Therapies for Chronic Pain and Fibromyalgia
Chronic musculoskeletal pain is the number one cause of disability in young adults and the number two cause of workplace absences and of visits to the family doctor. It costs North Americans over $80 billion per year. One of the most difficult conditions to treat is fibromyalgia syndrome (FMS). This pain syndrome is characterized by widespread body aching, associated fatigue, sleep problems, and occurs predominantly in females. It is estimated that FMS affects 2% of the general population.
To effectively manage this condition, a multidisciplinary team of healthcare professionals is required. The most effective approach is that of the four component theory originated by German physician Dr. Dietrich Klinghardt, MD PhD (see Figure 1).1 Dr. Klinghardt reasoned that medications such as anti-inflammatories, acetaminophen, muscle relaxants, etc. may all help to relieve pain in the short-term. However, if one gets to the root source (interference field) of the pain and resolves it, one gets the cure or long-term relief.
In this author’s own experiences in treating chronic pain and FMS patients for the past 20 years, it was found that the following therapies appear to be the most helpful in addressing each component illustrated in Figure 1. The following sections address each component in turn.
Structural cause of pain results from traumatic or overuse type injuries to the body’s musculoskeletal system. Traditional approaches vary from surgery for severe fractures to chiropractic/osteopathic manipulation for restricted joint movement. Properly prescribed and supervised exercise can stretch out tight muscles and strengthen weakened ones. Such exercise can be further enhanced with computer-assisted feedback (called surface EMG). This allows for much more individualized and activity-specific correction of subtle muscle imbalances that often perpetuate the pain state.
One commonly overlooked cause for persistent structural pain is that of weakened ligaments. Unlike muscle, ligaments (which are the fibrous tissues that join one bone to another) have very limited blood supply and tend to heal very slowly or incompletely. Also ligaments cannot contract and cannot be “exercised." A common cause of low back pain are weak sacroiliac ligaments at the base of the spine. These cannot be diagnosed by MRI scans and treatment is very much dependent on the manual skills of the treating therapist. For restricted or “stuck" joints, manipulation or mobilizing of the joint often restores normal movement. However, the joint with ligament injury and laxity remain unstable and the instability would only be perpetuated by repeated manipulation.
This author has found an older orthopedic medicine technique known as prolotherapy,2,3 to be helpful in such cases. This involves injecting mostly natural substances (such as dextrose and/or glucosamine, phenol, fish oil extracts) into the ligaments once every 4-6 weeks. By doing so, the ligaments are “challenged" to repair and heal back more fully. The typical patient requires from 2 to 6 injections for long-term relief of their back pain. One recent study suggests that even the needle itself at the bone-ligament interface may provide the specific mechanism of action.4 Emerging research includes human growth hormone (humatrope) intraarticular injections.
Such injections should only be done by physicians with special training (for example, through the Canadian/American Associations of Orthopaedic Medicine; www.aaomed.org). Prolotherapy works best when combined with appropriate short-term bracing (serola sacroiliac belt), avoidance of anti-inflammatories, and physiotherapy-directed exercises to enhance core stability of the spine. Failing that, surgical fusion would be a final option.
Case Report 1: Polio patient with chronic low back pain improved with prolotherapy.
A 45 year-old, married computer worker with diffuse pain worse in the low back was seen in Nov. 2000. Clinical exam revealed old polio (atrophic small flail right arm and shorter, thinner left leg; see Figure 2), 18/18 tender points (TePs) and marked tenderness in the left sacroiliac (SI) region. 2+ laxity noted with the shear test for SI instability. Nerve root tension tests were negative and EMG revealed only chronic neurogenic changes. Bloodwork and bone scan were negative for active sacroilitis. After trials of physiotherapy, chiropractic, orthotics (leg-length correction), prolotherapy injections — with P2G (phenol-glycerine-glucose) and lidocaine — were done to the SI ligaments on a monthly basis.
|Pre Rx||Post-6th Rx (06/01)|
|VAS (visual analog scale for pain)||8/10||4/10|
|Short-form McGill Questionnaire||24/45||19/45|
|Pain Disability Index||44/70||24/70|
|Oswestry LBP score||37/50||15/50|
|Algometry FMS avg. pain||2.13kg||3.0 kg|
This patient returned 2 years later for a tennis elbow complaint and was pleased to report continued back pain relief.
The body’s own biochemistry may perpetuate chronic pain include hormonal (hypothyroidism, menopause, diabetes) and hematology/ immune system (anemia, HIV, cancer etc.) deficiencies. After doing tests to rule out such diseases, one must also look for poor dietary habits (excess intake of processed carbohydrates, junk food, caffeine) and intake of toxins (smoking, chemical and environmental pollutants).
It is useful in the motivated patient to get appropriate dietary counseling from a registered dietician and, for more complex cases, to see a registered naturopathic doctor (ND). The latter professional has specialized training in the use of herbals, homeopathics,5 vitamins, other supplements,6 and dietary strategies.7,8
Detoxification approaches may include biological terrain testing, hair mineral analyses and intravenous therapies. Since many natural products also interact with drugs and chemotherapy, it would be preferable to see a naturopathic doctor who also has had training in traditional medicine. This would give a more balanced — and potentially safer — integrative approach.
Case report 2: Fibromyalgia patient can golf again after naturopathic therapies and oral guaifenesin (Dr. St. Amand protocol; see caption of Figure 3).
A 54 yr-old married retired left-handed IBM consultant had FMS for 15 years. Risk factors included childhood growing pains and hypermobility; left elbow fracture and right knee arthroscopy for osteoarthritis. Her mother had Charcot-Marie-Tooth disease (self-tested was EMG negative). She had extensive dental work and rows of amalgams and root canals. Hypertension for 2 years. Her best exercise tolerance was going on a treadmill at 1.9 mph for only a few minutes.