Psycho, Fake or what?

16. February 2007

Some of the pain syndromes out there are accepted by society, others are not. For example patients with fibromyalgia, modern medicine with its apparatuses has wiped out the stigma of being a fake. But still they are looked at as "Psychos". Also because the physicians can't find a way to help.

“Heeeelp: I'm in pain for 12 years!” – “Can anyone help me? I don't know what to do…” – “Why?” – Even if you are looking at the titles of the articles in the internet forum Fibromyalgie-aktuell (fibromyalgia today, a well visited specializing platform), you will understand, that people are seriously suffering. Fibromyalgia is a textbook example of a chronic pain disease. But still, some things are different.

Helpless physicians, blunt weapons

Whoever is suffering from chronic back pain or chronic arthrosis, certainly is not pleased with it. But the society somehow respects that pain. Those diseases are considered the results of a long life full of work or intensive sports. In addition they have a morphologic correlate: Attrite cartilage respectively the bone damage coming along with it in ostheoarthrosis patients can be proven by X-ray. In some cases of back pain patients, the MRI shows a prolaps of the Nucleus pulposus, you might find constricted Foramina intervertebralia or signs of problems in the joints between the vertebrae. None of this applies in fibromyalgia. Modern imaging reports regular results in all regards of the body's periphery. The physician does not see anything special in any of the spots, where the pain is felt. Even worse – non-steroidal antirheumatics, the most popular standard weapon of inner medicine against chronic pain – remains blunt. Physicians sitting with a fibromyalgia patient, mainly it's women, very often just shrug, at least inwardly. They try the full range of pain killers, try their luck with antidepressants and anticonvulsives and note a “psychically conspicuous” in their file. Quite often that is true, but it does not help the patient at all. And whoever puts his eyes on a note like that, certainly will not trust the physician any further than before.

The pain system is out of balance – but nobody knows why

Anyhow: Since functional MRI at least shows changes in the pain-conducting paths of the brain, it rarely happens, that fibromyalgia patients get a dressing down as fakes: “Neurobiological studies show, that fibromyalgia patients have abnormalities in the central brain structures, which normally are responsible for pain perception in healthy people”, says Daniel Clauw of the clinic for rheumatology at the University of Michigan. With his research over the past ten years, he contributed considerably to physicians accepting, that the pain described by fibromyalgia patients is real. Laboratory results point in that direction as well: A considerably increased concentration of substance P is detected in the cerebrospinal fluid of many fibromyalgia patients. “That makes fibromyalgia something special within the group of related psychiatric diseases demarcating it biochemically from other chronic pain diseases as well as from depressions”, emphasizes Professor Dieter Pongratz of the neurological clinic at the LMU Munich. Pongratz speaks for fibromyalgia at the Deutschen Gesellschaft für Muskelkranke (German association of muscle patients). Only recently he submitted a Standpunktpapier (paper) on the issue. However: Neither fMRT nor liquor puncture are routine methods for a physician to do a fibromyalgia diagnosis. Fibromyalgia remains an exclusion diagnosis. The pain at those 18 trigger spots only allows that diagnosis, if there is no other explanation for the pain. Now the diagnosis should be made quick to spare patients from suffering for years or even decades of uncertainty. “One of the mistakes in the past was to keep the type of ailments open with statements like ‘mainly exclusion of an inflamed-rheumatic disease'”, says Pongratz. The patient was under the impression, that a large number of professionals did not know, what he or she was suffering from, which made his or her disease some sort of a mystery.”

Good news for wimps

It's better than nothing – not being treated as a nutcase. But what the fibromyalgia patients really need is a sound therapy. Which looks rather dull for now: Up to today not a single drug is approved, that is specifically accredited by placebo-controlled double studies for the treatment of fibromyalgia. Which does not mean there is no evidence at all. The Europäische Rheumaliga (European rheumatology league) recently has collected all information in a new therapy guideline. This guideline was presented last year at the annual congress EULAR 2006 and will be published soon. One main focus is put on physical therapy procedures: “Strong hints point towards a physical therapy in a heated pool together with physical exercise being at least as good as any pharmacological treatments”, says Dr. Ernest Choy of the clinic for rheumatology at King's College in London. Quite a bit speaks for pure weight training as well, while cognitive behavior therapy gets poor grades from rheumatologists. Autogenic training shows a bit better results, says Choy. And pills? At the moment, Tramadol has the most positive study results, as well as some other weak opioids, sodiumchannel-blockers such as Tolperison and the renown Paracetamol are possible options. Rheumatologists have made good experience with antidepressants like Amitryptilin or Fluoxetin as well as with anticonvulsives like Tropisetron or Pregabalin. More severe weapons should be avoided, if possible: “We advise against strong opioids and corticoids”, says Choy in Amsterdam.

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