Tag: fibromyalgia

Mind-body interventions: applications in neurology

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A comprehensive review  on mind-body interventions and its application in various neurological disorders was recently published in Neurology. The authors Wahbeh, Elas and Oken searched Medline and PsychoInfo databases to identify clinical trials, reviews and published evidence on mind-body therapies and neurological diseases.

Meditation, relaxation, breathing exercises, yoga, tai-chi, qigong, hypnosis and biofeedback are some of the mind-body interventions that have been used in various neurological conditions like general pain, back and neck pain, carpel tunnel syndrome, headaches (migraine and tension), fibromyalgia, multiple sclerosis, epilepsy, neuromuscular diseases, stroke, falls with aging, Parkinson disease, stroke and attention deficit hyperactivity disorder (ADHD).

The authors do a good job in shifting through all the data to try to identify the effectiveness of mind-body interventions. As they point out in their discussion , many patients as many as 62% use complementary and alternative medicine therapies (CAM). Some with and many without the knowledge of their physicians. One of the reason why CAM therapies are popular is that they are relatively easy to implement, cheap (though many patients have to pay out of their pocket. Some insurance companies shall reimburse if you have a letter from your doctor) and more importantly as the authors point out it makes the patients feel empowered. They feel that they are in control of some of the decision making in their disease process and treatment. Moreover it gives a sense of general well being.

The authors righly point out that is difficult to scientifically judge whether these interventions are all effective. The reason for this is that many of the studies included small number of subjects and some of them did not have a control group. Moreover it is hard to blind these studies so as to avoid a placebo effect. Like suppose I want to study whether acupuncture is effective for lower back pain. One group I give acupuncture. Ideally I should have a control, a group which receives sham acupuncture so as to null the placebo effect. Now this is difficult to implement.

Th authors in their review conclude that there are several neurological conditions where the evidence in favor of mind-body therapies is quite strong such as migraine headaches. In other conditions the evidence is limited due to small clincial trials and inadequate control group.

It is reasonable to conclude that CAM therapies like yoga, tai-chi and qigong improve balance in the elderly and decrease the incidence of falls. Moreover they give a sense of well being and happiness. Meditation exercises whether it is mindfulness meditation, transcendental meditation or concentration meditation with the repetition of a word like Om or a mantra

“Hare Krishna Hare Krishna

Krishna Krishna Hare Hare 

Hare Rama Hare Rama

Rama Rama Hare Hare”

all help in relaxation and reducing stress. This may decrease blood pressure and reduce the incidence of strokes and heart attacks. Brain changes have been observes during meditation in EEG and imaging studies and there is evidence that these exercises have wide spread effects on the endocrine and immune systems as well neurotransmitters. Hatha yoga may help in improving mobility and balance and thus decreasing fall risk. As the authors point out righly Bikram yoga  which is carried out in very hot temperatures is likely not good for patients with MS, as it may worsen their weakness. This is called Uhthoff phenomena.

There is also some evidence to suggest benefits of these interventions in patients who have chronic lower back and neck pain, those with fibromyalgia, osteoarthritis as well as carpel tunnel syndrome (some studies suggest benefit while others do not).

My advise to patients who want to try out CAM therapies for various neurological conditions is to take their doctors into confidence. It is likely that some of these therapies when used along with allopathic medicines shall give added benefits and likely make you feel better. Like with any other therapy one must find a knowledgeable practitioner who knows what he or she is doing.

Then one can truly reap the benefits of these ancient therapies.

Personal Regards,

Nitin Sethi, MD

Fibromyalgia and other chronic pain syndromes

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Hmm since fibromyalgia is in the news nowdays, maybe it is a good time to talk about it on the braindiseases weblog. I did my internal medicine residency before I did neurology and I remember reading about fibromyalgia in Harrison’s Principles and Practices of Internal Medicine (this book is called the bible of internal medicine, a book every good internal medicine doctor should know well). Fibromyalgia occupied half a page and was right at the end of the section a kind of neglected disease. Many doctors (and I include myself in that group) do not consider that the disease actually exists.

We all have patients in our practice who carry the diagnosis of fibromyalgia, they have constant complain of pain in different areas of the body. When they first present to a doctor a work-up is carried out to determine the etiology of this constant pain. However inspite of multiple tests including but not limited to blood tests, imaging studies and sometimes even invasive studies no cause can be found. All the inflammatory markers in the blood come back negative (these include tests like ESR). These patients frequently have other diagnosis which fall into the category of psychosomatic disorders like IBS (irritable bowel syndrome) and chronic fatigue syndrome. Some of them may carry psychiatric diagnosis like depression or somatisation disorder. Thus fibromyalgia has been in the past a kind of waste-basket diagnosis given to patients with unexplained complaint of chronic pain referrable to different parts of the body. Since we did not truly believe that the disease exists, we did not have any good treatments for it. Doctors either treated these patients with anti-depressants or pain killers. This caused some unintended problems with some patients becoming dependent on pain killers like vicodin.

So do we know anything more of fibromyalgia now than in the 90’s?

Do we understand its pathophysiology better today?

Does the disease actually exists?

Fibromyalgia is currently diagnosed as per the criteria laid out by the American College of Rheumatology (ACR).

FIBROMYALGIA CRITERIA

A. Widespread pain must be present for at least 3 months. This pain must appear in all of the following locations:

  • Both sides of the body
  • Above and below the waist
  • Along the length of the spine

B. Pain in at least 11 of 18 specific areas called tender points on the body. The pain experienced when pressing on a tender point is very localized and intensely painful (not just tender). Tender points are located in the following areas:

  • The left or right side of the back of the neck, directly below the hairline
  • The left or right side of the front of the neck, above the collar bone (clavicle)
  • The left or right side of the chest, right below the collar bone
  • The left or right side of the upper back, near where the neck and shoulder join
  • The left or right side of the spine in the upper back between the shoulder blades (scapula)
  • The inside of either arm, where it bends at the elbow
  • The left or right side of the lower back, right below the waist
  • Either side of the buttocks below the hip bones
  • Either knee cap

Other long-term symptoms that may indicate fibromyalgia include:

  • Morning stiffness
  • Fatigue
  • Sleep disturbance
  • Numbness or tingling in the hands and feet
  • Headache

We nowdays think that these patients have an altered perception of pain and other visceral as well as somatic sensations. Let me explain this with a crude example. Suppose you have inflammation in your left shoulder joint, your brain shall get sensation from the sensory receptors located in the periphery of the joint.  The sensation shall travel to the sensory cortex of the brain (the part of the brain dealing with sensation) and you shall experience pain as a result. It is believed that fibromyalgia patients have altered pain perception in their brain, they either feel the pain too much or that it persists for longer than it is supposed to (crudely put maybe their brain is more pain sensitive). Some recent work involving functional MRI and other imaging studies does give some scientific evidence to suggest this.

Whatever the etiopathogenesis behind this disorder (if in fact the disorder does exist in the first place) now there are new drugs in the market been touted (and FDA approved) for the treatment of fibromyalgias. One of them is pregabalin marketed under the name of Lyrica. My personal experience using this drug in patients with fibromyalgia is very limited. If you or any of your loved ones is diagnosed with fibromyalgia, I would advise you to see a doctor with interest and experience in this disorder so that you can get benefits of newer treatment modalities.

Personal Regards,

Nitin Sethi, MD