An Excerpt from the Aquatic Therapy Journal

. . . indicates extensive material eliminated. This excerpt represents approximately 1/3 of the original article. Bibliography, Resources and Glossary from the original article are not included.

A DIFFERENT APPROACH FOR TREATING FIBROMYALGIA CLIENTS IN THE AQUATIC ENVIRONMENT

Personal Observations by David Ogden, PT

In the past when treating a fibromyalgia client, both of us ended up frustrated and disappointed. Nothing they or I did provided a lasting, positive effect. At best, modalities such as hot packs, ultrasound and massage provided only temporary relief. When the client went into the gym and exercised, it would often turn out to be a one-time event. Afterward the client would go home to bed for two or three days to recover from the well-intentioned exercise therapy.

When I began working with these clients in the aquatic environment, I hoped they could exercise without incurring the adverse reactions experienced on land. That did not happen. So began the problem solving … how to meaningfully intervene in an aquatic setting with the fibromyalgia client?

FMS – The Causes and Symptoms

. . .universally their symptoms suggest an autonomic nervous system chronically out of control. .

The Mistake

After I reviewed all my information on fibromyalgia I realized my approach to the person with fibromyalgia was a situation of putting the cart before the horse. Placing them into a pool and exercising from the onset was merely reinforcing what they were already doing so well … inappropriate and excessive muscle recruitment during functional performance. To put the horse in front of the cart, I had to make these clients aware of what muscles they were unconsciously contracting: 1) clenching the teeth; 2) shoulder shrugging; 3) upper chest or paradoxical breathing; 4) intense, penetrating staring with the eyes usually accompanied by knitting of the eyebrows; 5) globally excessive muscle guarding and compensatory ways of moving in response to chronic pain. In many instances the compensatory movement patterns they demonstrated were contributing to their overall discomfort and fatigue.

The New Approach

I began by putting the clients in chest deep water, facing them, and holding their hands in mine. (By holding their hands I could detect the level of muscular tension not only in their bodies as a whole, but in specific areas.) This enabled me to verbally cue the client about inappropriate and unnecessary muscle recruitment during performance. I also observed them for visual cues revealing inappropriate muscle recruitment, i.e., hiking shoulders, intense gaze with vertical furrowing between the eyebrows, chin thrust forward, etc. Essentially I was able to tactilely and to visually evaluate their movement patterns and tension.

We begin with side stepping. As soon as clients start the activity, I observe through my hands where in their bodies inappropriate states of muscular tension occur or for muscular contractions not needed for the task required. Since the clients are oblivious to this tension, I bring it to their attention by asking, "What are your teeth doing? Are they clenched? Are your hip muscles working harder than they need to? What are your eyes doing? Is your gaze hard or soft? Are you pulling your eyebrows together? What are your shoulders doing?" . . . .

The Water

The aquatic environment is an ideal setting for working with fibromyalgia clients. Specifically, the setting should be a therapeutic pool heated between 91 and 94 degrees F. The warmth promotes relaxation. Depending on the depth of the water in which the client is performing, buoyancy can eliminate gravity up to 90%. By decreasing gravity, the degree of apparent work normally required from the postural and lower extremity musculature is significantly reduced. Clients can perform many functional activities in the water without the pain and limitations they might experience on land. Elimination of gravity also helps in training the client to move with the least amount of effort (muscle recruitment) possible (Ruoti, Becker). . . .

The water can also be used as a biofeedback mechanism with clients in shoulder deep water. (I sometimes add ankle weight to help them stabilize at this depth.) Have clients let the buoyancy gently move their arms out to the sides. Most will do this demonstrating the hand or a portion of the hand above the water. If they ‘let go’ and allow the buoyancy to act, the hand usually remains just below the surface of the water. Point this out and gently encourage them to ‘play’ with allowing the arm to be buoyed by the water rather than lifted up by them. This helps to stop excessive muscle recruitment in the shoulder.

Breathing

. . ."Breathe easily into the belly, not the chest. Let your stomach expand as you inhale, and consciously contract the transversus (abdominals) during exhalation. This means your stomach will relax during the inhalation and be "pulled in" during the exhalation. It feels different and uncomfortable when first beginning. It will eventually become natural and automatic." (Sova)….

Rapid, shallow upper chest breathing elicits a sympathetic nervous system response. (Sova) Many clients report "fibro-fog" after days of increased stress. We breathe faster under stress and that may cause hyperventilation, which can affect the blood chemistry and affect the thinking process. Hyperventilation may also cause fibromyalgia clients to be "obsessed" with various thoughts (Starlanyl).

Learning appropriate breathing intimately affects overall feelings of well being because it elicits a parasympathetic nervous system response.

Verbal Cues

Through experience I have learned to avoid using two words with fibromyalgia clients. They are "relax" and "exercise".

If you tell a fibromyalgia client to relax they’ll try as hard as they can to do so. We don’t want them to try hard, we want them to just "let go". . . In Ai Chi the words ‘surrender’ and ‘collapse’ are used. Those may work for you.

Exercise is a word with negative connotations for most clients with fibromyalgia, especially if they’ve had land therapy. Tell clients that rather than exercising they’re learning how to move as effortlessly as possible. . .

Control

. . . . Fibromyalgia clients need to give up control.

Progression

Sessions progress as clients are able to avoid excessive muscle recruitment during simple activities (such as walking forward, backward, sideways, diagonaling forward to the right or left, or back to right or left). At that point add turbulence when a direction of walking or limb movement is changed. Determine if they’re able to release initial increased muscle tension in response to turbulence. If they are successful with this you can start using resistant or buoyant devices.. . .

Stretching should be added. Monitor and verbally assist the clients as they stretch. . . .

As fibromyalgia clients further progress I begin introducing Feldenkrais techniques in water as taught by Debbie Ashton. . . .

Performance of PNF patterns is also helpful in relearning more appropriate patterns of movement.

Ai Chi allows slow movement synchronized with diaphragmatic breathing. At the same time Ai Chi creates a state of relaxed focus during performance.

Incorporation of an unpredictable command format for other movements helps the client learn how to change movement performance without going into excessive muscle recruitment, and then subsequently maintaining it. . . .

Homework

. . .dare them to set aside forty-five minutes to one hour a day to do whatever they wish (which may be absolutely nothing) without allowing in-person or phone interruptions. . .

Graduation

What happens after the one-on-one aquatic therapy comes to an end? I recommend clients continue with either a home or group arthritis or walking aquatic program. . . .

Frustration

. . .Our job is not to judge these people but to accept that our efforts may not work for everyone.

The ‘Feel’ of the Session

I cannot emphasize enough the role of good-natured humor during one-on-one therapy or rehab. . . .

During a fibromyalgia session, I play soothing music. . .

Summary

In summary, the first goals with fibromyalgia clients are increasing their awareness and control. The awareness is of inappropriate and excessive muscle recruitment when performing functionally. Control means substituting more appropriate muscle recruitment during physical performance and/or in reaction to mental and emotionally charged scenarios. From there progression to resistive exercises can be initiated without reinforcing unnecessary and/or excessive muscle recruitment patterns. The progression varies with each client. So does the degree of success. However, I can say that none of these clients leave therapy ‘unchanged.’ After the first session, most demonstrate a facial expression reflecting a new sense of realization about themselves and the condition that they have.

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