OFFICE HOURS
• Times are for adjustments only
• New patients separately scheduled
MON
8 am - 9:40 am
12 noon - 12:40 pm
4 pm - 5:40 pm
TUES - closed
WED
8 am - 9:40 am
12 noon - 12:40 pm
4 pm - 5:40 pm
THUR
4 pm - 5:40 pm
FRI
8 am - 9:40 am
12 noon - 12:40 pm
SAT & SUN - closed
Articles and Reports |
|
 |
|
 |
|
| Fibromyalgia |
| Tue 05/25/04 by Dr. Stephen D. Ambrose |
| FIBROMYALGIA - A REFERENCE FOR PATIENTS Prepared and Written by Dr. Stephen Ambrose, DC What is Fibromyalgia (FM)? Fibromyalgia (fi-bro-my-Al-juh) is thought to be an irritability of the muscles, fascias and tendons causing a syndrome of pain that is widespread and migratory. Fibromyalgia is not a disease of exclusion, but has specific criteria identified by the American College of Rheumatology. These include 11 of 18 tender spots in a standard distribution, and widespread pain of greater than three months duration. However, certain disease processes and syndromes are similar to fibromyalgia and must be ruled out. These include thyroid dysfunction, sleep disturbance including sleep apnea, inflammatory arthropathies (arthritis), depression, etc. Who is affected? According to the American College of Rheumatology, fibromyalgia affects 3 to 6 million Americans. Women, especially of childbearing age are 7x more likely to get fibromyalgia, but children, the elderly, and men can also be affected. What are the symptoms? FM is characterized by the presence of multiple tender points and a constellation of symptoms. Pain - The pain of FM is profound, widespread and chronic. It knows no boundaries, migrating to all parts of the body and varying in intensity. FM pain has been described as deep muscular aching, throbbing, twitching, stabbing and shooting pain that defines the very existence of the Fibromyalgia patient. Neurological complaints such as numbness, tingling and burning are often present and add to the discomfort of the patient. The severity of the pain and stiffness is often worse in the morning. Aggravating factors which affect pain includes cold/humid weather, non-restorative sleep, physical and mental fatigue, excessive physical activity, physical inactivity, anxiety and stress. Fatigue - In today's world many people complain of fatigue; however, the fatigue of FM is much more than being tired. It is an all-encompassing exhaustion that interferes with even the simplest daily activities. It feels like every drop of energy has been drained from the body, which at times can leave the patient with a limited ability to function both mentally and physically. Think of a time when you had the flu and felt exhausted?this is similar. Sleep Problems - Many Fibromyalgia patients have an associated sleep disorder which prevents them from getting deep, restful, restorative sleep. Medical researchers have documented specific and distinctive abnormalities in the stage 4 deep sleep of FM patients. During sleep, individuals with FM are constantly interrupted by bursts of awake-like brain activity, limiting the amount of time they spend in deep sleep. Other symptoms - Additional symptoms may include: irritable bowel and bladder, headaches and migraines, restless legs syndrome (periodic limb movement disorder), impaired memory and concentration, skin sensitivities and rashes, dry eyes and mouth, anxiety, depression, ringing in the ears, dizziness, vision problems, Raynaud's syndrome, neurological symptoms and impaired coordination. How is it diagnosed? Currently there are no laboratory tests available for diagnosing Fibromyalgia. Doctors must rely on patient history, self-reported symptoms, a physical examination and an accurate manual tender point examination. This exam is based on the standardized American College of Rheumatology criteria. Proper implementation of the exam determines the presence of multiple tender points at characteristic locations. It is estimated that it takes an average of five years for a FM patient to get an accurate diagnosis. Many doctors are still not adequately informed or educated about FM. Laboratory tests often prove negative and many FM symptoms overlap with the symptoms of other conditions, thus leading to extensive investigative costs and frustration for both the doctor and patient. Another essential point that must be considered is that the presence of other diseases, such as rheumatoid arthritis or lupus, does not rule out a FM diagnosis. Fibromyalgia is not a diagnosis of exclusion and must be diagnosed by its own characteristic features. To receive a diagnosis of FM, the patient must meet the following diagnostic criteria: ? Widespread pain in all four quadrants of the body for a minimum duration of three months ? Tenderness or pain in at least 11 of the 18 specified tender points when pressure is applied What causes fibromyalgia? Since it is believed that there isn?t one single cause of fibromyalgia, a number of factors must contribute. These factors may include: Autonomic Nervous System Dysfunction The autonomic nervous system is the portion of the nervous system that controls the function of the different organs and systems of the body. For instance, it regulates body temperature, blood pressure, heartbeat rate, and bowel and bladder tone. It is called autonomic because it is something that our body does automatically since we don?t consciously control these things. The autonomic nervous system works closely with our hormonal system and neurotransmitter system and it is particularly involved with something referred to as the hypothalamic-pituitary-adrenal axis. The autonomic system is divided into two branches: sympathetic and parasympathetic. The sympathetic system prepares in response to stress or emergencies while the parasympathetic system favours digestive functions and sleep. The action of these two branches of the autonomic nervous system is by something called neurotransmitters and hormones. Dysfunction in the autonomic nervous system is manifested in abnormalities in the levels of neurotransmitters, hormones and abnormal action of the hypothalamic-pituitary-adrenal axis. These are discussed further. Neurotransmitters Neurotransmitters are the substances that nerves in the autonomic nervous system use to communicate with each other. They are the vehicles that carry information back and forth between your body and mind. Certain neurotransmitters such as serotonin, substance P, and beta-endorphins have all been studied looking for causation. ? Substance P Several different studies have shown that substance P ? a neurotransmitter that causes pain to be felt ? is elevated threefold in the spinal fluid of patients with fibromyalgia. Elevation of this neurotransmitter leads to an enhanced pain perception. Thus, for the same painful stimulus, a person with higher levels of substance P will feel more pain than another person. ? Endorphins Recent studies have looked at the neurotransmitter beta-endorphin in the immune cells of patients with fibromyalgia. Beta-endorphin is the opioid produced by the body to fight pain. It is also involved in stress responses, pain suppression, and mood disorders. Interestingly, high beta-endorphin levels in the brain suppress the immune system. One study found that the beta-endorphin levels of fibromyalgia patients is close to half that of the healthy population. Spinal manipulation helps to release beta-endorphins through affecting mechanoreceptors in the spinal joints. This may be why so many patients with FM obtain relief with chiropractic. ? Serotonin Some studies suggest that fibromyalgia sufferers may have decreased levels of the neurotransmitter serotonin, which is linked to depression, migraines and gastrointestinal distress. Most antidepressant medications raise levels of serotonin explaining low doses of these drugs help some patients with FMS. **** IMPORTANT! When prescribing medications for fibromyalgia it is important to evaluate whether the medications will alter neurotransmitter levels. In some cases, drugs prescribed for fibromyalgia can alter the neurotransmitter levels even more, worsening the patient?s condition. Hormones Cortisol Hormones have also been studied in order to uncover if any abnormalities exist in the levels of various hormones of fibromyalgia patients. Two specific hormones that have been shown to be abnormal are cortisol and growth hormone. The body releases cortisol in times of stress, both physical and mental. It can partially explain why fibromyalgia patients feel constantly ?off? or ?drained?. Growth Hormone With growth hormone the problem seems to be underproduction. Normally, during exercise and during sleep the body is supposed to produce a several fold increase in the production of growth hormone. In fibromyalgia, the autonomic nervous system responsible for the release of growth hormone is under-responsive and the required increase in the hormone is not seen. Growth hormone has a powerful effect on the connective tissues in your body. It directly stimulates vital cellular products such as fibroblasts, mast cells, ground substance and collagen fibers. It is important in wound healing because it is the rapid production of collagen fibers by fibroblasts that is necessary for repair. Growth hormone is normally released during deep levels of sleep but people who suffer from fibromyalgia have this level of sleep disrupted and therefore have very low levels of growth hormone. This can lead to a decreased repair response, decreased immune response and fibromyalgia symptomatology. Norepinephrine Norepinephrine is a hormone that is released by a part of your autonomic nervous system known as the sympathetic system. By releasing this hormone and controlling the release of epinephrine via the adrenal gland, the sympathetic nervous system is able to control your bodily functions that aren?t under conscious control: heart rate, blood vessel contraction, sweating, salivary flow, intestinal movements, and even the little hairs on your arms. As with growth hormone, fibromyalgia patients seem to suffer with reduced levels of epinephrine responses, especially in response to low sugar levels or exercise. Abnormal levels of norepinephrine will cause symptoms to be felt all over your body. These symptoms may manifest as the chronic fatigue and pain associated with fibromyalgia. Hypothalamic-Pituitary-Adrenal Stress Axis Recent studies have shown that this axis that lies in the brain may have a role in the development of fibromyalgia syndrome. Among other things, the hypothalamic-pituitary-adrenal axis (HPA) is the part of your brain that deals with how your body handles stress, both physical stress and psychological stress. Many patients with fibromyalgia report the onset of their symptoms after a significant period of emotional stress or a specific traumatic event. Fibromyalgia sufferers also report a higher level of daily stress and that their symptoms are significantly aggravated by stress. This points to over-activation of the HPA axis as a possible cause of fibromyalgia. Actually, most of the symptoms associated with fibromyalgia, such as sleep disorder, headache, and irritable bowel can be traced back to increased activity of the HPA axis. Curiously, studies have shown that the main stress hormone that is secreted in the HPA axis in response to stress ? cortisol ? is lower than normal. Therefore whether it is overactivity or underactivitiy of the HPA axis is not entirely clear. What is clear is that there is an alteration in the HPA axis and more research is required to identify the precise nature of this alteration. Sleep Disturbances Some researchers theorize that the sleep disorders seen with fibromyalgia may actually be a cause, as opposed to symptom ? of the syndrome. Stage 4 sleep is the deepest level of sleep and is the one that is most lacking in fibromyalgia sufferers. Evidence that sleep disturbance may be a possible of fibromyalgia was given by a study that was able to induce fibromyalgia-like symptoms in normal volunteers by depriving them of deep sleep. It is during stage 4 sleep that a hormone called somatomedin C is released into the system. Without enough deep sleep, fibromyalgia sufferers show abnormally low levels of this hormone which is essential for the body to rebuild itself. Lack of this hormone may be causing the characteristic muscle pain and fatigue commonly seen in fibromyalgia. Also, release of growth hormone occurs primarily during stage 3 and stage 4 of non-REM sleep. Thus disturbed sleep will affect the release of this hormone causing abnormalities in your body. One third of patients with fibromyalgia have low insulin growth factor (IGF) levels, an indication of low growth hormone secretion. Interestingly, amongst fibromyalgia sufferers, the severity of the sleep disorder seems to correlate with the number of tender points they have Sleep deprivation is also known to cause some of the symptoms involved with ?fibrofog.? People who lack enough sleep or poor deep sleep have been known to experience feelings of being in a fog, loss of control of though processes and poor memory. Studies have shown that exercise increases the amount of time spent in deep sleep. Thus, it is not surprising that exercise has been confirmed to be of value in the treatment of fibromyalgia. Injury or Microtrauma to Muscles It has been suggested that the pain of fibromyalgia may be related to microtrauma in deconditioned muscles and that exercise helps fibromyalgia sufferers by conditioning these muscles. For example, pain in the muscle causes spasm in the muscle, causing more pain, which in turn causes more spasm. The muscle becomes chronically congested, and the delivery of oxygen and other nutrients, as well as the removal of metabolic wastes and acids, becomes impaired. A recent study looked at the relationship between neck injuries and the onset of fibromyalgia. It found that fibromyalgia was 13 times more likely to occur following a neck injury than an injury to the lower bodies. However, muscle biopsies have not been able to identify any difference in sore muscles when compared to other non-tender parts of the body. Also, some tender points are not over muscles or tendons but over bones or fat pads. Scans of fibromyalgic muscle tissue by electron microscope have revealed some abnormalities in the levels of a muscle sugar called glycogen. Abnormal organelles called mitochondria that are involved in energy production have also been found in fibromyalgia patients. So while there is some evidence that abnormalities in the metabolic properties of the muscles may be involved in fibromyalgia, it is more probable that these injuries to muscles don?t cause fibromyalgia, but rather, they may awaken a hidden genetic predisposition. Another way whereby injuries may be involved with fibromyalgia is that an injury to the upper spinal region may affect the central nervous system and may trigger the development of fibromyalgia in some people. Head injury, viruses, and severe stress easily overwhelm the brain. When an injury to the brain occurs, it triggers a cascade of biological events involving neurotransmitters, hormones and changes in blood flow, to protect the traumatized area. Unfortunately for the patient, such defensive action by the brain can cause serious problems in the body. Some of the things that they can cause are many of the same symptoms that fibromyalgia patients may be suffering from. Several studies are currently analyzing brain wave activity to see if there are differences between normal people and fibromyalgia sufferers. Other Possible Causes Other less frequently theorized causes include: ?Central nervous system dysfunction. Some believe that fibromyalgia sufferers have an abnormal nervous system that leads to abnormal processing of sensory stimuli. This means that the patient?s nervous system processes normally non-painful sensory stimuli as being painful. This phenomenon in which pain results from a stimulus that should not normally be painful is known as allodynia. ?Changes in muscle metabolism, such as decreased blood flow, causing fatigue and decreased strength. ?Infectious agents such as a virus but no such agent has been identified. Also, if fibromyalgia were infectious we would expect so see an increased incidence in spouses of an affected patient and this is not the case. ?Immune system abnormalities. Several changes in immune system function have been found in fibromyalgia, generally in the direction of increased activity. Hyperactive immune system symptoms can be induced in normal volunteers through sleep deprivation. This may link sleep dysfunction and immune function as causative agents in fibromyalgia. ?Muscle tension. Muscles that are in a chronic state of contraction will not relax fully, even with rest. Muscles constantly taxed this way can produce an unlimited variety of unpleasant symptoms. It should also be noted that contracted muscles not only cause the brain to release certain chemicals that can cause pain, but that they greatly restrict the oxygen that they take in, which can produce drastic side effects since oxygen is responsible for regulating the fluid levels in soft tissues as well as repairing injuries. Tense muscles can also press adjacent nerves, causing pain, tingling and numbness. Stressed nerves can create weakness in affected muscles and restrict motion in nearby joints. A muscle?s constant state of contraction will cause it to shorten, limiting motion and causing muscle aches and stiffness. This may be another reason why spinal manipulation, by lengthening soft tissues around the spine has been shown to help with fibromyalgia patients. ?Genetic predisposition. Although no specific inheritance pattern has been identified, an increased incidence in relatives of affected patients had been noted. Therefore, development of fibromyalgia may involve certain predisposing factors that are inherited, as well as precipitating factors such as trauma, infection, stress or sleep disruption. Current studies on twins with fibromyalgia are examining the possibility of genetic predisposition to the syndrome. How is Fibromyalgia treated? One of the most important factors in improving the symptoms of FM is for the patient to recognize the need for lifestyle adaptation. Most people are resistant to change because it implies adjustment, discomfort and effort. However, in the case of FM, change can bring about recognizable improvement in function and quality of life. Becoming educated about FM gives the patient more potential for improvement. Please refer to the TIPS and LINKS pages at the end of this report. An empathetic physician who is knowledgeable about the diagnosis and treatment of FM and who will listen to and work with the patient is an important component of treatment. It may be a family practitioner, an internist or a specialist (rheumatologist or neurologist, for example). Pain Management - Over-the-counter pain medications, such as acetaminophen combined with one of the newer non-narcotic pain relievers (e.g. Tramadol?) may provide benefit. Also considered are low doses of antidepressants (e.g. tricyclic antidepressants, serotonin reuptake inhibitors) or benzodiazepines. Physicians already know that antidepressants are "serotonin builders" and can be prescribed at low levels to help improve sleep and relieve pain. Also, an important aspect of pain management is a regular program of gentle exercise and stretching, which helps maintain muscle tone and reduces pain and stiffness. Spinal manipulation as a drugless and non-invasive measure has shown to provide significant relief for FM symptoms. Many patients not wishing to take medications may be offered this route. Sleep Management - Improved sleep can be obtained by implementing a healthy sleep regimen, which includes going to bed and getting up at the same time every day, making sure that the sleeping environment is conducive to sleep (i.e. quiet, free from distractions, a comfortable room temperature, a supportive bed), avoiding caffeine, sugar and alcohol before bed, doing some type of light exercise during the day, avoiding eating immediately before bedtime and practicing relaxation exercises as you fall to sleep. When necessary, there are new sleep medications that can be prescribed, some of which can be especially helpful if the patient's sleep is disturbed by restless legs or periodic limb movement disorder. Psychological Support - Learning to live with a chronic illness often challenges an individual emotionally. The FM patient needs to develop a program that provides emotional support and increases communication with family and friends. Many communities throughout the United States and abroad have organized Fibromyalgia support groups. These groups often provide important information and have guest speakers who discuss subjects of particular interest to the FM patient. Counseling sessions with a trained professional may help improve communication and understanding about the illness and help to build healthier relationships within the patient's family. Nutrition - Be somewhat skeptical of anything other than B vitamins and magnesium. The reasons are that the FDA does not regulate herbal and nutritional products. Also, certain herbs may have side effects with the FM patient taking antidepressants, pain medications and other pharmaceutical products. Ask your patient what they?re taking?don?t assume your patient is only following your recommendations. TIPS FOR FIBROMYALGIA First?have your doctor perform a comprehensive exam and history to rule out other causes such as hypothyroidism, polymalgia rheumatica, peripheral neuropathies, dysmenorrhea, depression, lupus, multiple sclerosis and rheumatoid arthritis. 1. Find empathic doctors who take your fibro symptoms seriously. If your doctor doesn?t seem to care or seems like they don?t want to work harder, change doctors. 2. Get a team together including a PCP, chiropractor, nutritionist, endocrinologist and rheumatologist. 3. Sleep and organization are the two most important factors to help yourself. 4. Make sure that medications are not only given on the basis of pain, but effects with neurotransmitters as well. Consider serotonin-altering medications. 5. Consider a referral to an endocrinologist for further testing. Determine cortisol, beta-endorphin, growth hormone, calcium, magnesium, neurotransmitter and other biochemical levels. 6. Start a low-impact, aerobic exercise program. Include yoga. 7. Fibromyalgia has no cure ? rather successful management 8. Cognitive behavior therapy can be very helpful?particularly for patients who feel helpless with this condition. 9. Chiropractic is one of the most often used types of alternative therapy, especially for chronic pain illnesses, such as fibromyalgia. It is based on the belief that certain conditions are caused by impairment of your nervous system due to problems in your joints, muscles, ligaments, tendons and bones. Chiropractors have been shown to successfully treat several conditions, including fibromyalgia, by manipulating joints with stretches and adjustments. A recent study showed that following for weeks of treatment, 21 patients with fibromyalgia improved compared with control subjects receiving medication alone. Make sure that the patient knows that they should expect some type of improvement within the first 3 weeks of care. Helpful Information for FIBROMYALGIA Our office cares about you. This information will help you to become more empowered and knowledgeable about your problem. Fibromyalgia is a muscle and fatigue disorder that affects up to 5% of the population. It has no known cause or cure. Fibromyalgia comes from the Latin word "fibra" meaning "fiber," the Greek word "myos" meaning "muscle," and the Greek word "algos" meaning "pain." Put the words together and you have "muscle fiber pain." Fibromyalgia Syndrome (FMS) is a chronic (long-term) disorder characterized by widespread pain in the muscles, ligaments and tendons. As a chronic condition, fibromyalgia is ongoing but it doesn?t cause inflammation to the muscles or internal organs. Also, fibromyalgia is definitely not fatal. As you may be experiencing, most patients with fibromyalgia feel like they ache all over. Muscles may feel like they have been pulled or overworked. The muscles affected most are in the shoulders, buttocks, neck, and lower back. FMS may also be accompanied by fatigue, headaches, depression and sleep difficulties. Although there is no known cure, our practice strongly believes in empowering our patients to take an interactive approach to FMS. Therefore, we have included information, which may help you. BOOKS: Fibromyalgia for Dummies Roland Staud, M.D. The Fibromyalgia Handbook, 3rd Ed. A 7-Step Program to Halt and Even Reverse Fibromyalgia Harris W. McIlwain The First Year--Fibromyalgia: An Essential Guide for the Newly Diagnosed Claudia Craig Marek Chronic Fatigue Syndrome, Fibromyalgia, and Other Invisible Illnesses Katrina Berne ORGANIZATIONS: Fibromyalgia Syndrome Resource www.fibromyalgia-symptoms.org Fibromyalgia Network www.fmnetnews.com National Fibromyalgia Association www.fmaware.org Fibrohugs Fibromyalgia Site www.fibrohugs.com Arthritis Foundation www.arthritis.org Information for handout provided by: Dr. Stephen Ambrose, DC doc@doctorambrose.com |
Related documents
Fibromyalgia Report (86kb) - Click here to view/download
