NON-INVASIVE NEUROPSYCHIATRIC

APPROACHES TO FIBROMYALGIA 

Non-Invasive Brain Stimulation and Fibromyalgia

Traditional fibromyalgia treatments and diagnosis were presented in previous blog posts; This article touches upon two other novel techniques, both non-invasive and outpatient-based, that may become regular considerations in fibromyalgia treatment.

Transcranial Direct Current Stimulation (tDCS).  tDCS is a simple and painless procedure involving the stimulation of the brain located between two electrodes placed on the scalp.  The extremely small electrical current emanates from a 9-volt battery.  Although not yet FDA-approved for transcranial use, preliminary studies of tDCS, particularly of the primary motor cortex of the brain, show some promise in the use of this non-invasive treatment for pain and sleep-related fibromyalgia (Fregni F, et al. Arthritis Rheum. 2006; 54(12):3988-98; Roizenblatt S, et al., Pain Pract 2007; 7(4):297-306; Short B, et al. Pain 2009).

Transcranial Magnetic Stimulation (TMS).  TMS involves the application of magnetic pulses over the scalp without using electrodes or direct electrical stimulation.  Unlike ECT (electroconvulsive treatment), patients remain awake and alert during each TMS treatment, and can drive to and from the office due to a lack of cognitive and other side effects associated with ECT.   The procedure is well-tolerated with few side effects compared to medication treatment.

While TMS has been FDA-approved, safe, proven, and well tolerated in the treatment of depression, preliminary research suggest that TMS may be a potential off-label alternative for treatment-refractory fibromyalgia, particularly if associated with depressive symptoms.

Recent Studies on TMS and Fibromyalgia Treatment

Since research has demonstrated that TMS can diminish chronic pain, there has been considerable interest in the application of TMS to fibromyalgia-related pain.  Preliminary and promising studies on the use of TMS to treat fibromyalgia  have recently been published.

Three potentially different TMS approaches to fibromyalgia treatment have been studied:

• Two studies indicate that high frequency TMS of the left primary motor cortex could become a future standard of fibromyalgia treatment:

A 2007 randomized, double-blinded, controlled study of 10 daily sessions of TMS in 30 patients with fibromyalgia demonstrated that patients who received active TMS experienced significant pain reduction that lasted up to 2 weeks after the last TMS session (Passard A, et al, Brain 2007;130;2661-2670).

Another preliminary, randomized, double-blinded controlled study of 40 fibromyalgia patients (A. Mhalla et al.  Pain 152(2011) 1478-1485) showed that, compared to the group that received sham (ie, fake) procedures, there was a significant and sustained improvement in pain, activity, sleep, fatigue, outlook and general quality of life in the TMS group with fibromyalgia.

• High frequency TMS to the left prefrontal cortex appears promising according to one recent randomized, controlled study:

10 patients with fibromyalgia received ten sessions of TMS over a two week period.  Those who received active TMS experienced a statistically significant reduction of 29% of their daily pain, which was followed by a significant reduction in associated depressive symptoms two weeks later and continued pain relief.  The patents who underwent sham procedures experienced only a 4% improvement in pain.  The authors of the study point out that the rapid onset of pain reduction in this pilot trial approximates that of pregabalin and duloxetine, although with markedly fewer side effects  (Short EB et al. 2011).  Interestingly, in this study, it was clear that improvement in pain symptoms occurred prior to a reduction in depression.

¢ Although two very small preliminary studies have focused on the application of low frequency TMS to the right front side of the brain.  More research is needed before conclusions can be made about the efficacy of this technique.  (Sampson SM et al., Pain Med. 2006; 7(2);115-8; Short B, et al., 2009).

Although the use of the NeuroStar TMS device for depression has been FDA-approved, its use to treat fibromyalgia without depression would be an off-label application of this device.  Clearly more studies with larger numbers of subjects are needed to better determine optimal treatment protocols, pulse frequency and location of treatment (motor cortex, prefrontal cortex, or both) for TMS to become a routine treatment for fibromyalgia.

TMS for Depression with or without fibromyalgia.  

While medication and psychotherapy are usually the first-line treatments for clinical depression, TMS is a non-invasive, highly tolerated, FDA-approved outpatient procedure for treatment-resistant depression, shown to be as effective as medication plus an augmentation agent.   Since depression often co-occurs with fibromyalgia, TMS should be considered for the management of treatment-refractory depression with associated  fibromyalgia pain.

If you have concerns about depression and chronic pain, think you may be suffering from depression and/or fibromyalgia, and want to know more about possible treatment options, contact your general physician, a psychiatrist, or a rheumatologist.

The West Coast TMS Institute, located in Sherman Oaks, Los Angeles, approaches depression in a comprehensive manner and is very sensitive to the needs of patients suffering from depression with or without fibromyalgia.

If you found this blog on fibromyalgia interesting, check out our next behavioral health post on posttraumatic stress disorder, or PTSD.

Fibromyalgia Treatment Does not Only Focus on Pain

FIBROMYALGIA TREATMENT – COMMON NON-DRUG AND MEDICATION APPROACHES

Because of its varied symptoms, fibromyalgia treatment involves a multimodal approach that includes drug and non-drug therapies.

• NON-MEDICATION 

  FIBROMYALGIA TREATMENT

  (Arnold, L. J Clin Psychiatry 2008;69 (suppl 2))

• Education.  If you suffer from fibromyalgia, you might feel overwhelmed and daunted by the many fibromyalgia treatment options.  Educating yourself about fibromyalgia enables you and your family to approach your health with a positive, hopeful, and realistic attitude. The more you know about fibromyalgia, its symptoms, potential causes and treatment options, the more equipped you will be to work proactively and effectively with your physician.

• Self Care.  You might feel discouraged by your pain and fatigue, but it is possible to take care of yourself.  Regularly eating healthy, having a sleep routine, participating in low impact aerobic exercise, and balancing daily activities with rest are foundations to comprehensive fibromyalgia treatment.  Following up with your physician as recommended is also key to fibromyalgia treatment.

• Cognitive Behavioral Therapy (CBT) and Mindfulness Meditation.  Learning and reinforcing more realistic appraisals of one’s environment or situation can reduce the experience of pain, depression and anxiety. Mindfulness meditation can also help you accept feelings and emotions, even when they are uncomfortable, which can ” in the long run ” help reduce pain (Short B, et al., J Pain Manag. 2009 Jan 1; 2(3)259-276).  These approaches should be considered important options in fibromyalgia treatment.

• Surgery is not a fibromyalgia treatment.

• FIBROMYALGIA TREATMENT -

  MEDICATION APPROACHES

  (Clauw DJ. J Clin Psychiatry.2008; Russel IJ. CNS Spectr. 2008;13:3(Suppl 5):27-33)

The following discussion of  medications that physicians commonly consider when approaching fibromyalgia is for general information only.   Remember that decisions about fibromyalgia treatment is best made when you and your physician weigh the risks versus the benefits of pursuing any particular medication or, if necessary, drug combination.

• Pain-Focused Fibromyalgia Treatment.  Some with fibromyalgia feel that ” if only their physical pain were relieved by medication — they would be able to manage their other symptoms effectively using the non-drug approaches above.  In such cases, tramadol and acetaminophen (eg, Tylenol) may provide sufficient relief.  Tramadol can interact with numerous other medications, causing adverse reactions, so be sure to let your doctor know all of the medications and over the counter supplements you are taking.

Though there is limited research evidencing their effectiveness in fibromyalgia, opiates (eg, hydrocodone) or NSAIDS (eg, ibuprofen) are commonly used to treat fibromyalgia pain.  With opiates, there is a potential for abuse, dependence, tolerance and overdose, so it is important to take only the amount prescribed and to let all your physicians know all the medications you are taking in order to avoid complications

• Pain, Depression and Anxiety-Focused Fibromyalgia Treatment.  For more complicated fibromyalgia that is associated with pain, depression and/or anxiety, tricyclic antidepressants (TCA’s) such as amitriptyline and cyclobenzaprine, or serotonin-norepinephrine re-uptake inhibitors (SNRI’s) such as duloxetine and milnacipran are often the first steps in treatment.   TCA’s and SNRI’s are thought to promote descending brain pathways that inhibit excessive pain perception.

Some people suffering from depression may have bipolar depression; It is therefore important to try to rule-out this disorder prior to initiating a TCA or an SNRI, as these medications increase the risk of switching a bipolar depressed patient to a manic state, particularly if mood stabilizers are not already employed (Arnold, L. J Clin Psychiatry 2008;69 (suppl 2).

Pregabalin and gabapentin are anticonvulsants thought to inhibit excessive pain transmission via ascending pain pathways to the brain,  These agents can be helpful with pain while also reducing anxiety (Arnold Psychiatr Clin N Am 33 (2010)375-408).

• Pain and Insomnia-Focused Fibromyalgia Treatment.  When pain and insomnia are the most disturbing symptoms, pregabalin or antidepressants commonly used for sleep, such as amitriptyline, trazodone and doxepin, may be good treatment choices.   Sodium oxybate, a metabolite of the inhibitory neurochemical GABA, and an approved treatment for excessive daytime sleepiness and narcolepsy, has been used off-label in very extreme cases of fibromyalgia-related insomnia.

• Pain, Insomnia and Depression-Focused Fibromyalgia Treatment.  For those with fibromyalgia who suffer from this painful triad of symptoms, a combination of an SNRI with pregabalin, gabapentin, trazodone or, in extreme cases, sodium oxybate can be effective in fibromyalgia treatment.

In complicated fibromyalgia, it is not uncommon to require multiple medications to address all or most symptoms, often increasing the risk of interactions and side effects.  Communicate clearly with your physician if you experience side effects or interactions. Consult with your doctor before changing medications or doses.

 Our next blog covers non-drug, investigational fibromyalgia treatment that appears promising.

Fibromyalgia: More Than Just A Pain Condition

Identifying Fibromyalgia

The American College of Rheumatology describes fibromyalgia as a chronic pain disorder characterized by widespread, generalized soft tissue pain in at least 11 of 18 specific tender points lasting for at least 3 months (Wolfe F et al. Arthritis Rheum. 1990;33(2):160-72).   Recently, it has been argued that the presence of tender points is not necessary for the diagnosis of fibromyalgia.  Instead, it has been suggested that, alongside generalized chronic soft tissue pain for at least 3 months, a majority of the following symptoms is sufficient (Pope & Hudson. Int J Psychiatry Med. 1991; 21:205-232):

• Disturbed sleep
• Headache
• Fatigue/exhaustion/stiffness
• Sensations of numbness or tingling
• Irritable bowel symptoms
• Neuropsychiatric problems, such as cognitive difficulties, depression or anxiety.  The cognitive problems associated with fibromyalagia, often called fibro-fog, include poor memory, a sense of mental slowness, dulling and distractibility.

How common is fibromyalgia?

Fibromyalgia affects women 7 times more often than men, and between 2% to 5% of the general population suffers from fibromyalgia (Short B et al. J Pain Manag. 2009 Jan 1;2(3):259-276).  While fibromyalgia is most prevalent in middle age, it can affect anyone over the age of 10 years old.

How common are psychiatric disorders in people with fibromyalgia?

It is estimated that, for fibromyalgia sufferers, the lifetime prevalence is as high as 62% for depression and as high as 60% for anxiety disorders (Arnold L. J Clin Psychiatry. 2008;69(supp 2)).  Depressive disorders are risk factors for even more painful symptoms of fibromyalgia, and poorer overall functioning.

What are the main causes of fibromyalgia?

• Central Nervous System (CNS) and Hormone Dysfunction.  Fibromyalgia is thought to be associated with dysfunctional brain and spinal card processing, activation and inhibition of painful sensations; Therefore, compared to most people, those suffering from fibromyalgia perceive pain more intensely.  Interestingly, like those suffering from depression, people with fibromyalgia commonly demonstrate difficulties regulating the stress hormone cortisol, among other neurochemicals.

• Inflammation.  Increases in inflammatory cytokines are also thought to contribute to both depression and fibromyalagia (Short B et al., 2009).

• Genetic Predisposition.  While it is not completely clear what exactly causes fibromyalgia, a genetic susceptibility to developing fibromyalgia clearly exists.  Individuals with fibromyalgia are over 8 times more likely than those without fibromyalgia to have a family member with fibromyalgia (Arnold L., 2008).  The increased pain sensitivity associated with fibromyalgia may be due to a polymorphism of a gene that codes for the serotonin transporter (5HTT), a genetic abnormality also commonly seen in those suffering from clinical depression (Short B et al., 2009).

•  Injury.  Physical soft tissue or nerve injury with incomplete healing may also lead to the development of overly sensitive peripheral sensory nerves that trigger, or coincide with, changes in central nervous system pain processing seen in fibromyalgia.

• Depression and Anxiety.  Clinical depression, anxiety disorder, personal and work-related stressors and uncomfortable working conditions also appear to trigger fibromyalgia; In many cases, however, it can be argued that it is the fibromyalgia symptoms that trigger anxiety or depression.  Due to the overlap of many symptoms and triggers of depression and fibromyalgia, many believe that fibromyalgia is part of a group of illnesses called Affective Spectrum Disorders, which also include migraines, irritable bowel syndrome, ADHD, clinical depression, and various anxiety disorders (Bradley LA. J Clin Psychiatry 2008;69(suppl 2)).

• Mimicking Conditions.  It is important that other conditions or diseases that can mimic the symptoms of fibromyalgia be ruled out and treated, such as nerve and muscle injuries, joint disorders, infections, and hormonal disorders such as low thyroid hormone states and vitamin D insufficiency.

There is Hope for Fibromyalgia - Now that we have reviewed what is fibromyalgia, our next post will soon discuss various treatments for fibromyalgia.