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while completing the assessment. Similar discrepancies are evident when comparing ratings from other visits. Post-study results After 6 months of assessment-based MRMT® treatments, the patient’s BMI had decreased by 5% (a clinically relevant amount [18]) to 26.4 kg/m2 , and her HbA1C had dropped to 6.5% (a 12% decrease). In addition, her daily dose of glimepiride had been reduced by 75% to 1 mg once daily due to much improved glucose control. She also reported substantial changes in her activity level, including integrating exercise into her daily routine. To monitor changes in activity level, the patient reported acquiring a Fitbit® activity and sleep tracker (Fitbit, Inc.; San Francisco, CA). Continued progress At two months post-study, the patient reported continuing to exercise daily and maintaining a calorie deficit in her diet. She noted that this contributed to better management of both FM and her diabetes symptoms. The patient continued with a monthly maintenance schedule for MRMT® treatments and noted that she was able to self-manage mild flares of FM. Currently, due to a variety of personal circumstances, this patient is no longer in treatment with MRMT®, but reports continued enhanced ability to self-manage her condition based on her experience with MRMT® treatments. Discussion It is now widely accepted that the best way to manage symptoms of FM is to improve a patient’s ability to function and increase their level of activity [8,19]. This case study demonstrates the benefits of the individualized approach of MRMT® for a patient suffering from of 6 months of MRMT® treatments based on changes in both the patient’s and the therapist’s ratings of pain and function. We also compared patient and therapist ratings, and assessed overall changes in the patient’s activity level, diabetes control, and quality of life. Results Baseline data At the time the patient presented for MRMT®, she was taking several medications including metformin (1000 mg, taken orally twice daily), glimepiride (2 mg, taken orally twice daily), and sitagliptin (100 mg, taken orally once daily) for Type 2 diabetes. Her symptoms were extreme fatigue, chronic pain and sleep disturbance which affected her activity levels, irritable bowel syndrome, and mild depression. This patient also reported high levels of work-related stress compounded by regular absenteeism from work due to her FM-related pain. Her initial BMI was 27.6 kg/m2 , and her HbA1C levels had ranged between 7.4% and 7.9% since 2002. Comparison of pain and function ratings When we compared the patient’s self-assessment of pain and function to the therapist’s standardized professional assessments, we found that the patient overrated her level of function 80% of the time and underrated her pain level 55% of the time (Table 1), indicating that the patient was not considering the psychological expression of her pain. For instance, when the patient traveled out of the country and missed a treatment, she self-rated her pain level as 4 and her function level as 90% when she returned for her 6th visit. The therapist, however, rated her pain level at 7 and her function as only 40% during that visit. During this 6th visit, the patient exhibited a depressed mood, guarding with her Table 1: Patient Assessment Data. Visit # Patient Pain Rating Patient Function (%) Therapist Rating of Physical Pain Therapist Rating of Psychological Pain Total Therapist Pain Rating Therapist Function (%) BMI Average Distance Walked Shaded boxes indicate visits when patient under-rated her pain level; a ND = Not Determined; b Difference = Difference in scores from visit 1 to visit 11; c PS = Post-study. DOI: 10.23937/2469-5793/1510086 ISSN: 2469-5793 Bowyer et al. J Fam Med Dis Prev 2018, 4:086 • Page 5 of 6 • into consideration the psychological differences of the patients. For instance, while it is often difficult to get FM patients to engage in exercise due to fears about pain flare-ups, encouraging FM patients to pursue a “start low and go slow” exercise plan [22] as they proceed through MRMT® treatments may be effective. While this case study, by definition, is limited to the study of one patient, we are encouraged by these results and intend to pursue future research that enhances our

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