www.pspbc.ca patient with fibromyalgia supporting patient self-management dr. rahul gupta

www.pspbc.ca

Patient with Fibromyalgia

Supporting Patient Self-Management

Dr. Rahul Gupta

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Review process & purpose of Brief Action Planning (B.A.P.)

Navigate common challenges through learning 3 key tips/tools

Explore a case study illustrating B.A.P. and tips/tools in action

Practice tools to develop comfort and skill

Learning Objectives

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23 year old female diagnosed with fibromyalgia and depression at age 14. Mother died of stomach cancer when she was age 16.• Seen by multiple rheumatologists, never feels believed • Has been on amitryptiline, duloxetine, gabapentin, pregabalin, cyclobenzaprine in past and none have helped. No meds for 2 years. • Frustrated, crying a lot, in constant pain “everywhere”• On disability, fatigued, can’t stay asleep• Initial PHQ Nov 2013: 18 (very difficult)

Case StudyVisit 1 (Nov 22, 2013)

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Is there anything you would like to do for your health in the next week or two?

Patient starts crying even louder: “what’s the point, it will just lead to more pain and

frustration!!”

Case Study-continuedVisit 1 (Nov 22, 2013)

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Group Question: What would you do?

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Mindfulness: “On purpose, attending to the present moment, nonjudmentally”

Often caught in own mind chatter, remembering past experiences with this patient, thinking about what to say next, worried about time

May be (knowingly or unknowingly) judging patient

Technologies may be competing for our attentionBeckman et al.. The Impact of a Program in Mindful Communication on Primary Care Physicians. Academic Medicine; 87(6): 815-819

Tip # 1: Mindful Listening

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“I’m really tired of coping with my chronic pain and I can’t live like this any longer”

Repeat: direct re-statementRephrase: saying the same thing in slightly different wordsSounds like you are pretty exhausted, and have had enough. Is that accurate?”Paraphrase: make a guess at the meaning, usually adding something that was not said directly“It sounds like mentally you are in a lot of pain too, is that fair to say?”

Miller & Rollnick, Motivational interviewing: Preparing people for change (2nd ed.).2002. The Guilford Press.

Reflective Statements

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“What’s the point, it will just lead to more pain and frustration!!”

Rephrase: “ Sounds like you are afraid to feel disappointed again, is that right?”

“Yes, I’ve heard this all before and it never changes things” Paraphrase: “So you are feeling like you have no control over your

future?” “Yes!”…(patient starts to calm down) …“but I haven’t given up” “I can appreciate it is not fun to feel no control. Would it be ok if I

share a few ideas that have worked for others when they feel powerless, to see if that generates ideas for you?”

“OK.”

Example Case: Reflective Statements

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“Would it be ok if I share a few ideas that have worked for others, to see if that generates ideas for you?”

OK. You could work on this “Control worksheet”

to generate some ideas, you could join a support group for people like you, or review some online resources.


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She chose the Control Worksheet, and one example explored

NOT IN CONTROL: Food at boyfriend’s place IN CONTROL: Bring her own food, stock up his place She planned to work on worksheet further at home Given pain diagram to fill out “When would you like to follow up?”: 14 days

TIME for visit #1: 35 minutes


THINGS I DO HAVE CONTROL OVER:

What I put into my bodyAsking for helpHow I react when in painBring her own food, stock up his place

THINGS I DON’T HAVE CONTROL OVER:

Family historyWhat is covered by MSPWhen my pain acts upFood at boyfriend’s place

CASE STUDY: CONTROL WORKSHEET

“Is there anything you would like to do for your health in the next week or two?”

“How confident (on a scale from 0 to 10) do you feel about carrying out your plan?”

“Would you like to check in with me to review how you are doing with your plan?”

Behavioral MenuBehavioral Menu

If Confidence <7, Problem-Solve BarriersIf Confidence <7, Problem-Solve Barriers

Follow-upFollow-up

Elicit a Commitment StatementElicit a Commitment StatementSMART Behavioral PlanSMART Behavioral Plan

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Is there anything she would like to do for her health in the next week or two?

“Stop over-doing it with her knitting projects”

Case StudyVisit 2 (Dec 13, 2013)






Follow-upFollow-up


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Frederickson & Branigan. Cognition and Emotion, 2005;19, 313-332.

Group Question: Quality of goal?

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Need to overcome negativity bias Need to optimize power of imagination Research suggests shifting focus to positive

visuals enhances cognitive abilities and inspires action

“Broaden and Build theory” of positive emotions


Tip #3: Help CreatePositive Visuals

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“How would you prefer to manage your creative work periods?”

“Chunk it into manageable times.” “What would that look like, as a starting place for the next 2

weeks?” “15 minutes knitting, then 5 minute movement break “Maximum 3 hours per day.” “What will this give you?” “A sense of productivity.”


Case Example: Visit 2 (continued)

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Help them flip their stated problem or negative

visual into a visible “positive” outcome.

What would you RATHER have/feel?

What do you want MORE of?

What would having ______ look or feel like?

What would _____ bring you?

Example Questions: Positive Visuals






Follow-upFollow-up


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“Chunk creative work into manageable times”

“So can you repeat your plan?” “I will knit for 15 minutes then take a 5 minute movement

break, and repeat this pattern for a maximum 3 hours per day, so that I can feel more productive”

“When shall we follow up?”: 3 weeks Also agreed to complete PDI

Time for visit #2: 20 minutes







Follow-upFollow-up


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“Be more prepared for stressors”.

How confident are you that you can do all this?”

“5/10” “What would you need to tweak to be at

least 7/10 confident?” “Only expect to stretch in AM if pain < 5/10.

Walk 2x/wk”. (revised plan re-stated) “F/U?”: “3 weeks” Time for visit #3: 20 minutes

Case StudyVisit 3 (Jan 10, 2014)

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“How did it go with your plan?” 15/5 felt too short, so went to 25/5 or stopped if

pain 7/10 Also had decided to increase movement. Walked

2x in week. Tried to stretch in AM, but found her pain/mood upon waking “got in the way”

Pain/fatigue has increased overall, but feeling happier and productive

Has filled out pain diagram and PDI (55)


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“How did it go with your plan?” Did in fact go through control worksheet, and wrote in

her journal++! Did not do pain diagram “Some movement is great, what did you learn?” “While can’t control pain, can pace myself differently” “While can’t control others actions, can prepare for

triggers ahead of time” (hunger, traffic, fatigue) “While can’t stop pain, can stretch & build strength”


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“So what’s next?” “Not get so thrown off by triggers”.

Case Study-continuedVisit 3 (Jan 10, 2014)

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“Not get so thrown off by triggers”.

“How would you rather handle things?” “Be more prepared for stressors”. “What would you like to do in the next 1-2 weeks?” “Trips to Vancouver- bring food, protect sleep routine. In

AM- have uplifting music ready to play. Day- maximum 1 appointment per day . Walk in nature 3x per week”.

How confident are you that you can do all this?” “5/10”


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Still lots of challenges (fatigue, mood, triggers) Experiencing wins:

› Trips to Vancouver much more restful › Mood more even through the day (less crying)› Walking & knitting routines successful› Pain is the SAME…but more optimistic for future,

feeling stronger, and responding to pain with + self-talk

(Visits 10 minutes each)

Case StudyVisit 4 & 5 (Jan 31 & Feb 21, 2014)

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“Never felt this not depressed in adult life!” PDI score now 39 (from 55, in Jan 2014) PHQ9 score down to 7 (from 18, in Nov 2013) “Successfully finishing goals is leading to more

motivation” “When setbacks happen, I know it’s not a

catastrophe” “No overall change in pain, but trusting my body

more” “More energy now- want to walk, get stronger” “More support in relationship through

communicating needs”

Case StudyVisit 6 (March 14, 2014)

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“What’s next?” “Reinforce patterns- firm resolution for

exercise, 30/5 time chunks, build confidence in eventual work”

Visit 10 minutes

Case Study-continuedVisit 6 (March 14, 2014)






Follow-upFollow-up


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Can break B.A.P. segments over several visits

Focus on building relationship & self-efficacy Visit lengths and frequency reduce over time

Case Highlights: Using B.A.P.

www.pspbc.ca patient with fibromyalgia supporting patient self-management dr. rahul gupta

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