Archive | February, 2010

Fibromyalgia Research

 

Fibromyalgia Research

Research

Most of the research findings in fibromyalgia point to an abnormal function of the central nervous system (CNS), which includes the brain and spinal cord. There also appear to be a variety of abnormalities occurring in the peripheral soft tissues (muscles and connective tissue) and the peripheral nervous system that communicates with the CNS. This dysfunctional relationship between the CNS and peripheral systems is believed by most investigators to be the source of the many body-wide symptoms. Fibromyalgia could be considered a disease of the CNS, but this would be too narrow of a view in understanding the complex web of neuro-endocrine and physiologic processes participating in this condition.

Central nervous system research on fibromyalgia:

  • Alterations in pain-related chemical transmitters have been reported in the spinal fluid (particularly substance P, nerve growth factor, serotonin, norepinephrine, and corticotropin releasing factor).
  • Elevated levels of pro-inflammatory cytokines, which are substances that form a communication link between your body’s immune and neurological systems, have been found by many research teams.
  • Different brain imaging techniques by several research centers have all shown that the blood flow and metabolic processes in the brain are significantly disturbed.
  • Almost all people with fibromyalgia report difficulties staying asleep (e.g., the natural processes in the brain that maintain sleep appear to be disrupted).
  • The autonomic nervous system, whose control center (mesencephalon and intermediolateral cell column) resides at the base of the brain to communicate with the CNS to regulate the peripheral tissues, is not functioning properly.
  • Research on the primary pain control system in the spinal cord indicates that it is not filtering out or dampening incoming noxious signals from the peripheral tissues.
  • Several research studies pertaining to memory function tests show that people with fibromyalgia have an impaired ability to concentrate. (“Fibro Fog” related to the hippocampal area of the brain).

Research findings show that the peripheral tissues are also involved in producing the symptoms of fibromyalgia:

  • Muscles are often tight and knotted with myofascial trigger points (areas in the belly of muscles that refer pain to other regions and cause restrictions in range of motion).
  • High levels of a nitric oxide-producing enzyme was documented by one research team to help explain why patients have exercise intolerance.
  • Excessive levels of oxidative chemicals that irritate the tissues were found in the connective tissues in the tiny space between the muscle fibers.
  • Reduced blood flow to the muscles as well as a reduction in the number of capillaries supplying nutrients to the tissues were confirmed by different research teams … these findings are hypothesized to be caused by the malfunctioning in the autonomic nervous system.

The cause of fibromyalgia is not the same for everyone.

Various triggering events are thought to precipitate its onset. A few examples would be an infection (viral or bacterial), an automobile accident, an injury, surgery, or the development of another disorder, such as rheumatoid arthritis, lupus, or hypothyroidism. These triggering events probably do not cause fibromyalgia, but rather, they may result in the setting off of underlying physiological abnormalities that are already present.

Fibromyalgia Diagnosis

Fibromyalgia Diagnosis

Diagnosis of Fibromyalgia

If you have persistent symptoms of severe widespread pain and exhaustion, yet your blood tests and imaging studies are not showing a pathological process, you may have fibromyalgia syndrome or chronic fatigue syndrome. Both are serious chronic illnesses that have specific criteria for diagnosis. The diagnosis of these conditions does not tell what is causing the condition, and that is the most important thing to understand. The most confusing concept for most people to understand is that each person with these symptoms can have different, individual physiological processes causing their condition.  Physiological processes that are usually overlooked or misunderstood by our symptom oriented healthcare system. Understanding these complex processes, and knowing how to measure and interpret diagnostic tests to establish the mechanisms of these processes, is of utmost importance for each individual patient.

Also, you should be aware that the distinction between fibromyalgia and chronic fatigue syndrome is very subjective, and up to 70% of fibromyalgia patients meet the diagnosis for chronic fatigue syndrome.

Fibromyalgia Syndrome (FMS)

Routine lab tests do not detect the widespread pain of fibromyalgia. Instead, the diagnosis is made by a physical exam that takes about five minutes. When light pressure is applied to the surface of the muscles throughout the body, patients with fibromyalgia find this painful, especially at the tender points used for diagnosis. As you can see this is not a very sophisticated approach to the complex problem of fibromyalgia.

To meet the fibromyalgia criteria for diagnosis, patients must have:

A. Widespread pain in all four quadrants of their body for a minimum of three months

B. At least 11 of the 18 specified tender points

The 18 sites used for the fibromyalgia diagnosis cluster around the neck, shoulder, chest, hip, knee, and elbow regions. The finger pressure that must be applied to these areas during a “palpation” exam is roughly equivalent to the amount that causes the finger nail bed to blanch or start to become white. Over 75 other tender points have been found to exist, but are not used for diagnostic purposes.

While many chronic pain syndromes display symptoms that overlap with fibromyalgia, the 1990 American College of Rheumatology (ACR) multi-center criteria study (published in the February 1990 issue of Arthritis and Rheumatism) evaluated a total of 558 patients, of which 265 were classified as controls. These control individuals weren’t your typical healthy “normals.” They were age and sex matched patients with neck pain syndrome, low back pain, local tendonitis, trauma-related pain syndromes, rheumatoid arthritis, lupus, osteoarthritis of the knee or hand, and other painful disorders. These patients all had some symptoms that mimic fibromyalgia, but the trained examiners were not foiled—they hand-picked the fibromyalgia patients out of the “chronically ill” melting pot with an accuracy of 88%. Fibromyalgia is not a wastebasket diagnosis!

Although the above diagnosis focuses on tender point count, a consensus of 35 fibromyalgia experts published a report in 1996 saying that a person does not need to have the required 11 tender points to be diagnosed and treated for fibromyalgia (Wolfe F, et al. J Rheumatology 23(3):534-9, 1996). This criteria was created for research purposes and many people may still have fibromyalgia with less than 11 of the required tender points as long as they have widespread pain and many of the commonly associated symptoms below.

  • fatigue
  • irritable bowel (e.g., diarrhea, constipation, etc.)
  • sleep disorder (or sleep that is unrefreshing)
  • chronic headaches (tension-type or migraines)
  • jaw pain (including TMJ dysfunction)
  • cognitive or memory impairment
  • post-exertional malaise and muscle pain
  • morning stiffness (waking up stiff and achy)
  • menstrual cramping
  • numbness and tingling sensations
  • dizziness or lightheadedness
  • skin and chemical sensitivities

Do you think you have fibromyalgia?

If you think you have Fibromyalgia or Chronic Fatigue Syndrome order the Fibromyalgia DVD on the Home page …and watch the patient testimonials on the Testimonial page.

FAQ about Fibromyalgai

FAQ about Fibromyalgia

1. What is fibromyalgia?

Fibromyalgia syndrome (FMS) is a widespread musculoskeletal pain and fatigue disorder. Fibromyalgia means pain in the muscles, ligaments, and tendons—the soft, fibrous tissues in the body. Most patients say that they ache all over and may feel like they were strained or overworked. Sometimes the muscles twitch and sometimes they burn. More women than men are affected by fibromyalgia (75% versus 25%) and people of all ages can have fibromyalgia.

2. What causes fibromyalgia?

Although the cause is often hidden, there are many triggering events that often precipitate its onset. Examples include: infections (bacterial or viral), physical trauma (such as an automobile accident), or the development of another disorder, such as rheumatoid arthritis, lupus, or hypothyroidism. These triggering events probably do not cause fibromyalgia, but rather they may arouse physiological abnormalities that are already present.

Abnormalities that may be related to your symptoms include the following:

  • alterations in pain-related chemical transmitters (particularly substance P, nerve growth factor, serotonin, and norepinephrine)
  • immune system dysfunction (e.g., abnormally elevated levels of cytokines that form the communications link between your immunologic and neurologic systems)
  • sleep disturbances
  • hormonal irregularities
  • differences in brain function that are being explored with the help of modern brain neurological function examination techniques
  • the body’s responses to exercise and stressors (chemical, environmental, physical, mental and emotional)
  • dysregulation of the autonomic nervous system (your sympathetic and parasympathetic nervous system)
  • elevated substance P and nerve growth factor are increased in the spinal fluid of people with fibromyalgia

3. How is fibromyalgia diagnosed?

These diagnostic criteria are established for the diagnosis. Upon physical examination, patients will be sensitive to pressure in certain areas of the body, called tender points. To meet the diagnostic criteria patients must have widespread pain in all four quadrants of their body for a minimum duration of three months and at least 11 of the 18 specified tender points. The 18 sites used for diagnosis cluster around the neck, shoulder, chest, hip, knee, and elbow regions. However, if a person has widespread pain, at least six or more tender points and many of the commonly associated symptoms of fibromyalgia (such as disturbed sleep, irritable bowel syndrome, frequent headaches, fatigue, and memory problems), they should still be diagnosed and treated for fibromyalgia. Roughly 75% of chronic fatigue syndrome (CFS)-diagnosed patients will meet the fibromyalgia criteria.

4. How is fibromyalgia treated?

The traditional medical approach is to address the symptoms of the condition.  For example Ambien, Lunesta, clonazepam, and trazodone are just a few of the medications that may be used to aid sleep. For addressing the pain and the symptoms in general, medications that boost serotonin and norepinephrine (neurotransmitters that modulate sleep, pain, and immune system function) are commonly prescribed in low doses, such as amitriptyline, cyclobenzaprine and Cymbalta. Ultram may help with the pain, although stronger opioids may be needed. Muscle relaxants, anti-epileptics (such as Neurontin and Lyrica) and other drug categories may be prescribed as well.   Please take a moment to research these drugs and their side effects on the website www.drugs.com then consider what a different approach might offer.  This different, functional approach is outlined below.

What makes our treatment approach different is that we treat the person and not their diagnosis. Our approach begins with a thorough history, a physical and functional neurological examination, and extensive laboratory testing of blood, urine, saliva and stool samples.  Based upon the findings of these clinical and laboratory examinations we can understand your physiology and nervous system and how it is creating your symptoms.  By restoring normal physiologic and nervous system function you can improve your health and stop the processes that are causing your symptoms.

5. What is the prognosis?

The prognosis varies from person to person. Patients with autoimmune conditions as a component of their fibromyalgia remain autoimmune their entire lives.  However, their quality of life can be greatly enhanced with treatment and ongoing regulation of their lifestyle and diet. Others can resume their lives with some modifications to their lifestyle and diet and feel as though their condition is no longer an obstacle to their enjoyment of life.

6. What can I do to help myself?

General things like lifestyle modifications may help you conserve energy and minimize pain. Learn what factors aggravate your symptoms and avoid them when possible. Many patients find warm water (hot tub or shower) to be soothing. Hot wraps for particularly painful areas are also beneficial. Maintaining a rigid sleep schedule (e.g., ensuring that you receive at least eight hours of sleep per night and that you have a routine for easing you into sleep) is one method endorsed by patients to help minimize daytime fatigue and reduce nighttime sleep difficulties. Gentle movement and stretching exercises will help you maintain your function, which is essential when the body is tired and the muscles hurt.

Specific measures to help yourself get better need to be individualized based on your particular physiology.  What is good for one person may be useless or even harmful to another.

7. Is there a cure?

As there are many underlying causes for the symptoms of fibromyalgia, there is not specifically a “cure” for those underlying causes because they are part of your physiology that has gone haywire.

Consider as an example of this, the common symptom of GERD (gastroesophageal reflux disease).  Here you have a condition in which the presence of stomach acid in the esophagus causes irritation to the normally neutral pH esophageal tissue.  Now, the traditional symptom oriented approach is to reduce the production of acid with an acid suppressing medication. This helps with the acid burning of the esophagus for a while. But the symptoms come back.  And what has this done for the underlying cause of the GERD? Nothing! Or it has made it worse.

Why? Because the problem is not too much acid being produced but too little acid , and where the acid is being allowed to go.  It works like this. In your stomach parietal cells produce hydrochloric acid and lower the acidity of your stomach to a pH of 1 (like battery acid in your car).  The cells of your stomach secrete a mucous lining to protect themselves from this acid.

Your stomach has this strong acid to digest proteins in your food.  If there is less acid produced in your stomach then the proteins in your food are not digested well.  These proteins begin to putrefy in your stomach and form the byproducts of putrefaction, these byproducts are acids and gas.  The build up of pressure in the stomach from the gas and acids formed by the putrefaction of the undigested food proteins pushes the contents of the stomach up through the esophageal sphincter (a muscular ring of tissue around the esophagus that acts like a belt) into the esophagus causing the burning of GERD.

One other interesting fact about the esophageal sphincter is that the normal tightness of the sphincter is controlled by the presence of the strong acid level of the stomach.  When the stomach acid gets weaker (as in taking antacid medications), the ability of the esophageal sphincter to tighten to keep stomach acid where it belongs is impaired.  The true correction of this condition would be to restore the normal digestive processes and the symptoms would go away as a result.

There is much more to this story, but I think you can see the point of simply treating symptoms and not the underlying cause of the symptoms.

Patients need to beware of the many cures that are being promoted on the Internet and in the media. Look at the risks, and side effects associated with the particular treatment and whether it is simply symptom oriented, or is directed at the causes of the symptoms.

8. Why do some doctors think that the pain is all in my head?

Doctors cannot see a pathological process causing your symptoms and may not understand the sources of your pain or fatigue. What they do see is your anxiety and frustration with having to deal with these symptoms daily, which may wrongfully lead them to conclude that your symptoms are of a psychological nature. The old school of thought regarding pain is that it is produced by tissue injury, and there is no obvious source of tissue injury in patients with fibromyalgia. Regardless, if your doctor does not believe that your symptoms are real, you owe it to yourself to find another doctor who believes in you, understands the individual nature of fibromyalgia and will work with you to help reduce your symptoms.

9. Do I just need to exercise, like my medical doctor says?

Although some degree of regular exercise is essential for maintaining function, and if done in warm water, it can improve circulation. Yet, exercise alone will not be enough to treat your fibromyalgia. Many studies on the use of exercise to treat fibromyalgia have been published over the years, and while the documented benefits are minimal, these studies are heavily promoted at medical conferences and widely publicized in the medical journals. Exercise is easy to prescribe and doesn’t cost anything, so it tends to be one of the first therapies that a doctor recommends, especially if they have limited experience with the management of fibromyalgia.

10. What is fibromyalgia pain like?

The pain of fibromyalgia can be anywhere on the body. People describe the pain as deep muscular aching, throbbing, shooting, and stabbing. Intense burning may also be present. Quite often, the pain and stiffness are worse in the morning, and you may hurt more in muscle groups that are used often.

11. What is the fatigue like?

This symptom can range from mild to incapacitating. The fatigue has been described as “brain fatigue”—patients feel totally drained of energy. Many patients say that they feel as though their arms and legs are filled with concrete, and they have difficulty concentrating (i.e., brain fog).

12. I have trouble sleeping. Is this part of the fibromyalgia?

Most fibromyalgia patients have difficulty with getting deep, restful sleep.  If you have difficulty falling asleep, or you fall asleep only to be awakened through the night, there are reasons this occurs.  The reasons involve the complex interplay between the nervous system, the metabolic and endocrine systems.

13. I have a lot of GI problems. Are these symptoms part of fibromyalgia?

GI problems are often a contributory condition to fibromyalgia.  Dysbiosis (a prevalence of opportunistic or pathologic bacteria, yeast or parasites in the gut), leaky gut syndrome, and food sensitivities to dietary proteins may result in an ongoing inflammatory process that up-regulates the body’s immune system, leading to a ripple effect throughout your body.

Irritable Bowel Syndrome (IBS), with symptoms of constipation, diarrhea, frequent abdominal pain, abdominal gas, and nausea is found in roughly 40 to 70% of fibromyalgia patients.  Gastrointestinal Esophageal Reflux Disease (GERD) is equally common in people with fibromyalgia. This may include heartburn, chest pain, regurgitation, indigestion, and a chronic cough, among other symptoms.

14. How common are headaches in fibromyalgia?

Recurrent migraine or tension-type headaches are seen in about 70% of fibromyalgia patients and can pose a major problem for this group. For some people, aggressive treatment of the migraines also provides tremendous relief of the general pain of fibromyalgia.

15. Is TMJ disorder associated with fibromyalgia?

Temporomandibular Joint Dysfunction (TMD) causes tremendous facial and head pain in 25% of fibromyalgia patients. However, close to 75% of fibromyalgia patients have a varying degree of jaw discomfort. Typically, the problems are related to the muscles and ligaments surrounding the jaw joint, and not necessarily the joint itself.

16. What factors aggravate the symptoms of fibromyalgia?

Changes in weather, cold or drafty environments, hormonal fluctuations (premenstrual and menopausal states), stress, depression, anxiety, infections (flu or a cold), and over-exertion can all contribute to symptom flare-ups. Repetitive use of the same muscle group can strain the muscles and lead to more pain.

17. What specialist should I see for treating my fibromyalgia?

The best doctor to see is one who has experience treating fibromyalgia patients successfully. There is no specific health specialty that “owns” this condition, so it is important to inquire about a physician’s level of experience and their general philosophy for treating fibromyalgia.

18. Does fibromyalgia get worse over time?

The longer you have fibromyalgia the more ageing effect on your brain. Some patients may be likely to improve because they have a good doctor willing to work with them to find which therapies they respond to. Also, as people age, other medical conditions can aggravate the symptoms of fibromyalgia, so it is imperative that patients seek aggressive treatment for age-related conditions, such as arthritis. A preventive maintenance program with exercises and a healthy diet may prove worth while.

19. Can I still work with fibromyalgia?

Balancing work and chronic illness is always a challenge, but most patients with fibromyalgia are able to remain employed. The answer to this question really depends upon one’s job and whether job accommodations can be made to ease the symptoms. Also, the development of other medical conditions may make fibromyalgia symptoms more severe and lead to the need to consider early retirement or disability.

20. Is there a special diet I should be eating?

Yes. Specifically, there may be foods that you are sensitive to.  You could have a food sensitivity and not have any GI symptoms, but you could have other symptoms such as joint pain and stiffness, mental fog, sinus congestion, neurologic symptoms and others. Proper testing to determine if this condition exists in your body is important in determining what diet would be best for you.

Also, providing your body with a well regulated blood sugar level and adequate nutrients is extremely important in optimum function of your bodily systems.

Generally a diet full of fruits and vegetables and adequate protein may supply your body with antioxidants, which are known to be useful for protecting your tissues and to minimize the development of “other” sources of pain. Irritable bowel syndrome and acid reflux are both common in people with fibromyalgia, so it is wise to avoid foods that irritate these conditions.