One Doctor's Detailed Fibromyalgia Treatment Protocol

[Guest guest]

, M.D., on Treatment of Fibromyalgia in Detail

ImmuneSupport.com

08-07-2002

By M.D., FRCP

If you are reading this you probably have a common syndrome of

chronic musculoskeletal pain called fibromyalgia. This chronic pain

state is now appreciated to be caused by abnormalities of sensory

processing within the spinal cord and brain. As such you will usually

experience a bewildering (both to you and your doctor) array of

bodily and psychological problems that can seldom be " cured " .

However, armed with both patience and knowledge, many fibromyalgia

patients can be helped to live with less pain and be more productive.

In my own evolving experience of dealing with this problem, I can

identify seven aspects of management that are of importance for your

doctor to successful manage your fibromyalgia.

My Advice to Doctors who care for Fibromyalgia Patients

1. Realize that FM patients are going to be a chronic challenge.

2. Be non-judgmental and prepared to be an advocate.

3. Understand the pathophysiological basis for symptoms.

4. Analyze and treat pain complaints in a systemic approach.

5. Recognize and treat psychological problems at an early stage.

6. Recognize associated syndromes of disordered sensory processing.

7. Involve all FM patients in a program of stretching and gentle

aerobic exercise.

Treatment of pain in fibromyalgia

Pain is the primary over-riding problem for most of you. Many of the

problems you experience are largely a secondary consequence of having

chronic pain. When pain is even partly relieved, fibromyalgia

patients experience a significant improvement in psychological

distress, cognitive abilities, sleep and functional capacity. A total

elimination of pain is currently not possible in the majority of

fibromyalgia patients. However, worthwhile improvements can nearly

always be achieved by a careful systematic analysis of the pain

complaints.

As a generalization, fibromyalgia-related pain can be divided into

general pain (i.e., the chronic background pain experience and focal

pain (i.e., the intensification of pain in a specific region ?

usually aggravated by movement). The latter is probably a potent

driving force in the generation of central sensitization. Attempts to

break the pain cycle, to enable patients to be more functional are

especially important.

In general, most FM patients do not derive a great deal of benefit

from NSAID preparations or acetaminophen, although NSAIDs are very

useful in the treatment of associated joint pain problems such as

osteoarthritis. Prednisone and other steroids have been shown to be

ineffective in the long term treatment of fibromyalgia.

General Pain. The use of NSAIDs (e.g., ibuprofen, aspirin, etc.) is

usually disappointing; it is unusual for FM patients to experience

more than a 20% relief of their pain, but many consider this to be

worthwhile. Narcotics (propoxyphene, codeine, and oxycodone) often

provide a worthwhile relief of pain. In most patients, concerns about

addiction, dependency and tolerance are ill founded. Ultram

(Tramadol) and Ultracet (tramadol + Tylenol), are the most useful

pain medications in many patients. They both have the advantages of

having a low abuse potential and is not a prostaglandin inhibitor;

tramadol reduces the epileptogenic threshold and it should not be

used in patients with seizure disorders.

Currently, opiates are the most effective medications for managing

most chronic pain states (Friedman OP 1990, Portenoy 1996). Their use

is often condemned out of ignorance regarding their propensity to

cause addiction, physical dependence and tolerance (Melzack 1990,

Portenoy et al 1997, Wall 1997).

While physical dependence (defined as a withdrawal syndrome on abrupt

discontinuation is inevitable) is inevitable, this should not be

equated with addiction (Portenoy 1996). Addiction is a dysfunctional

state occurring as a result of the unrestrained use of a drug for its

mind-altering properties; manipulation of the medical system and the

acquisition of narcotics from non-medical sources are common

accompaniments. Addiction should not be confused with " pseudo-

addiction " . This is a drug-seeking behavior generated by attempts to

obtain appropriate pain relief in the face of under-treatment of

pain.

Opiates should never be the first choice for pain relief in

fibromyalgia, but they should not be withheld if less powerful

analgesics have failed. In my experience many fibromyalgia patients

want to try opioid medications, but then give up on them due to

unacceptable side effects, such as mental fog, increased tiredness,

dizziness, constipation and itching.

Local Pain. Although you are experiencing widespread body pain -- a

manifestation of central sensitization -- you will also have multiple

areas of tenderness in muscles - so called " myofascial trigger

points " . The severity of pain and the location of these " hot spots "

typically varies from month to month, and the judicious use of

myofascial trigger point injections and spray and stretch (see

section on focal pain) is worthwhile in selected patients. It is

often worthwhile for your physician to identify the most symptomatic

points for myofascial therapy. The steps involved in the injection of

trigger points are:

1. Accurate identification of the trigger point.

2. Identification and elimination of aggravating factors.

3. The precise injection of the myofascial trigger points with 1%

procaine (a local anesthetic).

4. Passive stretching of the involved muscle after the local

anesthetic has taken effect; this is often aided by spraying the

overlying skin with an ethyl chloride spray. In most FM patients,

this myofascial therapy needs to be repeated over a period of several

weeks and occasionally over several months.

Unresponsiveness is usually due to failure to eliminate an

aggravating factor, imprecise injection of the trigger point, or

failure to inject satellite trigger points. Trigger points are

usually injected with 3 to 5 ml of 1-% procaine. Please note that

these are not " steroid shots. "

Performing " myofascial spray and stretch " often enhances the efficacy

of trigger point injections immediately after the injections. Spray

and stretch consists of an application of a vapocoolant spray, such

as ethyl chloride over the muscle with simultaneous passive

stretching. A fine stream of the spray is aimed toward the skin

directly overlying the muscle with the active trigger point. A few

sweeps of the spray are passed over the trigger point and the zone of

reference. This is followed by a progressively increasing passive

stretch of the muscle.

Evaluation by an occupational and physical therapist often provides

worthwhile advice on improved ergonomics, biomechanical imbalance and

the formulation of a regular stretching program. Hands-on physical

therapy treatment with heat modalities is reserved for major flares

of pain, as there is no evidence that long-term therapy alters the

course of the disorder. The same comments can be made for

acupuncture, TENS units and various massage techniques.

Treatment of Sleep Disorders

Non-restorative sleep is a problem for most of you and contributes to

your feelings of fatigue and seems to intensify their experience of

pain. Effective management involves (1) ensuring an adherence to the

basic rules of sleep hygiene, (2) regular low grade exercise, (3)

adequate treatment of associated psychological problems (depression,

anxiety etc.) and (4) the prescription of low dose tricyclic

antidepressants (amitryptiline, trazadone, doxepin, imipramine etc.

Some fibromyalgia patients cannot tolerate TCAs due to unacceptable

levels of daytime drowsiness or weight gain. In these patients,

benzodiazepine-like medications such as Ambien (zolpidem) are usually

very useful. Some fibromyalgia patients suffer from a primary sleep

disorder, which requires specialized management. About 25% of male

and 15% of female fibromyalgia patients have sleep apnea. Unless

specific questions about this possibility are asked sleep apnea will

often be missed. Patients with sleep apnea usually require treatment

with positive airway pressure (CPAP) or surgery. By far the commonest

sleep disorder in fibromyalgia patients is restless leg syndrome.

This can be effectively treated with L-Dopa/carbidopa (Sinemet 10/100

mg at suppertime) or clonazepam (Klonopin 0.5 or 1.0 mg at bedtime).

Exercise for Fibromyalgia Patients

Fibromyalgia patients cannot afford not to exercise as deconditioned

muscles are more prone to microtrauma and inactivity begets

dysfunctional behavioral problems. However, musculoskeletal pain and

severe fatigue are powerful conditioners for inactivity. All

fibromyalgia patients need to have a home program with muscle

stretching and gentle strengthening, and aerobic conditioning.

There are several points that need to be stressed about exercise in

FM patients: (i) Exercise is health training, not sport's training.

(ii) Exercise should be non-impact loading. (iii) Aerobic exercise

should be done for 30 minutes each day. This may be broken down into

three 10 minute periods or other combinations, such as two 15 minute

periods, to give a cumulative total of 30 minutes. This should be the

aim -- it may take 6-12 months to achieve this level. (vi) Strength

training should emphasize on concentric work and avoid eccentric

muscle contractions. (vii) Regular exercise needs to become part of

the usual lifestyle; it is not merely a 3-6 month program to restore

them to health. Suitable aerobic exercise includes: regular walking,

the use of a stationery exercycle or Nordic track (initially not

using the arm component). Patients who are very deconditioned or

incapacitated should be started with water therapy using a buoyancy

belt (Aqua-jogger).

Recognition and treatment of psychological distress

As you suffer from chronic pain there is a distinct possibility that

you may develop secondary psychological disturbances, such as

depression, anger, fear, withdrawal and anxiety. When " an event " is

associated with the onset of the fibromyalgia you may adopt the role

of a " victim " . Sometimes these secondary reactions become the " major

problem " for some patients. The prompt diagnosis and treatment of

these secondary features is essential to effective overall management

of fibromyalgia patients. Some fibromyalgia patients develop a

reduced functional ability and have difficulty being competitively

employed. In such cases your doctor will hopefully act as an advocate

in sanctioning a reduced or modified load at work and at home.

Unless you have a severe psychiatric illness (e.g., major depressive

illness or a psychosis), referral to psychiatrists is usually non-

productive. Psychological counseling, particularly the use of

techniques such as cognitive restructuring and biofeedback, may

benefit some patients who are having difficulties coping with the

realities of living with their pain and associated problems.

Fibromyalgia associated syndromes

It is not unusual for fibromyalgia patients to have an array of

bodily complaints other than musculoskeletal pain. It is now thought

that these symptoms are a result of the abnormal sensory processing ?

as described in the previous section. Recognition and treatment of

these associated problems are important in the overall management of

your fibromyalgia.

-Non-restorative sleep

-Cognitive dysfunction

-Chronic fatigue

-Cold intolerance

-Restless Leg Syndrome

-Multiple Sensitivities

-Irritable Bowel Syndrome

-Dizziness

-Irritable bladder syndrome

-Neurally Mediated Hypotension

1. Chronic fatigue: The common treatable cause of chronic fatigue in

fibromyalgia patients are: (1) inappropriate dosing of medications

(TCAs, drugs with antihistamine actions, benzodiazepines etc.), (2)

depression, (3) aerobic deconditioning, (3) a primary sleep disorder

(e.g. sleep apnea), (4) non-restorative sleep (see above) and (5)

neurally mediated hypotension (see below). A new drug called Provigil

is of some help when used intermittently for management of fatigue.

2. Restless leg syndrome: This strictly refers to daytime (usually

maximal in the evening) symptoms of (1) unusual sensations in the

lower limbs (but can occur in arms or even scalp) that are often

described as paresthesia (numbness, tingling, itching, muscle

crawling) and (2) a restlessness, in that stretching or walking eases

the sensory symptoms. This daytime symptomatology is nearly always

accompanied by a sleep disorder - now referred to as periodic limb

movement disorder (formerly nocturnal myoclonus). Treatment is simple

and very effective ? DOPA / Levodopa (Sinemet) in an early evening

dose of 10/100 (a minority require a higher dose or use of the long

acting preparations).

3. Irritable bowel syndrome: This common syndrome of GI distress that

occurs in about 20% of the general population is found in about 60%

of fibromyalgia patients. The symptoms are those of abdominal pain,

distension with an altered bowel habit (constipation, diarrhea or an

alternating disturbance). Typically the abdominal discomfort is

improved by bowel evacuation. Due to abnormal sensory processing

these symptoms may be quite distressing to fibromyalgia patients.

Treatment involves (1) elimination of foods that aggravate symptoms,

(2) minimizing psychological distress, (3) adhering to basic rules

for maintaining a regular bowel habit, (4) prescribing medications

for specific symptoms; constipation (stool softener, fiber

supplementation and gentle laxatives such as bisacodyl), diarrhea

(loperamide or diphenoxylate) and antispasmodics (dicyclomine or

anticholinergic / sedative preparations such as Donnatal).

4. Irritable bladder syndrome: This is found in 40-60% of

fibromyalgia patients. The initial incorrect diagnoses are usually

recurrent urinary tract infections, interstitial cystitis or a

gynecological condition. Once these possibilities have been ruled out

a diagnosis of irritable bladder syndrome (also called female urethal

syndrome) should be considered. The typical symptoms are those of

suprapubic discomfort with an urgency to void, often accompanied by

frequency and dysuria. In a sub-population of fibromyalgia patients

this is related to a myofascial trigger point in the pubic insertion

of the rectus abdominus muscles ? and may be helped by a procaine

myofascial trigger point injection). Treatment: involves (1)

increasing intake of water, (2) avoiding bladder irritants such as

fruit juices (especially cranberry), (3) pelvic floor exercises (e.g.

Kagel exercises) and the prescription of antispasmodic medications

(e.g. oxybutinin, flavoxate, hyoscamine).

5. Cognitive dysfunction: This is a common problem for many

fibromyalgia patients. It adversely affects the ability to be

competitively employed and may cause concern as to an early dementing

type of neurodegenerative disease. In practice the latter concern has

never been a problem and patients can be reassured. The cause of poor

memory and problems with concentration is, in most patients, related

to the distracting effects of chronic pain and mental fatigue. Thus

the effective treatment of cognitive dysfunction in fibromyalgia is

dependent on the successful management of the other symptoms.

6. Cold intolerance: About 30% of fibromyalgia patients complain of

cold intolerance. In most cases this amounts to needing warmer

clothing or turning up the heat in their homes. Some patients develop

a true primary Raynaud's phenomenon (which may mislead an unknowing

physician to consider diagnoses such as SLE or scleroderma. Many

fibromyalgia patients have cold hands and feet, and some have cutis

marmorata (a lace like pattern of violaceous discoloration of their

extremities on cold exposure). Treatment involves: (1) keeping warm,

(2) low-grade aerobic exercise (which improves peripheral

circulation), (3) treatment of neurally mediated hypotension (see

below), and (4) the prescription of vasodilators such as the calcium

channel blockers (but these may aggravate the problem in-patients

with hypotension).

7. Multiple sensitivities: One result of disordered sensory

processing is that many sensations are amplified in fibromyalgia

patients. In general fibromyalgia patients are less tolerant of

adverse weather, loud noises, bright lights and other sensory

overloads. Treatment involves being aware that this is a fibromyalgia-

related problem and employing avoidance tactics.

8. Dizziness: Is a common complaint of fibromyalgia patients. Before

this symptom is attributable to fibromyalgia a thorough for other

causes should be pursued (e.g. postural vertigo, vestibular

disorders, 8th nerve tumors, demyelinating disorders, brain stem

ischemia and cervical myelopathy). In many cases no obvious cause is

found, despite sophisticated testing. Treatable causes related to

fibromyalgia include: (1) proprioceptive dysfunction secondary to

muscle deconditioning, (2) proprioceptive dysfunction secondary to

myofascial trigger points in the sterno-cleido-mastoids and other

neck muscles, (3) Neurally mediated hypotension (see below) and (4)

medication side effects. Treatment is dependent on making an accurate

diagnosis. In patients in whom no obvious cause is found a trial of

physical therapy, concentrating on proprioceptive awareness may prove

worthwhile.

9. Neurally mediated hypotension: Patients with this problem usually

have a low blood pressure that does not go up normally on standing or

on exercise. Although such patients often have a low ambient BP with

postural changes, these findings are not a prerequisite for

diagnosis. A tilt table test with the infusion of isproterenol is the

most reliable way to confirm this diagnosis. Treatment involves: (1)

education as to the triggering factors and their avoidance, (2)

increasing plasma volume (increased salt intake, prescription of

florinef), (3) avoidance of drugs that aggravate hypotension (e.g.

TCA's, anti-hypertensives), (4) prevent reflex (prescribe ¢-

adrenergic antagonists or disopyramide) and (5) minimize the efferent

limb of the reflex (prescribe a-adrenergic agonists or anti-

cholinergic agents).

Source: www.myalgia.com. © 2002 M.D., FRCP.

--

Dodge

A skeptic is a person who, when he sees the handwriting on the wall,

claims it's a forgery.

Read my blog at:

http://jumpthis.wordpress.com