Dr. Lapp's Stepwise Approach to Managing Fibromyalgia and Chronic Fatigue Syndrome
By Charles W Lapp, MD •
July 12, 2002
80% of sufferers of Chronic Fatigue Syndrome / Fibromyalgia feel better and can take control of their lives again by following the Stepwise Approach to Chronic Fatigue Syndrome and Fibromyalgia. The Stepwise Approach uses traditional medical therapy complimented by proven wellness techniques to restore well-being and help the sufferer to improve naturally.
This is accomplished through education, proper nutrition, low level graded activities, medical management of symptoms, and supportive therapies.
"Education begins with reassuring the patient that they have a recognized disorder," says Dr. Lapp. "Most are relieved just to hear that they are not dying and that they aren’t crazy." The more you know about your medical condition, the more equipped you will be to handle its ups and downs. If new symptoms arise that make your doubt your diagnosis, ask your doctor about them.
It is nearly impossible to continue with the next five steps of treatment unless you are convinced your diagnosis is correct and you have a good handle on what to expect in the way of symptoms.
"Avoid strict bed rest," says Lapp. "That just leads to deconditioning." Dr. Lapp recommends balancing light activity with frequent bed rest breaks. In fact, he has been working with physical and occupational therapists to put together a rehabilitation program to help get patients on their feet and moving up the treatment ladder. Several ingredients in Dr. Lapp’s activity rehabilitation program are described below.
"In both CFS and FMS, pain, spasms and shortening of the muscles can all lead to abnormal posture with the head forward and the shoulders somewhat rounded. This frequently leads to back-of-the-neck headaches, temporal headaches, neck and shoulder muscle tension, and shallow breathing." So if you already feel tired and achy, these problems will make you feel worse.
Dr. Lapp suggests that patients routinely stretch their muscles throughout the day. If possible, consult a physical therapist about gentle stretches that you can do, including ones that can be done while sitting in a chair.
Dr. Lapp notes that most patients breathe using the muscles in the upper part of the chest. This aggravates neck and shoulder pain, and increases the odds of postural muscles wearing out before noon. To ease tension on muscles that are already under stress from CFS/FMS, Lapp recommends deep breathing through the lower part of your diaphragm - what he calls "belly" breathing. Put one hand on your chest and the other one on your stomach, then breath deeply. Practice breathing so that the hand on your stomach does most of the moving.
If you are not used to breathing this way, it will take several practice sessions throughout your day to retrain your lower diaphragm muscles to unconsciously do your breathing for you. "This type of breathing," says Lapp, "tends to relieve things like chest tightness, shortness of breath as well as spasms in the postural muscles."
To treat mild muscle soreness, use hot or cold packs (whichever works best for you). The spray and stretch technique, using a prescription coolant spray to help relieve muscle tightness, can also be taught to you by your doctor or physical therapist. Then you can perform this modality on an as-needed basis at home. "Massage and acupuncture have been extremely helpful in some of our patients," says Lapp.
Other local techniques like transcutaneous electrical nerve stimulation (TENS) and ultrasound may provide some relief, but Lapp hasn’t found them as beneficial as the other methods just mentioned.
Dr. Lapp’s version of this modality is to have patients float in tepid pool water or even a tub at home. You only need to be in the water for 15 minutes and the water should be around 85 degrees. You don’t have to do water aerobics, although you may eventually work up to this activity as you start to feel better and gain more endurance.
How could this type of therapy work? Dr. Lapp presumes it helps patients in two ways:
1. The cool water tends to down regulate the immune system, so patients feel less fatigued and less flu-like.
2. The water pressure squeezes the fluid in the legs and trunk tissues where it may tend to accumulate, and pushes it back into circulation where it is more helpful.
Low-level interval exercise:
Exercise no more than two to five minutes at a time and follow it up with five minutes of rest. Dr. Lapp says using this type of low-intensity interval exercise on a daily basis can help reduce the burning and searing types of pain, but it will not erase your pain altogether.
Three or four visits to a knowledgeable physical therapist may be enough to teach you how to perform many of the above modalities at home, as needed. While most health insurance plans will not cover unlimited trips to physical therapists, a limited number of sessions for hands-on training should be covered.
You may have to emphasize the short duration of the therapy needed and that it is medically necessary to learn how to do these techniques correctly.
Once you are at the therapy clinic, have them show you a home program on how to stretch and strengthen your postural muscles.
Dr. Lapp recommends a basic prudent diet. The emphasis is on potatoes, rice, pasta, fresh fruits, vegetables and light meats (e.g., chicken and fish). "We’ve always told patients to stay away from sugar, caffeine, alcohol, NutraSweet and tobacco," says Lapp. "Many of your patients with irritable bowel syndrome have been found to be sensitive to dairy and wheat, so these may be withheld from their diet to see if it makes a difference.
The basis of our treatment includes vitamins and supplements, not so much because patients feel better when they take them, but we’re trying to make them as healthy as possible."
Lapp suggests patients take a good multivitamin and may also recommend other supplements such as Vitamin B12; minerals like magnesium, potassium, and chromium; and supplements that may help decrease muscle fatigue such as Coenzyme Q10 and essential fatty acids.
Therapies targeting sleep, fatigue, headaches and pain are included in this category. "Of these four," says Lapp, "sleep is probably the most important to treat."
"Most of my patients complain that sleep is like butting their head against a brick wall all night long. Klonopin (an anti-seizure drug) and doxepin (a tricyclic drug) are the cornerstones of our therapy, followed by trazadone and maybe a hypnotic like Ambien. Lapp has had some success with using low doses of melatonin at night and bright-light therapy in the morning.
A small dose of Prozac, Zoloft, Paxil or Serzone may help some patients with daytime fatigue. Lapp has also found some success with drugs that raise the body’s dopamine levels, such as Wellbutrin and others.
Dr. Lapp uses Diamox, which selectively decreases intracranial pressure, and calcium channel blockers which are thought to increase cerebral blood flow. "Sometimes we have to turn to analgesic sedatives like Fiorinal," says Lapp. He added that for vascular type headaches (migraines), he found Midrin and Imitrex (sumatriptan) helpful.
"There are no tricks for the treatment of basic pain," says Lapp. However, he has found that increasing water intake (along with salt) often helps reduce pain. "It’s inexpensive, safe and easy," says Lapp. Pain neurotransmitter altering drugs like desipramine, as well as other tricyclics like doxepin mentioned previously for sleep, may also help. Lapp has also been using a new drug, Neurontin, and has found it to help some patients headaches and muscle pain.
People with chronic illnesses often battle depression and anxiety problems, and they need to be treated. "I have not seen anybody recover from CFS/FMS that has very severe depression," says Lapp, "so it must be addressed." Allergies, chronic infections (including yeast problems), and chemical sensitivities (odors, fumes and smokes) also need to be treated when present. While specific medical treatments may be helpful for allergies and infections, Lapp finds that teaching avoidance is the best way for patients to deal with chemical sensitivities.
Chronic illness can create additional stressors, financial pressures and problems at work. It can also cause family dysfunction. Unfortunately, by the time FMS/CFS patients are diagnosed they often find themselves stranded without quality support structures to help them better cope with their illness. Dr. Lapp does not aggressively treat these problems himself, but he does refer patients to a counselor skilled in helping people with chronic illnesses.
Lapp says preventive care may often be overlooked when a person is chronically ill. On the self-help level, he recommends that patients avoid sunbathing. "The heat can make you tired and weak, so avoid it."
Other recommendations include flu shots to prevent serious infections, bone density measurements to check for osteoporosis, annual examinations with routine blood workup to check for things like cholesterol levels, standard screens for cancer, periodic review of medications, and regular documentation of the progression or regression of the illness to signal problems in therapy or the possible onset of other disease.
This explanation of The Stepwise Approach was transcribed from a presentation given by Dr. Lapp to the Nashville, Tennessee Support Group. It is reproduced here with kind permission of Dr. Lapp. ©2011 Hunter Hopkins Center, P.A. (http://DrLapp.com) All rights reserved.
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