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Fibromyalgia New Ideas, Improved Outcomes

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Title: Fibromyalgia New Ideas, Improved Outcomes


1
Fibromyalgia New Ideas,Improved Outcomes
  • Stevan Cordas DO MPH
  • Clinical Assistant Professor
  • University North Texas Health Science Center

2
What Is Fibromyalgia
  • Fibromyalgia (FMS) is a medical condition with
    widespread chronic muscular pain syndrome of 3
    months or more duration affecting all regions of
    the body with pain produced at 11 of 18 specific
    tender points on the body with digital pressure
    of 4 kgs. (American college of Rheumatology 1990)

3
History
  • At one time it was felt to be a inflammatory
    myositis or inflammation of the muscles (Gowers
    1904). It then was called psychogenic rheumatism
    as it was thought have purely an emotional origin
    (Boland 1947). Then it was termed fibrositis
    until 1974.

4
Diagnosis
  • There are three criteria for the diagnosis of
    fibromyalgia
  • Chronic fatigue and/or pain present at least
    three months and bad enough to interfere with a
    person's normal activities (job, housekeeping,
    hobbies, etc.).
  • Sleep problems (especially non-refreshing sleep)
    present at least three months.
  • Pain and tenderness in at least 11 out of 18
    specific spots all over the body.

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Prevalence
  • Fibromyalgia affects .5 of adult males and 3.4
    of adult women. It is estimated that 5 of
    patients in the primary physician practice have
    this disorder. 30 of patients seen by the
    rheumatologist have this disorder.

7
Precipitating Events
  • Flu-like illness
  • HIV infection
  • Parvovirus
  • Lyme disease
  • Toxic oil syndrome
  • Siliconosis
  • Chronic sleep disturbance
  • Physical trauma (like whiplash injury)
  • Emotional trauma
  • Medications, steroid withdrawal
  • Persistent stress

8
Pathophysiology
  • Not universally accepted by the medical
    profession as a distinct disorder, fibromyalgia
    is sometimes called a generalized pain disorder
    or widespread myofascial pain syndrome. There is
    increasing evidence that this disorder has unique
    neuroendocrine features. The muscle, its
    spindle, and its autonomic attachments are all
    normal.

9
Disturbed Brain Activity
  • Substantial findings implicate disturbances in
    the neuroendocrine axis as central to its
    etiology. This is particularly true of the
    relationship between the neuroendocrine axis and
    sleep.

10
Disturbed Brain Activity
  • The sleep electroencephalogram of patients with
    fibromyalgia indicates disturbance of the non-REM
    sleep phase by intrusions of alpha waves with
    infrequent progression to stage 3 and stage 4
    sleep.

11
Abnormalities Seen in Fibromyalgia
  • Release of growth hormone occurs primarily during
    stage 3 and stage 4 of non-REM sleep. One third
    of patients with fibromyalgia have low insulin
    growth factor (IGF) levels, an indication of low
    growth hormone secretion. Furthermore, symptoms
    of fibromyalgia may be created by disturbing
    non-REM sleep. (Modofsky)

12
Neuroendocrine Abnormalities
  • Elevation of cerebrospinal fluid substance P
    levels (a tachykinin neurotransmitter associated
    with enhanced pain perception) to three times
    normal levels.

13
Neuroendocrine Abnormalities
  • Low levels of 5 hydorxy tryptophan and 5 hydroxy
    indole amino acid, a metabolite of serotonin, are
    found in the spinal fluid. (Russell)
  • DHEA are often reduced and adrenal responses are
    blunted to provocation. (Bennett)

14
Neuroendocrine Abnormalities
  • Provocation of symptoms during tilt table testing
    and a significant prevalence of neurally mediated
    hypotension.
  • Low plasma volume in some.
  • Low magnesium levels.
  • Thyroid T4 to T3 conversion sometimes present.

15
Differential Diagnosis
  • Drug induced myopathy.
  • Connective tissue myopathy (SLE, RA etc.).
  • Myofascial pain syndromes.
  • Polymyalgia rheumatica.
  • Genetic myopathies.
  • Hypothyroidism.
  • Hypersensitivity related myopathy.

16
Comorbid Conditions Associated With Fibromyalgia
  • Migraine headache
  • Irritable bowel syndrome
  • Depression
  • Restless leg syndrome
  • Temporomandibular joint syndrome
  • Myofascial pain syndrome

17
Treatment
  • Traditionally, the care of FM patients has
    consisted of
  • 1.Antidepressants, to help patients sleep better,
    raise their tolerance for pain, and treat
    depression if it's present. For depression, the
    dose is somewhat higher.
  • 2. Pain medications.

18
Treatment
  • 3. Soporifics to help insomnia such as Klonipin,
    Ambien, Doxepin, Sonata and more commonly
    trazadone or amitryptiline (Elavil).
  • 4. Muscle relaxants especially cyclobenzaprine
    (Flexeril).

19
Treatment
  • 5. Stretching exercises and physical therapy.
  • 6. Cognitive and other psychological methods.

20
Treatment
  • 7. Nonsteroidal anti-inflammatory agents (e.G.,
    Ibuprofen), to reduce inflammation (probably
    mistakenly) and for pain relief.

21
Antidepressants
  • Antidepressants have the specific effect of
    causing a person to spend more of their night in
    the deeper stages of sleep, making them very
    helpful for FM sufferers. They also have a
    completely different effect in the spinal cord,
    causing a person to become less sensitive to
    pain. Many patients find this effect very
    helpful.Vanlafaxine (Effexor) appears to be more
    effective than SSRI agents alone in regards to
    pain.

22
Strong Analgesics
  • In this class are drugs like Ultram, Darvocet,
    and the narcotics (Tylenol w/ codeine, Vicodin,
    Percodan, morphine, etc.). While these
    medications can be used in severe flare-ups, we
    discourage their use in fibromyalgia. They tend
    to be addictive They cause numerous side
    effects And they tend to cause a tolerance,
    requiring higher and higher doses to get the same
    effect.

23
Strong Analgesics
  • Several studies have shown propoxyphene (the
    primary analgesic in Darvocet) to be no more
    effective than aspirin as a pain reliever. If any
    drug from this class is required, we encourage
    the use of Ultram, since it has the lowest
    potential to cause addiction or tolerance.

24
Topical Analgesics
  • Custom pharmaceuticals
  • Ketamine
  • Gabapentin
  • Lidocaine
  • Ketoprofen
  • Others
  • Cordas cream (special combination of the best)

25
Goals
  • Our goal is not to prolong or place you on
    disability.
  • Our goal is restore you to a functioning human
    being with self esteem and dignity restored -
    whole in mind, body and spirit.
  • Our goal is to make you pain-free physically and
    emotionally.

26
Our Treatment Method
  • Eliminate disorders that can mimic this condition
    (especially lupus and Lyme disease).
  • Eliminate localized pain syndromes caused by
    trauma, disease, stress and posture.

27
Our Treatment Method
  • Apply stretching techniques with myofascial
    trigger point therapy, a highly effective
    hands-on treatment, also employ craniosacral and
    indirect osteopathic care when appropriate.
  • Recognize and treat undetected hypothyroidism,
    sex, adrenal and pituitary dysfunction in
    fibromyalgia patients.

28
Our Treatment Method
  • Recognize and treat the impact of candida, foods
    and other hypersensitivities on fibromyalgia.
  • Utilize psychotherapists who have personal
    experience with fibromyalgia or similar
    disorders. Emphasize newer methods such as
    cognitive therapy and energy psychology.

29
Our Treatment Method
  • Place a strong emphasis on self-care, putting
    control of the disease back in the hands of the
    patient.
  • Continually research and apply promising new
    techniques in fibromyalgia care. These include a
    restoration of proper neurotransitter levels,
    nutritional and dietary balance.

30
Common Nutritional supplements used
NADH, Coenzyme Q 10, B and C vitamins,
antioxidants, melatonin, 5 hydroxy tryptophan,
grapeseed extract, magnesium glycinate or malate
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33
Thyroid Therapy
  • This is one of the most effective medical
    treatments we prescribe at our center . we have
    observed that many patients with FM have normal
    thyroid function tests despite having classic
    symptoms of poor thyroid function. Research
    thyroid tests and AK tests will reveal the
    problem.

34
Thyroid Therapy
  • Some patients appear to have a reduced ability to
    convert the form secreted by the thyroid gland
    (T4) into the much more active form (T3), which
    causes most of the hormone's effect. Other
    patients appear to have an inhibited thyroid
    receptor (this is the protein in the cells that
    thyroid hormone binds to in order to cause its
    effect).

35
The Secret Ingredient
  • Amino Acids
  • The Hinz Method

36
Restoring Neurotransmitters
  • Various physical and mental stimuli cause
    activation of cerebral (brain) responses of an
    electrical type.
  • This electrical information activates the
    production of a variety of chemicals made within
    the brain.
  • The major chemicals are called neurotransmitters.

37
Restoring Neurotransmitters
  • Within our nervous system are over a 1000
    compounds which are contributory to brain and
    nervous system growth, development, maintenance
    and death.
  • Over 400 are termed neurotransmitters. They are
    sometimes referred to as neurohormones. The most
    important ones that we will be dealing with are
    serotonin, norepinephrine, dopamine and
    epinephrine.

38
Neurons
  • There are estimated to be 100 billion neurons in
    our brains to carry the electrical information.
  • The neuron is the name of the individual unit or
    nerve cell in our nervous system.
  • There are several types and many shapes of
    neurons.

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Neurotransmitters Do Not Cross the Blood Brain
Barrier
  • Serotonin.
  • Dopamine.
  • Norepinephrine.
  • Epinephrine.
  • ALL must be synthesized in the brain from
    precursors.

45
Hinz Method
  • Provide optimum neurotransmitter balance in the
    therapeutic range.
  • Monitor this with urinary neurotransmitter
    testing.
  • Avoid overutilization of vitamins or amino acids.
    The right amount is the right amount.

46
Results of the Hinz Method
  • 80 resolve completely.
  • 20 are so much better they do not care about the
    residual pain.
  • lt1 need high dose to get better.

47
Summary
  • Fibromyalgia is a chronic painful disorder
    affecting the muscles.
  • Emotional problems are often present, make it
    worse but are not always the source of the
    problem.
  • Newer methods significantly improve these
    patients by balancing the cerebral
    neurotransmitters and other hormones.

48
Thank you for coming.
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