Fibromyalgia and Associated Pain, a combined approach to treatment

A combined treatment for Fibromyalgia using hypnotherapy and osteopathy

At the Joseph Clinic in South Woodford, East London a combined approach to treating fibromyalgia using hypnotherapy and osteopathy is being used by James Rutherford, hypnotherapy and Dr Eftekhari, osteopathy.  Both have treated patients, successfully, independently over a period of time.  Now they are combing emotional, unconscious pain control and a musculo skeletal treatment approach to help give relief to sufferers.

For more information contact the Joseph Clinic, 0208 989 81 43 to speak to Dr Eftekhari or

0779 210 82 72 to contact James Rutherford.

see more information concerning Dr James Rutherford on About

see more information concerning Dr Eftekhari on Joseph Clinic

Fibromyalgia: You hurt all over, and you frequently feel exhausted. Even after numerous tests, your doctor can't find anything specifically wrong with you. If this sounds familiar, you may have fibromyalgia.

Fibromyalgia is a chronic condition characterized by widespread pain in your muscles, ligaments and tendons, as well as fatigue and multiple tender points — places on your body where slight pressure causes pain. Fibromyalgia is more common in women than in men. Previously, fibromyalgia was known by other names such as fibrositis, chronic muscle pain syndrome, psychogenic rheumatism and tension myalgias.

Although the intensity of your symptoms may vary, they'll probably never disappear completely. It may be reassuring to know, however, that fibromyalgia isn't progressive or life-threatening. Treatments and self-care steps can improve fibromyalgia symptoms and your general health.

IBS and Fibromyalgia

Scientific study of IBS now examines its overlap with other medical conditions. Researchers have discovered that IBS not only co-occurs at high rates with some other digestive tract disorders, such as functional dyspepsia (stomach distress and indigestion), but also co-occurs at much higher rates than expected with four chronic health problems that have little to do with the intestinal tract:
                       Fibromyalgia,
                       Chronic Fatigue Syndrome,
                       Temporomandibular Joint Disorder (TMJ or TMD),
                       Chronic pelvic pain.


Of these four, the high rate of co-occurrence between IBS and Fibromyalgia is by far the best established. Six studies show that Fibromyalgia occurs in 20% to 65% of IBS patients.1,19 Conversely, 13 studies report that between 35% and 77% of Fibromyalgia patients have IBS. In other words, in samples of patients with either condition, the other occurs at rates so far above normal that this cannot be happening by chance. The reasons for this high overlap are currently a matter of considerable interest to experts.


Common Characteristics of IBS and Fibromyalgia


IBS and Fibromyalgia are both chronic and complex conditions that have a number of characteristics in common, as the reader may already have appreciated. Many investigators have examined such commonalities to see if they provide a causal link explaining why these disorders occur together so frequently. Yet its probably fair to say that, to date, these attempts have resulted in more frustration and confusion than insight.


For example abnormalities in autonomic nervous system function have been repeatedly found in both IBS and Fibromyalgia, but the pattern of dysfunction is different and, in some ways, tends in opposite directions in the two disorders.


n Stress plays a definite role in both disorders, and hormones involved in the body’s response to stress (such as corticotrophin-releasing hormone [CRH] and adrenocorticotropin hormone [ACTH]) also show some abnormality in both conditions. But the pattern seems to be exaggerated stress hormone activity in IBS and suppressed activity in Fibromyalgia.


n Pain sensitivity is a shared and central characteristic of both IBS and Fibromyalgia, but here again the pattern isn’t comparable. In IBS, pain sensitivity is typically increased inside the intestine, but patients don’t show the tender points that characterize Fibromyalgia. Conversely, when Fibromyalgia patients are tested for pain, they show musculoskeletal tenderness but none of the heightened intestinal sensitivity seen in IBS.


And so the physiological patterns of these disorders are proving more different than alike. This fact challenges the view of some medical theorists that Fibromyalgia and IBS, along with other chronic health problems, are merely different surface reflections of the same broader “somatic syndrome,” with the same underlying physical and psychological causes. Wessely and colleagues20, who principally promoted this view, had even suggested that which diagnosis patients receive might be happenstance, depending on what kind of medical expert they visit. (For example, in the same patient a rheumatologist might see Fibromyalgia and a gastroenterologist might see IBS.)


This view seems unwarranted considering the mounting evidence of multiple physiological differences between IBS and Fibromyalgia.


The Consequences of Living with Both Disorders


What are the consequences of having both IBS and Fibromyalgia? A few studies have investigated this question, but the results are inconsistent and make it hard to draw many general conclusions.


One relatively large Italian study recently found that if IBS patients also have Fibromyalgia, their bowel symptoms are more severe, but they don’t have worse psychological symptoms.21 An Israeli research team reports that patients who have both IBS and Fibromyalgia have poorer quality of life, poorer physical functioning, greater sleep disturbance, and (in contrast with the Italian findings) more psychological distress than those with only one disorder.22


Yet Chang and colleagues conducted two smaller studies in the United States that contradicted the Italian findings. They found that IBS patients with Fibromyalgia had less abdominal pain than patients suffering only from IBS,23 and that IBS patients without Fibromyalgia were less sensitive to pain at traditional Fibromyalgia tender points than even healthy subjects.24


Although it is hard to draw firm general conclusions from these data, it seems that having both disorders at least worsens overall physical functioning and quality of life.


Treatment of IBS


As the previous discussion shows, IBS is a mysterious and complicated disorder, and its symptoms appear to result from several variables that may be different from one patient to the next. This makes conventional medical treatment, which typically addresses health problems through focused targeting of a main cause, difficult and relatively ineffective.


In fact, despite the marvels of modern pharmaceuticals and medical technologies, the most frequently used treatment approaches aren’t biomedical. The first large-scale survey of medical care for IBS in the United States, conducted in a large health maintenance organization (HM)) in the Seattle area and published in 2004, found that the three most common interventions physicians used were education, reassurance, and suggestions for diet change, such a fiber-rich foods or fiber supplements.25 These simple methods are often sufficient to help patients with mild IBS symptoms.


For patients with moderate symptoms, one or more of many medications are also used. They treat the most distressing symptoms, such as diarrhea or pain. Such treatments can ameliorate a distressing symptom, but there’s little evidence that most of these medications are effective in treating IBS.26


In the last few years, the first two medications approved for IBS treatment, alosetron and tegaserod, have become available in the United States. However, these drugs are applicable only to certain subsets of patients. Objectively examined, the research shows that few patients benefit more by taking them than by taking any other medication. In controlled research studies, only 5% to 17% more patients report improvement with them than with a placebo (that is, with an inert or “fake” pill).27


In addition to prescription medications, many IBS patients take over-the-counter medications for their symptoms. Many also use herbal medications and other alternative therapies.


Data on the outcomes of the medical care given IBS patients make it hard to escape the conclusion that it is ineffective. Less than half of IBS patients say they are satisfied with the outcome of conventional medical treatment.28 The large HMO survey of IBS care by Whitehead and colleagues25 mentioned above found that 6 months after visiting doctors for their bowel symptoms, only 49% of patients reported being any better, and only 22% showed 50% or greater improvement. For patients with the most severe symptoms the rates of improvement were even poorer.


Additional Treatments


The symptoms of patients with severe IBS continue unabated despite their seeing doctors and receiving typical medical care. So, various alternatives or additions to conventional treatment have been, and continue to be, tested. Two such options for severe IBS patients unresponsive to regular medical interventions seem most promising.


n One is the use of antidepressant medications. They are often effective in reducing pain even when the patient isn’t depressed. (The same has been observed for Fibromyalgia.) The older class of antidepressants, called tricyclics, seems more effective than the newer and more popular selective serotonin reuptake inhibitors (SSRIs).


n The other effective way to improve outcomes in severe IBS cases is through psychological treatments. A wide range of psychological treatments has been tested, but cognitive-behavioral therapy and hypnosis are currently the two types best supported by research as effective in a large proportion of patients. Both have been shown to reduce the severity of bowel symptoms by 50% or better in some studies,29 and the benefits often last for years.


The Future Direction of Treatment

We have every reason to believe that IBS treatment will soon become more effective.

n Several medications are under development, some of which are likely to be more effective than the two currently available.

n Psychological treatment and antidepressants are becoming more widespread as adjunctive treatments.

n Furthermore, there is growing interest in testing the benefits of using different treatments in combination, which may be more effective than any particular treatment alone.

n Finally, treatment will probably become increasingly customized, and therefore more successful, by basing it on tests that identify the causal factors present in each patient.

Much remains to be understood about IBS and how it can be reliably treated. A great deal of research and money is currently devoted to improving our understanding and therapies. And the pace of discovery is accelerating like never before. Getting a better handle on the nature of this complex disorder will also reveal the reasons for the high coincidence of IBS and Fibromyalgia, which today continues to be a mystery despite much hard work by researchers.


* * * *
References
1. Whitehead WE, Palsson O, Jones KR. Systematic review of the comorbidity of irritable bowel syndrome with other disorders: What are the causes and implications? Gastroenterology. 2002;122:1140-1156.


2. Drossman DA, Camilleri M, Mayer EA, Whitehead WE. AGA technical review on irritable bowel syndrome. Gastroenterology. 2002;123:2108-2131.


3. Russo MW, Gaynes BN, Drossman DA. A national survey of practice patterns of gastroenterologists with comparison to the past two decades. Journal of Clinical Gastroenterology. 1999;29:339-343.


4. Heitkemper MM, Jarrett M, Bond EF, Chang L. Impact of sex and gender on irritable bowel syndrome. Biological Research for Nursing. 2003;5(1):56-65.


5. Palsson OS, Drossman DA. Psychiatric and psychological dysfunction in irritable bowel syndrome and the role of psychological treatments. Gastroenterology Clinics of North America. 2005;34(2):281-303.


6. Whithead WE, Palsson OS. Is rectal pain sensitivity a biological marker for irritable bowel syndrome: psychological influences on pain perception. Gastroenterology. 1998;115:1263-1271.


7. Posserud I, Ersryd A, Simten M. Functional findings in irritable bowel syndrome. World Journal of Gastroenterology. 2006;12(18):2830-2838.


8. Ringel Y. Brain research in functional gastrointestinal disorders. Journal of Clinical Gastroenterology. 2002;35(Supplement 1):S23-S25.


9. Crowell MD. Role of serotonin in the pathophysiology of the irritable bowel syndrome. British Journal of Pharmacology. 204;141(8):1285-1293.


10. Wood JD. Neuropathophysiology of irritable bowel syndrome. Journal of Clinical Gastroenterology. 2002;35(Supplement 1):S11-S22.


11. Rhodes DY, Wallace M. Post-infectious irritable bowel syndrome. Current Gastroenterology REports. 2006;8(4):327-332.


12. Neal KR, Barker L, Spiller RC. Prognosis in post-infective irritable bowel syndrome: a six year follow up study. Gut. 2002;51(3):410-413.


13.Palsson OS, Whitehead WE. Comorbidity associated with irritable bowel syndrome. Psychiatric Annals. 2005;35(4):320-329.


14. Drossman DA. Do psychosocial factors define symptom severity and patient status in irritable bowel syndrome? American Journal of Medicine. 1999;107(5A):41S-50S.


15. Levy RL, Von Korff M, Whitehead WE, Stang P, Saunders K, Jhingran P, et al. Costs of care for irritable bowel syndrome patients in a health maintenance organization. American Journal of Gastroenterology. 2001;96:3122-3129.


16. Sandler RS, Everhart JE, Conowitz M, Adams E, Cronin K, Goodman C, et al. The burden of selected digestive diseases in the United States. Gastroenterology. 2002;122:1500-1511.


17. Miller V, Hopkins L, Whorwell PJ. Suicidal ideation in patients with irritable bowel syndrome. Clinical Gastroenterology and Hepatology. 2004;2(12):1064-1068.


18. Gralnek IM, Hays RD, Kilbourne A, Naliboff B, Mayer EA. The impact of irritable bowel syndrome on health-related quality of life. Gastroenterology. 2000;119(3):654-660.


19. Lubrano E, Iovino P, Tremolaterra E, Parsons WJ, Ciacci C, Mazzacca G. Fibromyalgia in patients with irritable bowel syndrome. An association with the severity of the intestinal disorder. International Journal of Colorectal Diseases. 2001;16(4):211-215.


20. Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many? Lancet. 1999;354(9182):936-939.


21. Lubrano E, Iovino P, Tremolaterra F, Parsons WJ, Ciacci C, Mazzacca G. Fibromyalgia in patients with irritable bowel syndrome. An association with the severity of the intestinal disorder. International Journal of Colorectal Disease. 2001;16(4):211-215.


22. Sperber AD, Atzmon Y, Neumann L, Weisberg I, Shalit Y, Abu-Shakrah M, Fich A, et al. Fibromyalgia in the irritable bowel syndrome: studies of prevalence and clinical implications. American Journal of Gastroenterology. 2003;98(6):1354-1361.


23. Chang L, Berman S, Mayer EA, Suyenobu B, Derbyshire S, Naliboff B, et al. Brain responses to visceral and somatic stimuli in patients with irritable bowel syndrome with and without fibromyalgia. American Journal of Gastroenterology. 2003;98(6):1354-1361.


24. Chang L, Mayer EA, Johnson T, FitzGerald LZ, Naliboff B. Differences in somatic perception in female patients with irritable bowel syndrome with and without fibromyalgia. Pain. 2000;84(2-3):297-307.


25. Whitehead WE, Levy RL, Von Korff MV, Feld AD, Palsson OS, Turner MJ, et al. Usual medical care for irritable bowel syndrome. Alimentary Pharmacology & Therapeutics. 2004;20m:1305-1315.


26. American College of Tastroenterology Functional Gastrointestinal Disorders Task Force. Evidence-based position statement on the management of irritable bowel syndrome in North America. American Journal of Gastroenterology. 2002;97:S1-S5.


27. Talley NJ. Evauation of drug treatment in irritable bowel syndrome. British Journal of Clinical Pharmacology. 2003;56(4):362-369.


28. Thompson WG, Heaton KW, Smyth GT, Smyth C. Irritable bowel syndrome: the view from general practice. European Journal of Gastroenterology & Hepatology. 1997;9:689-692.


29. Gonsalkorale WM, Houghton LA, Whorwell PJ. Hypnotherapy in irritable bowel syndrome: a large-scale audit of a clinical service with examination of factors influencing responsiveness. American Journal of Gastroenterology. 2002;97(4):954-961.


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Olafur S. Palsson, PsyD, is a Clinical Psychologist and Associate Professor in the Division of Gastroenterology and Hepatology, Department of Medicine at the University of North Carolina, Chapel Hill. Donald P. Moss, PhD, is a Clinical Psychologist, Integrative Health Studies, Saybrook Graduate School, San Francisco, California.

*Dr. Sharon Ostalecki, PhD – herself a Fibromyalgia patient - is a nutritionist with a practice specializing in Fibromyalgia and Chronic Fatigue Syndrome, based in Novi, Michigan. Dr. Ostalecki is founder and president of Helping Our Pain & Exhaustion (H.O.P.E.) http://www.hffcf.org/ – a nonprofit organization dedicated to Fibromyalgia awareness building and education. She is also the Michigan Representative for the National Fibromyalgia Association and an active member of the Leaders Against Pain Coalition.