The Neural Plasticity Model of Fibromyalgia Theory, Assessment, and Treatment: Part 3
The treatment of fibromyalgia follows directly from the assessment. The basic premise is to reduce the source(s) of pain in the periphery while simultaneously reducing the CNS dysfunction, without irritating or reinforcing the pain pathways. As one or several of these mechanisms may be involved in the maintenance of the dysfunction, a multi-faceted strategy is recommended. This should consist of: a) trying to calm the system with medication(s), naturopathic substances, and relaxation training techniques; b) alter the muscle, joint (peripheral) activity using different sEMG techniques, physical therapy, and massage therapy; and c) alter the CNS activity using EEG neurotherapy techniques.
Before discussing biofeedback and other treatments, a brief discussion of medications and the impact upon biofeedback is needed. In general it has been found that the use of medication(s) can both enhance and retard treatment. If the individual is in a significant amount of distress at the start of treatment, then medications can be used as a means of pain control, or to treat severe anxiety or depression that may prevent initiating other forms of treatment. However, as treatment progresses, medication(s) may retard progress, for as the treatment works the need for the medication decreases. When this happens the individual will start to show signs of being over medicated. It is important for the clinician to have an up-to-date and comprehensive pharmaceutical reference available in order to understand the interaction between treatment and medications and to support the patient.
The pain component cannot be treated specifically with just one type of medication. Different analgesic classes may prove useful in reducing pain intensity and/or frequency for a determined period of time. Combined classes of medicines may prove more useful, e.g. tramadol (Ultram), vicoprophen, etc., in that they may reduce pain by blocking different receptors. Opiates may be reserved for complicated cases, which have shown a poor response to pain treatment with other classes of analgesics. NSAIDs have generally not proven very effective in treating fibromyalgia.150 All pain medication must be prescribed and taken under clear guidelines and control. Recently, Jacob Teitelbaum (work in progress 1999) indicated that in a double blind study the application of a combination of medications and naturopathic substances significantly reduced fibromyalgia symptoms. Unfortunately, the authors do presently not know the exact nature of this combination and readers need to be cautioned that this work is preliminary and needs further review.
Where possible, substitution of herbal remedies and OTC nutritional supplements for pain medications should be considered. A number of herbal remedies have demonstrated some promise in alleviating musculoskeletal pain, including sangre de grado,151 capsaicin,152 and devil’s claw (harpagophytum procumbens). Similarly, the OTC nutritional supplements methyl-sulfonyl-methane (MSM),153 glucosamine,154,155 and S-adenosyl-l-methionine (SAMe) have all been shown effective in alleviating some types of musculoskeletal pain, including inflammatory and arthritic pain.
A recent commercial release of a combination herbal and nutrient remedy for fibromyalgia called FM Relief®† combines many of the ingredients that have shown clinical promise in relieving musculoskeletal pain (i.e., malic acid, salicin, magnesium hydroxide, methyl-sulfonyl-methane, glucosamine sulfate, chrondroitin sulfate, 5-HTP, curcumin, boswellia) and may be a useful adjuvant or even alternative to some of the pain medications commonly prescribed to people with fibromyalgia.156
There is also evidence that one important factor in musculoskeletal pain is low plasma magnesium levels157,158 and, moreover, that many medications commonly prescribed to people with chronic pain interfere with the body’s metabolism of magnesium.159 Calcium is also an important nutritional factor in muscle and bone health. Therefore, it is recommended that myofascial and fibromyalgia pain patients take a calcium and magnesium supplement at least four times per day (i.e., with meals and just before bedtime) to attain a total daily dose of approximately 1000-1500 mg of calcium and 600-800 mg of magnesium. Clinical experience shows that calcium and magnesium can be effective in reducing muscle spasming and tension as well as chronic headaches. A moderately large dose (200-400 mg) of magnesium can abort a migraine or tension headache, and high doses of calcium can be very effective in reducing some of the symptoms of PMS.160 Calcium and magnesium can also help induce sleep.
The anxiety/depression component may be controlled with adequate doses of anxiolytic/antidepressant agents. Different medications may be used in the same individual over time if the response is less than adequate. Dosing may differ according to the intensity of the anxiety/depression symptoms over time. Tricyclics such as amitriptyline (Elavil) have traditionally been used in low dosages (i.e., 10-25 mg hs) to enhance sleep, improve negative mood, and take the edge off chronic pain, but more recently, SSRIs (e.g., Paxil, Prozac, Zoloft, etc.) have been employed with a view to reduce depression and stabilize affective symptoms. While the older tricyclic antidepressants have proven themselves as moderately effective adjuvants to analgesics in treating chronic pain,161 the newer SSRIs may be less effective in this regard.162 Many physicians now combine a low bedtime dose of amitriptyline or trazodone with a moderate morning dose of an SSRI.
Research on the effectiveness of various medications in the treatment of fibromyalgia would appear to point to amitriptyline (Elavil) (10-50 mg hs) and cyclobenzaprine (Flexeril) (10-30 mg) as the most consistently beneficial.150
There is some evidence that mild depressive symptoms may respond well to herbal remedies such as St. John’s wort (hypericum), or certain OTC nutritional supplements such as S-adenosyl-l-methionine (SAMe), l-tryptophan or 5-hydroxy-tryptophan (5-HTP),163 whereas mild generalized anxiety may respond well to kava kava (piper methysticum) or valerian (valeriana officinalis).164 The problem of sleep inadequacy may be treated partially with the antidepressant medications described above, especially amitriptyline and trazodone. However, it may be relevant to consider the use of herbal remedies such as chamomile, lemon balm, kava kava, or valerian, or nutritional supplements such as melatonin,165 l-tryptophan, or 5-HTP163 before adding specific sleep medication, especially those of the benzodiazepine group which frequently cause more problems in the long term.
It is important to remember that once treatment is underway medications will often reduce the speed of recovery, as rebound effects and symptoms of an overdose will occur as the need for medication is reduced. Medications of the benzodiazepine group, steroids, and opiates tend to suppress the electrophysiological signal making treatment more difficult. It is also important to monitor what herbal supplements and medications patients are taking in order to avoid potential interactions.