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6 Articles in Volume 1, Issue #6
Accurate Diagnosis
Getting Off the Pain Roller Coaster
Getting to the Point
Opioid Rotation: Mechanisms, Concepts, and Benefits
The Neural Plasticity Model of Fibromyalgia Theory, Assessment, and Treatment: Part 4
The Pain and Sleep Relationship

The Neural Plasticity Model of Fibromyalgia Theory, Assessment, and Treatment: Part 4

The final installment of this series reviews EEG neurotherapy as a direct treatment technique and also discusses outcomes measurements for fibromyalgia.

Research evidence to date strongly suggests that EEG neurotherapy can be an important tool for affecting neuroplasticity. From a “regulatory challenge” model point of view, EEG neurotherapy is a method of gently challenging the brain out of equilibrium or homeostasis, to which it will attempt to return. Successive, repetitive exercise of the brain’s self-organizing system will lead to an improved ability to maintain homeostasis and improved stability of the regulatory system.81

As mentioned previously there appears to be a significant alteration in the brain wave activity of people with fibromyalgia that is primarily reflected in an excess of slow wave activity. With respect to the treatment of fibromyalgia, EEG neurotherapy is primarily focused on the alteration of the slow wave activity through the reduction of slow wave amplitude. It is believed that the abnormal qEEG evident in people with fibromyalgia reflects a disregulation in the brain’s self-organizing system that results in a concentration of power in the slow wave frequencies (primarily theta, although some lower frequency alpha is also seen) and prevents the brain from shifting freely and appropriately in response to task demands. It is thought that this concentration of power prevents or reduces an individual’s ability to shift into slower delta frequencies in order to get deep sleep and prevents or reduces a shift into faster beta frequencies so sustained focused concentration can occur.

The basis for EEG neurotherapy comes from the current widespread acceptance of the concept that the brain’s neuronal connections are continuously being modified by ongoing experiences.184-187 Some of these changes include increases in dendritic length, increases (or decreases) in spine density, synapse formation, increased glial activity, and altered metabolic activity.188 Cerebral blood flow has been altered in response to photic and auditory stimulation as well.149

EEG neurotherapy may be presently subdivided into two subtypes based upon the conditioning properties — operant and classical. Operant conditioning techniques utilize certain features of the EEG, such as digitized amplitudes of selected frequency ranges, presented in a visual display on a computer screen to the patient in relative real time as a form of biofeedback. The patient’s task is to actively learn to modify these displayed features to achieve a pre-determined, specified goal of EEG change through maintenance of some “correct psychophysiological state.”

Lubar and his associates189 use an operant conditioning procedure in their neurotherapy protocol for treating attention-deficit disorder. In this procedure an active electrode is placed on the scalp over the brain at CZ or FZ and referenced to both ears (i.e., monopolar referencing setup). The goal is to decrease the level of theta and slow alpha activity while simultaneously increasing the level of low beta activity apparent in the EEG as recorded from these locations. A computer displays real-time information to the learner on the amplitude of the slow wave frequencies to be decreased as well as the amplitude of the low beta activity to be increased. When a pre-determined differential is obtained, the learner is rewarded with an auditory or a visual stimulus reinforcing the achieved pattern of EEG activity and the “mental state” that produced it.

Studies of the use of similar operant conditioning biofeedback techniques in treating fibromyalgia are extremely limited, with only anecdotal reports and uncontrolled studies of improvements reported. Controlled studies using such EEG biofeedback techniques in altering ADD dysfunctions (decreasing theta and slow alpha and increasing SMR or lower beta) demonstrate significant and long-term changes with improvements in functioning and measured intelligence noted (see Lubar55,189,190). Until more comprehensive research is completed, the use of this technique in treating fibromyalgia must be considered exploratory in nature.

Classical conditioning techniques utilize light, sound, kinesthetic, or electromagnetic stimulation to drive the brain and alter brain wave parameters. In the classical conditioning model, multimodal sensory stimuli in the environment are seen to contribute to the background EEG. A device is used to provide multimodal rate-modulated stimulation to drive the background EEG to a modified rate over repeated training sessions in which the random sensory stimuli in the environment are coincident with the rate modulated stimuli.135

There are two basic forms of classical conditioning EEG treatment — photic stimulation (or photic combined with auditory stimulation) and electromagnetic (infrared) stimulation. As with the operant conditioning programs, controlled studies are few, with most of the classical conditioning data coming from the treatment of ADD/ADHD191 and, in the fibromyalgia areas, from Siever192 and Ochs (research in progress).

Chaudhuri193 reported on the treatment of 23 people with fibromyalgia using EEG-Driven Stimulation® (EDS) (see Ochs194) to normalize brain wave activity. Patients averaged 25 hours of EDS therapy over a period of approximately 12 weeks. Nine patients showed significant improvement in their symptoms, 11 showed some improvement, and three showed no change by the end of treatment. No data as to what specific changes occurred is available.

Russell191 demonstrated that intermittent photic stimulation coupled with binaural sound, activated groups of neurons in the visual and auditory cortex. The rate of stimulation was controlled by the dominant frequency of each individual’s brain. Forty treatments produced significant improvements in cognitive functioning, which lasted over time (16 months). Micheletti has recently replicated these results.195

Siever192,196 has used similar techniques in treating fibromyalgia and chronic fatigue syndrome. Using photic stimulation (white light produced by incandescent bulbs covered by a translucent plastic sheet tinted light blue) and auditory stimulation (pulsing isochronal tones at a frequency of 170 Hz) techniques, Siever and his colleagues in a number of uncontrolled studies, have demonstrated significant change in a number of commonly reported fibromyalgia symptoms.192,196-198 Reported positive changes include a reduction in pain, anxiety, and fatigue.

There are two basic forms of classical conditioning EEG treatment — photic stimulation (or photic combined with auditory stimulation) and electromagnetic (infrared) stimulation.

Finally, Ochs199 has treated a number of people with fibromyalgia as well as chronic fatigue syndrome using an infrared (IR) rehabilitation device. This device distributes the results of the IR stimulation through the central nervous system initially along the visual pathways, and may affect autonomously-generated CNS myalgia by stimulating a re-mapping of the pain afferents on the striate cortex. Stimulating the central mechanisms may also account for reported reductions in cognitive symptoms, mental fog, depression, movement and balance disorder, sleeping problems, low energy during the day, as well as reductions in pain. Exposures to the IR stimulation range from one to seven minutes per treatment session, once or twice a week, with an average of 22 treatments.

Presently the use of EEG neurostimulation techniques must be considered exploratory in nature. However, there is enough promising anecdotal information available to promote its use as a treatment device but controlled studies are needed. If as suggested, the CNS reacts to and is altered by repeated stimulation, then these techniques may have promise in reversing this process of neurosensitization.

Outcome Studies

A more recent trend in literature is to view the treatment of fibromyalgia from a multidisciplinary approach. The overall effectiveness of combining treatment modalities focused on both the central and peripheral nervous systems in alleviating the complex psychological and somatic complaints associated with fibromyalgia is demonstrated by recent clinical outcomes studies by Donaldson21 and Mueller.67 Both these retrospective studies demonstrated that a multidisciplinary approach to the treatment of fibromyalgia shows a high success rate with positive long-term results.

Donaldson21 studied 252 consecutive referrals over a period of one year to a chronic pain treatment center in Calgary, Alberta. All subjects were physician referred, with 157 (62 percent) meeting the ACR 1990 criteria for fibromyalgia. All subjects received a four-point evaluation including: a) trigger point evaluation; b) sEMG evaluation; c) physiotherapy evaluation; and d) an EEG evaluation as designed by Ochs.199,200 This evaluation was then repeated post treatment, whenever possible. All subjects received a comprehensive treatment program, which included: a) trigger point therapy; b) physiotherapy; c) sEMG neuromuscular retraining as outlined in Donaldson;84 and d) EEG neurotherapy as designed by Ochs.194,199-201 These subjects were on average 44.2 years old (range 14 - 85 yrs), 80 percent female, in pain for an average of seven years, with a total score of 29.3 on the McGill Pain Questionnaire.37 SEMG evaluation showed significant muscle dysfunctions primarily affecting the upper trapezius (47.2 percent of the sample) and other muscles in the neck. The EEG evaluation indicated the presence of elevated theta activity 28.1 percent of the time, alpha activity 14.3 percent of the time, and theta/alpha 17.3 percent. This dominance was evident at seven of 13 sites examined including FP, F3, FZ, C3, CZ, C4, and PZ.

A combined therapy program of sEMG biofeedback, massage therapy, physiotherapy, and EEG neurotherapy showed, after one year, that out of 44 who had completed treatment, four reported increased symptoms, 10 reported virtually a 100 percent decrease in symptoms, with the remaining 30 all improved to varying degrees. There was a marked pattern to the improvement; with cognitive dysfunctions clearing up in two to three weeks, pain decreasing and becoming localized in two to three months, and sleep improving in approximately three months. Long-term follow-up of the subjects that improved showed they maintained the improvement over a further one-year follow-up.

The overall effectiveness of combining treatment modalities focused on both central and peripheral nervous systems in alleviating the complex psychological and somatic complaints associated with fibromyalgia is demonstrated by a recent clinical outcomes study of a series of 30 consecutive fibromyalgia patients treated at a chronic pain center in Edmonton.67 All patients (27 female, three male; aged 50.7 ± 12.0 years) included in this study had been previously diagnosed with fibromyalgia by a treating physician, fully met the American College of Rheumatology classification criteria for fibromyalgia as determined by both their history and a physical examination with tender point palpation and dolorimetry, and were actively symptomatic at the time of their intake to treatment. Disease chronicity averaged 5.7 ± 4.9 years.

Although there was some individual variation, patients were generally treated three to five times per week exclusively with a form of EEG neurotherapy that uses photic stimulation interactively controlled by the patient’s own dominant EEG frequency — EEG-Driven Stimulation® (EDS)† — until their in-session self-reports began to reveal a positive change in perceived mental clarity, mood, and restorative sleep as well as a shift from experiencing “all-over-body” pain to more localized aches and pains. Once this shift in self-reported symptoms became apparent (i.e., mean of 16 ± 6 weeks; range six to 29 weeks), the number of EDS sessions per week was gradually reduced and two to three weekly sessions of physical therapies were added. Physical therapies included some combination of trigger point massage, intramuscular stimulation, myofascial and positional release, stretch and spray, sEMG-assisted neuromuscular retraining,84 prescribed muscle stretching, and strengthening exercises, dependent on each patient’s individual needs. As a group, these patients averaged 37.3 ± 15.6 hours of EDS and 14.7 ± 8.0 hours of physical therapies over the course of approximately three to four months of treatment.

Because all patients received differing amounts of the various therapy modalities, it was not possible to determine which therapy accounted for the majority of the patients’ improvements.

Significant pre- versus post-treatment changes were obtained on the Symptom Check List 90-R (SCL-90-R),109 the Fibromyalgia Impact Questionnaire (FIQ),202 repeated patient self-reports of selected key symptoms using a 10 cm visual analog scale (VAS), spectral EEG bandwidth power, number of positive fibromyalgia tender points, mean pain threshold over tender points, and total percent of body perceived as painful as indicated on a human figure drawing. Patients rated themselves as an average of 62.2 percent ± 21.6 percent improved overall (range 20 to 90 percent) at the time of their follow-up, an average of 8.2 ± 4.3 months after treatment was terminated.

Treatment was associated with significant improvement in SCL-90-R Global Severity Index scores, as well as on seven of nine subscales; with greatest change in those symptoms included within the Somatization, Obsessive-Compulsive, Depression, and Anxiety subscales. Broadly, SCL-90-R profiles shifted from clinical to normal levels. Similarly, patient VAS ratings for sleep quality, pain intensity, level of fatigue, level of cognitive clouding, level of depression, and level of anxiety improved significantly from intake to discharge (i.e., 134.5 percent, 68.5 percent, 39.7 percent, 66.1 percent, 65.4 percent, and 67.6 percent improved, respectively).

EDS therapy was associated with a significant decrease in average levels of cortical delta (1-4 Hz), theta (4-8 Hz), and alpha (8-12 Hz) power as measured in pre- versus post-treatment EDS brain maps (i.e., 31.3 percent, 28.9 percent, and 18.7 percent reductions, respectively). Changes in low beta (12-18 Hz) and mid beta (18-24 Hz) power were not significant.

Treatment also resulted in a significant decrease in the average percent of the body perceived as painful, as indicated on a human figure drawing,203 from a mean of 33.0 percent ± 12.4 percent at intake to 10.1 percent ± 11.2 percent at discharge. Similarly, treatment resulted in a significant reduction in number of positive tender points (from 15 ± 2 at intake, to 8 ± 3 at discharge) for the group; with all patients meeting the criteria of at least 11 of 18 tender points positive for pain at less than 4.0 kg/cm2 of pressure on intake and only four patients (13 percent) still meeting this criteria on discharge. As a group, the mean pain threshold over the 18 fibromyalgia tender point locations increased significantly; from 2.6 ± 0.5 kg/cm2 to 3.8 ± 0.9 kg/cm2 of pressure.

Finally, there were significant increases in patients’ “activities of daily living” (50 percent increase), average days per week in which patients “felt good” (from 1.1 to 4.4 days), and average number of nights per week patients “slept well” (from 1.8 to 5.2 nights) as reported on the FIQ at treatment intake versus at follow-up, an average of eight months post-treatment.

Because all patients received differing amounts of the various therapy modalities, it was not possible to determine which therapy accounted for the majority of the patients’ improvements. However, it was noted that reductions in EEG delta and theta amplitudes correlated significantly with improvements in SCL-90-R Global Severity Index, Somatization, Depression, and Anxiety scores as well as with improved ability to perform activities of daily living, increased number of days in which patients felt good, and increased number of nights patients slept well as indicated on the FIQ. The number of sessions of EDS therapy correlated most strongly with patients’ self-report of reduced pain and improved sleep over the course of treatment sessions. Time spent in physical therapies was most strongly correlated with reductions in patients’ number of positive tender points, increased pain threshold, and decreased percent of the body experienced as painful.

This data is consistent in that it suggests a change in the CNS activity is necessary before a change in the remainder of the symptomatology may occur. This points to a centrally mediated control mechanism as a key component to change.

Clinical Comment

Presently it is not known which of the treatment components, discussed in this series of articles, are necessary and sufficient in order to effect change. Physical treatment without EEG neurotherapy does not seem to address the CNS issues, with patients frequently demonstrating only modest initial improvements but rarely any significant or lasting improvement in their symptoms. On the other hand, EEG neurotherapy on its own, while appearing to reduce the CNS dysfunction, does not address the peripheral sources of pain and appears to lead to a relapse in pain over the course of time. For those individuals whose fibromyalgia was caused by or is at least partially maintained stress, psychotherapy or counseling as well as somatic biofeedback therapies are needed to give them the coping skills necessary to manage stress without a relapse.

Conclusion

Fibromyalgia syndrome appears to be caused by, or have elements of, neurophysiological dysregulation. The presence of altered muscle activity and brain wave patterns point in this direction. The dysregulation appears to involve motor, sensory, and brain components, all of which interact to produce a dysfunction that is resistant to single modality treatment.

For whatever reason, the investigation of these dysfunctions has ignored the possibility of muscular dysregulation as the pathogenesis of pain. There is clear and reliable data demonstrating the presence of muscle dysfunction(s), particularly muscular cocontraction(s) in a number of diseases primarily developmental in nature. The re-emergence of these patterns may reflect significant pathology involving the thalamus, or a breakdown in the learned inhibitory control mechanisms acquired as children. Whether central and/or peripheral control mechanisms individually or in combination are responsible for the breakdown remains to be seen. Biomechanical (joint) dysfunctions, muscular dysfunctions, posture, ergonomics, disease, and stress all have a part in causing the re-emergence of muscle dysregulation.134 This potentially could explain the wide variety of etiological factors, which have been shown to be related to the onset of these dysfunctions.

Fibromyalgia syndrome appears to be caused by, or have elements of, neurophysiological dysregulation.

Coderre states “in some cases peripheral tissue damage or nerve injury leads to a pathological state characterized by one or more of the following: pain in the absence of a noxious stimulus, increased duration of response to brief stimulation, reduced pain threshold, increased responsiveness to suprathreshold stimulation, and spread of pain and hyperalgesia to uninjured tissue”.64 This perhaps explains the altered sensitivity to pain and other sensory changes.

Most interesting are the alterations in cognitive functioning as reported with fibromyalgia and such similar conditions as chronic fatigue syndrome. These changes appear to involve the entire cortex, although the preliminary qEEG data suggests more of a frontal impact. It is possible to speculate that the thalamus (which regulates sensory input from the body) becomes over-loaded, reducing the stimulation of the cortex and producing the “idling-like” response as seen in the frontal areas (personal communication R. Thatcher — March, 1999). Jacobs204 examined the role of serotonin (particularly 5HT) and its role in thalamic activity. They note that the activity of serotonergic neurons is almost totally suppressed during REM sleep, a period of profound muscle inhibition. They also state that brain serotonergic neurons: a) facilitate motor output while; b) simultaneously suppressing sensory information processing; and c) has an auxiliary role in autonomic activity. While the authors do not mention or connect their article to fibromyalgia, the functions mentioned previously are very similar to the disregulations reported in fibromyalgia. It is also possible that other factors such as a reduction of activation in the reticular arousal system (RAS) may have an influence. Further research in these areas, particularly on the thalamus, is needed. It is also possible that the data presented above reflect epiphenomena, the origin of which remains to be determined.

The above theoretical position differs substantially from those presently in vogue. Clinics throughout North America are now reporting successes in treating people with fibromyalgia by using a combination of treatments. There is enough data from studies and clinical investigations to form a substantial database from which to make the suggestion that fibromyalgia syndrome has a neurophysiological basis that warrants further investigation. This is particularly true given the numbers of individuals that have been successfully treated using multidisciplinary techniques centered about the use of sEMG biofeedback and EEG neurotherapy combined with myotherapies and counseling.

Last updated on: January 6, 2012
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