Fibromyalgia New Ideas, Improved Outcomes

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Fibromyalgia New Ideas,Improved Outcomes

• Stevan Cordas DO MPH
• Clinical Assistant Professor
• University North Texas Health Science Center

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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)

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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.

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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.

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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

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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.

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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.

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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.

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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)

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Neuroendocrine Abnormalities

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

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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)

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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.

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Differential Diagnosis

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

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Comorbid Conditions Associated With Fibromyalgia

• Migraine headache
• Irritable bowel syndrome
• Depression
• Restless leg syndrome
• Temporomandibular joint syndrome
• Myofascial pain syndrome

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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.

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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).

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Treatment

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

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Treatment

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

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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.

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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.

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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.

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Topical Analgesics

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

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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.

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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.

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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.

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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.

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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.

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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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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.

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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).

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The Secret Ingredient

• Amino Acids
• The Hinz Method

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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.

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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.

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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.

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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.

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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.

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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.

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Thank you for coming.