Disabled Traveler: Overview of Fibromyalgia And Its Treatments (January 2012)

The Fibromyalgia syndrome (FMS) is one of the diseases that were reputed to be all in your head. Not any more, at least not in the "imaginary" sense. This was particularly, aggravating because it could be so painful. Actually, even though the pain is primarily at the sensitive points of the figure below ( uploaded from Wikipedia Commons), it does have something to do with your brain. It has do do with a loss of gray matter in the FMS afflicted brain. Gray matter is a critical component that contains neuronal cell bodies, as the other component, white matter, contains mostly the axons or nerve connections. The photograph below is a lateral view of a real brain, not a sketch. Nine times more women than men are afflicted.

[![][1]][2]

Fig (1): Lateral View of Dissected Brain (John A Beal, Wikipedia)

_ For the fun of it, here is the key to the numbers on Fig (1) identifying the main brain brain regions..Skip if you are in a hurry…
_

1. entriculus lateralis, Cornu frontale
2. Ventriculus lateralis, Pars centralis
3. Calcar avis
4. Ventriculus lateralis, Cornu occipitale
5. Trigonum collaterale
6. Eminentia collateralis
7. Hippocampusduloxetine, milnacipran
8. Ventriculus lateralis, Cornu temporale
9. Capsula interna
10. Nucleus caudatus

_As you can see a lot of the grey matter is at the surface of the brain._ Loss of gray matter is associated with chronic pain [3] aging [4] or trauma [5]. So, maybe, gray matter loss is not the hallmark of necessarily degenerative process. That is if aging is not a degenerative, but I digress…

_**In terms of manifestations, FMS is mostly pain without an apparent cause **_ [6], and particularly focused on tender points such as shown in Fig (2) below . But it also can include: fatigue, sleep disturbance, and joint stiffness. bowel and bladder abnormalities, numbness and tingling and cognitive dysfunction.

[![][3]][4]

Fig (2) : Skeletal muscles and Some Fibromyalgia Tender Points

_**So, are there a treatment for FM**_ ? The answer is qualified yes

Academia classifies the overall pain reduction as : "..full response (at least a 50% change), response (30-49% change), and no response (less than a 30% change.[8]". This is the kind of pain reduction you can expect from the drugs on the market. Let us do the math: a 40% reduction means 60% remains. Hmmm….

The most common are:

1. Drugs like (Lyrica/Pregablin) [9] or Gabapentin / Neurontin [9] succeed in decreasing the pain level by 30% to 50% in many people, 30% being more likely [10]. They both are anticonvulsants and were used initially against epilepsy, and are used commonly against neuropathic pain
2. Duloxetine (Cymbalta) is an antidepressant serotonin-noradrenaline reuptake inhibitor (SNRI)
3. Milnacipran (Savella) also an SNRI, but interestingly approved in the US only for FMS

More drugs against FMS can be found in [11]. Since FMS is a syndrome, every patient can respond substantially differently to the drugs, hence the variety. But again, in most cases the 30% to 50 % pain reduction is the goal. I have not seen a study claiming 75% or better. FMS also usually affects sleep and sometimes cognition, so your _doctor has to balance all your needs and your tolerance to the side effects. For example use of Lyrica can bring about dizziness, sleepiness, blurred vision, dry mouth, swelling of the hands and feet, weight gain._

_**So many have turned to alternative medicine for help. These complementary or alternative medical (CAM) include three categories:**_

1. Nutrition, herbs and supplements
2. Massage
3. Mind Body techniques and Tai-Chi

_**Nutrition, herbs and supplements: **_

Cathy Wong, in about.com [12] has a excellent article on this.

* _**Magnesium:**_ "…Magnesium, along with malic acid (a fruit acid found naturally in apples) are often suggested for people with fibromyalgia because they are both needed for the generation of energy in cells in the form of adenosine triphosphate (ATP)…"

* Note: The FMS benefits seem to be strongly dose dependent, up to 300 mg magnesium and 1200 mg malic acid per day) for 6 months.
* A study [13] of people with poor sleep shows lower Magnesium levels that can be remediated by supplementation. FMS patients do suffer from poor sleep patterns

* _**Vitamin D**_ : While there is a vitamin D deficiency both in women with FMS and and in men with musculoskeletal problem, the benefits of this vitamin D supplementation need to be shown.[14,15]
* 5-HTP (Triptophan): Thought to work like serotonin antidepressants, possibly with less side effects. [16]
* Vitamin B-12 : From [17], homocysteine has been found in the cerebrospinal fluid of FMS patients, indicating low B-12
* Capsaicin ; From Cathy Wong, [12] , there is a FMS study validating the use of capsaicin for FMS. Could not find it.

_**Massage**_:

There are some indication that massage-_**myofascial release therapy **_can improve the quality of life of FMS people [18]. You need a masseur seriously trained in this particular discipline. The technique involves "..Relaxing contracted muscles, increasing circulation and lymphatic drainage, and stimulating the stretch reflex of muscles and overlying fascia…" (Wikipedia) .

The " Trigger Point Therapy Workbook" [19] , though not a book on massage, is a good introduction to the myofascial concepts and all around a resource for FMS patients.

_**Mind Body techniques and Tai-Chi:**_

Last , but not least, Tai-Chi [20] and Mind Body techniques have been shown to be of help against FMS [21]. Both claim some success. Interestingly the Mind Body study's cohort were all women, but the Tai-Chi study did not mention gender. [21] claims benefit in "coping with pain, anxiety, depression and somatic complaint" as well as sustainability of the benefits 3 years later…

The Tai-Chi claims are broad :"..components may influence neuroendocrine and immune function as well as neurochemical and analgesic pathways that lead to enhanced physical, psychological, and psychosocial well-being and overall quality of life in patients with fibromyalgia.."

_**Hope this helps,**_

_**Talk to your Doctor**_

_**Sources:**_

[1] [Journal of Neuroscience][5] ; "Accelerated Brain Gray Matter Loss in Fibromyalgia Patients: Premature Aging of the Brain?" ;April 11, 2007

[2][ Journal of Pain ][5]; "Changes in gray matter density in fibromyalgia: correlation with dopamine metabolism." ; 2009

[3] [Current Rheumatology Report ;][6] ":Variations in brain gray matter associated with chronic pain." ;

[4][ American Journal of Neuroradiology ][7]; "Age-related total gray matter and white matter changes in normal adult brain. Part I: volumetric MR imaging analysis." ; 2002

[5] [Journal of Neurotrauma][8] ; "Selective metabolic reduction in gray matter acutely following human traumatic brain injury."; 2004

[6] [Wikipedia ; Fibromyalgia][9]

[7] [Cochrane Summaries:][10] "Gabapentin for fibromyalgia" ; 2011

[8][ Journal of Medical Economics][11] ; "Cost effectiveness of duloxetine in the treatment of fibromyalgia in the United States" ; 2011

[9] [Arthritis and Rheumatism ][12]; "Pregabalin for the treatment of fibromyalgia syndrome: results of a randomized, double-blind, placebo-controlled trial." 2005

[10][ Journal of Pain][13] ; "Comparative efficacy and harms of duloxetine, milnacipran, and pregabalin in fibromyalgia syndrome." ; 2010

[11] [Drug Class Reviews ][14]; "Drug Class Review: Drugs for Fibromyalgia: Final Original Report [Internet]" ; Oregon Health and Sciences U.; 2011

[12] [About.com ; Cathy Wong ][15]; "Herbs and Supplements for Fibromyalgia";2007

[13] [Magnesium Research ][16]; "Magnesium supplementation improves indicators of low magnesium status and inflammatory stress in adults older than 51 years with poor quality sleep."

[14] [Annals of Rheumatic Disease][17] ; "Musculoskeletal pain is associated with very low levels of vitamin D in men: results from the European Male Ageing Study."; 2010

[15] [Saudi Medical Journal ][18]; "The relation between vitamin D deficiency and fibromyalgia syndrome in women" ; 2011

[16][ Rheumatism Disease Clinic Of North America ][19]; " Neuroendocrine perturbations in fibromyalgia and chronic fatigue syndrome." ; 2000

[17] [Scandinavian Journal Of Rheumatology][20] ; "Increased concentrations of homocysteine in the cerebrospinal fluid in patients with fibromyalgia and chronic fatigue syndrome." ; 1997

[18] [Evidence based Complementary and Alternative Medicine][21] ; "Benefits of massage-myofascial release therapy on pain, anxiety, quality of sleep, depression, and quality of life in patients with fibromyalgia." ; 2010

[19] [The Trigger Point Therapy Work Book"][22]; Clair and Amber Davies ; New Harbinger Publications ; 2004

[20] [New England Journal Of Medicine ][23]; " A Randomized Trial of Tai Chi for Fibromyalgia" ; 2010

[21] [Psychotherapy and Psychosomatics][24] ; "Mindfulness training as an intervention for fibromyalgia: evidence of postintervention and 3-year follow-up " ;2007

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Tuesday, January 24, 2012

Overview of Fibromyalgia And Its Treatments (January 2012)

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