Richard G. Petty, MD

The Neurology of Fibromyalgia

Fibromyalgia can be a particularly nasty illness, not least because people who suffer from it have often been misdiagnosed and occasionally even accused of malingering. But the pain can be very real and very severe. There are some very good reasons for believing that it is a neurological problem involving regions of the brain and spinal cord that are involved in modulating pain.

A new study from the University of Bath and Royal National Hospital for Rheumatic Diseases in England has raised some intriguing possibilities for treatment. A year ago, researchers from the same institution reported that there is a reorganization of the sensory regions of the brain n people with chronic pain.

In this new study, researchers asked patients to look at a reflection of one arm while moving their other arm in a different direction that was hidden behind a mirror positioned in front of them at a right angle. So one limb was obscured from view behind the mirror while they could clearly see the other limb and its reflection.

This simple experiment created a mismatch between what the brain sees from sensory input and what it feels through the motor system that controls movement.

Of the 29 fibromyalgia patients involved in the study, 26 reported feeling a transient increase in pain, temperature change or heaviness in their hidden limb - all symptoms of a flare up of their condition.

This suggests that a mismatch between sensory and motor neurons could be at the root of the fibromyalgia.

This study adds to the growing body of evidence that many of the symptoms of fibromyalgia may be triggered or perpetuated by a sensory-motor conflict.

That opens up all kinds of new possibilities for treatment.

Ear Acupuncture and Knee Surgery

There is growing interest, particularly in Europe, about the use of acupuncture and acupressure in combination with conventional Western Medicine.

Researchers from Ernst Moritz Arndt University in Greifswald in Germany have reported the results of a study to see whether acupuncture would help 120 people undergoing surgery of the knee.

Their main measurement was the patients' need for postoperative pain medication.

The patients were randomly received true auricular (ear) acupuncture at the main points that Chinese medicine says are important in treatment: the Lung, Shenmen and Knee points.

The control group had a sham procedure: they were “treated” at three non-acupuncture points on the outside of the ear: the auricular helix. The “real” and the “sham” treatments were given on the ear on the same side as the knee, before ambulatory knee arthroscopy. Permanent press needles were left in place for one day after surgery and post-operative pain was treated with ibuprofen. Pain intensity was similar in both groups at all time points, but those in the acupuncture group required significantly less post-operative ibuprofen than controls.

This fits with clinical experience and is a good first study.

Not only may this provide personal benefit for the patients, but if acupuncture can reduce post-operative costs, you can be sure that insurance companies are going to get very interested very quickly.

Fibromyalgia is Real! A Battle That Should Not Have To Be Fought Again

Fibromyalgia is a chronic, widespread pain in muscles and soft tissues accompanied by fatigue, it is a fairly common condition, affecting 3% to 6% of the general population, and is most commonly diagnosed in people between the ages of 20 and 50, though onset can occur in childhood. The disease is not life-threatening, though the degree of symptoms may vary greatly from day to day with periods of flares (severe worsening of symptoms) or remission. The syndrome is generally perceived as non-progressive, yet that issue is still a matter of debate.

The cardinal symptoms of fibromyalgia are chronic, widespread pain and tenderness to light touch together with moderate to severe fatigue. Those affected may also experience heightened sensitivity of the skin ("allodynia"), tingling of the skin that is often needle-like, a deep ache in the muscle and , less often, the tendons, prolonged muscle spasms, weakness in the limbs, and nerve pain. Chronic sleep disturbances are also characteristic of fibromyalgia, and some studies suggest that these sleep disturbances are the result of a sleep disorder called alpha-delta sleep , a condition in which deep sleep (associated with delta EEG waves) is frequently interrupted by bursts of brain activity similar to wakefulness (i.e. alpha waves). Deeper stages of sleep (stages 3 & 4) are often dramatically reduced, and that is the likely cause of the cognitive problems that so often accompany fibromyalgia.

There is not any structural damage in an organ, though it may sometimes start after trauma, such as a motor vehicle accident.

It is that last fact, that there is s often no obvious physical pathology, that has lead so many people to claim that fibromyalgia is “nothing more than” pain associated with depression. I have has some interesting “discussions” with health care professionals convinced that people wit fibromyalgia do not have a “real” illness, and that they need psychotherapy or antidepressants. Yet pain is pain, and the false dichotomy: “Is the pain my mind or in my body?” helps nobody.

Twenty-five years ago, Muhammad B. Yunus and his collaborators published the first controlled study of the clinical characteristics of fibromyalgia syndrome. That seminal article, published in Seminars in Arthritis and Rheumatism, led directly to formal recognition of this disease by the medical community. Last month, again in Seminars in Arthritis and Rheumatism, Muhammed makes another enormous contribution to the field of chronic pain and fatigue by meticulously synthesizing and interpreting the extensive body of scientific literature on fibromyalgia and his own insights into the concept of central sensitivity syndromes (CSS) that include irritable bowel syndrome, migraine and restless legs syndrome.

In fact there are at least 13 separate conditions that are related to central sensitization (CS), where the central nervous system becomes extremely sensitized with respect to certain parts of the body, so that even mild pressure or touch would cause much pain. This hypersensitivity may also be associated with other symptoms such as poor sleep and fatigue.

Muhammed took a rather more biological approach to fibromyalgia in the past, now emphasizes a biopsychosocial perspective:

“In my view, this is tremendously important because it is the only way to synthesize the disparate contributions of such variables as genes and adverse childhood experiences, life stress and distress, posttraumatic stress disorder, mood disorders, self-efficacy for pain control, catastrophizing, coping style, and social support into the evolving picture of central nervous system dysfunction vis-à-vis chronic pain and fatigue. Science and medicine now have rational scaffolding for understanding and treating chronic pain syndromes previously considered to be 'functional' or 'unexplained.' Neuroscience research will continue to reveal the mechanisms of CS, but only if informed through a biopsychosocial perspective and with the interdisciplinary collaboration of basic scientists, psychologists, sociologists, epidemiologists, and clinicians."

One of the reasons that I so like this new version of his model is because it fits so well with the concept of  “Salience Disruption Syndrome.” A fancy name for a common problem that I talk about in Healing, Meaning and Purpose.

So very many people are super-sensitive to the environment and also have trouble in filtering out and deciding what is important. As a result pain, attentional problems, impulse control disorders, addictions and several other things tend to cluster together.

Happily we now have an array of novel techniques for dealing with these problems, and I plan to put out more books and papers on ways in which we can help.

Mindfulness and Depression

 

Mindfulness meditation has rightly been receiving a lot of attention recently. It is quite simply a technique in which you become intentionally aware of your thoughts and actions in the present moment, non-judgmentally. Though originally a Buddhist technique, it is something that can be practiced by anyone, and there are, in fact, similar techniques that have been developed by Christian mystics and Sufis.

It has recently been discovered that some of the techniques that were developed so that a mystic or meditator could carry on without distraction, may also have value in treating clinical problems. After all, if a group of people has spent a thousand years developing tools and techniques for managing the mind, it might be a good idea to see what they have discovered!

There have recently been several excellent books on the use of mindfulness in the management of depression:
The Mindful Way Through Depression 
Relaxation, Meditation and Mindfulness
Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition

This whole field was moved forward by some research from San Francisco (NR822) that was presented at the end of May at the 2007 Annual Meeting of the American Psychiatric Association in San Diego. The researchers used Mindfulness-Based Cognitive Therapy (MBCT) in a group of 53 people with treatment resistant depression.

MBCT is based on the Mindfulness-based Stress Reduction (MBSR) eight-week program that was developed by Jon Kabat-Zinn in 1979 at the University of Massachusetts Medical Center. Research has show that MBSR can be enormously empowering for people with chronic pain, hypertension, heart disease, cancer, and gastrointestinal disorders, as well as for psychological problems such as anxiety and panic.

Mindfulness-based Cognitive Therapy grew from this work. Zindel Segal, Mark Williams and John Teasdale adapted the MBSR program so that it could be used for people who had suffered repeated episodes of depression.

The results of the study presented in San Diego showed that MBCT was effective in reducing depression when compared to treatment as usual: what we call “TAU.” What seems to happen is that MBCT gives people a set of skills for detaching from the stream of depressive thoughts and feelings. As a result the symptoms decrease. Though the study will need to be expanded and replicated, this is clearly a fertile area for research.

This work is also interesting in the light of recent research showing that mindfulness training may improve the activity of some of the subsystems of the brain dedicated to attention, as well as helping  some people with mental illness control their aggressive behavior. Mindfulness training may also help to reduce subjective reduces distress and improves positive mood states. It seems to be particularly good at reducing distracting and ruminative thoughts and behaviors.

And just for good measure, mindfulness may help some smokers quit.

“The purpose of meditation is not enlightenment, it is to pay attention even at extraordinary times, to be of the present, nothing-but-in-the-present, to bear this mindfulness of now into each event of ordinary life.”
--Peter Matthiessen (American Naturalist and Writer, 1927-)

“Meditation is not to escape from society, but to come 
back to ourselves and see what is going on. Once there is 
seeing, there must be acting. With mindfulness, we know 
what to do and what not to do to help.”
-- Thich Nhat Hanh Vietnamese Buddhist Monk, 1926-)

“Conscious means "having an awareness of one's inner and outer worlds; mentally perceptive, awake, mindful." So "conscious business" might mean, engaging in an occupation, work, or trade in a mindful, awake fashion. This implies, of course, that many people do not do so. In my experience, that is often the case. So I would definitely be in favor of conscious business; or conscious anything, for that matter.”
--Ken Wilber (American Philosopher, 1949-)

Motivation, Manipulation and Empowerment

It would be good to know how many people really change after they’ve done one of those motivational seminars. Undoubtedly some do, but most do not.

This stands in stark contrast to inspirational speakers who often change people for life.

If you try to “motivate” an adult to change their behavior, after an initial brief period during which they get excited about what they are learning, they will most likely resist what they perceive as manipulation. People who do change normally don’t maintain the new behavior because the primary motivation was external.

If we are trying to help people eat a more healthy diet, or take some exercise, research has shown that the best way to initiate and maintain a new behavior is for an individual to have an expert who can teach, guide and facilitate. That together with a peer supporter: someone who will help you along, and diet and exercise with you. You know yourself better than anyone else ever can.

The trick is to work with someone who may know a bit more about psychology, physiology and metabolism and can use that information to help you to develop a personalized program. The expert can help you move forward by asking question to identify your own motivators, locus of control (do you feel that you are the captain of your own ship, or do you believe that you are more a plaything of fate?) ego-fears, reward system and action style (do you like to break tasks down into small steps and work at one at a time in sequence, or do you like to work on one task, then pull out something else that like to do and do you have some other way of getting things done?)

There was recently a study  from the UK that showed that the behavior of children with special needs was improved by a good diet and regular exercise. No surprise there. But the problem is this: how do you maintain the diet and exercise programs?

I spent many years working with young people with weight problems and/or diabetes. They usually also had some mood or behavioral problems. Issuing young people with a great long list of “Thou shalt nots” is guaranteed to backfire: youngsters are rebellious anyway. Tell them all the things that they can’t do, and force them into eating a certain way, and you will have a rebellion on your hands that will make the Storming of the Bastille look like a picnic. It is much better to come to an agreement that may include having days on which they can “cheat.”

A while ago I wrote about the way in which psychologists have moved beyond the pain/pleasure dichotomy as the major motivators of human behavior. Rewards and punishments are called extrinsic motivators, while intrinsic motivators are a composite of genes, learning, environment and temperament. I gave a few examples of motivators culled from the current literature:

1. Clarity of vision

2. Encouragement

3. Personal engagement

4. Recognition

5. Pride

6. Free flow of energy and information

7. Appropriate reward systems (money is often not the best one!)

8. Personal and group expectations

9. Creating shared goals

10. Transpersonal motivation: Inspiration and leaving a legacy.

I had several excellent questions: couldn’t people practice altruism because it gives them pleasure? Yes, they could, but that is not what the research data shows. Though people can derive pleasure from all kinds of things, the evidence base suggests that human motivations are far more complex.

It has also become possible to visualize regions of the brain while people are engaged in different tasks, and altruism does not seem to engage most of the circuits that we normally associate with pleasure or pain.

Yet more evidence that pleasure and pain and far from being the only - or maybe even the main - motivators of human behavior.

“No one ever does anything from a single motive”
--Samuel Taylor Coleridge (English Romantic Poet, 1772-1834)
   
“No one can motivate you, until you motivate yourself.”
--Jawaharlal Nehru (Indian Politician and Statesman, 1889-1964)

“Motivation is everything. You can do the work of two people, but you can't be two people. Instead, you have to inspire the next guy down the line and get him to inspire his people."
--Lee Iacocca (American Businessman and Former CEO of Chrysler, 1924-)

“Motivation is what gets you started. Habit is what keeps you going.”
--Jim Rohn (American Businessman, Author, Speaker and Philosopher)

“Do not brood over your past mistakes and failures as this will only fill your mind with grief, regret and depression. Do not repeat them in the future.”
--Sri Swami Sivananda (Indian Physician and Spiritual Teacher, 1887-1963)

“The need for devotion to something outside ourselves is even more profound than the need for companionship.”
--Ross Parmenter (American Expert on Mixtec Documents, Journalist and Music Reviewer for the New York Times, 1920-1999)

“He who wishes to secure the good of others has already secured his own.”
--Confucius (Chinese Philosopher, 551-479 B.C.E.)

Back Pain, The Brain and Pain Cycles

A German research team using a specialized imaging technique called diffusion tensor imaging (DTI) to look at the differences between back pain sufferers' and healthy volunteers' brains found that individuals suffering from chronic low back pain also had micro-structural changes in their brains. The findings were presented at the annual meeting of the Radiological Society of North America in Chicago by the lead researcher Dr Jurgen Lutz, a radiologist at Ludwig-Maximilians University in Munich, Germany.

DTI tracks the movement of water molecules in the brain's gray and white matter. Individual water molecules are constantly in motion, colliding with each other and other nearby molecules, causing them to spread out, or diffuse. DTI allows us to analyze water diffusion in the tissues of the brain. In normal white matter, water diffuses in only one direction. So if they are moving in the “wrong” direction, we can use this as an indication that there are changes in the fiber pathways.

The investigators studied 20 patients who were experiencing chronic back pain with no precisely identifiable cause and 20 age- and gender-matched healthy volunteers. DTI was performed to measure the diffusion in several areas of each patient's brain. 
 



They discovered the brains of patients with chronic back pain had a more complex and active microstructure compared with the healthy volunteers' brains.

The changes were found in regions of the brain associated with pain-processing, emotion and stress response, including the cingulate gyrus, postcentral gyrus and superior frontal gyrus.

Although it is possible that theses structural disturbances are a cause of chronic pain, it is more likely to be the other way round.

This leads us to a very important concept that is not talked about as much as it should be: it is the idea of pain cycles. Pain cycles can have a physical or psychological origin and are thought to be maintained by some of the centers in the brain that process pain and emotional distress. The two are often mixed together: pain is extremely common in both depression and in bipolar disorder, and pain can, of course, make you feel depressed.

Theses pain cycles will often persist for long periods after the original cause of the pain has gone. So we may continue to feel pain long after a broken bone has healed, or we may continue to suffer emotionally long after a bad relationship should have been dead and buried. Many interventions like acupuncture or injecting steroids or anesthetics into trigger points can interfere with the pain cycle. Similarly there are many therapies, including some of the tapping therapies, that seem to “re-set” some of the systems in the nervous and subtle systems of the body.

In my forthcoming book Sacred Cycles, I talk a lo about these vicious pain cycles and how to interrupt them.

“Pain is part of being alive and we need to learn that. Pain does not last forever, nor is it necessarily unbeatable, and we need to be taught that.”
--Rabbi Harold S. Kushner (American Rabbi Aligned with the Progressive Wing of Conservative Judaism and Writer, 1935-)

“Softness is a dream in every ache to become a better soul.”
--John Kells (Irish-born British Grand Master of T’ai Chi Ch’uan, 1940-)

Arthritis and Sex

Today being Valentine's Day (you did remember didn't you?), Arthritis Care in the United Kingdom has taken the opportunity  to publicize its free booklet on sex, relationships, intimacy and arthritis, downloadable from its website (pdf).

Integrated Medicine is all about empowering and caring for the whole person, so I was very pleased to see this document. I spent some very happy times helping people with various types of arthritis, and I was astonished how infrequently anyone had ever asked them about the ways in which the illness impacted normal daily activities and had ever given them any advice on ways to work around problems.

Let me quote form the Arthritis Care news release:

"One of the reasons we produced the guide is to address issues people felt awkward discussing. It may be embarrassing to talk to your consultant rheumatologist, nurse or GP about emotional and sexual things, or matters of self-image and self-esteem - and they may be embarrassed to be asked. So where do you turn?' said Kate Llewelyn head of publications at Arthritis Care, who was diagnosed with rheumatoid arthritis at the age of thirteen.

The booklet provides a valuable insight for healthcare professionals and for the partners and families of people with arthritis, highlighting issues of concern to them, and suggesting practical and achievable solutions.

For people with arthritis, or other disabilities, difficulty can start before any relationship, pre-dating any date.

'Managing pain and other symptoms is exhausting, and it stops many people getting out and socializing. As a result, arthritis can be isolating, keeping you from making friends or seeing family, let alone dating and finding a partner. And maybe you are not very mobile, so can't dance, or play sport, or can't drink because of your medications. What's more, although anti-discrimination law means venues must now offer better access for disabled people, you still may find it harder to do things people without arthritis take for granted', said Kate Llewelyn.

Once a relationship has been formed, the challenges continue; the couple must work out ways of ensuring their personal and sexual relationship is sustained and developed, overcoming and working round the incurable and debilitating condition.

The report discusses a number of very practical matters: how pain and also medication can interfere with sex drive and some can cause weight gain. Many forms of arthritis are also associated with anemia and/or chronic fatigue.

It also discusses some of the psychological factors that can interfere with the sex lives of arthritis sufferers. For example, men may feel emasculated if they cannot perform their 'traditional' roles like playing sport or carrying heavy objects. Women may feel unfeminine if they put on weight with steroids, cannot do the housework or lift their children as a result of having arthritis. Others, with limited joint movement, or severe pain may be put off sex altogether, or find some of the traditional sex positions too uncomfortable.

'The book has got diagrams of lovemaking positions which people of differing physical abilities and limited movement have found useful. If you've got problems with your spine, or hips, or knees, it makes sense to experiment with positions that place least weight or strain on the rogue joints. Of course, after joint surgery or replacement, you may be advised to take a temporary break from sex, but, relationships are more than sex, and, with this guide, abstinence may make the heart grow fonder', said Kate Llewelyn.

Sex is rarely discussed with people strugglig with chronic illness, often because health care providers get embarassed about it.

It is essential for that to change, and I want to say a big thank you to Arthitis Care for having the courage to do this.

Temporomandibular Joint Dysfunction and Posttraumatic Stress Disorder

Over the last few years I’ve had the privilege of visiting Croatia several times. I was one of the first Western academics to go back there to teach after the war, and I’ve made many good friends. It is a beautiful country with lovely people and it is a terrible shame what happened there.

One of the big problems that remain is the incredible number of people suffering from posttraumatic stress disorder (PTSD). There continues to be some debate about whether PTSD can only occur in response to one major traumatic event in which a person feels that their life is in danger, or whether it can also occur as a result of repeated less serious traumata. We have discussed the relationships between PTSD, resilience and neurological dysfunction, and of the association between PTSD and laterality.

There has also been at least one report of an association between PTSD and atypical facial pain.

A new paper from colleagues in Croatia has clarified this association by showing that people with PTSD are at increased risk of temporomandibular muscle and joint disorder, or TMJD, which used to be known simply as temporomandibular joint (TMJ) dysfunction. This is intuitively obvious, but it is an important finding. The main complaint was of headache, and it is important not to dismiss these headaches as migraine, tension headaches or as some kind of somatization.

There is currently an $8 million project underway to establish valid and reliable TMJD diagnostic criteria. It is to be hoped that the results of the study will advance the field of TMJD research and aid clinicians in their practices. At a meeting of the American Association of Dental Research in Orlando, Florida in March, Richard Ohrbach  from the University of Buffalo presented data from the study indicating that 82% of People whose recurrent headaches have been diagnosed as tension-related actually had TMJD.

In April of this year, we had the first meeting of the National Institutes of Health Pain Consortium. There’s a good report in Clinical Psychiatry News about ongoing studies from the University of Washington in Seattle. Niloofar Afari presented data that confirms the findings in the Croatian study. And provides yet more useful information.

The investigators used state records to identify twins and surveyed more than 1,700 female twins by mail and by telephone. The results so far indicate that the association between PTSD and TMJD is real and that there may be a genetic predisposition to the association.

It is important not to miss this possible association. Misdiagnosis can cause a lot of needless suffering.

How to Stick a Knife Through Your Arm

I know that probably sounds a bit gross, but sometimes Nature does our experiments for us.

And this particular experiment involved a young Pakistani boy who worked as a street "entertainer" by sticking sharp objects into various parts of his anatomy. He was able to do this not because of some form of religious fervor or yogic control, but because he had a congenital inability to feel pain.

That may sound like a good thing but it is not. Pain exists to warn you: how else would you know is you have stepped on broken glass or put your hand on a hot plate?

Investigators on three continents collaborated to track down the boy's problem at the molecular level. The research is published in the journal Nature, and will likely open up a whole new approach to treating pain.

The boy dies four years ago at the age of fourteen, but the investigators were able to track down six of the boy's extended relatives who were also totally numb to pain. However they had some feeling: a pinprick would feel like pressure. They all had  frequent cuts and bruises and problems using their limbs, and they all had old injuries to their lips or tongues from biting themselves as young children.

Since the late 1990s researchers have been studying the culprit gene product, a sodium-conducting ion channel called NaV1.7, which sits on the ends of pain-sensing cells. In 2004 researchers in China identified members of two families who have a nasty condition called erythromelalgia, in which the slightest warmth causes literally burning pain in their hands and feet.

Work by the group in China and Stephen Waxman's group at Yale in West Haven, Connecticut, discovered that the cause of this condition is a mutation in the NaV1.7 channel that makes it become hyperactive. In effect the mutated channel overstimulates pain-sensing neurons, causing them to register pain more frequently. By contrast, the mutation in the pain-free Pakistanis knocks out NaV1.7 activity, so no firing of the pain-sensing neurons.

This work will inevitably lead to a search for new ways of damping down pain. Now that we have a good idea of the way in which a single mutation can either cause too much pain or none at all, the nest step is to see if we can deelop comprehensive treatment strategies based on these new insights.

Cluster Headache: A New Approach

By a strange "coincidence", just a couple of days after posting about cluster headaches, the BBC is carrying an article about a woman with cluster headache who was successfully treated by a neurosurgeon who implanted a nerve stimulator attached to the greater occipital nerve at the back of the skull.

It has been known for some time that there is a type of atypical cluster headache that can be treated by blocking these nerves. Some experts feel that since cluster headache is usually driven by the hypothalamus, headaches that can be stopped by nerve blockade or nerve stimulation are not cluster headaches at all.

That is something for us to sort out at scientific conferences.

But for now, there is at least one person - who was featured in the BBC's article - who has been cured after everything else failed.

But here's the strange thing: none of the neurologists or neurosurgeons has a clue how the treatment works.

Yet anyone versed in Traditional Chinese Medicine would tell you immediately the nerve runs directly above a key acupuncture point - Fengchi, or Gallbladder 20 - that is often used in treating severe headaches. Because disturbances in the subtle systems of the liver and gallbladder are common in many types of headache.

In other words, knowledge of the subtle anatomy of the body can explain how the nerve stimulator is working, but the best of current Western neurological science cannot.

A beautiful example of how the combined approaches of Integrated Medicine can help and inform everyone involved.

And it is the patient who gets all the benefits.

Cluster Headache

There are dozens of types of headache, but one of the most serious and debilitating is called "cluster headache."

It is a very severe headaches of a piercing quality that most often occurs near one eye or temple. The pain typically lasts for fifteen minutes to three hours. The headaches are usually unilateral and occasionally change sides.

It is difficult to overstate the severity of the pain. I once mentioned that I could always tell if there was someone in the clinic experiencing a cluster headache because everyone could hear him banging his head against the wall to try and get some relief. They may also be described as "suicide headaches:" a reference to the excruciating pain and resulting desperation that has culminated in actual suicide.

There are some odd symptoms that may accompany the headache, such as:

• Stuffy or runny nose in the nostril on the affected side of the face
• Red, flushed face again on the side of the headache
• Swelling around the eye on the affected side of the face
• Reduced pupil size
• Drooping eyelid

As the name implies, cluster headache usually comes in clusters that last for a week or two or as long as two months. In about 10-15% of people they are chronic. The periodicity of the clusters is remarkable and has lead many of us to speculate an involvement of the brain's "biological clock" or circadian rhythm. In an observational study we found that clusters were more likely to begin in the month of birth of the sufferer, though we never knew how much to read into this.

Cluster headache is far more common in tall men: most are over six feet tall. When we first described cluster headache in women in the early 1980s it was a rarity, though more women have been getting cluster headache in recent years: we have no idea why. Some years ago we also described that they were more common in men who smoked heavily and drove more than 15,000 miles each year. It was impossible to say whether the smoking was cause or effect. Cluster headache is, along with diabetes and multiple sclerosis, an illness that becomes more common in peple who live far from the equator.

We and others also found that nitrates could trigger episodes in some people: that first came to light when we saw three men who used them during sex.

Cluster headaches are most likely to be due to an abnormality in the hypothalamus, which could explain why cluster headaches frequently strike around the same time each day, and during a particular season, since one of the functions the hypothalamus performs is regulation of the biological clock and the metabolic abnormalities that have been reported in some patients.

During the onset of a cluster headache, the most rapid abortive treatment is the inhalation of pure oxygen (12-15 litres per minute in a non-rebreathing apparatus). When used at the onset of headache this can abort the attack in as little as 5 minutes. Once an attack is at its peak, using oxygen therapy appears to have little effect. Alternative first-line treatment is subcutaneous administration of triptansumatriptan and zolmitriptan. Because of the rapid onset of an attack, the triptan drugs are usually taken by subcutaneous injection rather than by mouth. While available as a nasal spray, it had been thought that the spray would not be effective to sufferers of cluster headache due to the swelling of the nasal passages during an attack. However new research from London has shown that 5-mg and 10-mg doses of zolmitriptan intranasal spray are effective within 30 minutes and well tolerated in the treatment of acute cluster headache.

Lidocaine (or any topical anesthetic) sprayed into the nasal cavity may relieve or stop the pain, normally in just a few minutes, but long term use is not suggested due to the side effects and possible damage to the nose and sinuses.

Previously vaso-constrictors such as ergot compounds were also used though less so now becuase of their side effects and new options being available. Oddly enough some sufferers report a similar relief by taking strong cups of coffee immediately at the onset of an attack.

Many different types of prophylaxis have been tried, with lithium, the calcium channel blocker verapamil at a dose of at least 240mg daily, and the anticonvulsant topiramate.

Now a new report in the journal Neurology suggests that 22 out of 26 people with cluster headache who used psilocybin reported that the drg aborted their attacks. 25 of 48 psilocybin users and 7 of 8 LSD users reported cluster period termination; 18 of 19 psilocybin users and 4 of 5 LSD users reported remission period extension. The authors conclude that research on the effects of psilocybin and LSD on cluster headache may be warranted.

From what we do understand about the pathogenesis of cluster headache it is not difficult to see how psilocybin and LSD may help. But it did worry me that this report might lead to people self-medicating with hallucinogens without any kind of support or guidance.

That being said, this recent report shows once again the importance of listening to what people have to say: they often have the answers inside of them. And those answers may lead to a new range of treatments.

 

Music Therapy

Music therapy has been in use for millennia: in the Bible David played his harp to try to ease the suffering of King Saul and there are whole systems of musical healing in the traditional healing systems of China and India. I have commented before on the extraordinary power of music.

Apart from our experience, there is an astonishingly large and diverse body of scientific literature on music therapy, not just to help individuals, but also on possibly improving the performance of health care providers. Many surgeons attest that they do a better technical job if they are listening to music.

This month’s issue of the British Journal of Psychiatry carries an interesting article about the value of music therapy in people with schizophrenic illnesses. Though small, it indicates that music therapy can be helpful, and speaks to the integrity of many components of the nervous systems of people with this large and diverse group of problems.

There is good evidence that music therapy may help with:

• Treatment-related distress in people having treatment for several cancers
• Autistic spectrum disorders 
• Calming people who are having cardiac catheterization procedures
• Pain relief 
• Distress after total knee replacement
• Pain after leg fractures
• Apathy in people with dementia
• Sleep and heart rate patterns in pre-term babies

This is by no means an exhaustive list: I have found several hundred studies, many of which are quite well designed. There are also several professional organizations such as the American Music Therapy Association.

It is clearly important to choose the right kind of music: I would guess that Metallica is less likely to soothe the fevered brow than Steve Halpern.

Background music can be wonderful for improving the ambience of your home or workplace. But you can also be more focused in your use of music to help or support other types of health and wellness programs.

Select the music that you like: there are now many wonderful programs geared toward using music for healing: I can give you a list of some that I have tested. The good ones will entrain your heart rate, some of your brain rhythms and the subtle systems of your body.

If you can find 20 minutes, the right music listened to while sitting or lying with your eyes closed can be as effective as a short meditation. For this to work well, it is best to use good quality headphones and to allow the music to wash over and soak you like a warm bath, while gradually slowing and deepening your breath.

I’ve also made extensive use of specifically chosen music during massage, acupuncture, yoga, and while practicing t’ai chi ch’uan and qigong. Some purists don’t like using music while doing these activities, but I’ve usually found that music can enhance each type of practice.

Try it and see what you think.

Qigong in the Treatment of Depression

I first started teaching T’ai Chi Ch’uan and qigong over 20 years ago, and I was always impressed by the apparent benefits for people with chronic low mood. Not so much in people with severe depression, but in people who were just chronically miserable.

During a visit to Hong Kong in 2004, I heard about some interesting research that’s just been published. Researchers from the Department of Rehabilitation Sciences at the Hong Kong Polytechnic University and Kwai Chung Hospital, examined the effects of regular qigong in 82 older people with a diagnosis of depression. After just eight weeks of regular daily practice, there was an overall improvement in mood, self-efficacy and personal well-being. By week sixteen there were really quite marked improvements not just in mood, but also in activities of daily living and how people felt about themselves.

We know that there are close links between mood and the immune system, so this research fits in with a study from Tokyo in which a breathing method said to enhance Qi was shown to reduce stress and modulate the function of the immune system.

There are many studies of qigong, but they are of variable quality. Another one which supports both of these two studies comes from Korea, where something slightly different - qigong therapy - was shown to help both pain and mood in older people with chronic pain form a variety of causes.

I do not think that we have enough evidence to try using qigong alone in the treatment of depression, which is, after all, a potentially fatal condition. But I do think that Qigong is an important part of an Integrated Medicine program, and I am creating more resources for people to do the first stages of qigong on their own.

Curing Chronic Pain: Its All Done with Mirrors

There is a fascinating new approach to treating chronic pain. 

The story goes back two years, to the publication of important research from a team at the Royal National Hospital for Rheumatic Diseases, in Bath in England. They wrote a paper in which they tried to link joint pain in neurological conditions. They wanted to see how the pain of rheumatoid arthritis, fibromyalgia and complex regional pain syndrome might relate to phantom limb pain (PLP) experienced by many amputees.

They suggested that in each condition there is reorganization in the sensory regions of the cerebral cortex. And it is this reorganization that generates pain and an altered body image. It seems to be just the same in rheumatology patients as has previously been hypothesized for amputees with PLP; that is a motor/sensory conflict. The body and the sense don’t match and it hurts. Their initial research indicated that something incredibly simple: using a mirror could help people correct of this conflict. They were able to show that a mismatch between motor output and sensory input creates sensory disturbances, including pain, in rheumatology patients and also in healthy volunteers.

In a second paper the investigators were able to show that doing a movement while looking at a distorting mirror could quickly induce uncomfortable symptoms in fit healthy people.

For over two decades, David Blake - the senior author of this research - has championed the idea that there is an important neurological component in inflammatory arthritis. It all started with a simple observation that has puzzled generations of clinicians: why is it that joint involvement in inflammatory arthritis is so often symmetrical? It isn’t surprising if both hips get arthritis: they will likely both have been subjected to a lot of wear and tear. But why should arthritis involve the second joint of the index finger in both hands? It has always looked as if this might imply some neurological contribution.

The idea is that although pain may have originated in inflamed joints, it is maintained and exacerbated by the nervous system. This fits with a fact that has been known to acupuncturists for centuries and has been replicated in pain clinics around the world. If you can interrupt what we call the pain cycle - constant chronic pain that feeds on itself and gets progressively worse – then you may often see pain relief for weeks or months, or sometimes even indefinitely. It is quite common for chronic pain to have had a clear physical precipitant, but to be maintained by key regions in the brain.

This new research strongly supports these observations, implies that the successful treatment of chronic rheumatological pain may involve a neurological approach, and offers a brand new therapeutic option.

“The speaker is only a mirror. Where you can see yourself. When you recognize yourself clearly, you can put aside the mirror.”--Jiddu Krishnamurti (Indian Spiritual Teacher, 1895-1986)

“Perception is but a mirror, not a fact. What I look on is my state of mind reflected outward.”--A Course in Miracles

Peripheral Neuropathy

Treating peripheral neuropathy can be one of the toughest problems facing a clinician. Peripheral neuropathy simply means disease affecting the peripheral nerves.

There are a great many cause of peripheral neuropathy. This is just a partial list to give you an idea of the things that a clinician has to think about before starting treatment:

1. Metabolic illnesses: Diabetes mellitus; porphyria; chronic renal failure; amyloidosis and disturbances in circulating proteins
2. Vitamin deficiencies: Vitamins, B1, B3, B6 and B12
3. Drugs and chemicals: Alcohol; Heavy metals like arsenic, lead and mercury; organic pesticides; several drugs used in cancer chemotherapy; isoniazid; nitrofurantoin
4. Infections: Lyme disease; Herpes zoster (shingles); Diphtheria; Brucellosis; Leprosy; Tetanus; Botulism
5. Malignant illnesses
6. Inflammatory and autoimmune illnesses: Rheumatoid arthritis; Systemic lupus erythematosus; Polyarteritis nodosa; Sarcoidosis; Guillain-Barre syndrome; Celiac disease
   
7. Physical injury: Trauma, stretching and compression of nerves, which can include things like carpal tunnel syndrome.
8. Congenital illnesses

Many causes of peripheral neuropathy, particularly diabetes, may also damage the autonomic nervous system that controls the heart, blood pressure, swallowing, intestinal and bladder function.

Neuropathic symptoms typically start in the feet, because the nerves running down there are longer and more vulnerable than the ones going to the hands.
The most common symptoms are:

1. Numbness
2. Tingling
3. Abnormal sensations called dysesthesias
4. A characteristic form of pain, called neuropathic pain or neuralgia: people usually describe it as “pins and needles,” a steady burning sensation or “electric shocks.” These pains can be difficult to describe: typically pains, like stubbing your toe or stepping on something sharp, are transmitted through pain fibers. Neuropathy also involves other neurological pathways, so that the brain receives impressions that it cannot process.

There has been a revolution in out understanding of neuropathic pain in recent years. It is now considered to be a disease rather than a symptom. Normal pain is designed to protect you: you put your foot on a hot plate and you pull it away immediately. Neuropathic pain is different: it is non-protective and it persists and therefore behaves like a disease.

Multiple different classes of medications have been shown to be effective in some people with neuropathic pain, though most are not approved for use by the Food and Drug Administration:

1. Lidocaine patches and creams
2. Capsaicin creams
3. Opioid analgesics
4. Tricyclic antidepressants
5. Serotonin-norepinephrine reuptake inhibitors (SNRIs)
6. Anticonvulsants: Carbamazepine; gabapentin; pregabalin

Earlier this week, data presented at the European Federation of IASP (International Association for the Study of Pain) Chapters (EFIC) indicated that an innovative combination of painkillers might hold the key to unlocking the severe and relatively untreatable pain of peripheral neuropathy.

Dr Magdi Hanna, Director of Pain Clinical Research Hub at King's College Hospital in London, has been studying the combination of the strong opioid oxycodone (OxyContin) with gabapentin (neurontin) in over 300 patients with severe diabetic neuropathy. This combination demonstrated a significant 33% improvement on top of the best pain relief achievable using the maximum tolerated dose of gabapentin as monotherapy. The study was part funded by one of the medicine manufacturers.

This study is good news, but even in this study there were a great many people who were not helped. In another blog item, I’m going to talk about some of the unorthodox approaches that have helped some people.

Cutting and Self-injury

There’s an extremely disturbing trend: ever-increasing numbers of young people who are cutting themselves. Once rare, and something usually seen only in people with serious psychiatric illness, many school children encourage and goad each other into doing it, and there are websites dedicated to cutting, on which young people compare notes and even give each other advice on how to conceal what they are doing, by cutting themselves in places like the lower back.

We have been offered a great many explanations for this worrying development, but not much in the way of evidence. We know that most people who cut themselves are female adolescents or young adults, and apart from the obvious physical dangers, there is evidence that this behavior may lead to a more serious psychological condition called Borderline Personality Disorder. This can be a serious problem that carries a high risk of suicide. It is also of some theoretical interest, because there seem to be genuine cultural differences in borderline personality disorder. An estimated 5.8 million to 8.7 million Americans, mostly women, suffer from it, but it is far less common in most of Western Europe and Australia. Research over the last decade has indicated that the condition is becoming more common in these regions. People with the borderline personality disorder have a wide spectrum of difficulties that are marked by emotional instability, difficulty in maintaining close relationships, eating disorders, impulsivity, chronic uncertainty about life goals and addictive behaviors such as using drugs and alcohol. They also have major impact on the medical system by being among the highest users of emergency and in-patient medical services. Glen Close’s character Alex Forrest in the movie Fatal Attraction, had some of the features that we might expect in some with borderline personality disorder.

Researchers from the University of Washington in Seattle have reported that adolescent girls who engage in cutting behavior have lower levels of the chemical transmitter serotonin in their blood. They also have reduced levels of activity in the parasympathetic nervous system as measured by what is called respiratory sinus arrhythmia, a measure of the ebb and flow of heart rate as we breath. Low levels of this measure are typically found in people who are anxious or depressed. The study included 23 girls aged 14 to 18, who engaged in what psychologists call “parasuicidal” behavior. Participants were included if they had engaged in three or more self-harming behaviors in the previous six months or five or more such behaviors in their lifetime. The comparison group consisted of an equal number of girls of the same ages who did not engage in this behavior.

In line with previous research, the adolescents in the parasuicide group reported far more incidents of self-harming behavior than did their parents.

The findings of low serotonin and low parasympathetic activity support the idea that the inability to regulate emotions and impulsivity can trigger self-harming behavior. The primary problem is an inability to manage their emotions: the people who cut themselves have excessively strong emotional reactions and they have extreme difficulty in controlling those emotions. Their self-harming behavior may serve to distract them from these emotions.

A characteristic feature of borderline personality disorder is not just self-injurious behavior but also stress-induced reduction of pain perception. Reduced pain sensitivity has been experimentally confirmed in patients with the condition. The increasing incidence of the condition in Europe is attracting many European investigators and colleagues from Mannheim in Germany have recently traced the neurological circuits involved in this stress-induced reduced pain perception.

There is good evidence that people who cut themselves are more likely to have been victims of sexual abuse or violence as children, though that obviously does not mean that every person who harms themselves has had something bad happen to them in childhood. Sadly the research has become more complex because of the numbers of people who have been given false memories of abuse by well-meaning psychologists.

Treating people who cut themselves, whether or not they have borderline personality disorder can be very challenging. The first thing is to treat any underlying mood or anxiety disorder. A combination of medications and psychotherapy is normally used, with people making claims for the value of different types of therapy. Many therapists also say that they have helped people who cut themselves with tapping therapies, acupuncture, homeopathy and qigong. I’ve not been able to find any credible research evidence to support the use of those therapies, though I’ve also seen some success stories.

We also have the puzzle about why cutting and borderline personality disorder seems to have been less common in other parts of the world and are now increasing. There is research to show that it’s not just a matter of recognition or of calling the illness something else in Europe. I have a friend who is a senior academic at an Ivy League University, and an expert on borderline personality disorder. During a sabbatical in Scotland some 15 years ago, he could not find a single case. This matters, because if we can identify what’s changed, we may have some clues about treatment. There are hundreds of candidates, including environmental stress, diet and toxins.

There’s an important new study in which 13 children with autism showed marked improvement in some of their challenging behaviors when they were given 1.5gms of omega-3 fatty acids each day. This was only a six week study, but it needs to be replicated using larger numbers. It is also important to be alert to the possibility that some makes of omega-3 fatty acids on the market contain mercury. The one that we have found best so far has been OmegaBrite. http://www.omegabrite.com/ It will also be useful to see if dietary supplementation will help self-injurious behavior in other types of people.

Here is a list of some of the better information sites about self-harm.

The key to success with helping complex problems, as I point out in great detail in Healing, Meaning and Purpose, is a comprehensive approach:

Combinations are Key

Fibromyalgia and Childhood Abuse

There is a small and growing literature about a link between fibromyalgia and a history of abuse, primarily in childhood or early adolescence.

A new study has shown that people with fibromyalgia who had experienced physical abuse in childhood did not have the normal daily fluctuations in the stress hormone cortisol. They also had sudden surges in the hormone as soon as they were woken up, which can be a good stressor. People who had been sexually abused also had this odd cortisol response on being awakened. These findings suggest that severe traumatic experiences in childhood may be a factor in causing hormonal disturbances in people suffering from fibromyalgia. This adds to the growing body of evidence that in women having pain early in the day, there is a high likelihood that the entire stress hormone system does not function normally.

Colleagues from the Department of Psychiatry, UMDNJ-New Jersey Medical School in Newark, New Jersey have reported that women who have been raped are ten times more likely to experience chronic pelvic pain as well as generalized pain.

Another study has found close correlations between childhood abuse and the subsequent development of chronic pain. The link between rape and the subsequent development of fibromyalgia seems to be mediated by chronic stress, in the form of posttraumatic stress disorder.

What this means is that professionals need to consider this:

1. It is important careful to inquire about any history of past or present abuse or other severe trauma
2. That empathy and constructive validation of disease and suffering can be very helpful
3. That dysfunctional pain behaviors and personality traits may be a consequence of abuse together with a lack of resilience
4. That multidisciplinary treatments including psychotherapy may be the best approach to helping people. Using the methods of Integrated Medicine is often far better than reliance on potentially habit-forming medications.

If we remember that there is more and more evidence of inflammation and other physical problems in fibromyalgia, and that stress and maltreatment in early life can alter the structure and function of specific regions of the brain, what this all shows us is that abuse in childhood can have a long term impact on the way in which both the body and the brain functions.

Irritable Bowel Syndrome, Mood Disorders, the Serotonin Transporter and Integrated Medicine

Whenever we run into two common conditions, it’s easy to imagine links where none really exists. Three years ago some colleagues from Oxford reported on a person with bipolar disorder and irritable bowel syndrome, and commented that the association was uncommon.

However there may after all be a genuine link between mood disorders and irritable bowel syndrome, that is a disturbance in the “third arm” of the autonomic nervous system. The first arm is the sympathetic nervous system, the second the parasympathetic and the third is the enteric or gut nervous system that is closely linked with key regions of the brain.

Not long ago there was an interesting report of a woman who had multiple problems including environmental allergies, atypical bipolar disorder, irritable bowel syndrome and Raynaud’s phenomenon. Such odd constellations of problems are quite familiar to anyone working in the major referral centers around the world, and some can be exceedingly hard to treat. Tough cases like this often stimulate further research. I once tried and failed to treat a woman with a chronic illness. When she came back a year later to see if I had any new ideas, I told her that I now had a shelf of books and over a thousand reprint of papers about her condition: I don’t like failing someone. And I’m not unique in that.

A new study from the Karolinska Institute in Stockholm, has found that chronic widespread pain, which, as I explained recently, is the cardinal symptom of fibromyalgia, is prevalent and co-occurs with other symptom-based conditions such as chronic fatigue syndrome, joint pain, headache, irritable bowel syndrome, and psychiatric disorders. There is more and more evidence of a link between fibromyalgia, irritable bowel syndrome and depression. It is not just that people are sick and get depressed: as we shall see in a moment, the link is more subtle than that. Another illness seemingly linked to these three is interstitial cystitis.

Now some colleagues at the National Institutes of Health have been looking at a serotonin transporter (SERT) that regulates the entire serotoninergic system and its receptors. This transporter is found throughout the animal kingdom, telling us that it must be important.

In humans the gene is located on chromosome 17, and disturbances in it have been found in people with autism, ADHD, Tourette’s syndrome and bipolar disorder. Experiments using genetic engineering suggest that SERT may be a candidate gene for several human disorders, from obesity to irritable bowel syndrome. People who have disturbances in SERT tend not to respond so well to the serotonin reuptake inhibitors (SSRI’s) antidepressant medicines.

SERT is not the whole story. Some geneticists from Los Angeles have found evidence linking irritable bowel syndrome, depression, migraine and inheritance of mitochondrial DNA.

Many approaches have been tried to help people with these groups of problems. I always find it remarkable that psychological treatments can be so effective in conditions with a genetic component, for this once again proves that biology is not destiny.

The best approaches to conditions like irritable bowel syndrome and coexisting mood disorders is to use medications and psychological approaches. Many of us have also found that the addition of nutritional, environmental and subtle energetic approaches have been of great help, together with some work to uncover the meaning and transpersonal value of a chronic illness. That last piece is not the first priority, which is to help the person gain control of his or her life. But if we don’t do something to work with the meaning and purpose of an illness, it will usually come back in some form or other. This comprehensive approach differentiates Integrated Medicine from many other types of therapy.

Chronic Widespread Pain, Fibromyalgia and Anti-inflammatory Proteins

Chronic widespread pain is a common and distressing medical condition that can be difficult to treat and is usually associated with fatigue, poor sleep and depression. One major subgroup is fibromyalgia. A connection between fibromyalgia and cytokines – small proteins that act as messengers between cells – has been suspected for some time, since some cancer patients treated with the cytokine interleukin -2 develop fibromyalgia-like symptoms. A new study from Wurzburg in Germany, published in the August 2006 issue of Arthritis and Rheumatism examined cytokine profiles in patients with chronic widespread pain and found that they had significantly lower levels of the anti-inflammatory cytokines IL-4 and IL-10.

This is an important finding: Previous research has shown that IL-10, administered as a protein or via gene transfer, reduces sensitivity to pain. Similarly, IL-4 has been shown to dull the pain response. There is also another piece to this: genetic variations in different cytokine genes are associated with distinct diseases, such as the association between IL-4 gene variations and asthma, Crohn's disease, and chronic polyarthritis.

Although low levels of anti-inflammatory cytokines could be a consequence of chronic widespread pain and its treatment, it is much more likely that these proteins actually play a role in the causation of chronic widespread pain.

This new research raises all kinds of possibilities for the physical treatment of a particularly horrible set of illnesses.