Psychosocial considerations Because lymphedema is disfiguring and sometimes disabling and painful, individuals with lymphedema can experience mental, physical and sexual problems. They may benefit from Considerations for physical therapists Physical therapists often play an important role in the health and wellness of the patient with lymphedema. Physical therapy goals include: 11 ● Reduce girth circumference of affected extremities. ● Improve skin texture. ● Reduce risk of infection by providing patient education and facilitating patient independence in skin care. ● Promote patient independence in lymphedema management. When working with patients who are affected by lymphedema it is important to conduct a thorough initial evaluation that includes: 12
individual or group counseling that includes emotional support and provides information about the role of diet and exercise and advice for selecting comfortable and flattering clothes.
● Assessment of muscle strength. ● Assessment of extremity flexibility. ● Postural evaluation. ● Functional evaluation. ● Provision of patient education on skin care. Ongoing physical therapy treatment interventions may include: 11,12 ● Manual facilitation of lymphatic drainage. ● Compression bandaging of the affected extremity. ● Cautious, gentle range-of-motion exercises. ● Ongoing patient education on exercises to be performed at home, self-bandaging, and meticulous skin care.
FIBROMYALGIA
Muscular pains and fatigue are the hallmarks of fibromyalgia, a common but misunderstood disorder affecting approximately 5 million Americans, 80 to 90 percent of whom are women between the ages of 35 and 60. 1 Fibromyalgia is a rheumatic condition and not a form of arthritis, as often thought. It does not cause inflammation or damage to the joints, as does arthritis. Rheumatic diseases are characterized by inflammation and loss of function of one or more connecting or supporting structures of the body. Fibromyalgia is a syndrome, not a disease. The distinction is that a disease is a medical condition that has one or more specific causes and has recognizable signs and symptoms, whereas a syndrome is a condition characterized by a collection of Physiology Although no consistent pattern fits all patients with fibromyalgia, studies have found that many patients have abnormalities of hormonal, metabolic and brain chemical activity. For example, studies have shown that some patients with fibromyalgia have lower levels of serotonin. 3 Serotonin, an important neurotransmitter found in the brain, gut and other areas, plays important roles in mood, pain modulation and promotion of deep sleep. Abnormalities in serotonin production and distribution have been linked to many disorders, including depression and irritable bowel syndrome, which are common in fibromyalgia. Individuals with fibromyalgia can also have abnormal levels of a chemical in their spinal fluid called substance P , a neurotransmitter that helps send signals of pain and sensation to the brain. Research has shown a threefold increase in the level of substance P in the spinal fluid of patients with fibromyalgia, compared to that of healthy individuals. 4 Scientists believe that this substance may amplify the pain these individuals experience. Studying the Symptoms The symptoms of fibromyalgia vary among individuals, and also wax and wane in intensity over days and weeks. Flares of symptoms occur with increased exertion, systemic infections, soft-tissue injuries, lack of sleep, cold exposure, and psychological stressors. In addition to suffering from fatigue and widespread, generalized pain, individuals have multiple tender points that are painful when pressed. These occur in certain areas, including the back of the head, upper back and neck, upper chest, elbows, hips and knees (see figure 3). Other common symptoms are impaired sleep, morning stiffness, headaches, irritable bowel syndrome, restless legs syndrome, dizziness, painful menstrual periods, numbness or tingling of the extremities, memory problems, and heightened sensitivity to cold, noises, odors and bright lights. Anxiety and depression are common among patients with fibromyalgia.
symptoms and medical problems that occur together but can’t be pinned down to an identifiable, single cause. The cause of fibromyalgia is unknown, but scientists believe there may be genetic factors or a traumatic personal history, or a combination of the two, that make some people react strongly to stress or pain. For example, an emotionally stressful event, an injury or a viral infection can trigger the onset of the syndrome. Fibromyalgia is a chronic condition with no known cure. Most patients with fibromyalgia report that chronic pain and fatigue have adversely affected the quality of their lives and their ability to be competitively employed. role of substance P is among the areas of research being pursued by scientists to find the cause of fibromyalgia. A deficiency in growth hormone, which is secreted in the pituitary gland, occurs in about 30 percent of fibromyalgia patients. 5 Defective growth hormone secretion in these patients appears to be due to excess somatostatin, a hormone that inhibits the release of growth hormone. For some reason, these fibromyalgia patients have too much somatostatin in their bodies, preventing the release of growth hormone. 5, 6 Researchers have also found that fibromyalgia patients produce less cortisol in response to stress than do healthy people, possibly as a result of a defect in the hypothalamic-pituitary- adrenal axis, which controls cortisol production.7 Lower levels of cortisol produces symptoms common in fibromyalgia, including fatigue, weakness, muscle pain, depression and sleep disturbances. The sleep disturbances common with fibromyalgia cause individuals to wake up tired and unrefreshed despite having eight to 10 hours of sleep. Some studies suggest that brain- wave irregularities occur that disrupt the deep restorative stage of sleep. Restless legs syndrome may also contribute to poor sleep patterns. With restless leg syndrome, the leg muscles involuntarily contract every 20 to 40 seconds during sleep, arousing the individual from deep sleep even though he or she is usually unaware of the interruption. Some experts think that fibromyalgia does not actually cause sleep disturbances, but that poor sleeping patterns come first, and in fact it is sleep deprivation that causes many cases of fibromyalgia. The rationale for this theory is that disturbed sleep appears to trigger factors in the immune system that cause inflammation, pain, fatigue and a decreased pain threshold, all if which are common symptoms of fibromyalgia.
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