Transcription:
Significant Advances For The Treatment of Fibromyalgia

Melanie Cole (Host):  Fibromyalgia affects millions of Americans, predominantly women, and is often misunderstood by the medical community. In recent years, however, significant advances have occurred in our understanding of this condition. My guest today is Dr. Murray McAllister. He's a health psychologist and the clinical director of Pain Services for Courage Kenny Rehabilitation Institute. Welcome to the show, Dr. McAllister.  First, tell us what is fibromyalgia?

Dr. Murray McAllister (Guest):  Well, fibromyalgia is a chronic pain condition that is characterized by a few key symptoms. Those symptoms are widespread pain all over, excessive fatigue, and what might be considered a sensitivity to touch or mild pressure. So, what I mean by that is that people with fibromyalgia, as well as other chronic pain conditions, by the way, will often report that at some time during the course of their condition, they notice that things that are normally not painful have become painful. The classic example for fibromyalgia is that hugs hurt. The pressure to the skin and the muscles that are involved in a hug that shouldn't be painful have, in fact, become painful. We call this “allodynia” or “hyperalgesia”. People with fibromyalgia they report pain all over, the sensitivity to touch and pressure and excessive fatigue. Commonly, though, folks with fibromyalgia also report other symptoms, too. They can report they have light and unrestful sleep, irritable bowel symptoms, poor concentration, short term memory problems, anxiety, depression and these kinds of things.

Melanie:  Dr. McAllister, do we know what causes fibromyalgia?

Dr. McAllister:  That's a great question. In fact, we do. For many years, though, it was thought to be an idiopathic condition. Idiopathic means that we didn't know what causes it. But, recently, I would say in the last decade-and-a-half, basic science has come to find that fibromyalgia is caused by a condition called “central sensitization’ and to explain what that means, I have to first talk about how pain works in the body. In our society, we oftentimes think that injury or illness is the most important thing when it comes to pain and, of course, it is important, but no matter what the source of pain is, we also need a nervous system in order to have pain. The nerves in the body detect some kind of problem, like an injury, and they send those signals up the spinal cord and brain, which is also part of the nervous system. The brain processes those signals and creates pain in the body.  So, for example, if I had a four inch nail sticking in my foot, I'd feel pain in my foot, of course, but it's only because the nerves in my foot are sending signals up the spinal cord and brain and the brain is processing those signals into the experience of pain in the foot. So, that's how normal pain works. Now, in normally functioning nervous systems, it takes a certain amount of stimuli to cause pain. So, for example, usually it would take a slug in the arm to cause me pain in my arm; whereas, a gentle pat on my arm typically isn't a sufficient amount of force to cause pain. Now, if we got back to fibromyalgia here, what happens in fibromyalgia is that the nervous system becomes excessively reactive. So, it takes less and less stimuli to cause pain. So, the nerves in the body and spinal cord and the brain come to communicate to each other in such a way that the whole system gets stuck in this heightened state of reactivity. It's like it's stuck in this hair-trigger mode that any amount of stimuli can cause pain--for example, just sitting in a chair. Now, that amount of stimuli that occurs when sitting in a chair or having a grandchild sit on my lap shouldn't be painful, but for folks with fibromyalgia it is because those nerves are sending up the signals to the brain and the brain is processing it into pain. So, when the whole system gets stuck in this high state of reactivity, it's called “central sensitization”. That's what we know now is the cause of fibromyalgia.

Melanie:  That's fascinating and so well explained. How do you diagnose it?

Dr. McAllister:  Well, you know, it's basically based on the patient's self-report of symptoms. We all would love to have a reliable test for the condition, some kind of litmus test for it, but we also, unfortunately, don't have that. In the health care system what the providers does, essentially, is a checklist of possible causes for this widespread pain all over. So, they're going to rule out first, like rheumatoid arthritis, or lupus, or other rheumatological conditions. They'll rule out orthopedic conditions like bone fractures or ligament tears or sprains, things like that. They'll rule out cancer and making sure that somebody doesn't have cancer, but once all those tests come back negative, then, basically, the diagnosis is on the self-reported symptoms of the patient. Specifically, that would be the widespread pain all over and it has to be kind of pain below the waist and above the waist, on the right side, on the left . Of course, the pain typically moves back and forth from day to day, but it has to be on all four quadrants of the body at some time. Then, also, I should add, that it has to be for at least three months, which is the typical, common time for marking something as chronic. Now, just up until about a few years ago, health care providers diagnosed the condition by slightly palpating, or pushing on certain areas of the body called “tender points”. So, if the patient reported pain upon mild pressure at a sufficient number of these sites, they were considered to have fibromyalgia. In the last few years, we've realized that that's not a very reliable test and the field has come to recognize that we're just going to base the diagnosis on self-reported symptoms once everything else has been ruled out.

Melanie:  So, Dr. McAllister, I would like to ask you, because there seems to be some stigma around the condition of fibromyalgia. Why do you think that is and why are more women involved in this?  Do you think there's something stress related? Talk about that correlation for just a minute.

Dr. McAllister:  Yes. Well, first we take the issue of stigma. That's such a big issue for folks with fibromyalgia and for other chronic pain conditions, for that matter, too. You know, people in society without pain, they just don't understand how someone can have pain all over without an injury or, even if there was injury way back when that's maybe been a couple of years ago and it's all since healed up. So, people don't understand how pain can last for that long. They also don't understand that heightened sensitivity, so they don't understand when a hug can hurt and for most of us, hugs feel good. So, when a person says with fibromyalgia says that it hurts, it's hard to understand. I think in that lack of understanding and the difficulty in understanding, people, unfortunately, can turn to judge them. They can kind of think, "Oh, they must be crazy or a hypochondriac" or something. Unfortunately, in our society, mental health problems like that are really stigmatized. So, if a patient is mistakenly put into that category of conditions, they too get stigmatized and it's really unfortunate. You asked about the correlation with women. Yes, that's an interesting question. Studies have suggested that probably upwards to 90% of folks with fibromyalgia are women. We actually don't know why that is. I think most experts would suggest that it's probably due to a combination of multiple factors like biological and psychological/social factors. When we think about it, our health is super complicated. When we consider most common chronic health conditions today like, say, not only fibromyalgia or chronic pain, but, say, diabetes or heart disease, there's a result of many factors. They’re biological and genetic. There are also lifestyle and behavioral  factors that come into play as well as societal. The societal factors--the times in which we live--the common health problems that we deal with today like I was just mentioning, they're very different than what we or what our grandparents dealt with.

Melanie:  Oh, they certainly are and we are seeing some more of these autoimmune type diseases now. In just these last few minutes, tell us how it's treated, Dr. McAllister.

Dr. McAllister:  Well, yes, that's a great question. So, basic science and applied science has really found four categories of things that really work. Historically, fibromyalgia was thought to be something there was really nothing that could be done about it but in the last decade or two, we've really found that there are some effective things that could help. Now, I should add, though, that effective doesn't mean curative. There's no pill or procedure that can cure fibromyalgia but it's so effective in the sense of helping patients to get incrementally better. So, they have less pain over time or more energy over time and are more able to do those activities of life that they want to do. So, what are those four categories? First would be some form of mild aerobic exercise. So, for example, walking, or pool therapies, exercise bike when done on a regular basis over an extended period of time. So, once a patient can get to the point where they're able to do some kind of mild aerobic exercise for 20, 30, 40 minutes, three to five times a week--when they're able to do that, over time they're going to see less and less symptoms.  The second thing would be cognitive behavioral therapy, which is having an expert coach who essentially coaches folks on how to make these kinds of healthy lifestyle changes as well as learn some specialized cognitive and emotional coping strategies. Third category would be some kind of relaxation therapy. So, this is diaphragmatic breathing, progressive muscle relaxation but also things like meditation and mindfulness, tai chi, yoga--all of these have been shown in clinical trials to be helpful for chronic pain of all kinds, but fibromyalgia, in particular.  And then, the fourth thing that's been helpful are medications. There are essentially two classes of medications:  the tricyclic antidepressant and then anti-epileptic medication. Now, I should add just real quickly, because folks are oftentimes wondering, "What medications I should take?” and while they have been shown to be helpful in clinical trials, they're not the most helpful thing to do. The most helpful things are these mild aerobic exercises, the relaxation exercises done on a regular basis, as well as CBT. Now, by all means, folks should maybe take a medication if it's helpful, but it's in the combination of all four strategies that's really been shown to be the most helpful over time.

Melanie:  So, in just the last minute, what's your best advice with fibromyalgia and who they should seek for care?

Dr. McAllister:  I would say that my best advice would be to be open to understanding the cause of fibromyalgia and how the nervous system gets stuck in that high state of reactivity called “central sensitization”. So, if you understand that, and accept it, it becomes clear as to why you should be doing those four strategies of effective therapies because they all target the nervous system and reduce its reactivity over time.

Melanie:  Thank you so much. It is really great information. You're listening to The WELLcast with Allina Health. For more information, you can go to allinahealth.org. That's allinahealth.org. This is Melanie Cole. Thanks so much for listening.