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Dr. Zafirides Fibromyalgia Is Not All In Your Head? (Study)

Discussion in 'General Discussion Subforum' started by Peter Zafirides, Jun 19, 2013.

  1. Peter Zafirides

    Peter Zafirides Physician

    Hi Everyone,

    I thought you'd be interested in the latest scientific discovery with regards to fibromyalgia. This study was published in the journal, Pain Medicine. This was the actual headline of the article. We'll see where this finding leads...

    Just FYI.

    Kindly,
    Dr. Z

    ------

    Fibromyalgia Is Not All In Your Head, New Research Confirms

    (Researchers discover a rational biological source of pain in the skin of patients with fibromyalgia)


    Fibromyalgia, a painful condition affecting approximately 10 million people in the U.S., is not imaginary after all, as some doctors have believed. A discovery, published this month in PAIN MEDICINE (the journal of the American Academy of Pain Medicine), clearly now demonstrates that fibromyalgia may have a rational biological basis located in the skin.

    Fibromyalgia is a severely debilitating affliction characterized by widespread deep tissue pain, tenderness in the hands and feet, fatigue, sleep disorders, and cognitive decline. However, routine testing has been largely unable to detect a biological basis for fibromyalgia, and standard diagnosis is based upon subjective patient pain ratings, further raising questions about the true nature of the disease. For many years, the disorder was believed to be psychosomatic (“in the head”) and often attributed to patients’ imagination or even faking illness. Currently approved therapeutics that provide at least partial relief to some fibromyalgia patients are thought to act solely within the brain where imaging techniques have detected hyperactivity of unknown origin referred to as “central sensitization.” However, an underlying cause has not been determined, leaving many physicians still in doubt about the true origins or even the existence of the disorder.

    Now, a breakthrough discovery by scientists at Integrated Tissue Dynamics LLC (Intidyn), as part of a fibromyalgia study based at Albany Medical College, has provided a biological rationale for this enigmatic disease. The small biotechnology research company, founded by neuroscientists Dr. Frank L. Rice and Dr. Phillip J. Albrecht, reports on a unique peripheral neurovascular pathology consistently present in the skin of female fibromyalgia patients which may be a driving source of the reported symptoms.

    “Instead of being in the brain, the pathology consists of excessive sensory nerve fibers around specialized blood vessel structures located in the palms of the hands,” said Dr. Rice, President of Intidyn and the senior researcher on the study. “This discovery provides concrete evidence of a fibromyalgia-specific pathology which can now be used for diagnosing the disease, and as a novel starting point for developing more effective therapeutics.”

    Nerve Endings Come In Many Forms

    Three years ago, Intidyn scientists published the discovery of an unknown nervous system function among the blood vessels in the skin in the journal PAIN.

    As Dr. Rice explained, “we analyzed the skin of a particularly interesting patient who lacked all the numerous varieties of sensory nerve endings in the skin that supposedly accounted for our highly sensitive and richly nuanced sense of touch. Interestingly however, this patient had surprisingly normal function in day to day tasks. But, the only sensory endings we detected in his skin were those around the blood vessels”. Dr. Rice continued, “We previously thought that these nerve endings were only involved in regulating blood flow at a subconscious level, yet here we had evidencs that the blood vessel endings could also contribute to our conscious sense of touch… and also pain.”

    Now, in collaboration with renowned Albany Medical Center neurologist and pain specialist Dr. Charles E. Argoff, the study primary investigator, and his collaborators Dr. James Wymer also at Albany Medical College and Dr. James Storey of Upstate Clinical Research Associates in Albany, NY, clinical research proposals were funded by Forest Laboratories and Eli Lilly. Both pharmaceutical companies have developed FDA-approved medications with similar functions (Serotonin/Norepinephrine Reuptake Inhibitors, SNRI) that provide at least some degree of relief for many fibromyalgia patients.

    “Knowing how these drugs were supposed to work on molecules in the brain,” Dr. Albrecht added, “we had evidence that similar molecules were involved in the function of nerve endings on the blood vessels. Therefore, we hypothesized that fibromyalgia might involve a pathology in that location”. As the results demonstrate, they were correct.

    To analyze the nerve endings, Drs. Rice, Albrecht, and postdoctoral researcher Dr. Quanzhi Hou, used their unique microscopic technology to study small skin biopsies (less than half the size of a pencil eraser) collected from the palms of fibromyalgia patients, who were being diagnosed and treated by Drs. Argoff, Wymer, and Storey. The study was limited to women, who have over twice the occurrence of fibromyalgia than men. What the team uncovered was an enormous increase in sensory nerve fibers at specific sites within the blood vessels of the skin. These critical sites are tiny muscular valves, called arteriole-venule (AV) shunts, which form a direct connection between arterioles and venules (see diagram).

    As Dr. Rice describes their function, “We are all taught that oxygenated blood flows from arterioles to capillaries, which then convey the deoxygenated blood to the venules. The AV shunts in the hand are unique in that they create a bypass of the capillary bed for the major purpose of regulating body temperature.”

    A Thermostat for the Skin

    In humans, these types of shunts are unique to the palms of our hands and soles of our feet which work like the radiator in a car. Under warm conditions, the shunts close down to force blood into the capillaries at the surface of the skin in order to radiate heat from the body, and our hands get sweaty. Under cold conditions, the shunts open wide allowing blood to bypass the capillaries in order to conserve heat, and our hands get cold and put on gloves.

    According to Dr. Albrecht, “the excess sensory innervation may itself explain why fibromyalgia patients typically have especially tender and painful hands. But, in addition, since the sensory fibers are responsible for opening the shunts, they would become particularly active under cold conditions, which are generally very bothersome to fibromyalgia patients.“

    A role in regulating blood flow throughout the body.

    Although they are mostly limited to the hands and feet, the shunts likely have another important function which could account for the widespread deep pain, achiness, and fatigue that occurs in fibromyalgia patients.

    “In addition to involvement in temperature regulation, an enormous proportion of our blood flow normally goes to our hands and feet. Far more than is needed for their metabolism” noted Dr. Rice. “As such, the hands and the feet act as a reservoir from which blood flow can be diverted to other tissues of the body, such as muscles when we begin to exercise. Therefore, the pathology discovered among these shunts in the hands could be interfering with blood flow to the muscles throughout the body. This mismanaged blood flow could be the source of muscular pain and achiness, and the sense of fatigue which are thought to be due to a build-up of lactic acid and low levels of inflammation fibromyalgia patients. This, in turn, could contribute to the hyperactvity in the brain.”

    Dr. Albrecht also points out that alterations of normal blood flow may underlie other fibromyalgia symptoms, such as non-restful sleep or cognitive dysfunctions. “The data do appear to fit with other published evidence demonstrating blood flow alterations to higher brain centers and the cerebral cortex of fibromyalgia patients” he stated.

    Senior Research Chair of the Alan Edwards Center for Pain Research at McGill University, Dr. Gary Bennett, commented after seeing the results that “It is exciting that something has finally been found. We can hope that this new finding will lead to new treatments for fibromyalgia patients who now receive little or no relief from any medicine.”

    This discovery of a distinct tissue pathology demonstrates that fibromyalgia is not “all in your head”, which should provide an enormous relief to fibromyalgia patients, while changing the clinical opinion of the disease and guiding future approaches for successful treatments.
     
    rcohen likes this.
  2. chickenbone

    chickenbone Well known member

    I have been, in the past, diagnosed with Fibromyalgia. However, I strongly believe that, although it is highly possible that alterations in blood flow (and oxygen) likely happen in this ailment, the source of the problem is psychological. Medical Science, especially Big Pharma, is at their old tricks again, TREATING SYMPTOMS, NOT CAUSES. We certainly know that TMS causes real pain, so of course alterations in blood flow to muscles and nerves definitely happen and can probably be detected. However, the real, underlying cause of this ailment involves psychological factors. It also seems like most people with Fibro have a very similar psychological profile.

    I am not completely cured of it, but I am working on it via the psychological approach and I have experienced a lot of progress and freedom from pain. I had it really bad, was able to make major progress toward recovery and I think others could too if medical science will just get with the program. I really don't like to see this sort of thing because this represents, to me, a giant NOCEBO.
     
    IrishSceptic, rcohen and Birdie like this.
  3. chickenbone

    chickenbone Well known member

    Oh and another thing. I have detected, in myself, the sort of hyperactivity described in the article. I believe this to be the hyper-sensitization that comes with psychological trauma, unresolved conflict and generally "bad nerves". I believe it to have psychological origins. I have been trying to work on myself. Unfortunately, my husband and I retired to Panama, so I have no hope of seeing a mental health professional here, so I am doing my best on my own, using books and the internet.
     
  4. BruceMC

    BruceMC Beloved Grand Eagle

    I met a waitress in the Sierra last summer who reported this sequence of events surrounding how she developed fibromyalgia: 5 years ago she was involved in a car crash where she broke her jaw, dislocated her shoulder and fractured 3 ribs. Okay, after six months to a year she was all healed up. Then, 2 years ago she had an acrimonious breakup and divorce from a very controlling naval officer. Bango! Just after the divorce degree became final, she had an overwhelming attack of fibromyalgia. Later, as her ego mended and her sense of self-esteem came back, her fibro symptoms lessened and gradually went away.

    This whole sequence sounds very much as if it followed the classic two trauma sequence that Peter Levine describes in Waking the Tiger. To grossly oversimplify the process, the physical pain of the first trauma (the car wreck) was re-triggered later on by the emotional trauma of the divorce, which resulted in a bout of fibromyalgia that luckily enough she was able to overcome on her own by rebuilding her shattered personality. The pathologies in the hands of fibro patients discovered by the studies underwritten by Forest Laboratories and Eli Lily are probably there. But are they the ultimate prime cause of the pain or only byproducts of the psycho-dynamics of trauma? Still sounds like a symptomatic cure that ignores the underlying psychological conditioning behind the appearance of a patient's fibromyalgia. Sure, take a pill and reduce the fibro pain. But if you don't address the underlying psychological issues it will just manifest somewhere else and with a different set of symptoms. I've just seen too many cases where an operation on a knee leads to an operation on a shoulder followed by total hip replacement surgery as TMS symptoms continue to migrate around the patient's body in an effort to express underlying unresolved psychological conflicts.

    This sounds a whole lot like the same line of reasoning that blames lower lumbar pain or ulcers on a bacteria present in the lower spines of back patients or another bacteria present in the stomach lining of ulcer patients. In classical logic, you'd say that an epiphenomenon (the bacteria) is being mistaken for the prime cause of the condition (ulcer, fibro, back pain etc. etc.). It sounds to me as if it's just another way of evading the conclusion that emotional and mental states can change the biochemistry of both the body and the mind. One item of extreme interest in the case of those bacteria is that they are ubiquitous in all human beings. So what is it that causes them to "act up" and cause back pain or ulcers? Answer: States of consciousness caused by emotions.
     
  5. chickenbone

    chickenbone Well known member

    Exactly right, Bruce, well put.
     
  6. Forest

    Forest Beloved Grand Eagle

    Great points, Bruce and CB.

    While I disown any connection to Forest laboratories, I see this study as lending evidence to Dr. Sarno's theories. He has always said that TMS is caused by restriction in blood flow. The reduced blood flow to tissues such as muscle, nerve, and tendon lead to those tissue not having enough oxygen and becoming very painful. Given that fibromyalgia is clearly very severe TMS, to validate Dr. Sarno's beliefs, we should be examining fibromyalgia patients for changes in tissues that regulate blood flow.

    Not surprisingly, that's exactly what this paper finds. It finds that tiny little blood vessels that shunt blood around have excessive numbers of nerve fibers around them. The article doesn't attempt to explain how all of those nerve fibers got there, but suppose that someone has extreme TMS, and the unconscious brain is constantly sending signals all over the body to redirect blood flow. We know from brain plasticity that nerve tissue is constantly adapting to its circumstances. If the brain is constantly sending signals to the shunts in the hands of patients with fibromyalgia to redirect blood, then perhaps this causes an increase in nerve fibers in the tiny AV shunts that redirect the blood. I don't know if nerves in the skin are plastic to that degree, but what else would be causing this?

    Being typically cautious, the article doesn't speculate, which is wise. I would certainly not speculate myself, but I just want to point out that this data could easily fit in to Dr. Sarno's theories.

    I'm lucky to currently have access to a research library, so I downloaded the paper. It's very dense, but the following sentence caught my eye:
    Deep tissue ischemia? Ischemia implies lack of blood flow, so that is pure Sarno. Regarding central nervous system responsiveness, I think that we turn to Dr. Schubiner's contributions to understand that. In an interview I did with him, he wrote, "If you combine central sensitization with the psychological mechanisms that I discussed in the last question, I think you have a pretty good model for [TMS]."

    Another quote:
    Dr. Sarno always explained the mechanism of TMS as being through the autonomic nervous system (ANS). Half of the ANS is involved with triggering the fight or flight response and is called the sympathetic nervous system (SNS). The above sentence says that there are excess sympathetic nerves going to the little gates that control blood flow.

    This is just one study and I think it will be decades before anyone really knows what is going on. Dr. Sarno is very clear about the limitations on current knowledge regarding the mechanisms of TMS. Indeed, he's quite comfortable with the question marks that still remain, even referring to a "black box" at one point. To this, I must add that I, of course, am not a doctor and have only read a small part of it. But I do think it is very interesting to note that there are a wide variety of ways that any result can be interpreted.

    These researchers took little slices of skin on the pinky side of the hand and on the chest of some fibromyalgia patients and found that there were lots of nerve fibers in the little gates that control blood flow in the skin from the hand. Who knows what other parts of the body might have additional nerve fibers that are related to blood flow. Dr. Sarno identified muscle, nerve, and connective tissue as the main tissues that are affected by TMS. It could very well be that they also have additional nerve fibers as well and that those nerve fibers are cutting off blood flow in order to create the symptoms of TMS. We simply don't know. All that we really know is that people who read Dr. Sarno's books, who have struggled for years and years tend to get better.

    It's exciting to see. Thanks for sharing it, Dr. Z!
     
    rcohen, Ellen, BruceMC and 1 other person like this.
  7. Enrique

    Enrique Well known member

    Interesting points Forest!
     
  8. BruceMC

    BruceMC Beloved Grand Eagle

    "deep tissue ischemia". That says it all, Forest!
     
    Enrique likes this.
  9. Peter Zafirides

    Peter Zafirides Physician

    Forest,


    I thought the same thing as you when I read the article. This study certainly points to thinking in line with Dr. Sarno's original assertion with TMS - namely, that emotions lead to decreased blood flow that leads to pain.

    I absolutely believe in TMS/PPD. I was cured of my back pain back in 2000-2001 thanks to Dr. Sarno and Dr. Schectder.

    Despite our loyalties and beliefs, I think we have to consider all the research on pain and make a thoughtful choice as to whether the information merits further consideration.

    I do like the fact it has generated some meaningful discussion, though. Great points all around!!

    -Peter
     
    Fabi, IrishSceptic, rcohen and 2 others like this.
  10. hecate105

    hecate105 Well known member

    I agree with Forest & Peter Zafirides. It really looks this study is confirming the Sarno ideas. It gives a physical link between the function of blood flow alteration causing pain and the proliferation of people with fibromyalgia. It would be interesting to see if there is a correlation with other forms of TMS - people with unexplained migraine - or unexplained pain in just one part of the body. I hope those scientists have got plenty of time to follow all this up...
     
    Enrique likes this.
  11. chickenbone

    chickenbone Well known member

    Ha! It is about time we hear back from Dr. Z. I had a feeling he posted it tongue-in cheek!!

    Excellent post Forest, really spells it out. I also thought that the ischemia findings were interesting. I think Dr. Sarno hit the nail right on the head! Brilliant!!
     
    Forest likes this.
  12. Forest

    Forest Beloved Grand Eagle

    I couldn't agree more, Dr. Zafirides. I think that you provide a very valuable service to our community by keeping abreast of the new research and providing easy to read digests and podcasts at www.thehealthymind.com . The mind and body are incredibly complex, and we owe it to ourselves and others to be open to whatever new ideas scientific research brings our way.

    I thought I'd share another paragraph from the article that caught my eye: [my comments are in green]
    The prevailing hypothesis of FM [=fibromyalgia] primarily postulates a sensitization of pain pathways in the central nervous system (CNS) accompanied by evidence of increased excitatory neurotransmitters and inflammatory cytokines in the cerebrospinal fluid (CSF) (footnotes 5,13–17) [this sounds a lot like some of the ideas in Dr. Schubiner's books to me. He refers to the sensitization of pain pathways as "learned nerve pathways"]. The source and maintenance of the CNS sensitization is unknown [unconscious tension is hard to detect on laboratory instruments, so of course they haven't found it]. To date, a peripheral nervous system (PNS) and/or target cell pathology has not been identified in FM patients [because TMS doesn't involve any tissue pathology - it seems to involve biological systems working perfectly normally], although evidence of small fiber neuropathy and cutaneous compartment pathologies have been detected in skin biopsies among several other chronic pain conditions (footnotes 18–26) [these could be reactions to Autonomic Nervous System (ANS) signaling, as described in my earlier post]. Increasing evidence indicates that the excessive fatigue and widespread deep pain associated with FM is caused by peripheral tissue ischemia and hyperactivation of deep tissue nociceptors by anaerobic metabolites [anaerobic metabolites occur when cells don't have enough oxygen to do regular metabolism, so this sounds like something Sarno could predict] and inflammatory cytokines[cytokines are signaling molecules that are similar to the neuropeptides that Dr. Sarno refers to in The Mindbody Prescription], a process that would drive and maintain CNS sensitization (footnotes 1,27–29) [again, when I hear sensitization, I think of Dr. Schubiner's research]. The source of the ischemia[=not enough blood leading to not enough oxygen] is assumed to arise from excessive sympathetically[=autonomic nervous system, which Dr. Sarno describes as being key to TMS] mediated vasoconstriction[=blood vessels not leaving enough blood through], which can also be exacerbated by stress (footnotes 9,30–33) [Sympathetic = the half of the autonomic nervous system that is activated when we are stressed, so "sympathetically mediated vasoconstriction just means that blood vessels are getting smaller and not letting as much blood flow through because the part of the autonomic nervous system related to stress is telling them to cut down blood flow. Once again, I would think that this would be exactly what Dr. Sarno would predict].​

    It's fascinating stuff, and I love reading it, but, as Dr. Sarno noted in Mindbody Prescription, "Benjamin Franklin once said, “Nor is it of much Importance to us to know the Manner in which Nature executes her Laws; ’tis enough to know the Laws themselves.”" It seems that it could take decades of reading to understand this all, but if our goal is only to heal, we don't need to put that much pressure on ourselves. I know that I love reading about it and know that many others do as well, but if you are healing, just know that it works and focus on accepting the diagnosis in your own personal case and calming the fires of your own tension, whatever they may arise from. The TMS recovery program donated by Alan Gordon is a great place to start, but you've got to keep working it to be successful. Not being licensed professionals, we peers have the luxury of focusing on our own healing and just reading about the science for our own curiosity. I'm just glad that we have dilligent MDs and therapists like Dr. Zafirides integrating it all to keep us on the right track.
     

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