What is fibromyalgia

1
What is fibromyalgia?

• Clinical case definition
• chronic, widespread pain
• tenderness in at least 11 of 18 specified trigger
  points
• Wolfe F, et al, Arthritis Rheum, 199033160-172.

2
What is fibromyalgia?

• An illness experience
• widespread pain, fatigue, non-restorative sleep,
  headache, depression, anxiety, difficulty
  concentrating, alienation, fear, frustration
• ...in other words - genuine physical, mental, and
  emotional suffering

3
What is fibromyalgia?

• A complex picture
• Just because we can name it doesnt mean we
  understand it
• Case definitions are sterile
• FM is a multidimensional chronic pain syndrome
• The experience of suffering is real

4
Who gets fibromyalgia?

• One in every 50 people
• 3.4 of women
• 0.5 of men
• 7 of women aged 60-79
• Wolfe F, et al. Am J Med, 19953819-28.

5
How does fibromyalgia happen?

• Predisposing factors
• Family history of pain, depression, or alcoholism
• Personal history of physical, emotional, or
  sexual abuse
• Age, gender, obesity
• Poor levels of nutrition or fitness
• Chronic stress

6
How does fibromyalgia happen?

• Precipitating factors
• Physical trauma
• Emotional trauma
• Infection
• Sleep deprivation

7
How does fibromyalgia happen?

• Perpetuating factors
• Psychological distress
• Biomechanical strain
• Poor levels of nutrition or fitness
• Negative beliefs
• Lack of social support

8
What lab findings are abnormal in fibromyalgia?

• Blood
• Reduced adrenal cortisol output
• Related to abnormal communication between the
  hypothalamus, pituitary, and adrenal glands
• Crofford LJ, et al, Arthritis Rheum,
  1994371583-92.

9
What lab findings are abnormal in fibromyalgia?

• Blood
• Low levels of somatomedin C (IGF-1)
• Reflects abnormally low levels of growth hormone
  release during deep sleep
• Bennett RM, et al, J Rheumatol, 1997241384-89.

10
What lab findings are abnormal in fibromyalgia?

• Sleep
• Alpha waves appear inappropriately in deep sleep
• Interferes with the restorative stage of the
  sleep cycle
• Branco J, et al, J Rheumatol, 199724579-85

11
What lab findings are abnormal in fibromyalgia?

• Cerebrospinal fluid
• Substance P levels average 3 times higher in FM
  than in normal controls
• Substance P is a messenger that transmits pain
  signals to the brain
• Russell IJ, Arthritis Rheum, 1994371593-1601.

12
What lab findings are abnormal in fibromyalgia?

• Magnetic Resonance Imaging
• Chiari malformation
• Cervical spinal cord compression
• Present in 5 to 30 of patients with
  fibromyalgia
• Heffez D, ACR Abstracts, 63rd Annual Meeting,
  1999.

13
What lab findings are abnormal in fibromyalgia?

• Autonomic nervous system
• Sympathetic-parasympathetic nervous system
  imbalance
• Results in difficulty maintaining normal blood
  pressure and heart rate with changes in position
• Bou-Holaigah I, Clin Exp Rheumatol,
  199715239-46.

14
What lab findings are abnormal in fibromyalgia?

• Cerebral blood flow
• Decreased blood flow in the thalamus and caudate
  nuclei of the brain
• Decreased flow to these brain centers has been
  shown in other chronic pain syndromes
• Mountz JM, Arthritis Rheum, 199538926-38.

15
What lab findings are abnormal in fibromyalgia?

• Intestinal permeability
• Small intestine becomes hyper-permeable to
  molecules which act as toxins and antigens
• This leaky gut syndrome causes toxic noise to
  accumulate in the body
• Buskila D, et al, J Rheumatol, 199926(5)1167-71.
  
• Case studies, WholeHealth Chicago Centers

16
What lab findings are abnormal in fibromyalgia?

• IgG antibody
• Dermal deposits of IgG may trigger nerve
  irritation by mast cells
• Elevated IgG4 levels to food antigens may trigger
  delayed allergy reactions
• Enestrom S, et al, Scand J Rheumatol,
  199726(4)308-13.
• Case studies, WholeHealth Chicago Centers

17
Current therapies for fibromyalgia

• Drug therapy for pain
• Amitryptiline
• Cyclobenzaprine
• Tramodol
• Alprazolam/ibuprofen
• Goldenberg DL, et al, Arthritis Rheum,
  1986291371-77.
• Bennett RM, et al, Arthritis Rheum,
  1988311535-42.
• Biasi G, et al, Int J Clin Pharmacol Res,
  199818(1)13-19.
• Russel IJ, et al, J Rheumatol, 199219104-9.

18
Current therapies for fibromyalgia

• Drug therapy for sleep
• Zolpidem
• Clonazepam
• Trazodone
• Gamma-hydroxy-butyrate
• Rothschild BM, J Rheumatol, 199623(3)529-33.
• Scharf MB, et al, J Rheumatol, 199825(10)1986-90
  .

19
Current therapies for fibromyalgia

• Nutritional and herbal therapy
• 5-HTP
• St. Johns Wort
• Magnesium and malic acid
• Murray M, Am J Natural Med, 199714-19.
• Russell IJ, et al, J Rheumatol, 199522953-58.

20
Current therapies for fibromyalgia

• Hormonal support
• Thyroid (T3-T4)
• Adrenal (cortisol, DHEA, fludrocortisone)
• Growth hormone
• Teitelbaum J and Bird B, J Musculoskel Pain,
  1995391-110.
• Reid S, et al, Brit Med J, 2000320292-6.
• Russel IJ, et al, Arthritis Rheum,
  199336(9,suppl)S223.
• Bou-Holaigah I, et al, JAMA, 1995274(12)961-67.
• Bennet RM, et al, Am J Med, 1998104(3)227-31.

21
Current therapies for fibromyalgia

• Complementary medicine
• Acupuncture
• Chiropractic
• Massage therapy
• Trigger point release techniques
• Berman, et al, J Fam Pract, 199948(3)213-18.
• Blunt KL, et al, J Manip Physiol Ther,
  199720(6)389-99.
• Case studies, WholeHealth Chicago Centers

22
Current therapies for fibromyalgia

• Psychological counseling
• Cognitive therapy
• Relaxation techniques
• Emotional release
• Energy psychotherapy
• Vlaeyen JWS, et al, J Rheumatol, 1996,
  231237-45.
• Case studies, WholeHealth Chicago Centers

23
Current therpaies for fibromyalgia

• Exercise
• Mild aerobic
• Stretching
• Energy management
• Gowans SE, et al, Arthritis Care and Research,
  199912120-128.

24
Current therapies for fibromyalgia

• Integrative therapies
• Elimination diet
• Correction of leaky gut
• Detoxification regimens
• Control of fungal overload syndromes
• Correction of subtle hormone imbalances
• Case studies, WholeHealth Chicago Centers

25
Current thinking on fibromyalgia

• Theories
• Abnormal sleep and pain signal processing
• Hypothalamic dysfunction
• Autonomic nervous system dysfunction
• Subtle forms of gut-based toxic overload
• Intracellular blocks in energy production
• Spinal cord compression

26
Current thinking on fibromyalgia

• Integrative medicine
• Combines strengths of conventional and
  alternative medicine
• Evidence-based and empirical approaches
• Biography influences biology
• Listen to the patient

27
Current thinking on fibromyalgia

• Integrative medicine
• Humility about the true complexity of the problem
• Pragmatic partnership between patient and
  physician
• Multidisciplinary team approach

28
The most insidious form of quackery is the
closed professional mind.
29
You dont want your mind so open that your brain
falls out.
30
Conventional medicine - asserts that anything
that might be true isnt until it has been shown
to be so. Alternative medicine - asserts that
anything might be true until it has been proven
false. Integrative medicine - asserts that
open-mindedness, creativity, caution, and common
sense should prevail.
31
Current thinking on fibromyalgia

• Prognosis
• Some epidemiological studies suggest only 10
  improve significantly over the long term with
  conventional approach
• Integrative approaches are more optimistic 2/3
  of patients report moderate to major improvement
  within 6 months

32
He or she is the best physician who is the most
ingenious inspirer of hope. - Samuel Taylor
Coleridge