Fms Community Newsletter

Fms Community Newsletter #93

In This Issue:

~ Can Botox injections relieve pain?
~ Gabapentin, is it effective.
~ Cupping therapy and FM Pain
~ The Skinny on Accupuncture
~ Prolotherapy
~ Antidepressants and chronic pain
~ Magnet therapy: Can it relieve pain?
~ Botox Injections for Fibromyalgia?
~ Does Botox Relieve Fibromyalgia Pain?
~ Exercise and Fibromyalgia

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Can Botox injections relieve pain?

There's been little research on the effects of botulinum toxin type A (Botox) as a treatment for fibromyalgia, a chronic condition characterized by fatigue and widespread pain.

Here's what the research has shown so far:

One double-blind study of Botox at Ohio State University was terminated early because of adverse effects in participants, including confusion, increased pain and flu-like symptoms.
A review from South Africa reported on 16 people with fibromyalgia treated with multiple ? and in some cases, repeated ? injections of Botox. Several participants had increased pain in areas of the body that didn't receive injections. Other participants reported improvement.
The Food and Drug Administration hasn't approved Botox for the treatment of fibromyalgia. More clinical trials are needed to determine the safety and potential benefits of Botox as a fibromyalgia treatment.

Meanwhile, current treatment options for managing fibromyalgia include:

Exercise
Physical therapy
Antidepressants
Anti-seizure medications, such as gabapentin (Neurontin)
Cognitive behavior therapy
Acupuncture
Electromyogram biofeedback
Hypnotherapy
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Gabapentin (Neurontin), an anti-seizure medication, may be an effective fibromyalgia treatment.

In a 12-week study, published in April 2007, researchers looked at the potential treatment benefits of gabapentin in a group of 150 people with fibromyalgia. Participants who were treated with gabapentin reported less pain and fatigue and improved sleep compared with participants who received a placebo. The most common side effects of the medication are dizziness and drowsiness.

It is important to note that gabapentin has not been approved by the Food and Drug Administration (FDA) for the treatment of fibromyalgia. However, some doctors may prescribe it off-label for such use.

In June 2007, the FDA did approve pregabalin (Lyrica) ? an anti-seizure medication that is structurally related to gabapentin ? for fibromyalgia treatment. A study published in April 2005 suggested that pregabalin is more effective than is a placebo in reducing pain and fatigue and improving sleep in people with fibromyalgia. The most common side effects of pregabalin are dizziness and drowsiness.

If you have fibromyalgia and have questions about whether gabapentin or pregabalin may be an appropriate treatment for you, consult your doctor.

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Cupping therapy: Can it relieve fibromyalgia pain?

There's no conclusive evidence that cupping therapy relieves fibromyalgia pain. But anecdotal evidence suggests a benefit.

Cupping therapy is typically practiced by traditional Chinese medicine practitioners. The theory behind cupping is that it moves or stimulates your body's natural energy ? also called qi.

Basically, cupping involves heating the air inside a glass cup, which removes some of the air from the cup. The cup is then quickly placed on the skin and the resulting vacuum pulls the skin part of the way into the cup. The cup may be left in place for several minutes and then removed, leaving behind a bright red, circular welt. Although it sounds painful, it's not.

Many articles have been published on cupping. But many of these are case reports or anecdotes published in Chinese medical journals ? and not always available in English. There have been no peer-reviewed clinical trials specifically evaluating cupping as a treatment for painful conditions. Thus, although cupping has been a part of Chinese healing traditions for at least 3,000 years, available research hasn't yet documented its effectiveness. By Mayo Clinic Staff May 11, 2007

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Acupuncture:

Acupuncture involves the insertion of extremely thin needles to various depths at strategic points on your body. Acupuncture originated in China thousands of years ago, but over the past two decades its popularity has grown significantly within the United States. Although scientists don't fully understand how or why acupuncture works, some studies indicate that it may provide a number of medical benefits ? from reducing pain to helping with chemotherapy-induced nausea.

What happens during an acupuncture treatment session?
Acupuncture therapy usually involves a series of weekly or biweekly treatments in an outpatient setting. It's common to have up to 12 treatments in total. Although each acupuncture practitioner has his or her own unique style, each visit typically includes an exam and an assessment of your current condition, the insertion of needles, and a discussion about self-care tips. An acupuncture visit generally lasts 30 to 60 minutes.

During acupuncture treatment, the practitioner uses sterilized, individually wrapped stainless steel needles that are used only once and then thrown away. You may feel a brief, sharp sensation when the needle is inserted, but generally the procedure isn't painful. It's common to feel a deep aching sensation when the needle reaches the correct spot. After placement, the needles are sometimes moved gently or stimulated with electricity or heat.

How does acupuncture work?
The traditional Chinese theory behind acupuncture as medical treatment is very different from that of Western medicine. In traditional Chinese medicine, imbalances in the basic energetic flow of life ? known as qi or chi (chee) ? are thought to cause illness. Qi is believed to flow through pathways (meridians) in your body. These meridians and the energy flow are accessible through approximately 400 different acupuncture points. By inserting extremely fine needles into these points in various combinations, acupuncture practitioners believe that your energy flow will rebalance. This will allow your body's natural healing mechanisms to take over.

In contrast, the Western explanation of acupuncture incorporates modern concepts of neuroscience. According to the National Institutes of Health, researchers are studying at least three possible explanations for how acupuncture works:

Opioid release. During acupuncture, endorphins that are part of your body's natural pain-control system may be released into your central nervous system ? your brain and spinal cord. This reduces pain much like taking a pain medication.
Spinal cord stimulation. Acupuncture may stimulate the nerves in your spinal cord to release pain-suppressing neurotransmitters. This has sometimes been called the "gate theory."
Blood flow changes. Acupuncture needles may increase the amount of blood flow in the area around the needle. The increased blood flow may supply additional nutrients or remove toxic substances, or both, promoting healing.
Who is acupuncture for?
Acupuncture seems to be useful as a stand-alone treatment for some conditions, but it's also increasingly being used in conjunction with more conventional Western medical treatments. For example, doctors may combine acupuncture and drugs to control pain during and after surgery.

Because of the difficulty of conducting valid scientific studies of acupuncture ? numerous past studies have been proved inadequate ? it's hard to create a definitive list of the conditions for which acupuncture might be helpful. However, preliminary studies indicate that acupuncture may offer symptomatic relief for a variety of diseases and conditions, including low back pain, headaches, migraines and osteoarthritis. In a 2006 Mayo Clinic study, acupuncture significantly improved symptoms of fibromyalgia.

In addition, research shows acupuncture can help manage postoperative dental pain and alleviate chemotherapy-induced nausea and vomiting. It also appears to offer relief for chronic menstrual cramps and tennis elbow.

Pros and cons
As with most medical therapies, acupuncture has both benefits and risks. Consider the benefits:

Acupuncture is safe when performed properly.
It has few side effects.
It can be useful as a complement to other treatment methods.
It's becoming more available in conventional medical settings.
It helps control certain types of pain.
It may be an alternative if you don't respond to or don't want to take pain medications.
Acupuncture isn't safe if you have a bleeding disorder or if you're taking blood thinners. The most common side effects of acupuncture are soreness, bleeding or bruising at the needle sites. You might feel tired after a session. Rarely, a needle may break or an internal organ might be injured. If needles are reused, infectious diseases may be accidentally transmitted. However, these risks are low in the hands of a competent, certified acupuncture practitioner.

How to choose an acupuncture practitioner
In the United States, acupuncture services are offered by two types of medical professionals:

Medical doctors. About 3,000 medical doctors use acupuncture as part of their clinical practice. Most states require that these doctors have 200 to 300 hours of acupuncture training in addition to their medical training.
Certified acupuncturists. About 11,000 certified acupuncturists who aren't medical doctors practice acupuncture in the United States. To be fully certified, these professionals complete between 2,000 and 3,000 hours of training in one of several independently accredited master's degree programs. They also must successfully complete board exams conducted by a national acupuncture accreditation agency, the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM).
If you're considering acupuncture, do the same things you would do if you were choosing a doctor:

Ask people you trust for recommendations.
Check the practitioner's training and credentials.
Interview the practitioner. Ask what's involved in the treatment, how likely it is to help your condition and how much it will cost.
Find out whether the expense is covered by your insurance.
Don't be afraid to tell your doctor you're considering acupuncture. He or she may be able to tell you about the success rate of using acupuncture for your condition or recommend an acupuncture practitioner for you to try.

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Prolotherapy

Multiple studies of prolotherapy have reported conflicting evidence regarding its effectiveness in treating chronic pain. Some studies have shown a benefit, others have showed none.

Prolotherapy involves injecting painful ligaments and tendons with sugar solutions that are intended to stimulate production of connective tissue. A typical course of treatment is six to 10 sessions, sometimes with multiple injections at each session.

Proponents believe that these treatments restore strength and stability to ligaments and joints, which may relieve pain. Prolotherapy has been used to treat a number of painful musculoskeletal conditions, such as osteoarthritis and chronic back pain.

Prolotherapy is known to cause some pain at the injection site, but this is typically mild and temporary. As with any injection, there is a risk of infection, bruising, bleeding or tissue damage.

A 2007 review of five well-designed studies involving 366 participants concluded that prolotherapy alone was ineffective in treating chronic low back pain. However, when combined with other treatments ? such as spinal manipulation and exercise ? prolotherapy may improve chronic low back pain.

More research is needed to clarify what role, if any, prolotherapy plays in the treatment of chronic pain.

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~ Antidepressants and chronic pain

Some of the more effective and commonly used medications for chronic pain are drugs that were developed to control other conditions. Antidepressants are a mainstay in the treatment of many chronic pain conditions ? even when depression isn't a factor.

Tricyclic antidepressants
Amitriptyline is the antidepressant most commonly prescribed for pain, and it's the one that has been studied most thoroughly. Other tricyclic antidepressants used for pain include:

Imipramine (Tofranil)
Nortriptyline (Pamelor)
Desipramine (Norpramin)
Tricyclic antidepressants seem to work best for the burning or searing pain common after nerve damage, which sometimes occurs with diabetes, shingles or strokes. These drugs are also effective in some people for fibromyalgia, or as a preventative for migraines.

The painkilling mechanism of these drugs is still not fully understood. Tricyclic antidepressants may increase neurotransmitters in the spinal cord that reduce pain signals. But they don't work immediately. You may have to take a tricyclic antidepressant for several weeks before it starts reducing your pain.

Side effects
Tricyclic antidepressants don't cause dependence or addiction, and they're safe to take for long periods of time. But they can make you drowsy. To manage this side effect, take your tricyclic in the evening, just before bed. In addition, these drugs may cause dry mouth, constipation, weight gain, difficulty with urination and changes in blood pressure. If you have heart disease, these medications may not be a good choice. Discuss it with your doctor.

To reduce or prevent side effects, your doctor will likely start you at a low dose and slowly increase the amount. Most people are able to take tricyclic antidepressants, particularly in low doses, with only mild side effects. The doses that are effective for pain are typically lower than the doses used for depression.

Newer antidepressants
Two newer forms of antidepressants ? selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) ? have fewer side effects than tricyclic antidepressants and are sometimes used to treat chronic pain.

SSRIs include such drugs as paroxetine (Paxil) and fluoxetine (Prozac). People who have chronic pain may feel better while taking SSRIs, but this effect is believed to result more from the easing of accompanying depressive symptoms rather than from actual pain relief. Drugs such as venlafaxine (Effexor) and duloxetine (Cymbalta) are SNRIs, which appear to be more effective than SSRIs at pain control ? particularly pain caused by damaged nerves.

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Magnet therapy: Can it relieve pain?

There's no definitive evidence that magnet therapy relieves pain. However, anecdotal evidence seems to suggest that some people do experience some pain relief from magnet therapy.

Many theories have been proposed as to why magnet therapy may relieve pain. But none of these theories has been scientifically proved. Clinical trials involving magnet therapy have produced conflicting results. Some suggest effective pain relief from magnets, and others report no effect.

The vast majority of magnets marketed to consumers to treat pain are of a type called static magnets, because the resulting magnetic fields are unchanging. The other magnets used for health purposes are called electromagnets, because they generate magnetic fields only when electrical current flows through them. Currently, electromagnets are used primarily under the supervision of a doctor or in clinical trials.

Static magnets come in various strengths. Examples of products containing magnets include shoe insoles, heel inserts, mattress pads, belts and bracelets. Some of these products can be quite expensive.

Additional, larger and higher quality studies are needed to determine what role, if any, magnet therapy may play in pain relief. In the meantime, it is reasonable to say that some people appear to get some benefit from magnet therapy ? although this may be in part to a placebo effect. Also, no significant adverse effects have been reported with magnet therapy.

Bottom line: You must decide how much money you want to spend on a treatment that may or may not help but probably won't do any harm.

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Botox Injections for Fibromyalgia?

ABotulinum toxin type A (Botox) is produced by a bacterium called clostridium botulinum. The U.S. military originally purified the toxin about 30 years ago as a potential nerve agent. More recently, the toxin, which blocks neuromuscular transmission, has been used for medicinal purposes.

When injected in small quantities, Botox causes selective weakening and paralysis of muscles, thereby alleviating spasms and pain. Although the drug is approved only for certain problems involving the muscles of the eyes, doctors have used it to treat the muscular rigidity seen in various medical conditions including cerebral palsy, strokes, multiple sclerosis and some esophageal disorders, and for the pain of a muscular condition called myofascial pain syndrome. In fact, it was the successful use of Botox in some people with severe myofascial pain syndrome that led doctors to try it for fibromyalgia.

Although its use in fibromyalgia is not well studied, it is being pushed over the Internet and in the news media as the new ?miracle cure? for fibromyalgia. There are reports of patients with fibromyalgia getting some relief of their tender points (from injections) that lasts up to three to four months. Even though muscle pain is one of the major features of fibromyalgia, there are many other symptoms of the condition not helped by Botox.

If you decide to try Botox, be prepared to wait about eight days before you see any effects. The most relief occurs at about three weeks, and the injections can be repeated every three to four months. But be careful not to get them more often. Too frequent injections may cause you to develop immunity to the injections. Some patients who have received too much Botox, depending on the location of the injections, have developed facial and eyelid drooping, bruising, jaw weakness, headache, neck or back pain, and back weakness. Such symptoms last until the injections wear off.

When administered correctly, Botox appears to be safe. But the drug is expensive, costing $400 per injection.

JAMES MCKOY, MD
Rheumatologist

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Does Botox Relieve Fibromyalgia Pain?

Botox, which blocks neuromuscular transmission, has been used for medicinal and cosmetic purposes. When injected in very small quantities, Botox can cause selective weakening or paralysis of muscles. Therapeutically, it can relieve pain and spasms. A few small studies have investigated whether Botox injections (botulinum toxin type A) may be an effective treatment for fibromyalgia.

According to Mayo Clinic, a double-blind study of Botox at Ohio State University was halted because study participants experienced adverse events including confusion, flu-like symptoms, and increased pain. In another study, a South African review of 16 people with fibromyalgia treated with multiple Botox injections, several study participants experienced increased pain in body parts that were not injected while others showed improvement. The U.S. FDA has not approved Botox injections for the treatment of fibromyalgia. More clinical trials would be needed to determine safety and efficacy of Botox for fibromyalgia.

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Fibromyalgia and exercise.

Begin with stretching exercises and gentle, low-impact activity, such as walking or bicycling. Start your exercise program slowly because at the beginning, exercise may make your pain worse. Some muscle soreness is normal when you're starting to exercise, but sharp pain may be a sign that you have overworked your muscles.

As you progress with exercise, it will become more comfortable for you. For exercise to help, you must do it regularly. The goal is to get started and keep going, to gain relief from pain and to improve sleep. Below are some exercises you might want to try:

Walking: Start slowly by walking 5 minutes the first day. The next day, add a minute to this total. Keep adding 1 or 2 minutes a day until you are walking 60 minutes a day. When you reach this point, walk at least 1 hour, 3 or 4 times a week. If you find yourself struggling as you're working your way up to walking 60 minutes, go back to a length of time that was comfortable for you, and continue walking for this period of time for several days. Then continue to increase the minutes again until you reach the goal of 60 minutes. Try as many times as you need to reach the goal of walking for 60 minutes.

Walking/jogging: After you feel comfortable walking 3 or 4 times a week, you can alternate walking with slow jogging. Walk 2 blocks, then jog 1 block, walk 2 blocks, jog 1 block, and so on. Do this as often as it feels comfortable. Extend your exercise for longer periods if you feel comfortable.

Bicycling: Stationary bicycles (exercise bikes) offer the benefit of exercising indoors. Keep track of your mileage, or set a goal of bicycling for 60 minutes.

The type of exercise you choose is up to you. It's important that you start exercising and keep doing it. Exercise relieves much of the pain fibromyalgia causes. Some people even find that exercise makes all their pain go away. You will also feel better if you have some control over your own care and well-being.

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