COGNITIVE FUNCTION CHALLENGES FIBROMYALGIA by xiuliliaofz

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									COGNITIVE FUNCTION CHALLENGES
Including Coping and Compensatory Strategies
FIBROMYALGIA & CHRONIC FATIGUE IMMUNE DYSFUNCTION SYNDROMES

Jason Nupp, Psy.D.
Spalding Rehabilitation Hospital
Confused?
        REALLY confused?




Torpy, D., Ho, J, (2007). Corticosteroid-binding globulin gene polymorphisms: clinical implications and links to idiopathic chronic fatigue disorders .
Clinical Endocrinology 67(2): 161-167.
Accepting the confusion as reality...
  The Biopsychosocial Model
                Biological




                FMS/CFIDS




Psychological                 Sociological
Overview
   Determining What’s Wrong: Diagnosis 101
     Fibromyalgia Syndrome (FMS)

     Chronic Immune Dysfunction Syndrome (CFIDS)

   Cognitive Domains Related to FMS/CFIDS
   Perspectives From the People Who Have It (Qualitative)
     What factors affect quality of life?

   Perspectives From the People Who Study It (Quantitative)
     What does the research say?

   Possible Explanations for “Fibro Fog” and “Brain Fog”
     Biological

     Psychological

   Coping with Cognitive Challenges
   Developing Compensatory Strategies
Determining What’s Wrong: Diagnosis 101
       Fibromyalgia Syndrome (FMS)

                                                                               “ACR” Diagnostic Criteria
                                                                                  Widespread pain lasting ≥ 3
                                                                                   months
                                                                                  11 positive tender points out of
                                                                                   possible 18 using 4 kg of
                                                                                   palpation
                                                                                             Occiput
                                                                                             Low cervical
                                                                                             Trapezius
                                                                                             Supraspinatus
                                                                                             Second rib
                                                                                             Lateral epicondyle
                                                                                             Gluteal
                                                                                             Greater trochanter
                                                                                             Knee

Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. (1990) The American College of Rheumatology 1990 criteria for the
classification of fibromyalgia: report of the multicenter criteria committee. Arthritis Rheum 33:160–72.
        Chronic Fatigue Immune Dysfunction Syndrome (CFIDS)


                                                                                 “Fukuda” Diagnostic Criteria
                                                                                       Unexplained, persistent fatigue ≥
                                                                                        6 months that impairs daily
                                                                                        activity by 50%
                                                                                       4 out of 8 primary signs and
                                                                                        symptoms
                                                                                                Loss of memory or concentration
                                                                                                Sore throat
                                                                                                Painful and mildly enlarged lymph nodes in
                                                                                                 neck or armpits
                                                                                                Unexplained muscle pain
                                                                                                Pain that moves from one joint to another
                                                                                                 without swelling or redness
                                                                                                Headache of a new type, pattern or severity
                                                                                                Unrefreshing sleep
                                                                                                Extreme exhaustion lasting more than 24
                                                                                                 hours after physical or mental exercise



Fukuda K, Straus S, Hickie I, Sharpe M, Dobbins J, Komaroff A (1994). The chronic fatigue syndrome: a comprehensive approach to its definition and
study. International Chronic Fatigue Syndrome Study Group. Ann Intern Med 121 (12): 953–9.
Cognitive Domains Related to FMS/CFIDS

   Executive Functioning (planning,
    organizing, inhibition of behavior,
    error detection, insight)
   Attention (focus on specific stimuli
    to the relative exclusion of others)
   Memory (encoding, recall,
    recognition)
   Working Memory (temporary
    storage and management of
    information)
   Processing Speed (rate of
    processing stimuli and making use
    of it in thought and action)
Perspectives from the people who have it…
Qualitative Studies in FMS
    Arnold et al. (2008) conducted a qualitative analysis of 48
     FMS patients across the U.S.

    Substantial negative impact on social and occupational
     functioning

    Disrupted relationships, social isolation, reduced leisure
     activities, avoidance of physical activity, and career loss or
     inability to advance in career/education




Arnold, L., Crofford, L., Mease, P., Burgess, S., Palmer, S., Abetz, L., Martin, S. (2008). Patient perspectives on the impact of fibromyalgia. Patient
Education and Counseling 73: 114-120.
 Qualitative Studies in FMS
 Physical Domain
           Pain
           Fatigue
           Disturbed sleep

 Emotional/Cognitive Domains
          Depression, anxiety
          Cognitive impairment (decreased concentration, disorganization)
          Memory problems

 Social Domain
           Disrupted family relationships
           Social isolation
           Disrupted relationships with friends

 Work/Activity Domains
           Reduced activities of daily living
           Reduced leisure activities/avoidance of physical activity
           Loss of career/inability to advance in career or education
Arnold, L., Crofford, L., Mease, P., Burgess, S., Palmer, S., Abetz, L., Martin, S. (2008). Patient perspectives on the impact of fibromyalgia. Patient
Education and Counseling 73: 114-120.
Qualitative Studies in FMS
    Greatest impact on quality of life included pain, sleep
     disturbance, fatigue, depression, anxiety, and cognitive
     impairment
    Primary reported cognitive effects were on memory, thought
     processes, planning/organization, response time, word-finding
     and concentration
    These impairments have collectively been referred to by
     patients as “fibro fog”
    “Fibro fog” is reported to affect a wide range of activities
     including driving, social interactions, and work-related tasks


Arnold, L., Crofford, L., Mease, P., Burgess, S., Palmer, S., Abetz, L., Martin, S. (2008). Patient perspectives on the impact of fibromyalgia. Patient
Education and Counseling 73: 114-120.
Qualitative Studies in FMS
     Katz et al. (2004) investigated prevalence of reported
      cognitive difficulties in 57 patients with rheumatic disease
      with FMS and 57 patients without FMS
     Compared to the non-FMS sample, FMS patients more
      frequently reported memory decline, mental confusion, and
      speech difficulty
     Memory decline and mental confusion were coupled more
      often in FMS patients
     FMS patients were found to be at considerably higher risk
      for cognitive difficulty

Katz, R., Heard, A., Mills, M., Leavitt, F. (2004). The prevalence and clinical impact of reported cognitive difficulties (fibrofog) in patients with
rheumatic disease with and without fibromyalgia. Journal of Clinic Rheumatology 10(2): 53-58.
Qualitative Studies in FMS




Katz, R., Heard, A., Mills, M., Leavitt, F. (2004). The prevalence and clinical impact of reported cognitive difficulties (fibrofog) in patients with
rheumatic disease with and without fibromyalgia. Journal of Clinic Rheumatology 10(2): 53-58.
Qualitative Studies in CFIDS
    Afari & Buchwald (2003) suggest that cognitive
     problems are some of the most disruptive and
     debilitating symptoms reported in patients with CFS
    85% of patients describe impairments in attention,
     concentration, and memory function
    In CFS these are known as “Brain Fog”




Afari, N., Buchwald, D. (2003). Chronic Fatigue Syndrome: A Review. American Journal of Psychiatry 160: 221-236.
Qualitative Studies in CFIDS
    Capuron et al. (2006) conducted a meta-analysis
     showing that 50-85% of patients with CFS report
     cognitive difficulties that contribute significantly to
     social and occupational dysfunction
    Cognitive dysfunction manifests primarily in the form
     of concentration/attention problems, memory
     impairment, poor word-finding ability, decreased
     processing speed, motor slowing, and mental
     exhaustion

Capuron, L., Welberg, L., Heim, C., Wagner, D., Solomon, L., Papanicolaou, D., Craddock, R., Miller, A., Reeves, W. (2006). Cognitive dysfunction
relates to subjective report of mental fatigue in patients with chronic fatigue syndrome. Neuropsychopharmacology 31:1777-1784.
Summary of Findings
   Patients with FMS and CFS report a number of
    cognitive impairments referred to as “Fibro Fog”
    and “Brain Fog” respectively
   These impairments include attention, memory,
    executive function, processing speed, and speech
   These problems have a negative impact on daily
    function including driving, social interactions, and
    work tasks
Perspectives from the people who study it…
Quantitative Studies in FMS
    Suhr (2003) studied neuropsychological test performance on
     28 FMS patients, 27 chronic pain patients, and 21 healthy
     controls
    Measures included depression, pain, fatigue, subjective
     cognitive complaints, memory, executive functioning, intellect,
     attention, and psychomotor speed
    FMS patients had more memory complaints, reported greater
     fatigue, pain, and depression than other groups
    Groups were not found to be different on testing after
     controlling for fatigue, pain, and depression
    Depression related to memory performance
    Fatigue related to psychomotor speed
Suhr, J. (2003). Neuropsychological impairment in fibromyalgia: Relation to depression, fatigue, and pain. Journal of Psychosomatic Research
55(4): 321-329.
Quantitative Studies in FMS
    Hoover (2006) investigated neuropsychological
     performance of 61 women with FMS that were age and
     education-matched to 63 healthy women
    FMS patients were found to have significantly poorer
     performance on some measures of executive function,
     working memory, and sustained attention
    Neuropsychological measures were not found to be more
     significant predictors of group membership than were
     measures of symptoms relevant to FMS



Hoover, K. (2006). Neuropsychological function in Fibromyalgia. Dissertation Abstracts International: Section B: The Sciences and Engineering.
66(9-B): 5090.
Quantitative Studies in CFIDS
    Metzger et al. (2002) conducted a study examining
     discrepancies between perceived and actual performance by
     40 CFS patients and 40 age and education matched healthy
     controls
    Performance was compared on a measure of executive
     function
    After correcting for differences between groups for
     depression, there were no differences found in actual
     performance on the test
    CFS patients were found to consistently underestimate their
     performance relative to normal performance
    Performance correlated with patient’s ratings of mental effort
     and fatigue

Metzger, F., Denney, D. (2002). Patient perspectives on the impact of fibromyalgia. Patient Education and Counseling 73: 114-120.
Quantitative Studies in CFIDS
    Majer et al. (2008) examined 58 CFS patients and
     104 healthy controls on neuropsychological
     performance
    Controlled for major psychiatric disorders and
     medications known to affect cognition
    CFS patients were found to have significantly higher
     levels of impairment on tasks involving motor speed
     and working memory


Majer, M., Welberg, L., Capuron, L., Miller, A., Pagnoni, G., Reeves, W. (2008). Neuropsychological performance in persons with Chronic Fatigue
Syndrome: Results from a population-based study. Psychosomatic Medicine 70: 829-836.
Summary of Findings
   Many studies have found FMS and CFS patients
    exhibit deficits on neuropsychological testing
   Areas of impairment included sustained attention,
    working memory, processing speed, and executive
    function
   After controlling for factors such as pain,
    depression, and fatigue, performance was similar to
    that of healthy people
Possible Biological Explanations
                                                                                cortisol levels
                                                                                hippocampus is responsible for
                                                                                 memory function
                                                                                FMS patients have lower
                                                                                 salivary-free cortisol levels
                                                                                very low and very high cortisol
                                                                                 levels affect hippocampal
                                                                                 function
                                                                                selective effects on verbal
                                                                                 declarative memory, selective
                                                                                 attention, and divided attention


Sephton, S., Studts, J., Hoover, K., Weissbecker, I., Lynch, G., Ho, I., McGuffin, S., Salmon, P. (2003). Biological and psychological factors
associated with memory function in Fibromylagia Syndrome. Health Psychology 22(6): 592-597.
Possible Biological Explanations
                                                                               anti-68/48 kDa protein antibodies
                                                                               more common in both CFS (13.2%)
                                                                                and FMS (15.6%) patients (Nishikai,
                                                                                et al., 2001)
                                                                               suggests related immunological
                                                                                background
                                                                               patients with antibodies presented
                                                                                more frequently with hypersomnia,
                                                                                short-term amnesia, and difficulty in
                                                                                concentration
                                                                               may be used as a possible marker
                                                                                for fatigue and cognitive problems




Nishikai, S. ,Tomomatsu, S., Hankins, R., Takagi, S., Miyachi, K., Kosaka, S., Akiya, K. (2001). Autoantibodies to a 68/48 kDa protein in chronic
fatigue syndrome and primary fibromyalgia: a possible marker for hypersomnia and cognitive disorders. Rheumatology 40: 806-810.
Possible Biological Explanations
                                                                                pain factors
                                                                                pain has been shown to correlate highly
                                                                                 with processing speed, working memory,
                                                                                 free recall, and recognition memory
                                                                                 (Park, et al. 2001)
                                                                                pain and weakened immunity is
                                                                                 associated with increased inflammatory
                                                                                 cytokines
                                                                                inflammatory cytokines affect appetite,
                                                                                 sleep, and fatigue levels
                                                                                pain affects serotonin and
                                                                                 norepinephrine
                                                                                pain medications (particularly opiates)
                                                                                 have well-known effects on cognitive
                                                                                 function




Park, D., Glass, J., Minear, M., Crofford, L. (2001). Cognitive function in fibromyalgia patients. Arthritis & Rheumatism 44(9): 2125-2133.
Possible Psychological Explanations
                                                                                 clinical depression
                                                                                 20% of FMS patients in one
                                                                                  sample reported clinical levels
                                                                                  of depression (Sephton et al.,
                                                                                  2003)
                                                                                 correlated with immediate and
                                                                                  delayed verbal memory
                                                                                  performance in FMS
                                                                                 depression in FMS and CFS may
                                                                                  also affect domains such as
                                                                                  processing speed and attention




Sephton, S., Studts, J., Hoover, K., Weissbecker, I., Lynch, G., Ho, I., McGuffin, S., Salmon, P. (2003). Biological and psychological factors
associated with memory function in Fibromylagia Syndrome. Health Psychology 22(6): 592-597.
Coping With Cognitive Challenges




                  The focus should be on addressing
                  the “whole” person, not just the
                  individual symptoms of FMS/CFIDS.
Medications
   NSAIDs (ibuprofen, naproxen
    sodium)
   COX-2 Inhibitors (celecoxib)
   SSRIs (fluoxetine, sertraline,
    escitalopram)
   NDRIs (duloxetine)
   SNRIs (milnacipran)
   TCAs (amitriptyline)
   AEDs (gabapentin,
    pregabalin)
Physical Therapy
   range of motion exercises
   flexibility
   hydrotherapy
   manual therapy (e.g.
    myofascial release, joint
    manipulation, massage)
   gait alignment training
Psychotherapy
   Cognitive-Behavioral Therapy
    (CBT)
   relaxation training
   development of coping skills
   treatment of related conditions
    (e.g. depression, insomnia,
    pain)
Complementary and Alternative Medicine

   biofeedback therapy
   Mindfulness-Based Stress
    Reduction (MBSR)
   homeopathic approaches (e.g.
    Rhus Toxicodendron)
   nutritional supplements (e.g.
    magnesium)
   acupuncture
   E.T.P.S.
Developing Compensatory Strategies




                     Developing and implementing
                     compensatory strategies should
                     increase function and not simply
                     provide “symptom relief.”
Compensating Through Use of Technology

   computer-assisted cognitive rehabilitation using computer
    games (e.g. BrainAge™ and HAPPYneuron™) to address
    processing speed, memory, and attention
   PDAs and Smartphones to address memory and executive
    function/organizational skills
   Pulse Smartpens™ to assist with memory and executive
    functioning
   Speech recognition software (e.g. Dragon™) to address
    fatigue related to writing and note taking
Compensating Through Lifestyle Change

   diet/nutritional changes (avoid aspartame, MSG,
    caffeine, simple carbohydrates, yeast, gluten, dairy,
    nightshade plants)
   regular exercise (low to moderate intensity aerobic
    exercise at least 2x/week with strength training)
   maintain a regular, consistent, paced routine
    (sleep/wake, meals, rest breaks)
   stress reduction (relaxation, prayer/meditation,
    diaphragmatic breathing)
Compensating Through Environmental Change

   avoid cold and/or damp environments
   avoid exposure to strong odors
   create rest environments void of distractions (e.g.
    silence cell phone, turn off computer etc.)
   follow principles of sleep hygiene (e.g. bedtime rituals,
    bed for sleep/sex only, get up after 20 min. of
    unsuccessful sleep, etc.)
   avoid overheating
   reduce exposure to fluorescent lighting
Questions & Answers

								
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