Fibromyalgia: Poking around in the causal jungle

18. February 2014
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Constant pain everywhere, often with depression as well. With such symptoms accompanying fibromyalgia, for a long time no organic cause was able to be found. Study results now indicate that behind the condition, which is often misunderstood to be mental, there is a neural defect present.

Almost every thirtieth person in Germany suffers from the chronic pain of this disease. And yet it is dismissed by many doctors as a psychosomatic condition, or in the worst case is not even taken seriously. In fact, until recently neither the cause nor treatment of fibromyalgia syndrome were understood (FMS). Many patients changed doctor several times before getting the correct diagnosis and adequate treatment. Yet for more than 10 percent of these patients physicians very often prescribe ineffective opiates – contrary to the recommendations given by the current guidelines.

Impaired processing of stimuli in the CNS

Are fatigue and depression part of the disease or are they just a result of its persistent hypersensitivity present in various regions of the body? It seems as if great mental and physical strain are important triggers of the disease. Nevertheless, there is little hard data on and few insights into the genesis and course of its physiological progression. This has changed in the last few years at least in some important respects, because publications from Würzburg and Boston shed a few rays of light on what goes on in the body of fibromyalgia patients.

In November Marco Loggia from the Harvard Medical School published the results of his neurological research on the FMS brain. According to these results the strong sensations of pain could arise from a fault in the reward centre region. By using a pressure cuff the researchers delivered a short stimulus to the subjects. While the control group indeed showed a strong response in the area tegmentalis ventralis to the manifestation of stimulus and irritation, for 31 patients there were significantly weaker nerve impulses present. The researchers led by Loggia conclude that pain processing in the CNS had changed. “These findings may explain the increased sensitivity to pain, but also the lack of effect of analgesics such as opioids, as is observed with these patients”, suspects Marco Loggia.

Small Fibre Neuropathy

While the American research group recorded defects in the stimulus processing process, Nurcan Üçeyler and his colleagues at Würzburg Neurology seem to have discovered the typical symptoms involved in triggering abnormal pain sensations. Using quantitative sensory tests they determined thresholds for temperature and pain sensation for 25 FMS patients and compared them to those of depressive control subjects without pain syndrome. Just as with the determination of pain-associated evoked potentials, fibromyalgia patients reacted significantly more weakly. The cause of the restricted conduction was found by the researchers via punch biopsies of the skin: the number of small nerve fibres was lower than it was among patients with depression who had no fibromyalgia or than it was for healthy subjects.

Fibromyalgia thus seems to belong to the “small fibre neuropathies”, where only damaged A-delta fibres and C-fibres occur. The myelin sheath of nerves is very thin or totally absent. With the Würzburg patients as well the pathways with thicker sheaths are obviously not affected. A confirmation of the Würzburg results, which the journal “Brain” published in Spring, also appeared some months later in the journal “Pain”. Anne Louise Oaklander from Harvard also found among FMS patients a greatly reduced number of small nerves in the skin. Whether such a polyneuropathy causes the disease or is merely a symptom of another process for the time being remains something unclear.

Inflammatory Process

Why do patients with fewer nerve fibres have greater pain? Until now there has only been speculation: this could be due to overactivity of the damaged but not yet dead fibres, or to a selective choice of forwarding signals. Pleasant contact signals no longer reach the central nervous system, whereas painful stimuli remain as “left overs”.

More and more findings also suggest that there is an inflammatory process involved in the disease. Thus with the complete genome sequencing of patients some genetic variations were found which are closely associated with inflammatory cytokines. Elevated levels of inflammatory cytokine IL-17A were found by Brazilian researchers among their patients.

New guidelines dispense with “tender points”

Ten professional societies in recent years developed a new FMS guideline and published it in Summer 2012. In contrast to earlier times, the “tender points” of the body, used to characterise the condition more precisely, are no longer counted. Instead, an extensive questionnaire now seeks to more exactly describe the patients’ condition. It looks for pain regions, but also accompanying symptoms such as sleep quality or cognitive impairments.

The authors of the new treatment indications have tested a total of 52 different forms of treatment described for fibromyalgia patients. Only five of them were categorised under the label “strong recommendation”. With mild forms, specialists in pain medicine and rheumatology advise physical and psychosocial activity against depression, which often accompanies the disease. For more severe forms multimodal therapy is employed which includes drug treatment and appropriate behaviour management. The authors of two Cochrane reviews emphasise at least some use of cognitive behavioural therapy, as well as acupuncture.

Mistaken treatment choice due to billing incentives?

If one believes one survey, about half of the doctors still give their patients anti-inflammatory drugs such as ibuprofen, diclofenac or naproxen. Psychotropic drugs are still widespread. Both in the hospital as well as in outpatient departments most medical professionals still treat their patients following measures other than those in the current guidelines. These instructions for doctors and patients describe fibromyalgia syndrome as a functional somatic syndrome rather than a mental disorder.

Pain physician Dr. Ursula Marschall, Head of Barmer GEK’s Competence Centre for Health, provides a reason for the uncertainty: “Misuse of invasive measures is being triggered by billing incentives. In addition, the patient’s desire for relief of symptoms and medically futile attempts to locally treat chronic pain in multiple body regions enter the picture.”

The new scientific evidence should be the first step in extricating fibromyalgia syndrome from the field of purely psychologically induced pain and no longer focusing on immobilising the patient. As part of the next guidelines the task at hand could be to tackle the disease at its cause.

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8 comments:

Pharmacist

good item thanks for this knowledge i ‘d like to ask for treatment
00201155449004

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Doctor Susan Lowe
Doctor Susan Lowe

I no longer ‘buy’ this diagnosis one damn.. omega oils, sylimarin, picnogenol, brewer’s yeast, CoQ10, 1-a- day multi, ….gone….some ad d3 and a bit of cal, mag, pot & glucosamine…it’s the lack of trace nutrients!!!

#7 |
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koen Jansen
koen Jansen

If you check the link carefully, you will find the English version

#6 |
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Dr Bob Lister
Dr Bob Lister

We have been using cranial electrostimulation with the Alpha Stim device (alpha-stim.com) for the management of fibro for the last 5 yr with considerable success in alleviating, pain, anxiety and insomnia. A double blind study confirmed the benefits of this therapy. (Lichtbroun et al. 2001, J Clin Rheumatol ,7(2) 72-78.

#5 |
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MIchele Meyer
MIchele Meyer

I have been giving electronically assisited lymphatic sessions for over 18 years. The Tesla type high voltage, low frequency device cleans the toxins off the nervous system and reduces symptoms by 80 % in 1 treatment. I don’t know why money is not being spent to research what toxins are stored in the bodies that experience so much pain. If you detoxify , the pain goes away.

#4 |
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Michael Peuser
Michael Peuser

Michael Peuser
Das Aloe arborescens Miller – Rezept für die Kur gegen Fibromyalgie wird oft auch im 10 Tagesrhytmus angewandt. 10 Tage, 10 Tage Pause, 10 Tage, 10 Tage Pause usw. 3 Monate lang. Das Rezept ist 5.000 Jahre alt und stammt aus Persien. Die erste medizinische Universität Europas war in Salerno und diese stand unter dem Einfluss des Morgenlandes. Damals war die Aloe die meist verwendete Medizin und es wurden in Salerno schon Gedichte gereimt zum Thema Aloe.
Aloe arborescens Miller hat schmale Blätter und blüht rot. Nicht zu verwechseln mit der Aloe vera Linné mit den dicken fleischigen Blätter und die gelb blüht.

#3 |
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Michael Peuser
Michael Peuser

Fibromyalgie ist heilbar mit einem sehr einfachen Rezept:
Täglich 3 x 1 Esslöffel voll 15 min. vor den Mahlzeiten folgender Zubereitung:
300 g Blätter der Aloe arborescens Miller, mit Blatthaut aber die Stacheln vorher von den Kanten weggeschnitten. In Stücke schneiden und in ein Küchenmixgerät geben.
500 g echten Honig
4 Esslöffel Zuckerrohrschnaps oder Whisky oder Wodka
5 min durchmixen und fertig ist das Getränk.

3 Monate Kur gegen Fibromyalgie.

Siehe auch das Buch Kapillaren bestimmen unser Schicksal.

#2 |
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Dr Louise Olliver
Dr Louise Olliver

Very interesting. The link to the FMS Guideline is to a German publication’ is this available in English?

#1 |
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