Fibromyalgia

To find a unique way how to evaluate and to treat a Fibromyalgia is one of the most interesting themes for me during the last few years. I think that there is nearly nothing which bothers a human more than completely reasonless pain. It would be much more bearable if our pain would have some kind of causing agent.

There were some scientists from Würzburg/ Germany who examined 25 patients and found a disorder of small nerve fibers which means that it is still possible that the Fibromyalgia has an organic or physical cause. Due to my opinion we can find out much more about this disease in the next years. 20 years ago no one would have thought that a simple bacterial infection by Heliobacter pylori is the causing agent for a gastric ulcer. For most of the patients who suffer from a Fibromyalgia the origin of the disease could be found in some kind of mislead neuronal process. Only the minority of cases can be explained with a physical or organic disorder.

Chronic pain can be compared to an earworm:

You have once heard a melody and cannot get rid of it anymore. You were just about to forget the melody when you hear it once again in some shop or in the TV. As more you concentrate on the melody as stronger and as louder the earworm gets. You can perform every possible examination from a MRT till an EEG but none of them will make you get rid of this earworm. The melody settled down in your neuronal network. No one will be able to find this earworm which is stuck in your head but anyways it is real, you will hear it!

The chronic pain follows the same principle. It gets triggered by an acute pain which then initiates some learning processes in the brain. The brain accomodates to the new situation to the pain which had a warning function in the beginning which means that the brain tries to focus on this possibly life threatening pain. This mechanism is a completely normal condition which appears in every human.

Now it is most important to treat the pain to prevent the formation of a pain memory. The acute pain needs some kind of psychosocial disposition or a disorder in the pain- processing system. The causes for this can be of genetic, hormonal, psychic, social, neuropsychologic or environmental origin. Recent perceptions of the epigenetic show that a behavior can be inherited 1- 2 generations. There were some studies in Atlanta (2014) about mice which inherit fear for 2 generations. Another example are post- war children who dream about war or feel fear in normal situations.

Disorders in the metabolism of the brain can have their origin in a learned or gentically inherited factor. That is why we must not differentiate between an organic or a psychic cause for the disease because the pain must not have a specific cause like an injury.

It is proven that patients who suffer from a Fibromyalgia do suffer from some kind of psychic disorder like depression or fear above the average. We cannot say if the psychic disorder is the cause for the pain or the pain is the cause for the Fibromyalgia but anyways we have to treat both.

According to my opinion we will differentiate the Fibromyalgia into a primary and a secondary in the upcoming years. This would be possible by the help of pain questionairy and a specific anamnesis to create the perfect therapy plan.

One of the most important steps to treat the disease is the realization of the disease as well as its origin because otherwise the disease will spread and occupy other parts of our every days life like sleeping, well- being or our social contacts. Therefore it is hard to treat the disease only with a drug therapy because it is essential to erase the pain memory.

Bewiesen ist, dass bei Patienten mit Fibromyalgie überdurchschnittlich häufig psychische Störungen wie Depressivität und Ängstlichkeit vorkommen. Ob diese Patienten zuerst depressiv waren und darum Schmerzen entwickeln oder umgekehrt ist interessant, aber in keinster Weise zielführend für die Behandlung. Es gehört immer beides behandelt.

Es ist davon auszugehen dass in Zukunft die Fibromyalgie in eine primäre und eine sekundäre, eher psychosomatische Form differenziert wird. Das gelingt heute schon anhand der Schmerzfragebögen und der Anamnese. Danach orientiert sich dann auch die Behandlung.

Die Schmerzstörung hat die Tendenz sich auszuweiten und andere Bereiche des Lebens zu beeinträchtigen: Schlaf, Wohlbefinden, Verdauung, Leistungsfähigkeit, soziale Kontakte, Stimmung.....

Wichtig für die Behandlung ist das Verständnis der Grundlagen der Erkrankung. Die Erkrankung ist nur wenig durch Medikamente heilbar, sondern durch ein Verlernen des Schmerzgedächtnis.

Im Gegensatz zur landläufigen Meinung halte ich die Prognose für gut.

Due to the fact that a Fibromyalgia is caused by some kind of mislead learning process instead of any organic or physical disorder it is not possible to treat the disease with common therapies.

We try to create the perfect therapy plan with you which may include a multimordal therapy (combination of relaxing or cognitive therapy and stamina training), low intensity stamina training in combination with stretching exercises, Tai Chi or Yoga. It is hard to find the perfect medication but there are some drugs which have shown a positive effect

1. Amitriptylin 10- 50 mg/d

Duloxetin 60 mg/ d

Off- label medicamentation (individual treatment plan): Dulxetin, Pregabalin or Seretonin inhibitors like Fluoxetin.

medications:
Anxiolytika (Valium), Cannabinoide, Flupirtin, Ketamin, Kortikosteroide, Lokalanästhetika, Milnacipran, Muskelrelaxantien, Natriumoxybat, Neurolpetika, Nichtsteroidale Antirheumatika (Ibuprofen, Diclofenac), starke Opioide, Serotoninrezeptor (5HT3) Antagonisten

Non-drug procedures
Chirotherapie, hyperbare Sauerstofftherapie, Lasertherapie, Magnetfeldtherapie, Massage, Nahrungsmittelergänzungsprodukte, TENS

Auszug aus den aktuellen Leitlinien:

Farbcodes:
Geänderte Datenlage (neue RCTs ab 2007)

Neue Kriterien für Auf- und Abstufung des Empfehlungsgrades von Therapien

Sowohl neue Datenlage als auch neue Kriterien für Auf- und Abstufung des

Empfehlungsgrades von Therapien

• Leitlinien