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Multiple approaches best treatment for Fibromyalgia



06-Jul-2007

S. VARMA
Norwich Bulletin

Many people suffer from the debilitating effects of fibromyalgia, which involves chronic widespread muscular pain, fatigue and tenderness. Many people with fibromyalgia also experience symptoms such as fatigue, headaches, irritable bowel syndrome, irritable bladder, cognitive and memory problems (called "fibro fog"), temporomandibular joint disorder, pelvic pain, restless leg, sensitivity to noise and temperature, anxiety and depression. It is second only to osteoarthritis in frequency of visits to rheumatology clinics, and about 5 percent of women and 0.5 percent of men in the United States will be affected. The majority will be between 30 to 50 years old.

Although we still have much to learn about fibromyalgia, it is believed patients with it experience pain amplification because of abnormal sensory processing in the central nervous system. This is supported by studies showing multiple physiological abnormalities in patients, including increased levels of substance P in the spinal cord, low levels of blood flow to the thalamus region of the brain and low levels of serotonin.

It has also been suggested fibromyalgia might relate to an abnormality in deep sleep. Abnormal brain waveforms have been found in deep sleep in some patients. Tender points can be produced in normal volunteers by depriving them of deep sleep for a few days. Recent studies show genetics might also be a factor.

Here is some information on diagnosis and treatment from rheumatology.org and uptodate.com:

Diagnosis

Unfortunately, there are no "objective markers" -- evidence on X-rays, blood tests or muscle biopsies -- for this condition, so patients have to be diagnosed based on the symptoms they are experiencing.

The American College of Rheumatology has established general classification guidelines for fibromyalgia. These guidelines require widespread aching for at least three months and a minimum of 11 out of 18 tender points. However, not all physicians and researchers agree with these guidelines. Some believe the criteria are too rigid and fibromyalgia can be present even if the required number of tender points is not met, while others question how reliable and valid tender points are as a diagnostic tool.

Treatment

Fibromyalgia must be managed as a chronic condition, and should include both medication and non-medication treatments for symptoms. Drug therapy for fibromyalgia largely treats symptoms. Studies indicate the best pharmacological approach for treating pain, and improving disrupted sleep, is low doses of tricyclics including cyclobenzaprine (Flexeril) and amitriptyline (Elavil). Positive results also have been shown with dual reuptake inhibitors (Effexor), duloxetine (Cymbalta), tramadol (Ultram) that work similarly.






Conversely, long-acting opioids are typically not recommended for the treatment of fibromyalgia unless patients are resistant to other therapies. This is not because of issues with dependence, but rather because anecdotal evidence suggests these drugs are not of great benefit to most people with fibromyalgia.

Anti-inflammatory medications will generally work if the patients have associated arthritis. Recently, researchers studying antiepileptics such as pregabalin (Lyrica) have found these drugs may prove promising for fibromyalgia.

Other therapies

Complementary and alternative therapies can be useful for pain, although these treatments have generally not been well tested. Therapeutic massage to manipulate the muscles and soft tissues of the body may alleviate pain, discomfort, muscle spasms and stress. Similarly, myofascial release therapy, which works on a broader range of muscles, can gently stretch, soften, lengthen and realign the connective tissue to ease discomfort.

The bottom line is if you have fibromyalgia, a multi-modal approach to managing it is probably best.

Sandeep Varma, M.D., is a rheumatologist and medical director of the Backus Arthritis Center at the Backus Outpatient Care Center in Norwich. This column should not replace advice or instruction from your personal physician. E-mail Varma and all of the Healthy Living columnists at healthyliving@wwbh.org

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