FGID Therapeutic Interventions

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Functional
Gastro-intestinal Disorders

• What Can Rehabilitative Services Offer

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Objectives

• Physicians will
• Identify three reasons new treatments are needed
  for FGID.
• Discover eight rehabilitative methods available
  for the treatment of FGID.
• Learn where to refer patients requiring
  assistance in managing their symptoms after
  testing is complete.

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What is this lecture about

• This lecture is NOT
• A diagnostic lecture
• A practice guideline
• Replacement for medical intervention
• This lecture is
• An eye opener into the impact of FGID on daily
  life
• Presenting an adjunct service to improve patient
  satisfaction

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Are you practicing within the research?

• YES
• Medication
• Testing
• Dietary recommendations
• Counseling

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Are patients satisfied?

• NO
• Seek alternative treatments
• Do not accept the diagnosis
• Do not agree with treatments offered
• Dissatisfaction increases with severity of
  symptoms

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Are patients satisfied?

• In their study What do we know about what
  patients want? The doctor-patient communication
  gap in functional gastrointestinal disorders.
  Joanne Collins et al. determined
• Specialists underestimated the severity of
  patients' symptoms
• Patients and physician had conflicting views on
  best treatment.
• Patients rarely acknowledged FGID as their
  diagnosis.

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Why Not?

• No diagnostic marker for FGID
• Testing aimed at ruling out other issues
• Testing upper GI issues are limited
• Testing is expensive

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Diagnosis Requires Knowing About Your Patient
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Meds Have Side Effects
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Dietary Restrictions are Limiting
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Patients Dont Want Psychotherapy
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Why arent they Satisfied

• The symbolic dimension of food - a
  dimension that communicates a wide range of
  messages about identity and simultaneously
  facilitates social interaction -is not easily or
  painlessly altered (Waisbren SE, Rokni H, Bailey
  I, Rohr F, Brown T, Warner-Rogers J, 1997).
• Life is based around food and eating, you cannot
  avoid it

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Food is a social icon
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Why arent they Satisfied

• Patients are not motivated to attend
  psychotherapy.
• They want resolution of their symptoms not
  adjustment.
• Martens, U., Enck, P., Matheis, A., Herzog, W.,
  Klosterhalfen, S., Rühl, A., Sammat, I.
  (2010).

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Why is FGID more difficult than other chronic
diseases

• FGID sufferers have lower quality of life than
  other chronic conditions
• There is no cure
• There is no test
• There is poor explanation
• There is little support
• FGID symptoms mimic those of life threatening
  illnesses

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Fear of misdiagnosis
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Is this such an impending issue? It is not life
or death.

• The symptoms of FGID may not be life ending but
  they are life altering
• Lack of bowel or bladder control is demeaning and
  taboo to speak of. Yet one of the highest valued
  goals for spinal cord injured patients is bowel
  and bladder control (Taylor, 1976).

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Work interference

• Pain, depression, and poor support from
  colleagues and employer.
• Urgency of elimination and difficulty with
  elimination may miss or be late for meetings.
• A clients vocation may require him to stay at
  his post until relieved by another.
• There may be fear of passing wind or belching
  while in a confined area.

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Social interference

• Activities taking place outdoors such as the
  beach or picnic ground are restrictive of
  restroom access.
• Any length of driving distance can be an
  inhibitor.
• Patients may feel alienated at social functions
  if they are focused around food.
• Patients may feel safest staying in their own
  home environment due to embarrassment using
  public restroom.
• Patients may not FEEL like doing anything

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Feeling full at all times
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Financial drains

• Cost of FGI disorders
• Lost time from work
• The highest cost is NOT incurred due to
  testing
• K. A. Nyrop, et. al (2007) indicate higher cost
  correlates with symptom severity and patient
  dissatisfaction with care. The authors found
  diagnostic testing was not the greatest cause of
  the financial burden.

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What can Rehab offer

• Decrease pain catastrophizing behavior
• Cognitive Behavioral Therapy (CBT) CBT has been
  shown to help FGI disorders but psychologists who
  specialize in this area are difficult to find and
  patients are resistive to psychotherapy.
• Occupational therapists are a perfect option for
  this intervention and have a very client centered
  approach.

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What can Rehab offer

• Create healthy work and home environments
• Improve access to healthy foods and ease of
  avoiding trigger foods
• Time management, routine and habit building,
  stress management
• Adaptation and modification of work environment

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What Can Rehab Offer

• Pain Management
• (Desensitization)
• Acupressure
• (Gastric Flow)
• Abdominal exercise
• (Reduce bloating)

• Visceral Massage
• (Muscle spasm Reduction)
• Electrical Stimulation
• (Motility)
• Oral motor exercises
• (Control of belching)

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Review The Need

• Patients are not satisfied with current
  treatments.
• They are seeking alternative methods
• Collins, J., Farrall, E., Turnbull, D., Hetzel,
  D., Holtmann, G., et al. (2009).

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Review of the need

• The cost of FGID exceeds that of other chronic
  illnesses
• The quality of life is lower for FGID patients
  than those with other chronic illnesses
• Nyrop, K. A., Palsson, O.S., Levy,R.L., Von
  Korff, M., Feld, A.D., Turner, M.J., Whitehead,
  W.E. (2007).

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What is the next step

• Instruct the patient that treatment is
  management not a cure
• Inform therapist of the medical management piece
  to be reinforced
• Refer patients to the FGID Program
• at FallonClinic 508-555-5555

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• Thank You

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References

• Chen, L., Hsu, S., Wang, M., Chen, C., Lin, Y.,
  et al. (2003). Use of acupressure to improve
  gastrointestinal motility in women after
  trans-abdominal hysterectomy. The American
  Journal of Chinese medicine, 31, 781-790.

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• Collins, J., Farrall, E., Turnbull, D., Hetzel,
  D., Holtmann, G., et al. (2009). What do we
  know about what patients want? The
  doctor-patient communication gap in functional
  gastrointestinal disorders. Clinical
  Gastroenterology and Hepatology the official
  clinical practice journal of the American
  Gastroenterological Association, 7, 1252-4.

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• Guelrud, M., Rossiter, A., Souney, P.,
  Sulbaran, M. (1991). Transcutaneous
  electrical nerve stimulation decreases lower
  esophageal sphincter pressure in patients with
  achalasia. Digestive Disease and Science
  ,36,102933.

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• Hemmink, G.J., Ten Cate, L., Bredenoord, A.J.,
  Timmer, R., Weusten, B.L., Smout, A.J. (2010).
  Speech therapy in patients with excessive
  supragastric belching A pilot study.
  Neurogastroenterology and Motility, 22(1),
  24-28.

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• Gupta, N., Khera, S., Vempati, R. P., Sharma,
  R., Bijlani, R.L. (2006). Effect of
• yoga based lifestyle intervention on state and
  trait anxiety. Indian Journal of Physiology and
  Pharmacology, 50(1), 41- 47.

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• Hunt, M., Moshier, S., Milonova, M. (2009).
  Brief cognitive-behavioral internet
• therapy for irritable bowel syndrome.
  Behavior Research Therapy, 47, 797- 802.

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• Jin, H., Zhou, L., Lee, K., Chang, T., Chey, W.
  (1996). Inhibition of acid secretion by
  electrical acupuncture is mediated via
• beta-endorphin and somatostatin. American
  Journal of Physiology, 271, 524 30.

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• Martens, U., Enck, P., Matheis, A., Herzog, W.,
  Klosterhalfen, S., Rühl, A., Sammat, I.
  (2010). Motivation for Psychotherapy in Patients
  With Functional Gastrointestinal Disorders.
  Psychosomatics, 51, 225-229

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• Nyrop, K. A., Palsson, O.S., Levy,R.L., Von
  Korff, M., Feld, A.D., Turner, M.J.,
• Whitehead, W.E. (2007). Costs of health care
  for irritable bowel syndrome, chronic
  constipation, functional diarrhoea and
  functional abdominal pain. Alimentary
  Pharmacology and Therapy, 26, 237 248.

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• Taylor, D. (1976) Treatment goals for
  quadriplegic and paraplegic patients. American
  Journal of Occupational Therapy, 28, 22-29.

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• Tremolaterra, F., Villoria, A., Azpiroz, F.,
  Serra, J., Aguadé, S., Malagelada, J.
  (2006). Impaired viscerosomatic reflexes and
  abdominal-wall dystony associated with bloating.
  Gastroenterology, 130 (4), 1062-1068.

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• Waisbren, S.E., Rokni, H., Bailey, I., Rohr, F.,
  Brown, T., Warner-Rogers, J. (1997). Social
  factors and the meaning of food in adherence to
  medical diets results of a maternal
  phenylketonuria summer camp. Journal of
  Inherited Metabolic Disease, 20(1), 21-27.

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• Villoria, A., Serra, J., Azpiroz, F.,
  Malagelada, J. (2006). Physical activity and
  intestinal gas clearance in patients with
  bloating. The American Journal of
  Gastroenterology,101, 2552-2557.

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• Xing, J., Laeive, B., Mekhail, N., Soffer, E.,
• (2003). Transcutaneous electrical
• acustimulation can reduce visceral perception
  in patients with irritable bowel syndrome a
  pilot study. Alternative Therapies in Health
  Medicine, 10, 3842.

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