When the Orchestra Lacks Harmony, Bring in a Team

Thursday, August 9, 2007

By: Michael J. Gilewski, PhD

Reprinted from FMOnline


Fibromyalgia differs from many other diseases and conditions that affect one bodily organ or system. Circumstances that trigger FM differ in individuals. Symptom patterns also differ. One thing is clear, however: FM involves symptoms that manifest in multiple bodily systems. Why? Because of the “orchestra!”

Think of a situation when you’ve been suddenly startled. Within one-third of a second, the heart races, you hold your breath or breathe rapidly, digestion abates, senses become keen, the mind is sharp, the muscles are tense, and you’re ready for action. Many know this reaction as the stress or the “fight-or-flight” response. The process is a natural protective mechanism and essential for life. Although the fight-or-flight label is accurate, it does not capture the rich and powerful orchestra of numerous nerve pathways, chemicals, and bodily organs involved in the response. This “orchestra” is the autonomic nervous system (ANS) and associated chemical transmission.

The “conductor” functions involve several keys areas of the lower brain. The “music” is “composed” in the cerebellum. This “little brain” is a like a computer software library that coordinates activity through its rich fiber networks and links to the lower brain stem. With a tap and pulse of a neuronal “baton,” the entire orchestra can crescendo and arouse the body through the sympathetic nervous system. Yet with another gentle sway of the neuronal baton and a calming biochemical hand, the orchestra quiets the body via the parallel parasympathetic nervous system.

The parasympathetic or relaxation response is the opposite of the stress response. The heart and breath calm, the mind and senses turn inward, muscles relax for repair, digestion and healing are enhanced—the body engages its restorative functions. The sympathetic (stress and outer action) and parasympathetic (relaxation and inner restoration) are one nervous system and differ only in the patterns of nerve cell firing and the dominance of regulating brain or bodily chemicals. There is one orchestra with harmonious variations in a symphony of two movements—excitation and restoration. The conductor is responsible for the balancing function of the two ANS components, and the imbalance is a major factor behind the symptoms experienced in persons with FM, including the disrupted circadian rhythms associated with sleep.

Fibromyalgia—When the Strings are Wailing
FM is often characterized as “pain gone wild,” probably because the wailing muscular strings have such prominence. More accurately, FM is “stress gone wild,” with many other bodily instruments equally and sometimes more disrupted. The sympathetic stimulation of arousal and excitatory functions is overly active; the parasympathetic stimulation of calming and restorative functions is markedly reduced. Thus, there is the rapid “drum beat” of the heart when sitting in a chair with no apparent stressor, the gasping of the “woodwind” breath during a simple telephone conversation, and the blaring of the sensory “trumpets” and brass with normal exposure to light or sound are only a few such symptoms.

Figure 1 illustrates the autonomic nervous system from Gray’s Anatomy. Ignoring the technical details and the double representation of the spine, the organs depicted represent many of the instruments in the orchestra. With “1.C” (the top of the cervical spine) being the separation between the brain above and the spinal column below, there are both direct connections from the brainstem to various organs and indirect connections via the spinal cord. Of most relevance are the end organs themselves, which can explain why FM can disrupt or function over any combination of them—from dry eyes and chronic running sinuses to irritation of bowel and bladder.

What is not shown in the figure are the more distant affected parts of the body, such as the muscles. Also not apparent in the figures are the numerous connections in the brain stem and above that affect many chemical factories in the brain, hormone regulation, immune system function, attention, memory, executive thinking skills, mood, pain sensitivity and other brain functions. A person with FM may experience unending stress with no particular external trigger. The orchestra is essentially “burnt out.” Bodily systems play (or do not) to their own disharmonious tunes in an “orchestra pit” of fatigue. The conductor is still there, but has lost the ability to coordinate the bodily functions.

The harmonious music of well-regulated bodily energy comes through the balanced exchange of the loud excitation and soft, quiet restoration. FM may be stress gone wild, but more critically is also “relaxation gone!” Gone is the recharging from a good night’s sleep! Gone is the returned strength when resting after a walk! Gone is the energy that disappears more quickly than water on the hot desert sand! The orchestra has lost its harmony, and the focus of effective treatments for FM is to improve the body’s restorative capacity.

Re-training the Orchestra Through an Interdisciplinary Team
For the Cedars-Sinai Medical Center (CSMC) Fibromyalgia Treatment Program, theinterdisciplinary team—multiple professionals harmonizing their treatment—is a key ingredient to success. The focus for all disciplines is on helping persons with FM build restorative capacity. Prior to the onset of—and sometimes after developing—FM, many patients are highly responsible thinkers and doers focused on external tasks or other people. They can tighten their muscular “strings” easily, but find it hard to loosen them. They can beat their heart “drums” into rapid rhythm, but the slow and soft tap patterns are difficult to maintain. Mental “fingers” can glide quickly across the thought “keys” on the “piano” of the mind, but struggle with the reflective attention and self-control to appreciate the echoes of those sounds. The interdisciplinary team works in a coordinated and harmonious fashion to develop restorative skills. Self-awareness, paced activity, conscious relaxation, self-control of mood, proper exercise, and efforts to enhance restorative sleep are a few of the skills that are the focus of the program.


Another component of the CSMC program is a rehabilitation model–the goal being to enhance functional abilities and quality of life. The team teaches the person with FM conscious control of the balancing skills necessary for optimal function. Restorative stretching brackets exercise, and movement is paced and done with awareness of the body. Restorative sleep is a major goal with preparation through nutrition, calming activity, and self-discovery through a sleep log. Functional activity is confronted by calmness, preparation, and timed efficient effort. Stressors are greeted by a focusing breath and thoughtful decision. Persons often have basic capabilities, but efficient use of these capabilities requires re-orchestrated coordination with necessary restorative activity. The range from disability to ability is wide in FM. The goal of rehabilitation is to move forward on the path to greater ability and avoid the perilous spiral toward greater disability.

The CSMC interdisciplinary team consists of the person with FM, rheumatologist, physical therapist, occupational therapist, psychologist, and office coordinator. A consulting psychiatrist, psychologist providing biofeedback, and administrative supervisor are part of the team as needed. Other services within the medical center health system or in the community are integrated as well. The key to an interdisciplinary team is the orchestrated approach to rehabilitation with coordinated goals and treatment.

Not all programs can orchestrate a team of professionals in one clinic, who are knowledgeable about fibromyalgia and trained in appropriate treatment. More typical is themulti-disciplinary team. The hub of the team is typically a physician, chiropractor or other licensed independent professional. Around this hub are other professionals with skills in fibromyalgia treatment. The major difference is that all coordination and ultimate direction is done through the professional at the center. The coordinating professional is essentially the “conductor” and directs assistance to parts of the orchestra where it is needed. A third treatment alternative for persons with no access to treatment teams, even one knowledgeable professional in FM care and treatment can be a godsend. This individual can still serve as an effective makeshift team leader, helping the person with FM effectively use community resources, information from quality self-help books on FM, quality websites, and consultation with other professionals.

An Orchestrated Problem Requires a Team Solution
The wide range of nonspecific symptoms that comprises the illness can lead a person with FM on a wild chase from specialist to specialist. FM is an illness that involves a complex system of interactive bodily functions. If effective, the most useful remedies that manage one symptom should have reverberating positive effects to other symptoms. Whether a person with FM utilizes one professional or many, the solution to the disharmony of FM will be the balancing and restoring functions of an orchestrated plan of care. FM also requires a lifetime commitment for the person with FM to become more in tune with the body, to modulate the impact of internal and external stressors, and to conduct the mysterious but powerful restorative capacities in us all.

Michael Gilewski, PhD, is a diplomate in clinical psychology and has more than 20 years of clinical, administrative, and scientific practice, mostly in the rehabilitation and pain management. He was the psychologist on the founding Cedars-Sinai Fibromyalgia Treatment program team in 1992, and has been a treating psychologist intermittently since that time. His treatment approach blends knowledge of fibromyalgia with principles of pain management, neuropsychology and rehabilitation with the goal to restore optimal functioning. He is a CARF surveyor for medical rehabilitation. After more than 16 years at Cedars-Sinai Medical Center, he is now a psychologist in the Department of Physical Medicine and Rehabilitation at Loma Linda University Medical Center, Loma Linda, California.

Reference
Gray, H. (1918). Anatomy of the human body. Electronic version retrieved fromwww.bartleby.com/107/214.html.