How We Approach Fibromyalgia
Treatments (FMS)
CONTENTS:
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Fibromyalgia Treatments and Low Thyroid
Symptoms
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Links
to Useful Fibromyalgia Websites
Fibromyalgia (FMS) is a condition of sore muscles and increased
sensitivity to pain. The ?official? definition requires that at least 11 of 18 designated tender point sites be especially sensitive to pressure induced pain.
Other conditions must be excluded as the primary cause of pain. For example:
osteoarthritis, disc disease, Lyme disease, low thyroid. With severe
Fibromyalgia (FMS), most people also develop additional symptoms. These
include cognitive or concentration difficulties, chronic fatigue, joint aches,
poor sleep, or headache. Secondary depression and/or anxiety affect many, but
not all. People with moderate to severe Chronic Fatigue Syndrome(CFS) often
develop a similar range of additional symptoms.
Many people with severe
Fibromyalgia qualify for the diagnosis of both Fibromyalgia Syndrome (FMS)
and also Chronic Fatigue Syndrome (CFS).
Fibromyalgia Doctors:
Even a few
years ago many physicians believed that Fibromyalgia Syndrome (FMS) was
mainly a disguised form of psychological distress or depression. While a
few hold-outs remain, most physicians and official groups such as the
American College of Rheumatology now agree that Fibromyalgia Syndrome (FMS)
is both real and mainly physical.
For Fibromyalgia the
central problem appears to be not just in the muscles, but within the pain
signaling pathways of the brain and the spinal cord.
There is an amplification or an increased sensitivity to pain. Persons with
fibromyalgia experience pain at much lower levels of stimulation than do
normal controls. This has been proved by sophisticated imaging techniques
such as functional MRI. In fibromyalgia patients a modest stimulus causes
the brain?s pain centers to ?light up?. This proves that persons with
fibromyalgia are telling the truth about the pain that they feel, and that
this pain is physical and real. Think of pain pathways as a radio receiving
signals. In Fibromyalgia, the knob controlling volume is always turned way
up. The technical name scientists give this is neural sensitization.
FIBROMYALGIA TREATMENT: PRESENTATION TO RHEUMATOLOGY DIVISION, UMDNJ-ROBERT
WOOD JOHNSON MEDICAL SCHOOL, JANUARY, 2006
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Our
New Jersey offices have worked with more than 1000 persons who have mild,
moderate and severe Fibromyalgia Syndrome (FMS) and/or Chronic Fatigue
Syndrome (CFS).
Richard Podell,
M.D., medical director has lectured on Fibromyalgia Syndrome to professional
and consumer support groups. He has written for magazines and professional
journals, including Fibromyalgia Network and the Journal of Musculoskeletal
Pain. . A clinical professor at Robert Wood Johnson Medical School,
Dr. Podell headed one of 10 research teams for a Food and Drug
Administration approved study of Ampligen, an experimental treatment for
people with Chronic Fatigue Syndrome, many of whom also had Fibromyalgia.
Dr.
Podell is a member of the International Myopain Society, the main
professional organization of fibromyalgia physicians and scientists. He is a
member of the American Association for Chronic Fatigue Syndrome and the
American College of Nutrition. SEQ CHAPTER \h \r
1
The
New Jersey Chronic Fatigue Syndrome Association
awarded Dr. Podell their
2002 Achievement Award. He served on the expert committee of the New Jersey
Academy of Medicine and the New Jersey State Health Department. Dr. Podell
was co-author of a text for physicians on the diagnosis and treatment of
Chronic Fatigue Syndrome that also focused on Fibromyalgia. Dr. Podell
serves has served as a medical expert on severe Fibromyalgia Syndrome and on
Fibromyalgia disability in both New Jersey State and Federal Courts.
Edwina (Wendy) King, PhD, APRN,
an advanced practice nurse, is director of research, and also director of
behavioral medicine. Dr. King is a clinical associate professor at the
Robert Wood Johnson School of Allied Health. Dr. King has been
administrative director of our research program, including the Food and Drug
Administration approved Phase III trials of the drug Ampligen to treat
Chronic Fatigue Syndrome.
Philosophy: We
seek to combine the best of standard drug therapies with holistic support
for the body?s natural healing systems. Drug treatments for Fibromyalgia
can be very useful, but often they only partly control symptoms. Therefore,
we also seek to identify, understand and improve the body?s natural healing
systems. We work to remove obstacles that block their natural ability to
heal. We call this ?integrative medicine?, combining the best of both
worlds?standard mainstream medicine and holistic or complementary
alternative medicine.
One
conventional view is that the mind and body function separately, both in
health and in illness. Integrative Medicine believes that the opposite is
true. And most research science supports the integrative perspective?for
fibromyalgia, as well as for most other chronic health problems.
The
multiple systems of mind and body interact in a complex web of biochemical,
hormonal and metabolic relationships. In many important ways even such
distant organs as the brain, endocrine glands, immune system, gut, and liver
interact together as if they were one.
Fibromyalgia doctors
using an Integrative Medicine approach act to strengthen the body's healing
systems. Improving function for any part of the healing web, feeds through
to strengthen other parts of the system. This helps the well-being of the
person as a whole.
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Dozens of common ailments
can cause muscle pain and fatigue. Therefore, a main focus of our one and one
half hour long new-patient visit is to be sure that we consider potential
alternative and/or additional causes for your symptoms. That?s why we ask you
to complete our very detailed case history questionnaire so we can review it
before you come, and also to send us copies of prior lab reports.
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Just a few years ago, only one drug, Elavil (amitryptiline), had double blind studies showing benefit as fibromyalgia treatment.
Today more than a half a dozen medicines have good double blind studies to their credit. All these drugs have potential problems with side effects; but, when tolerated, each will help pain in roughly 50% of patients.
Lyrica (pregabalin) was the first medicine to be formally approved ty the Food and Drug Administration as a fibromyalgia treatment. At least three other fibromyalgia medicines are in the process of submitting for FDA approval: Cymbalta (Duloexetine), Zyrem (GHB), and Namenda (memantine). Fibromyalgia doctors and patients are fortunate now to have a broad range of options.
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Lyrica (pregabalin) is an anti-seizure drug that affects calcium channels. Pain improves by 50% for about one third of those who take it. Pain improves about 30% among half of patients.. Side effects can be a problem, with a fair incidence of increased fatigue, fluid retention, tremors, dizziness and weight gain. Neurontin (gabapentin), a similar drug, probably also works but with similar side effects.
Elavil (amitriptyline), a tricyclic antidepressant, acts to increase serotonin and norepinephrine brain neurotransmitters. As a fibromyalgia treatment Elavi is used, at much lower doses, than we use for depression. Elavil helps fibromyalgia in up to 50% of patients. Elavil can cause dry mouth, rapid heart rate and weight gain. Fibromyalgia doctors also recommend two medical cousins of Elavil-- Pamelor (nortriptyline) and Flexeril (cyclobenzaprine). Often these are better tolerated than Elavil itself.
SaveCancelCloseEdit FileWhe Cymbalta (duloxetine) is an NSRI?a norepinephrine and serotonin reuptake inhibitor. It is FDA approved for depression and for the treatment of diabetic nerve pain. Cymbalta is effective for fibromyalgia whether or not the fibromyalgia patient is also depressed. Cymbalta?s mechanism of action is similar to that of Effexor. But, in contrast to Cymbalta, Effexor?though a very good antidepressant-- has not proved effective for fibromyalgia. Namenda (memantine), another drug of this class is not yet on the market in the U.S.
n finished, click Save or Cancel below. Change Pe Xyrem (Sodium Oxybate) is approved by the FDA as a treatment for narcolepsy. However, three double blind studies show benefit for fibromyalgia pain and quality of sleep. Xyrem is the FDA approved form of GHB. On ?the street? GHB has been abused as a date-rape drug. Prescription Xyrem has not been abused. Xyrem can give wonderful relief among a modest proportion of patients. However, Xyrem often has side-effects.
Click
here for Information About GHB and Fibromyalgia.
rmissionsReadWriteExecuteUser Mirapex (pramipexole) has been approved by the FDA to treat Parkinson?s Disease. However, one very good double blind study shows major benefit for fibromyalgia pain. Mirapex is also very good for a particular disorder of sleep, periodic leg movement disorder (PLMD), also known as Restless Legs Syndrome. Fibromyalgia Treatment for Mirapex should start at a very low dose. We slowly increase the dosing over a period of several months.
Ultram (tramadol) is a safer, less addictive cousin of the codeine group of opioid pain medicines. It can be taken on an as needed basis or around the clock. Fibromyalgia doctors often dose Ultraum at bed time and again if you wake during the night. Improving pain control at night often improves sleep.
Prozac
- like SSRI anti-depressant drugs are usually not very useful for fibromyalgia pain; but they can be very useful for coexisting depression and/or anxiety. Non-steroidal anti-inflammatories such as aspirin, Ibuprofen, and Celebrex are less effective for FMS than they are for inflammatory conditions such as osteoarathritis and rheumatoid arthritis. Prednisone/Medrol/Cortisone is usually not useful for fibromyalgia. If corticosteroids help a lot, consider the possibility of a different illness e.g. polymyalgia rheumatica or temporal arteritis.
Well-Proved Natural Fibromyalgia Treatments:
Fibromyalgia doctors also recommend two very simple but powerful natural therapies. Both have multiple controlled studies showing benefit for treatment of fibromyalgia.
GroupOther 1) an appropriate program of slowly increasing exercise. But, this must be done carefully. Not too little and also not too much. We call this the ?Goldilocks method??do it ?just right?.
File VersionsWarning: Restoring an older version will overwrite the current file without backing it up. Ne 2) CBT or Cognitive Behavioral Therapy is a specialized form of practical psychology that emphasizes day-to-day coping skills rather than ?in depth? psychology. This is called cognitive behavioral therapy (CBT). Edwina (Wendy) King, PhD, APRN, our chief of behavioral medicine teaches basic and advanced relaxation skills and also reviews cognitive ?reframing techniques?. David Burns, M.D. has very good books on CBT under titles such as
Feeling Good and also The Feeling Good Workbook.
Fibromyalgia physicians agree: No fibromyalgia treatment plan is complete without attention to proper exercise re-conditioning and also to cognitive behavioral and stress reduction healing.
Physical Therapy is also often very helpful. This can true even if the physical therapist is not specially trained in the special issues of posture and muscle trigger points that are very important in fibromyalgia. However, these approaches must be slow and gentle, or else flare-ups can occur. Physical therapists (or massage therapists) with special interest in Fibromyalgia often do better. We have been very pleased with the work of Carol Cote, P.T. and her associates in Morristown and Hackettstown, NJ. (tel: 908 852 7575.) We discuss both exercise and psychological adjuncts below in the section
Functional Medicine Applications.
Each of the following innovative treatments help perhaps a proportion of people with moderate or severe FMS. The degree of benefit varies from mild to major.
These natural supplements might be useful: Magnesium, Malic Acid, 5 Hydroxy tryptophan. Acupuncture and frequency specific electrical stimulation might be useful for some. Low Vitamin D can bring out fibromyalgia. Be sure your doctor checks your blood level of 25 hydroxy vitamin D, and gets you up to a proper level.
w ArchiveArchive Name Natural Thyroid Treatments: All physicins agree that persons who have low thyroid are more vulnerable to fibromyalgia. An ?alternative medicine? minority believe that low thyroid can be a factor even if the thyroid blood tests are completely normal. There is some evidence to support this, but it is not completely proved.
For appropriate persons we will often consider adding natural thyroid hormone.
See our thyroid section below for a fuller discussion.
Back to Control PanelWeb Site .htaccess Editor Archive Gateway Disk Usage FTP FileManager FrontPage Extensions Secure Server Server Information Set Site Editor Site Backups and Resto Lyme disease is also a cause of fibromyalgia. Many people who have Lyme wind up with residual fibromyalgia. All agree that this is so. What remains controversial is whether such fibromyalgia-like ?post-lyme? syndrome are caused by on-going Lyme infection that requires further antibiotic treatment. Most ?main stream? experts believe that post Lyme fibromyalgia and other symptoms result from damage done by the original Lyme infection and do not have current infection. They do not believe that long term antibiotics will help. Certain alternative physicians dissent, and vigorously.
re SiteDelux View my Web sit Dr. Podell?s opinion. Chronic active Lyme disease cases due occur, and, some respond very well to antibioitics. However, in the majority of cases antibiotics do not help. The key issue is deciding who should attempt antibiotics and who should not.
B-List Medications:
e Visitor Statistics WebSite Creator by CM4all E-Mail AutoResponder Change Catch-All MailCentral Manage Spam Filter Newsletter Management POP Mail Domain Add Registered Domain to Account Custom DNS Record Domain Central Domain Pointin Zofran (odansetron) is a medicine usually used to treat the symptom of nausea caused by cancer chemotherapy. Zofran might also block the release of substance P, a pro-inflammatory neural hormone. Zofran is very expensive--if you don?t have a prescription plan. Constipation can be a major, even a dangerous problem. This must be watched carefully.
Zanaflex (tizanidine) is usually used to treat muscle spasticity in multiple sclerosis. Zanaflex modulates pain through certain sympathetic nervous system receptors. Zanaflex can be sedating and lower blood pressure. However, most people tolerate it. (Zanaflex is also fairly good for menopausal hot flashes.)
Baclofen also treats muscle spasticitity in multiple sclerosis. Baclofen stimulates GABA. Baclofen is usually well-tolerated. But sedation can be a problem.
g Manager Registrar Transfer Subdomain Pointing M Ketamine is an intravenous anesthetic that also blocks NMDA receptors. NMDA receptors play a major role in the central nervous system?s pain pathways. Oral Ketamine reduced FMS pain for about half the people . Unfortunately, Ketamine is also a potentially toxic drug. It?s abused on ?the street? under the name of ?Special K.? Ketamine is relatively safe and often useful as a topical salve. A compounding pharmacist can provide this. The anesthetic Lidocaine, given intravenously, is also effective, but, as an IV, is too toxic for office use. Lidocaine/Lidoderm patches, in contrast, are often useful for local areas of pain, and are very safe.
Folinic Acid (Leucovorin Calcium). Folinic Acid is a form of folic acid, that has been approved for use as a prescription drug. Recently a German research team reported a high degree benefit using Folinic Acid for Chronic Fatigue Syndrome. If that result can be confirmed, we might expect help for Fibromyalgia as well.
Other possibly useful medicines for Fibromyalgia Symptoms include: Dextromethorpphan, Amantadine, Memantine, Ritalin, Provigil, Seroquel, Zyprexa, Effexor, Deprenyl, Mestinon and low-dose Naltrexone and Guaifenesin.
Guaifenesin is a safe, mucus thinning agent found in Humibid, Entex and other medicines for respiratory infections. Dr. R. Paul St. Amand claims wonderful results using Guiafenesin to treat FMS. (What Your Doctor May Not Tell You About Fibromyalgia, Warner Books, 1999.) We have been skeptical, but recent testimonials are leading us to take a second look. For information on Guaifenesin and Fibromyalgia please see
www.guiadoc.com.
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People who have severe
Fibromyalgia Syndrome (FMS) may do better if they completely avoid both MSG
(monosodium glutamate) and also NutraSweet (aspartame), the artificial
sweetener. Both glutamate (in MSG) and the amino acid, aspartic acid (in
aspartame) stimulate pain augmenting receptors within the spinal cord.
These are called NMDA receptors. Some individuals with Fibromyalgia improve
very much on a Fibromyalgia diet that avoids MSG and aspartame.
In addition to these
restrictions, we find that many people with chronic illness tend to do
better with sensible diet therapy. Aim for five plus servings daily of
multi-colored fruits and vegetables. (Nutrition science defines one
?serving? as 1/2 a cup.) Eat modest-size meals without excess fats, sugars
or simple carbohydrates. Perhaps, easier said than done, but many patients
have reported benefit from just a few weeks on this ?Fibromyalgia diet?.
Occasionally, people
with Fibromyalgia improve with the elimination of foods to which they
personally are sensitive. Wheat/gluten, milk, yeast, and sugar are
occasionally culprits.
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Test for essential fatty
acid deficiencies. Supplement appropriately.
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Evaluate the methylation/SAMe/folic
acid/vitamin B 12 pathways. These are necessary for effective
brain and liver function
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Which
vitamins and minerals are sub-optimal? Supplement as needed.
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anager A Improve the mitochondria?s
ability to make ATP energy molecules. Options include: Glutathione, Lipoic Acid, Enada (NADH) phosphatidyl serine, L-Carnitine, Acetyl-L-Carnitine,
ccount CDP-choline, Coenzyme Q, ?adaptogenic? herbs
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Assess digestion, and the
gut?s bacterial and yeast balance.
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Measure the strengths and
weaknesses of liver detoxification pathways.
Biomechanical (body work)
therapies:
The
following body work
therapies can help Fibromyalgia-- but only if done by a professional who
understands the special vulnerabilities that are typical of FMS/CFS. Done
too vigorously, these therapies can make you worse. Effective therapeutic
massage and physical therapy techniques for FMS muscle pain go by several
names: Structural Integration, Janet Travell, M.D.-style Manual Trigger
Point Therapy, Myofascial Release and Deep Connective Tissue Therapy.
Trigger point
injections can
also help, as can chiropractic adjustment, and a podiatrist?s evaluation of
legs, feet and gait. Occasionally acupuncture and laser therapies are
useful.
Energy Therapies:
Reiki and magnets are sometimes reported as helpful. Currently, we are
studying a system of extremely low dose electrical stimulation to calm down
the pain pathways in the spine and the brain.
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One
school of thought claims that many Fibromyalgia patients have unrecognized
infections with atypical bacteria or viruses, including mycoplasma,
chlamydia, Lyme disease and HHV-6. They claim beneficial results from
long-term antibiotics.
Several studies support these claims, but none were large or well-designed
enough to put skepticism to rest. We work with Medical Diagnostic
Laboratory, one of the nation?s leaders in this area. We continue to
follow this research closely.
One school of thought
claims that many Fibromyalgia patients have unrecognized infections with
atypical bacteria or viruses, including mycoplasma, chlamydia, Lyme disease
and HHV-6. They claim beneficial results from long-term antibiotics. Several
studies support these claims, but none were large or well-designed enough to
put skepticism to rest. We work with Medical Diagnostic Laboratory, one of
the nation's leaders in this area. We continue to follow this research
closely. Breakthrough research on HHV-6 virus as a cause of chronic fatigue
syndrome was reported recently. This same approach, in theory, could also
help fibromyalgia.
Click here
for Chronic Fartigue
Syndrome, HHV-6 and transfer factor treatment.
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Does
hypothyroidism cause fibromyalgia?
Dr. Robert Lowe has proposed that a hypothyroid or low metabolism state is a
major cause of fibromyalgia. Dr. Lowe believes that low thyroid can be a
real problem even when standard thyroid hormone tests are normal. Dr. Lowe
recommends that we consider treating fibromyalgia with the T3 form of
thyroid hormone, using natural Armour thyroid or synthetic T3 thyroid
hormone, Cytomel.
Dr. Lowe?s website
especially focuses
on fibromyalgia and its relation to low thyroid. It?s also a stimulating
read with regard to a broad range of thyroid related health problems. This
is an excellent site.
The most eloquent and
Inform up-to-date source of information about natural thyroid treatments is at Mary Shoman?s Websites. Please visit her site:
about.com:thyroid disease.
See Thyroid, Hypothyroid and Fibromyalgia for our discussion of thyroid problems
See
Fibromyalgia
Disability: Medical Evidence That Supports The New Neural Sensitization Paradigm
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See our discussion of how to be your own fibromyalgia disability medical expert witness
See Fibromyalgia’s relation to shingles, post herpetic neuralgia (postherpetic neuralgia)
Fibromyalgia Network:
One of the best information sources for patients. Combines up to date coverage
of scientific and clinical research in language that patients can understand
and appreciate.
Dr. Devin
Starlyanyl's Fibromyalgia Site: Dr. Starlyanyl, a physician, has
fibromyalgia herself and has written a best-selling book for patients. Her
website is one of the largest and best.
Dr. John Lowe's Fibromyalgia
Website: One of the leading advocates of the use of T3 thyroid
hormone treatments for Fibromyalgia.
Guaifenesin and Fibromyalgia
Dr. R. Paul St. Amand focuses on Guaifenesin, a mucus thinning medicine, as a
key treatment for Fibromyalgia,
Green Turtle Bay Vitamin
Company: Produces an excellent
multi-vitamin (Power-Vites), a complex of natural sleep supports
(Power-Sleep), and other high quality supplements.
Fibromyalgia Treatment: Tips on the
benefits of trigger point therapy, moist heat and gentle stretching from a
former FMS sufferer.
Pro Health, Inc,
2040 Alameda Padre Serra, Ste.101, Santa Barbara, CA, 93103, tel: 805-564-3064
ext. 236. www.ProHealthNetwork.com. Contact person
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