and muscles that are used are
more elastic and less stiff.

The relationship between chronic pain and depression
is clarified in this section of the brochure. This is a
sensitive area for people with FM because chronic pain and
depression both are stigmatized in our culture, and there
is a relatively high co-morbidity of depression associated
with FM (Bennett, 1995). The reciprocal relationships
between treatment of depression and pain are explored. The
concept that depression and FM may co-exist without one
causing the other is presented by telling the patient the
pain is real and that the depression did not cause the
pain.

The purpose of section three is to educate the reader
about the positive effects of exercise on FM and to
motivate them with the incentive of feeling better both
physically and mentally. This section describes how
movement improves the function of muscles along with the
beneficial effects of exercise on sleep and mental health.

33

These are the incentives to exercise. This section
explains how exercise alters the physical environment by
increasing muscle blood flow, increased flexibility, and
increased efficiency. Sleep is improved by an increase in
the amount of time spent in slow—wave or deep sleep
following exercise (Dishman, 1992). This is important
because slow-wave sleep is associated with a well-rested
feeling upon awakening, and people with FM who often wake
feeling unrefreshed from sleep. Exercise also alters the
psychological environment by decreasing susceptibility to
pain, improving mood and promoting a sense of control.
Endorphins are alluded to as chemicals released by the
brain (in response to exercise) that decrease pain and
improve mood.

Concerns or barriers to exercise are covered in
section four of the brochure. The initial training
soreness associated with exercise is introduced, along with
encouragement to persist and to pace activity to avoid
overexertion. These are key points to improve adherence.
Personal barriers may include fatigue, shyness, fear of
failure or lack of coordination; suggestions are made to
help the person with FM overcome these barriers. Setting
an achievable goal is accomplished by having the person
choose an activity that they Can already do, starting slow
and stressing persistence over performance. Opportunities
for exercise are described in both private and group

34

settings. Since social activity decreases isolation and
may provide an external source of motivation, the reader is
encouraged to find an exercise partner.

The back of the brochure is the final page of content.
Referral to more information is provided with the address
and phone number of the local Arthritis Foundation.
Internet addresses are included for the national Arthritis
Foundation and the Fibromyalgia Network which are cost-free
sites offering information on FM.

In conclusion, the product of this scholarly project
is a patient teaching brochure written for the newly
diagnosed FM patient. The brochure will educate the reader
about FM and the benefits of exercise, address areas of
common concern regarding exercise, and provide resources
for further information.

RESEARCH IMPLICATIONS

FM is a recently recognized syndrome, with the
official diagnostic criteria published by the American
College of Rheumatology in 1990. FM offers rich
possibilities for research as science searches for an
etiology including sources of the overlap with irritable
bowel and bladders syndromes, depression, migraine
phenomenon, chronic fatigue syndrome and Raynaud’s
phenomenon. Interventions for treatment of FM are fertile
ground for research including medications, exercise,
psychotherapy and the alternative therapies. There is much

35

to learn about FM.

Qualitative and quantitative research opportunities
exist in this scholarly project. A proposed qualitative
pilot study could be conducted with a small group of
patients who were newly diagnosed with FM, asking them to
read the brochure, “Feeling better with fibromyalgia and
exercise” then respond to open ended questions about how
they felt afterwards. Themes that sounded hopeful or
optimistic might validate the approach used in the
brochure. Themes of doubt could be further explored: do
patients with FM feel more comfortable with a more
directive, detailed instruction booklet? Does the doubt
focus on their ability to exercise, or on belief in the
intervention's effectiveness? Qualitative research could
describe a reader's emotional response to the content of
the brochure.

Quantitative research might assess the impact of the
brochure on the patient's level of commitment to exercise.
The study design could be a before and after questionnaire
administered to a convenience sample of newly diagnosed FM
patients in a Rheumatology office. The level of commitment
variable could be assessed utilizing Prochaska's
Transtheoretical Model and stages of change (Prochaska,
Redding and Evers, 1997), having the patient rate their
intention to take action on a time line before they read
the brochure and afterward. A sample question might read,

36

”Choose the answer below which best describes your
intention to exercise:
a) I have no intention to exercise in the next 6
months.
b) I intend to exercise in the next six months.
c) I intend to exercise in the next 30 days and have
taken some steps in this direction.
d) I have already been exercising but only for less
than the past 6 months.
e) I have already been exercising for more than 6
months.”
The answers above correlate with the stages of change:
precontemplation, contemplation, preparation, action and
maintenance. The study hypothesis would be that the
brochure's impact would result in change toward a higher
level of the patient's commitment to exercise.

Confounding variables may impact results in this design
and prevent generalization to a larger population. These
include sample selection from a Rheumatology practice and
the intrinsic variable of depression. Convenience sampling
from patients in a Rheumatology practice might result in a
sample that is more symptomatic than one drawn from general
practice, thus these results might reflect a sicker
population than the general population of people with FM in
the community. Depression may also influence a subject's
perception of ability to exercise, or decrease their

37

motivation. Given the co-morbidity of FM and depression,
this might be a variable to exclude using a depression
scale. It might also add to our understanding to
incorporate depression as a study variable and interpret
results based on two subgroups of patients-depressed and
not depressed. Convenience sampling and depression may
limit the ability to generalize results of the study.

Another area of quantitative research interest might be
to measure change in primary care provider's level of
knowledge before and after reading the brochure. Using the
hypothesis that knowledge of FM and exercise would increase
after reading the brochure, a tool could be devised to
measure the major topics covered in the pamphlet. Research
on the provider perspective could also measure comfort with
prescribing exercise as an intervention with FM.

In conclusion, from the perspective of the patient or
the provider, there are qualitative and quantitative
research opportunities in this scholarly project.

SUMMARY

FM is a chronic pain syndrome affecting two to three
percent of the general population, resulting in personal
suffering and disability. People with FM experience pain,
stiffness, fatigue and sleep problems. Associated symptoms
overlap with other pain syndromes including migraine,
irritable bowel and bladder, and chronic fatigue syndrome.
The etiology of FM is unclear, but research has

38

demonstrated the benefits of exercise in the treatment of
FM symptoms. The Nightingale environmental adaptation
model and current literature on FM were used to design an
educational brochure for people with FM. The brochure was
intended to promote the use of exercise as an intervention
for fibromyalgia. The brochure provides information on FM,
pain, exercise and concerns, and offers resources for
patients to gain further information. Research
implications of this teaching tool were then explored from
a qualitative and quantitative viewpoint. The goal of the
advanced practice nurse is to help the person with FM
maximize their abilities and improve their quality of life.
Exercise improves both the physical and mental health of

people with FM.

39

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50

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You've been diagnosed with
fibromyalgia and now you are wondering what
you can do to feel better.

Fibromyalgia (FM) is a chronic pain
syndrome that effects an estimated three to six
million people in the United States. The most
common symptoms of FM include generalized
pain, stiffness, fatigue and poor sleep. About
half the patients who have FM also have
feelings of swelling or numbness in their arms
or legs. Associated symptoms include
headaches, irritable bowel or initable bladder
syndromes, painful menstrual periods,
circulation problems, difficulty concentrating,
and anxiety or depression.

Researchers have not yet discovered
the cause of FM, but we have learned some

things that can help you to feel better.

What Affie KI'IA'LAW

Chronic pain is diflermt fiom acute
pain. Acute pain often signals an injury and is
treated by short-term rest. Chronic pain exists
without objective signs of tissue injury and is
made worse by immobility. In chronic pain you
have to move despite the pain. It is only afier
you relieve the immobility that pain relief will
come.

0 FM is not an inflammatory condition so you
will not harm your muscles by moving them.

0 Improving the quality of sleep may ease the
symptoms of FM.

0 Muscles are thixotropic. That means when
muscles are cold and not used, they become
shorter and sfifier. Sedentary lifestyles make
FM symptoms worse.

0 Chronic pain may lead to depression.
Treating the depression may help the pain,
and treating the pain may help the
depression. This does not mean that the pain

is not real, or that the depression caused the

pain.

 

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A regular exercise program can help you to feel
better.

0 Movement improves blood flow to muscles,

bringing in more oxygen and making muscles
produce more fuel so they function more
efficiently. Muscles that are used are warmer,
more elastic and less stifi‘. People who
exercise have muscles that are more flexible
and less stiff.

Exercise may improve your sleep. There is
an increase in the amount of time spent in
slow-wave or deep sleep following exercise.
Slow-wave sleep is associated with a well-
rested feeling upon awakening.

People who exercise feel better mentally.
They are less depressed and have a sense of
control over their lives. Exercise releases
chemicals in the brain that decrease pain and

improve mood.

 

 

Concerns For More information i

. Whenever people (even trained athletes) begin

 

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symptoms in the beginning of any exercise. . . . E X 6 FCAS 6
Don‘t be discouraged— your muscles will irhnimiifinfif:§
adjust. Pacing yourself is important so that
you don't overexert in the beginning. Fibromyalgia Network
Persistance is the key to getting past this http://www.finnemews.com/
initial stage and the rewards will be worth the
effort.
. You may not feel up to exercising, or feel
uncomfortable to try in front of other people.
Choose something you at do like walking,
stretching, swimming, yoga or tai chi. Start
slow (for instance ten minutes, twice a day),
and exercise every day if possible. There are
videos available by loan fiom the Arthritis
Foundation which may be used at home.
Exercise may also be a social activity: there
are classes at local health clubs and water
exercise sessions offered at the public
schools. Consider finding a partner to Copyright 1999 by
Susan Sugden

exercise with. It can be helpful to find out

you are not alone with FM.

 

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