Neuroimaging in Fibromyalgia

[medicineman1]

Hello all-

Wondering if you have stumbled across any texts or research articles re: neuroimaging in FM- that have decent slide material imaging?

My understanding in a very simply stated way is that Spect scanning picks up regional blood flow differences in FM, while FMRI is more focused on pain processing centers.

The FMRI data is confusing as it suggests there is increased uptake in many areas as compared to controls, and decreased uptake in other areas- and the argument seems weak-it appears that there is increased uptake in somatosensory areas, and decredased uptake in the limbic areas- I have yet to find a well writen clear hypothesis for this. And the imaging provided in the researcg is confusing.

Anyone shed some light on this-

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[Aether2000]

It appears neuroimaging for most types of pain including FMS is in the developmental state, and has not been well defined enough for diagnostic use.

 

[lobelsteve]

Pain catastrophizing and neural responses to pain among persons with Fibromyalgia
R. H. Gracely,1 M. E. Geisser,2 T. Giesecke,3 M. A. B. Grant,1 F. Petzke,3 D. A. Williams1 and
D. J. Clauw1

Functional Magnetic Resonance Imaging Evidence of
Augmented Pain Processing in Fibromyalgia
Richard H. Gracely,1 Frank Petzke,2 Julie M. Wolf,3 and Daniel J. Clauw2

Decreased Central μ-Opioid
Receptor Availability in Fibromyalgia
Richard E. Harris,1 Daniel J. Clauw,1 David J. Scott,2
Samuel A. McLean,3 Richard H. Gracely,1
and Jon-Kar Zubieta2,4

 

[drrinoo]

Any thoughts on the evolutionary adaptation of FMS.
I don't understand how Darwinian natural selection would allow FMS to survive. The rate of human evolution has accelerated over the past 100K years relative to the preceding 2 Million years...so, even if we assume that FMS existed 100K years ago...it seems unlikely that a hunter gatherer or agricultural society would tolerate FMS.

It only seems that a democratic society with access to technology (things to take care of our daily chores) could permit the recognition and the tolerance of FMS....however, from an evolutionary standpoint this condition must have take several hundred thousand years to develop.

 

[Ligament]

I understand your sentiments Rinoo, but this could be applied to nearly all chronic pain issues that we see on a daily basis.

Has anybody done a study on the incidence and severity of chronic pain in a hunter gatherer society? That would be an awesome study!

Any thoughts on the evolutionary adaptation of FMS.
I don't understand how Darwinian natural selection would allow FMS to survive. The rate of human evolution has accelerated over the past 100K years relative to the preceding 2 Million years...so, even if we assume that FMS existed 100K years ago...it seems unlikely that a hunter gatherer or agricultural society would tolerate FMS.

It only seems that a democratic society with access to technology (things to take care of our daily chores) could permit the recognition and the tolerance of FMS....however, from an evolutionary standpoint this condition must have take several hundred thousand years to develop.

 

[Aether2000]

The diagnosis of FMS (or the equivalent older terms) has exploded over the past 20 years, partially due to pseudovalidation as a "disease" by the rheumatologists and partially due to an increased permissivity in our society to whine about every little ache and pain as though they are all incapacitating. There is much confusion among patients and doctors alike regarding differences between CFS and FMS. Notwithstanding all of this, there does appear to be an increase in the frequency of occurrence in Western populations. The etiology remains elusive, but unsubstantiated theories abound including viral, prions, autoimmune, bacterial antibody production, secondary hypophyseal axis dysfunction, etc. I often wonder if the myriad chemicals used to treat our food or are used as additives may be partially at play. Or the chemicals the leak into our bottled water from the plasticizer softeners used to make the plastic bottles malleable.
There are neurological markers of abnormalities such as myelin sheath diameter increases in FMS, HLA markers, 2,3 DPG concentration alterations, and other demonstrated abnormalities, but their occurrence is not of sufficiently high percentage or require nerve biopsies in order to make a diagnosis for which there is no universally effective treatment. The neuroimaging studies in SPECT scanning of the thalamus and FMRI/PET do show abnormalities but these may well be secondary manifestations of chronic pain. Therefore we see these patients offering them skepticism due to the demonstrated psych overlay that is pervasive, and distaste for the mention of a not-well-understood syndrome, for which we have no treatment other than symptom management. It is a very frustrating situation for patients and physicians alike.

 

[Tenesma]

there are obviously genetic issues at play - and it won't be long before we do buccal swabs to confirm FMS...

 

[drrinoo]

The diagnosis of FMS (or the equivalent older terms) has exploded over the past 20 years, partially due to pseudovalidation as a "disease" by the rheumatologists and partially due to an increased permissivity in our society to whine about every little ache and pain as though they are all incapacitating. There is much confusion among patients and doctors alike regarding differences between CFS and FMS. Notwithstanding all of this, there does appear to be an increase in the frequency of occurrence in Western populations. The etiology remains elusive, but unsubstantiated theories abound including viral, prions, autoimmune, bacterial antibody production, secondary hypophyseal axis dysfunction, etc. I often wonder if the myriad chemicals used to treat our food or are used as additives may be partially at play. Or the chemicals the leak into our bottled water from the plasticizer softeners used to make the plastic bottles malleable.
There are neurological markers of abnormalities such as myelin sheath diameter increases in FMS, HLA markers, 2,3 DPG concentration alterations, and other demonstrated abnormalities, but their occurrence is not of sufficiently high percentage or require nerve biopsies in order to make a diagnosis for which there is no universally effective treatment. The neuroimaging studies in SPECT scanning of the thalamus and FMRI/PET do show abnormalities but these may well be secondary manifestations of chronic pain. Therefore we see these patients offering them skepticism due to the demonstrated psych overlay that is pervasive, and distaste for the mention of a not-well-understood syndrome, for which we have no treatment other than symptom management. It is a very frustrating situation for patients and physicians alike.

nice discussion. behavioral/psychological adaptations are bound to vary from group to group or society to society....but there must be some biological substrate that was conserved to confer a genetic advantage for survival...

if it was exclusively environmental toxin exposure, then one would expect a higher prevalence in society and an equal distribution among men and women....

if it were viral/prion/autoimmune type manifestation....the development of FMS in adults would suggest that there was a lack of exposures to toxins in childhood....e.g. the sandbox hypothesis about allergies....

another possibility is the FMS is a pns/cns variant of ADHD...constantly seeking/suppressing/abnormally processing sensory inputs...and causing maladaptive behaviors....this would account for its' development in modern society

since one behavioral adaptation of FMS is incredibly good recall of their chronic pain, perhaps this was the adaptation...in ancient societies, a survivor of an injury that leads to chronic pain...could provide as an in built warning system to other members of the group that such and such event can lead to disability....

Dawkins has come up with the concept of meme transmission...may be in one way chronic pain/FMS is a meme that benefits group learning to avoid certain hazardous activities that can lead to chronic pain.

Furthemore, FMS patients, unlike other patients with chronic disease are very active in getting treatment for their condition....they may with draw from life but are very good at bringing attention to their problems

If we can understand the natural selection process that led to the survival of FMS.....we might better understand the etiology...alternatively, FMS may be a recent arrival-as Algos has alluded, along with the advent of ADHD.....distinct from other entities that have been around for hundreds of thousands of years....schizophrenia or depression... schizophrenia would have been useful in an ancient battlefield and hence, its survival by natural selection

 

[Doctodd]

id agree with some of those concepts if i thought ADHD existed as a medical condition.

 

[Ligament]

Furthemore, FMS patients, unlike other patients with chronic disease are very active in getting treatment for their condition....

aka vampirism aka chi suckers 😉 just kidding, could not resist.

 

[Mister Mxyzptlk]

aka vampirism aka chi suckers 😉 just kidding, could not resist.

Google "energy vampires".

I still have trouble with FMS as a disease entity. It's as if we bundled a bunch of people together and invented a disease for them because they have common symptoms. A few hundred years ago syphilis and gonorrhea were felt to be the same disease.

Suppose you were practicing in more primitive times and noticed that every once in a while someone would get red spots on their skin and be sick. Some of them got better, some died, some were left with chronic problems. Well, you could dub them all "Red Spotted Skin Disease" and try to find a unifying cause, or you could also divide them into meningitis, measles, typhus and Rocky Mountain Spotted Fever.

Back in ancient times when I was in medical school we had hepatitis A and B, and something we called "non-A, non-B" instead of hepatitis C because we didn't know if there was more than one virus beyond A and B. Yet now we don't hesitate to lump symptoms together into a single disease without better understanding of the etiology.

I have seen plenty of people misdiagnosed as FMS simply because they had multiple pain sites. When I saw them it was apparent that they had a neck problem and a back problem and maybe some peripheral arthritic disease. Squeeze those folks at the magic spots and guess what? they meet the criteria! Others had polymyositis or other systemic illnesses. Sometimes I think FMS should really be called "Lazy Doctor Syndrome". Other times I think it should be called "depression".

To me, embracing FMS as a valid clinical entity shows the same lack of critical thinking as believing we are the prime cause of global warming (FYI -this year's cold weather erased the last 100 years of global warming).

I suffer from Irritable Doctor Syndrome but I just learned to live with it.

 

[Intubate]

nice discussion. behavioral/psychological adaptations are bound to vary from group to group or society to society....but there must be some biological substrate that was conserved to confer a genetic advantage for survival...

if it was exclusively environmental toxin exposure, then one would expect a higher prevalence in society and an equal distribution among men and women....

if it were viral/prion/autoimmune type manifestation....the development of FMS in adults would suggest that there was a lack of exposures to toxins in childhood....e.g. the sandbox hypothesis about allergies....

another possibility is the FMS is a pns/cns variant of ADHD...constantly seeking/suppressing/abnormally processing sensory inputs...and causing maladaptive behaviors....this would account for its' development in modern society

since one behavioral adaptation of FMS is incredibly good recall of their chronic pain, perhaps this was the adaptation...in ancient societies, a survivor of an injury that leads to chronic pain...could provide as an in built warning system to other members of the group that such and such event can lead to disability....

Dawkins has come up with the concept of meme transmission...may be in one way chronic pain/FMS is a meme that benefits group learning to avoid certain hazardous activities that can lead to chronic pain.

Furthemore, FMS patients, unlike other patients with chronic disease are very active in getting treatment for their condition....they may with draw from life but are very good at bringing attention to their problems

If we can understand the natural selection process that led to the survival of FMS.....we might better understand the etiology...alternatively, FMS may be a recent arrival-as Algos has alluded, along with the advent of ADHD.....distinct from other entities that have been around for hundreds of thousands of years....schizophrenia or depression... schizophrenia would have been useful in an ancient battlefield and hence, its survival by natural selection

Just because something exists does not imply that it was "selected" by natural selection, or that it is in any way beneficial. We're talking about a disease here, not a trait (arguable maybe). With only a few exceptions (sickle cell), disease is selected against. Natural selection will likely get rid of fibromyalgia in time, unless it somehow confers a survival benefit.

 

[Mister Mxyzptlk]

Meme transmission? FMS is culturally propagated? Fine. I will refer all of them to an anthropologist.

To ask about a selective advantage to FMS assumes that it is (1) hereditary and (2) not a recent mutation. Since that has not been established, there is no point in speculating about its selective advantages.

I don't think schizophrenia would offer much selection benefit because it doesn't necessarily make people violent, and if it does it certainly doesn't make them skillful fighters. And since violent psychotics are usually not selective about their violence they would pretty much attack people at random and hence be stoned to death and dropped into a peat bog or something if there were no wars going on to employ their skills.

 

[SSdoc33]

"To me, embracing FMS as a valid clinical entity shows the same lack of critical thinking as believing we are the prime cause of global warming (FYI -this year's cold weather erased the last 100 years of global warming)."

Gorback, please don't tell me you think humans arent the cause of global warming. or that you dont believe in it at all. you have made so many great and insightful comments that id like to think you know what you are talking about.

 

[Aether2000]

Global warming has definitely not made it to the frozen tundra of the Midwest. I am considering moving somewhere it is known to exist.

 

[Mister Mxyzptlk]

Gorback, please don't tell me you think humans arent the cause of global warming. or that you dont believe in it at all. you have made so many great and insightful comments that id like to think you know what you are talking about.

Although greenhouse gases probably contribute to warming, our contribution to global warming is negligible compared to the effects of the sun. As I mentioned before, this year's temperatures wiped out 100 years of global warming. Temperatures dropped about 0.65 - 0.75 C - the single steepest drop in temperature ever recorded. North American snow cover is the highest in 50 years (much of it seems to have landed on Algos). Antarctic ice is at an all time high. We have set new record lows in many parts of the country. It snowed in Baghdad for Pete's sake.

Did the atmospheric CO2 scrubbers finally kick in, or could it possibly be that there are greater forces in the universe than ourselves? If you look at the big picture we are little more to the Earth than a bad case of head lice.

The sky is falling, but now it seems it is falling the other way. Now there is talk of a possible ice age. http://www.dailytech.com/Solar+Acti...hers+Predict+Another+Ice+Age/article10630.htm

How bad can it really be when Al Gore lives in a 20-room mansion that consumes 20 times the national average in energy? Obviously he's not all that worried.

 

[Josh L.Ac.]

Wouldn't FMS be selected against in a population only if the disadvantages it confers showed up before those with the trait/disease had offspring?

 

[SSdoc33]

Although greenhouse gases probably contribute to warming, our contribution to global warming is negligible compared to the effects of the sun. As I mentioned before, this year's temperatures wiped out 100 years of global warming. Temperatures dropped about 0.65 - 0.75 C - the single steepest drop in temperature ever recorded. North American snow cover is the highest in 50 years (much of it seems to have landed on Algos). Antarctic ice is at an all time high. We have set new record lows in many parts of the country. It snowed in Baghdad for Pete's sake.

Did the atmospheric CO2 scrubbers finally kick in, or could it possibly be that there are greater forces in the universe than ourselves? If you look at the big picture we are little more to the Earth than a bad case of head lice.

The sky is falling, but now it seems it is falling the other way. Now there is talk of a possible ice age. http://www.dailytech.com/Solar+Acti...hers+Predict+Another+Ice+Age/article10630.htm

How bad can it really be when Al Gore lives in a 20-room mansion that consumes 20 times the national average in energy? Obviously he's not all that worried.

ok, i guess this is kind of off the topic of fibromyalgia, but, are you completely nuts? ill tend to believe every major climate expert than one recent article in "the daily tech" internet site.

the fact that you dont believe that humans can have this effect on our environment is simply believing what you want to believe. the evidence, despite whatever esoteric blog you might happen to read today, is very very clear. why not also buy into the JFK conspiracy or the loch ness monster?

i had a pathology professor in med school (who happened to be one of the smartest perople ive ever met) that smoked several pipes every day because he was convinced that he didnt have the gene that can contribute to lung cancer. everybody else knew better, but he believed what he wanted, and not the facts.

al gore's mansion and private jet notwithstanding, this Texas nonsense that you are spouting off is simply dangerous and irresponsible.

 

[Mister Mxyzptlk]

ok, fine, whatever you say.

 

[medicineman1]

thanks for the input (even the albeit tangential)- ha ha!

So do you comprehensive pain docs (stevelobel, Drusso, gorback, algos, ligament)- a few of the pros - do u guys manage these patients as part of your comprehensive practice, or defer back to the rheum doc, & or primary care doc? Have you had success w Lyrica?

I had a grand rounds and presented using dr. Gracely's stuff- for imaging-

For the record- after having sifted through a million articles - I dont believe that psych causes FM- there is no doubt an association- I feel that central sensitization is the neuropathic component for the pain complaint- how it all ties together- there are findings in the HPA axis, and undetermined Limbic issues- its very complex, who knows?

The fact that the same cluster of complaints have been documented for over 100 years in every socioeconomic, ethnic, and cultural area of society (worldwide) - not just modern western civilization- makes me believe its a real entity- we just dont have enough data to explain it which is frustrating-

Am I interested in following and treating these people as part of my practice - I dont know- but I felt that this was an interesting project for me- preparing for a grand rounds and looking at all the info- very puzzling syndrome-

 

[lobelsteve]

thanks for the input (even the albeit tangential)- ha ha!

So do you comprehensive pain docs (stevelobel, Drusso, gorback, algos, ligament)- a few of the pros - do u guys manage these patients as part of your comprehensive practice, or defer back to the rheum doc, & or primary care doc? Have you had success w Lyrica?

I had a grand rounds and presented using dr. Gracely's stuff- for imaging-

For the record- after having sifted through a million articles - I dont believe that psych causes FM- there is no doubt an association- I feel that central sensitization is the neuropathic component for the pain complaint- how it all ties together- there are findings in the HPA axis, and undetermined Limbic issues- its very complex, who knows?

The fact that the same cluster of complaints have been documented for over 100 years in every socioeconomic, ethnic, and cultural area of society (worldwide) - not just modern western civilization- makes me believe its a real entity- we just dont have enough data to explain it which is frustrating-

Am I interested in following and treating these people as part of my practice - I dont know- but I felt that this was an interesting project for me- preparing for a grand rounds and looking at all the info- very puzzling syndrome-

I find them a terribly easy population to treat.

1. Teach them the underlying process (postulated) of the diagnosis (syndrome)not disease.

2. Let them know what to expect with optimal management

3. Let them know that from a medication standpoint, that Lyrica, Flexeril, Zanaflex, Limbrel, Tramadol ER, Lexapro, Rozerem, Lunesta are about the only medications that I am willing to try.

4. They must be involved in an exercise program, monitored by PT x3-4 weeks, then to the gym on their own.

5. Clinical psychology is always recommended.

The ones who are compliant get a little better, the noncompliant ones never come back. The seekers go down the road and typically get Darvocet from some schmuck. More importantly, I undiagnose FMS in 8/10 of these folks. Like Gorback said, cervical and lumbar spondylosis with a little myofascial referred pain- looks like FMS without the psych component. I have seen FMS patients with ESR's over 50, +RF, -ANA and sent out of Rheum practices as there was not an infusion or the exam was not positive enough.

 

[AviatorDoc]

Notwithstanding the ACR criteria, it seems everyone has their own criteria for what exactly FMS is or isnt, if it is at all.

One question: What do you call chronic, widespread myofascial pain, with concombinant sleep disturbance and mood disorder?

 

[ampaphb]

Notwithstanding the ACR criteria, it seems everyone has their own criteria for what exactly FMS is or isnt, if it is at all.

One question: What do you call chronic, widespread myofascial pain, with concombinant sleep disturbance and mood disorder?

Functional Somatic Syndrome (Mod Rheumatol. 2007;17(3):179-84):

Functional somatic syndrome (FSS) is defined as a group of related syndromes characterized more by symptoms, suffering, and disability than by structural or functional abnormality. The diagnostic criteria and/or symptoms of FSS often overlap, and co-morbidity is commonly found among the diseases of FSS. For example, patients with irritable bowel syndrome often suffer from chronic pain, and a high percentage of co-morbidity can be found with fibromyalgia. Accumulating evidence indicates the presence of visceral and somatic hyperalgesia in FSS as a common feature, and the central sensitization mechanism has been suggested to play an important role in the pathophysiology of FSS. In the present article, the authors introduce the concept of FSS focusing on its possible relevance to rheumatology in terms of pain perception. A possible implication of mast cells and proteinase-activated receptor-2 (PAR-2) in FSS is also reviewed.