Osteoporosis: The Risks and Treatment Options

By Gordon C. Gunn M.D.

According to the National Osteoporosis Foundation (NOF), it is estimated that 10 million Americans (80% of them women) have osteoporosis (severe bone loss with a high risk for bone fracture) and an additional 18 million have osteopenia (moderate bone loss). Once men reach age 65-70 bone mass loss occurs at the same rate as women, and 1/3 of all hip fractures each year occur in men. Bone is a dynamic tissue and is constantly being removed (reabsorbed) by cells called ‘osteoclasts’, while cells called ‘osteoblasts’ are forming new bone. After age 30, bone re-absorption gradually starts to exceed bone formation leading to a lower bone density. By the time women are in there 80’s, 50% will have osteoporosis in one or both hips. Vertebral (spinal) fractures lead to chronic pain, disability and height loss. Hip fractures are associated with increased risk of hospitalization, long-term disability and death.



Risk factors for Osteoporosis Include:

  • Age (50 yrs and over)
  • Cigarette smoking
  • Low body weight
  • Personal history of bone fracture
  • Family history of osteoporosis or hip fracture
  • Caucasian or Asian heritage
  • Long-term (>6 months) steroid therapy (severe asthma or arthritis)
  • Estrogen deficiency occurring with menopause
  • Alcoholism / Drug use
  • Inadequate physical activity
  • Malabsorption disorders (IBS, eating disorders, stomach stapling)
  • Inadequate calcium intake

 


Determination of Bone Density:

Bone mineral density (‘BMD’) is measured by a precise, accurate and extremely low radiation machine called a DEXA (dual-energy x-ray absorptiometry). When the BMD is measured, it is compared to a healthy young adult of the same sex and is reported as a “T-score”. If the T-Score is 10% to 25% below the average for a healthy young adult, osteopenia is present.

  • Normal T-score is above 0 to – 1.00
  • Osteopenia T-score is between –1. 00 and – 2.50
  • Osteoporosis T-score is lower than – 2.50



Preventive and Treatment Measures:

  • Calcium: 1200 mg/day through diet and/or supplements.
  • Calcium Carbonate should be taken with food
  • Calcium Citrate and Calcium Phosphate can be taken at any time of the day.
  • Vitamin D3: 1000 I.U/day; Increases absorption of calcium into bone.
  • Weight bearing exercise: Weight bearing means exercise in which bones and muscles work against gravity as the feet and legs bear the body’s weight. This may include walking, jogging, stair climbing, dancing and tennis. Weight lifting improves muscle mass and bone density.
  • Avoid smoking, excessive alcohol intake, carbonated drinks, and excessive caffeine intake.



Medical Treatment of Osteopenia (T-scores < -2.0) and Osteoporosis:


  1. Estrogen therapy is preventive by reducing progressive postmenopausal bone loss and decreasing the risk of vertebral (spine) fractures. Long-term estrogen replacement (over 10 years) has not demonstrated any increased risk of breast cancer. Data supports beneficial cardiovascular effects of estrogen replacement when started early in menopause.

  2. SERMS –Selective Estrogen Receptor Modulators
    1. Raloxifene (“Evista”):
      1. 2nd Generation SERM used to prevent and treat bone loss.
      2. Evista reduces the risk of spinal fractures by 35-60%.
      3. Cardiovascular benefit as cholesterol levels may be improved.
      4. Does not increase the risk of breast or uterine cancer.
      5. Possible side effects include hot flashes, leg cramps and rarely, blood clots.
    2. b Bazedoxiphene
      1. New 3rd Generation SERM
      2. FDA approved combined with conjugated estrogen for menopausal symptoms (Duavee)
      3. FDA approval for treatment of osteoporosis is pending
      4. Bazedoxiphene is approved in Europe for treatment of severe osteopenia and osteoporosis for patients who do not take others forms of medications (e.g. Bisphosphonates, Prolia, etc.).
      5. When used with estrogen for HRT (Duavee), it replaces progesterone, as it protects the uterine lining (endometrium) from growing and eliminates uterine bleeding.
      6. Also has a protective effect on breast tissue, similar to “Tamoxifen” (1st Generation SERM) used for prevention of breast cancer)


  3. Bisphosphonates:
    1. Used to treat bone loss by inhibiting bone breakdown and therefore increases bone density.
    2. Types of medications:
      1. Fosamax (Alendronate)-Daily or weekly, oral
      2. Actonel (Risedronate)-weekly or monthly, oral
      3. Boniva (Ibandronate)-monthly, oral or intravenously every 3 months
      4. Reclast (Zoledronic Acid)- yearly intravenously
    3. A common side effect of this class of drug is irritation of esophagus.
    4. Rare cases of osteonecrosis (destruction of bone tissue) of the jaw or non-traumatic fracture of thigh bone (femur) have been reported, but have not been shown to be due to these medications. As a precaution, I recommend discontinuing the medication one month prior to a tooth extraction, implant or root canal. The medication may be resumed one month after the procedure.


  4. Denosumab (Prolia)
    1. FDA approved for treatment of postmenopausal osteoporosis.
    2. Decreases osteoclastic activity of bone reducing the incidence of vertebral, non-vertebral, and hip fractures
    3. Administered by injection every 6 months
    4. Important that blood calcium and Vit. D levels are normal
    5. Report possible side effects are primarily musculoskeletal pain (back and extremities)



References:

  • National Osteoporosis Foundation http://www.nof.org
  • Osteoporosis and Related Bone Disease, National Resource Center http://www.osteo.org
  • U.S. Dept. of Agriculture (USDA) Food and Nutrition Information Center http://www.nal.usda.gov.fnic
 

Meditation

By Gordon C. Gunn, M.D.

What Exactly is It?


Taoism – Seeking Balance
Taoism is not a religion, nor a philosophy. It is a “Way” of life. The Tao is a belief in the natural order of things. It is like a river or a force that flows through every living object, as well as through the entire universe. It is similar to the belief of God practiced by religions throughout the world, including Confucianism, Buddhism, Islam, Judaism and Christianity.

Taoism asks that each person focus on their world in order to ultimately discover his or her inner harmonies and the harmony of the universe. It is a theology heavily focused on meditation and contemplation. The original source of Taoism is said to be the ancient I Ching, the Book of Changes. The primary figures in Taoism are Lao Tzu and Chuang Tzu, two scholars who dedicated their lives to balancing their inner spirits.

The most common graphic representation of Taoist theology is the circular Yin/Yang figure. It represents the circular balance of opposites throughout the universe. Separating the Yin & Yang is to separate the polar aspects of our lives and see them with clarity. Meditation is a way to seek an awareness and appreciation of these opposites, so as to be able to balance them and bring them into harmony. When they are present equally, a natural state of calm and sense of balance is achieved. When one outweighs the other, there is confusion, disarray and absence of balance. The Yin/Yang is a model or concept of the Tao that allows each person to contemplate the state of his or her lives. When they are brought into balance, it is possible to experience perfect happiness. Meditation is a “Way” to achieve this balanced state of being.



What Exactly is Mindfulness Meditation?

Mindfulness is sense of presence or ‘being in the moment’ with a clear focus of what is happening around you – here, now, with clarity and being fully aware. It is a way of ‘meeting your world on purpose’ and without judgment. It is ‘paying attention on purpose’ to the unfolding moment-to-moment experience both within and without. Mindfulness is learning to remain ‘centered’ so as to see clearly and feel fully the changing and evolving flow of sensations, feelings (pleasant and unpleasant), emotions and sounds, as they enter your awareness.

In other words, mindfulness is simply a state of open and nonjudgmental attention to the contents of your consciousness, whether pleasant or unpleasant. Cultivating this quality of mindful awareness has been demonstrated in many neuro-scientific studies to modulate pain, mitigate anxiety and depression, improve cognitive function, and even produce changes in gray matter density in regions of the brain related to learning and memory, emotional regulation, and self awareness.

Meditation is the act of taking time to practice concentrated focusing upon a sound, an object, the breath, or movement or visualization in order to increase awareness of the present moment, to promote relaxation, reduce stress and enhance personal and spiritual growth. It works. How successful is directly related to the frequency and diligence of the time dedicated.

The teaching of Meditation varies among different schools of thought and interpretation of the Tao. Simply stated it can be represented in two basic, but different forms:

  • Mindfulness Meditation – focuses on the present experience, aware and feeling ‘the moment’ and accepts intrusive thoughts.
  • Concentration Meditation – focuses on a particular repetitive phrase, object, prayer or action (like a mantra) and rejects intrusive thoughts.



Achieving a state of Complete Relaxation is learning to develop a structural sensitivity to your body and being able to sink (relaxing) and ROOT to the earth (grounded) with a natural calm and with a solid attachment. When you are relaxed and rooted, you are able to bend with external forces without breaking, as a rooted tree bends with the wind.



The Practice of Mindful Meditation

The practice of mindfulness is extraordinarily simple to describe, but it is in no way easy. Here, as elsewhere in life, the “10,000 Hour Rule” of author, Malcolm Gladwell, tends to apply. True mastery probably requires special talent and a lifetime of practice. The simple instructions below are analogous to instructions on ‘how to walk a tightrope’:

  • Find a horizontal cable that can support your weight.
  • Stand on one end.
  • Step forward by placing one foot directly in front of the other.
  • Repeat.
  • Don’t fall.



Clearly, steps 3-5 entail a little practice. Fortunately, the benefits of practicing meditation and developing mindfulness arrive long before mastery ever does.

As every meditator soon discovers, distraction is the normal condition of our minds: Most of us fall from the wire every second, toppling headlong–whether gliding happily in reverie, or plunging into fear, anger, self-hatred and other negative states of mind. Meditation is a technique for breaking this spell of distraction, if only for a few moments. The goal is to awaken from our trance of discursive thinking–and from the habit of ceaselessly grasping at the pleasant and recoiling from the unpleasant–so that we can enjoy a mind that is undisturbed by worry, merely open like the sky, and effortlessly, aware of the flow of experience in the present. The ultimate state of awareness is not thoughts per se, but the state of thinking without knowing that one is thinking.

There are many different approaches or strategies to meditation. They all have the same goal – a positive and sincere attitude about your practicing. Rather than adding to your ‘should’ list, choose to practice because you care about connecting with your innate capacity for love, clarity and inner peace. There is no ‘right’ way to meditate. Striving to ‘get it right’ reinforces the sense of an imperfect, striving self. Rather, allow the meditation experience to be whatever it is, spontaneously, without trying (state of Wu Wei, defined below).



Meditation Instructions:

  • Sit comfortably, with your spine erect, either in chair or cross-legged on a cushion.
  • Close your eyes, take a few deep breaths, and feel the points of contact between your body and the chair or floor. Notice the sensations associated with sitting – e.g. feelings of pressure, warmth, tingling, vibration, etc.
  • Gradually become aware of the process of breathing. Pay attention to wherever you feel the breath most clearly–either at the nostrils, or in the rising and falling your abdomen.
  • Allow your attention to rest in the mere sensation of breathing. Do not try to control your breath. Just let it come and go, naturally.
  • Every time your mind wanders in thought, gently return it to the sensation of breathing.
  • As you focus on the breath, you will notice that other perceptions and sensations continue to appear: sounds, feelings in the body, emotions, etc. Simply notice these as they emerge in your field of awareness, and then return to the sensation of breathing.
  • Getting distracted or stalled with your thoughts is totally natural. The moment you observe that you have been lost in thought, return your attention to the breath, allowing your thoughts to resume passing by without any further consideration; like passing clouds.
  • Continue in this way until you can simply witness all objects of consciousness–sights, sounds, sensations, emotions, and even thoughts themselves–as they arise and pass away.



The key to successful mindfulness and complete relaxation is daily practice. Make a commitment to yourself to sit for a few minutes twice a day and enjoy the feeling. Five minutes after brushing your teeth in the morning and again in the evening is an easy way to start. Practice for a month, consider listening to meditative music or guided instruction (see references below). It becomes a journey.

There is a Zen teaching that states: “The most important thing – is remembering the most important thing”.

One of Taoism’s most important concepts is Wu-Wei, which is sometimes translated as “no-trying or “no- doing”. A better way to think of it, however, is as a paradoxical “Action of non-action.” Wu-Wei (pronounced ‘OOO-Way’) refers to the cultivation of a state of being in which our actions are quite effortlessly in alignment with the ebb and flow of the elemental cycles of the natural world. It is a kind of “going with the flow” or “being in the zone” that is characterized by great ease and awake-ness, in which – without even trying – we’re able to respond perfectly to whatever situations arise. Wu-Wei is an important principle in the martial arts. A master’s actions flow spontaneously in response to his circumstances, with just enough force — not too much, not too little -– effortless action. The state of “Wu-Wei” is to Try without Trying or to Do without intending to Do – Spontaneously!

A Swedish game called Mindball illustrates the power of possessing Wu-Wei. Mindball is a two-person game controlled by players’ brain waves in which players compete to control a ball’s movement across a table by becoming more relaxed and focused. Individuals who are in Wu-Wei have De (pronounced ‘Duh’), typically translated as ‘virtue’ or ‘charismatic power’. De is radiance that others can detect. If you have De, people like you, trust you, and are relaxed around you.

When learning the practice of meditation, many individuals find it useful to hear instructions in meditation spoken aloud, in the form of a guided meditation. UCLA’s Mindful Awareness Research Center has several guided meditations that you may enjoy and find helpful.

I strongly recommend a book written by Edward Slingerland, Professor of Asian Studies, University of British Columbia entitled: Trying Not to Try.


Web Resources:

  • http://www.contemplativemind.org/practices/tree/meditation
  • http://www.apple.com/itunes/appstore
  • One-Moment Meditation (OMM)
  • Mindfulness Daily
  • http://buddhify.com
  • http://Youtube.com/Headspace
  • https://www.youtube.com/user/YellowBrickCinema
 

Interstitial Cystitis

By Gordon C. Gunn, M.D.

Chronic pelvic pain is a common complaint in women. When the cause of pelvic pain is not successfully diagnosed, attention should be given to the bladder as the possible source. Interstitial Cystitis (or “I.C.”) is a bladder condition that can present as chronic pelvic pain. The classic symptoms of women with I.C. are frequent urination, bladder urgency and pelvic pain. (15% of women with interstitial cystitis will have very little or an absence of pelvic pain.) The pain is usually felt just above the pubic bone, but it may be felt in several other areas, including the vagina, lower back, front of the thighs or the lower abdominal area.

Having to urinate frequently at night is a very common symptom. The normal bladder will hold 12 to 16 ounces of urine before the sensation to urinate occurs. Women normally urinate four to eight times in 24 hours, depending on their fluid intake. In those women with interstitial cystitis the need to urinate will occur up to sixteen times a day. As their bladder fills with just a small amount of urine the pressure to urinate becomes increasingly painful. After urinating their pain may decrease, but still persist to some degree. Intercourse will cause their symptoms to increase in 75% of sexually active females with interstitial cystitis.

Many women treated for post-coital bladder infections may actually have interstitial cystitis. While adult women may experience a recurrence of their symptoms during or after sexual intercourse, younger women, age 17- 20, will sometimes have a delay for a day or two after intercourse. Interstitial cystitis symptoms may also be related to the menstrual cycle and commonly appear a week before it begins. Certain foods can cause a flare of symptoms in some patients, especially foods that have a very high potassium content. Symptom flares may also be related to allergies. Patients who may have been in remission for many months can experience a flare of symptoms during allergy season. Additionally, emotional and physical stress appear to contribute to flares in certain women.



The Cause of Interstitial Cystitis

There are many theories proposed as to what is the underlying cause and pathology of interstitial cystitis. People have proposed an immunologic mechanism as well as defects in bladder wall cell to cell connections in the bladder mucosa. Infectious and inflammatory etiologies have also been postulated. Most people believe a major factor in the cause of interstitial cystitis is a defect in the amount of a protective mucous that the bladder wall cells produce. Urine is irritating when it comes in direct contact with the cells of the bladder wall and the bladder produces a mucous made of protein to help protect the bladder cells from coming in direct contact with it. Women with interstitial cystitis are felt to have a defect in the production of this protective mucous layer. Evaluation and Diagnosis After other disease processes have been excluded, the “gold standard” examination to confirm the diagnosis of IC is cystoscopy with hydro distention under general or regional anesthesia. This procedure involves slowly stretching the bladder with fluid, thereby allowing your physician to see changes that are typical of IC. Some of these changes include the presence of glomerulations (pinpoint hemorrhages that occur on the bladder wall, and are seen in the majority of IC 2 patients), or Hunner’s ulcers (or patches), which may be present in a small minority. 10% of patients who present with symptoms of IC have neither glomerulations nor Hunner’s ulcers upon cystoscopy with hydro distention. However, these patients may have IC, and need to receive treatment for their symptoms. Office cystoscopy may often establish the diagnosis of I.C. Sometimes cystoscopy with hydro distention is performed as an outpatient procedure. This is because the bladder needs to be filled to a high pressure in order to see the typical abnormalities of IC, a pressure that would cause significant pain to an IC patient (or even a patient who does not have IC), who was not anesthetized.

HOW DOES HYDRODISTENTION WORK? Hydro distention was first advocated for use in the management of IC in 1930. It is believed that the distention of the bladder wall may cause the nerves to go into a “state of shock,” thereby stopping the transmission of pain. Also, it may stimulate production of bladder surface mucin, the normal protective coating of the bladder surface. Hydro distention is performed by filling your bladder to 80 cm water pressure for 8 minutes, at which point the bladder is drained and re-filled. A portion of the drained fluid is often blood-tinged. If you have IC, re-inspection of the bladder will most likely reveal the pinpoint hemorrhages (the hallmark finding in IC patients) that develop throughout the bladder after distention.

After the Procedure: After the cystoscopy with hydro distention procedure, you will be moved to a recovery room. As the anesthesia begins to wear off, you may experience pelvic pressure and/or pain. You will be required to urinate before being discharged from the hospital. Typically, your first voids after this procedure can be painful, and your urine may contain blood. A catheter is not commonly left in place after this procedure, as IC patients tend to experience pain with prolonged catheterization. Remember to ask for pain-relieving medications upon being discharged from the hospital. Oral pain-reducing medications can be prescribed to help alleviate any discomfort you may experience following the procedure. You may experience some discomfort for several weeks, including pelvic pain and/or urethral burning. Your physician will schedule a follow-up appointment with you to discuss various IC treatment options. If bladder instillations are being considered as a possible treatment, they should not be initiated until your bladder has had time to recover from the cystoscopy with hydro distention, usually 3 to 4 after the procedure.

There is no one simple test that can diagnose interstitial cystitis in all patients. A symptom diary is very helpful in raising suspicion that interstitial cystitis may be the cause of the patient’s pain. (Could add this to STAR’s capability) Cystoscopy (looking inside the patient’s bladder with a very small scope) is helpful in diagnosing interstitial cystitis and is one of the primary diagnostic tools that we use. The test can be performed very comfortably with the patient being awake. A chronically inflamed bladder is often seen with inflamed blood vessels. Commonly filling the bladder with water during cystoscopy, emptying it, and then refilling it with water again will cause the inflamed blood vessels to leak and bloody urine can be seen, which is classic of interstitial cystitis. There are other classic signs of interstitial cystitis that can be seen with the cystoscope. On physical exam, approximately 95% of patient’s will complain of a tender bladder during pelvic exam. A negative urine culture is important in the evaluation to rule out an acute bladder infection as cause of the patient’s symptoms. Interstitial cystitis is not caused by bacteria or infection. Documenting that the patient voids very frequently with a symptom diary is also an important part of the evaluation.

If the above tests are equivocal, an additional test that can be useful in diagnosing interstitial cystitis is called the Potassium Installation Test. What the test involves is instilling the bladder first 3 with sterile water. The patient then voids and a test solution of sterile water with some potassium is instilled and we ask the patient if her symptoms flare with the instillation of the potassium solution as compared to the water only solution. In patients with interstitial cystitis that have a decrease in the protective mucous layer of the bladder wall, the potassium will irritate the nerve fibers within the bladder wall and cause pain and a strong urge to void.

Interstitial cystitis is very much under diagnosed. A patient will see 4-6 doctors on average before a diagnosis of interstitial cystitis is made.



Treatment Diet & Self-Help

A diet low in acidic foods, and avoiding beverages such as coffee, tea, carbonated and/or alcoholic drinks, may be helpful in reducing IC symptoms. Prelief®, an over-the-counter dietary supplement, may help IC patients better tolerate acidic foods and beverages. Self-help measures include stress-reduction techniques, pelvic floor relaxation exercises, biofeedback, and bladder-retraining (once pain is under control). The mainstay of treatment of patients with interstitial cystitis is to recoat the bladder with protective protein that it is deficient in making on its own. This is achieved with simple office instillations of solutions that contain protein. In addition, a local anesthetic solution and at times a steroid are added to the instillation to help in achieving quick and maximal benefits. A small catheter is placed in the bladder through the urethra and the treating solution is instilled through this catheter and then the catheter is removed. Instillations are usually begun on a weekly basis and then spaced out as the patient responds to therapy. When the patient is no longer symptomatic, instillations can be completely stopped and then restarted when symptoms recur.

Watching one’s diet very carefully is a very important part of therapy as well. Avoiding foods that are high in salt and potassium can be helpful in minimizing symptoms. Avoiding alcoholic beverages, caffeinated drinks, acidic and spicy foods, canned foods that contain nitrates or nitrites is helpful. I recommend for everyone to keep a diet diary and to note any foods that flare their symptoms and then make an effort to avoid those foods.

The use of a low dose antidepressant medication is also helpful in treating interstitial cystitis. It has been shown clearly that antidepressants can act on nerve pain fibers to decrease their responsiveness. This directly decreases the amount of pain a person perceives. In addition, the chronic pain and sleep loss associated with interstitial cystitis may cause depression that antidepressant medication can help.

There is an oral medication called Elmiron, which is used to augment the protective mucous layer of the bladder wall. Elmiron is found to be helpful in 30-50% of patients. However, it may take 6-12 weeks before a significant effect is seen with this medication. In some patients over distending the bladder with fluid while the patient is under anesthesia is helpful. This is called hydro distension. The initial response after such a distention is actually increased pain for a few days to a week followed by resolution of symptoms.



IC Treatment

Prescription Oral Medications Mucosal Surface Protectants Elmiron® (pentosan polysulfate) Tricyclic antidepressants Elavil® (amitriptyline) Norpramin® (desipramine) Pamelor® (nortriptyline) 4 Sinequan® (doxepin) Tofranil® (imipramine). Medications That Block Mast Cell Degranulation: – Antihistamines Hydroxyzine: Vistaril® (hydroxyzine pamoate) / Atarax® (hydroxyzine hydrochloride). Anticonvulsants Neurontin® (gabapentin) Klonopin® (clonazepam) Muscle Relaxants & Anxiolytic Medications Valium® (diazepam) Baclofen® (Lioresal) Klonopin® (clonazepam – also classed as ananticonvulsant) Bladder Antispasmodic / Analgesic / Antiseptic Combinations Pyridium-Plus® Pyridium® Urised® Non-Analgesic Antispasmodics/Anticholinergics oxybutinin: Ditropan®, Ditropan XL® (extended-release formula) tolterodine: Detrol®, Detrol LA® (time-released) Levsin, Levbid® (sublingual), Levsinex ® (time-released) hyoscyamine: Cystospaz®, Cystospaz-M® (time-released) flavoxate: Urispas® dicyclomine: Bentyl® propantheline: Pro-Banthine® mirabegron: Myrbetriq Opioid Analgesics/Pain Medications – Short-acting opioid analgesics: Percocet® Vicodin® Lorcet® – Long-acting opioid analgesics: OxyContin® MS-Contin® Duragesic®



Summary

Interstitial cystitis is a chronic inflammatory condition of the bladder wall. It must be considered in any patient with chronic pelvic pain. Patients with chronic pelvic pain who have had gynecologic evaluations, including ultrasounds and laparoscopies without a definite diagnosis and persist with pain should be evaluated to see if interstitial cystitis is the cause of their pain. Treatment for the vast majority of patients is relatively easy and highly effective. If you think you may be suffering from any of the symptoms of interstitial cystitis, please call our office and make an appointment to be evaluated.
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Treatment strategy in fibromyalgia syndrome: where are we now?

By Sarzi-Puttini P, Buskila D, Carrabba M, Doria A, Atzeni F.

Semin Arthritis Rheum. 2008 Jun;37(6):353-65. Epub 2007 Oct 31.

Clinical Research Scientist, Rheumatology Unit, L. Sacco University Hospital, Milan, Italy. sarzi@tiscali.it

INTRODUCTION:
The treatment of the fibromyalgia syndrome (FMS) is not standardized and often ineffective, and the course of disease progression is unpredictable.

OBJECTIVES:
To highlight the efficacy of the pharmacologic and nonpharmacologic treatments administered to FMS patients.

METHODS:
Medline search for articles published between 1983 and 2007, using the keywords fibromyalgia, pharmacologic and nonpharmacologic treatment, and multidisciplinary modalities.

RESULTS:
Randomized controlled trials (RCTs) indicate that FMS has been treated by a wide range of drugs including antidepressants, opioids, nonsteroidal anti-inflammatory drugs, sedatives, muscle relaxants, and antiepileptic agents. Although the syndrome is now more widely recognized and understood, its treatment remains challenging and some physicians believe that no effective treatment exists. Only a few drugs have been shown to have clear-cut benefits in RCTs. FMS sufferers benefit from exercise and a number of the tested programs have involved more than 1 type of exercise. Two other major approaches are psychophysiologically based therapy, such as electromyography biofeedback, and interventions based on cognitive-behavioral therapy. Twelve controlled clinical studies have provided evidence supporting the efficacy of treatments administered to people with FMS by multidisciplinary teams using multicomponent strategies.

CONCLUSIONS:
It is difficult to draw definite conclusions concerning the most appropriate approach to managing FMS because of the methodological limitations of the available studies and the fact that the heterogeneity and nonstandardized nature of their therapeutic programs make them difficult to compare. An individually tailored multidisciplinary pharmacologic, rehabilitative, and cognitive-behavioral approach currently seems to be the most effective.

 

Read the Full Study

 

Vulvodynia: Diagnosis and Management

By BARBARA D. REED, M.D., M.S.P.H.

Barbara D. Reed, M.D., M.S.P.H., University of Michigan Health System, 1018 Fuller St., Ann Arbor, MI, 48109- 0708 (e-mail: barbr@umich.edu).

The diagnosis of vulvodynia is made after taking a careful history, ruling out infectious or dermatologic abnormalities, and eliciting pain in response to light pressure on the labia, introitus, or hymenal remnants. Several treatment options have been used, although the evidence for many of these treatments is incomplete. Treatments include oral medications that decrease nerve hypersensitivity (e.g., tricyclic antidepressants, selective serotonin reuptake inhibitors, anticonvulsants), pelvic floor biofeedback, cognitive behavioral therapy, local treatments, and (rarely) surgery. Most women experience substantial improvement when one or more treatments are used.

Vulvodynia is characterized by chronic discomfort in the vulvar region; the discomfort may range from mild to severe and debilitating. The diagnosis depends on a consistent history, lack of a documented infectious or dermatologic cause, and in most women, tenderness when gentle pressure is applied by a cotton swab to the vulva, introitus, or hymenal areas. The pain usually is present during and after intercourse, and other factors may exacerbate the pain (e.g., bicycle riding, tampon insertion, prolonged sitting, wearing tight clothes) (Table 1).1 In some women the pain is spontaneous.

 

Read the Full Study

 

Resistance exercise training improves heart rate variability in women with fibromyalgia

By Arturo Figueroa, J. Derek Kingsley , Victor McMillan and Lynn B. Panton

Clin Physiol Funct Imaging (2008) 28, pp49–54 doi: 10.1111/j.1475-097X.2007.00776.x

Arturo Figueroa, MD, PhD, 100B Sandels Building, College of Human Sciences, Florida State University, Tallahassee, FL 32306-1493, USA E-mail: afiguero@fsu.edu

Fibromyalgia (FM) is characterized by generalized muscle pain, low muscle strength and autonomic dysfunction. Heart rate (HR) variability (HRV) is reduced in individuals with FM increasing their risk for cardiovascular morbidity and mortality. We tested the hypothesis that resistance exercise training (RET) improves HRV, baroreflex sensitivity (BRS) and muscle strength in women with FM. Women with FM (n = 10) and healthy controls (n = 9), aged 27-60 years, were compared at baseline. Only women with FM underwent supervised RET 2 days per week for 16 weeks. Baseline and post-training measurements included HRV and spontaneous baroreflex sensitivity (BRS, alpha index) from continuous electrocardiogram and blood pressure (BP) recorded with finger plethysmography during 5 min in the supine position. RR interval, total power, log transformed (Ln) squared root of the standard deviation of RR interval (RMSSD), low-frequency power and BRS were lower (P<0.05), and HR and pulse pressure were higher (P<0.05) in women with FM than in healthy controls. After RET, mean (SEM) total power increased (387 +/- 170 ms(2), P<0.05), RMSSD increased (0.18 +/- 0.08 Ln ms, P<0.05) and Ln of high-frequency power increased (0.54 +/- 0.27 Ln ms(2), P = 0.08) in women with FM. Upper and lower body muscle strength increased by 63% and 49% (P<0.001), and pain perception decreased by 39% in women with FM. There were no changes in BRS, HR and BP after RET. Our study demonstrates that RET improves total power, cardiac parasympathetic tone, pain perception and muscle strength in women with FM who had autonomic dysfunction before the exercise programme.

 

Read the Full Study

 

Effect of aerobic exercise training on oxygen uptake and kinetics in patients with fibromyalgia

By Mustafa Dinler, Demirhan Diracoglu, Erdem Kasikcioglu, Omer Sayli, Ata Akin, Cihan Aksoy, Ahmet Oncel, Ender Berker

Rheumatol Int DOI 10.1007/s00296-009-1126-x

M. Dinler D. Diracoglu C. Aksoy A. Oncel E. Berker Department of Physical Medicine and Rehabilitation, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey

The aim of this study is to investigate relation between cardiopulmonary performance and muscular microcirculation in patients with fibromyalgia syndrome (FMS). Twenty-one female sedentary patients who were diagnosed as FMS, and 15 sedentary females were enrolled in to the study. All participants underwent a modified Bruce multistage maximal treadmill protocol with metabolic measurements and Near-Infrared Spectroscopy measurements. Exercise sessions were performed 3 times a week for 8 weeks. The results of the study suggest that cardiopulmonary system in charge of delivering oxygen to whole body and muscular microcirculation may have dysfunction in patients with FMS.

 

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Coenzyme Q10 distribution in blood is altered in patients with Fibromyalgia

By M.D. Cordero, A.M. Moreno-Fernández, M. deMiguel, P. Bonal, F. Campa, L.M. Jiménez-Jiménez, A. Ruiz-Losada, B. Sánchez-Domínguez, J.A. Sánchez Alcázar, L. Salviati, P. Navas

CLB-07001; No. of pages: 4; 4C:

Centro Andaluz de Biología del Desarrollo, Universidad Pablo de Olavide-CSIC, Carretera de Utrera Km 1, Sevilla 41013, Spain. Fax: +34 954349376. E-mail address: pnavas@upo.es (P. Navas).

Objective: Coenzyme Q10 (CoQ10) is an essential electron carrier in the mitochondrial respiratory chain and a strong antioxidant. Signs and symptoms associated with muscular alteration and mitochondrial dysfunction, including oxidative stress, have been observed in patients with fibromyalgia (FM). The aim was to study CoQ10 levels in plasma and mononuclear cells, and oxidative stress in FM patients.

Methods: We studied CoQ10 level by HPLC in plasma and peripheral mononuclear cells obtained from patients with FM and healthy control subjects. Oxidative stress markers were analyzed in both plasma and mononuclear cells from FM patients.

Results: Higher level of oxidative stress markers in plasma was observed respect to control subjects. CoQ10 level in plasma samples from FM patients was doubled compared to healthy controls and in blood mononuclear cells isolated from 37 FM patients was found to be about 40% lower. Higher levels of ROS production was observed in mononuclear cells from FM patients compared to control, and a significant decrease was induced by the presence of CoQ10.

Conclusion: The distribution of CoQ10 in blood components was altered in FM patients. Also, our results confirm the oxidative stress background of this disease probably due to a defect on the distribution and metabolism of CoQ10 in cells and tissues. The protection caused in mononuclear cells by CoQ10 would indicate the benefit of its supplementation in FM patients.

 

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Effects of muscle strengthening versus aerobic exercise program in Fibromyalgia

By Çifdem Bircan, Seide Alev Karasel, Berrin Akgün, Özlem El, Serap Alper

Rheumatol Int (2008) 28:527–532 DOI 10.1007/s00296-007-0484-5

Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Dokuz Eylül University e-mail: cigdem.bircan@deu.edu.tr

The purpose of this study was to compare the effects of aerobic training with a muscle-strengthening program in patients with fibromyalgia. Thirty women with fibromyalgia were randomized to either an aerobic exercise (AE) program or a strengthening exercise (SE) program for 8 weeks. Outcome measures included the intensity of fibromyalgia-related symptoms, tender point count, fitness (6-min walk distance), hospital anxiety and depression (HAD) scale, and short-form health survey (SF-36). There were significant improvements in both groups regarding pain, sleep, fatigue, tender point count, and fitness after treatment. HAD-depression scores improved significantly in both groups while no significant change occurred in HAD anxiety scores. Bodily pain subscale of SF-36 and physical component summary improved significantly in the AE group, whereas seven subscales of SF-36, physical component summary, and mental component summary improved significantly in the SE group. When the groups were compared after treatment, there were no significant differences in pain, sleep, fatigue, tender point count, fitness, HAD scores, and SF-36 scores. AE and SE are similarly effective at improving symptoms, tender point count, fitness, depression, and quality of life in fibromyalgia.

 

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Affective pain modulation in fibromyalgia, somatoform pain disorder, back pain, and healthy controls

By Bettina S. Arnold, Georg W. Alpers, Holger Suß, Eckart Friedel, Gregor Kosmutzky, Antje Geier, Paul Pauli

European Journal of Pain 12 (2008) 329–338

Corresponding author. Tel.: +49 931 312840; fax: +49 931 312733. E-mail address: alpers@psychologie.uni-wuerzburg.de (G.W. Alpers).

Previous research suggested that patients with fibromyalgia (FM) experience a higher pain intensity (clinical pain) than do patients with musculoskeletal pain after negative emotional priming compared to positive priming. To further examine affective pain modulation in FM, we applied an experimental pain induction to compare 30 patients with FM with 30 healthy (pain-free) participants (HC), and 30 patients with back pain (BP). For another group of 30 patients with somatoform pain disorder (SF), we predicted the same pain modulation as for FM. As primes we presented positive, neutral, negative, and pain-related pictures and assessed pain intensity in response to a fixed pressure weight. Overall, picture valence modulated pain intensities (in the order of pain-related > negative pictures > neutral), but the pain intensities between neutral and positive pictures did not differ significantly.

SF reported significantly higher pain intensities than did BP and HC; FM were in between, but did not differ significantly from the three other groups. There was no interaction of priming and group. Affective modulation of pain was not specifically altered in FM and SF, but SF were more sensitive to pressure pain than BP and HC.

 

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