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FM Highlights from 10th World Congress on Pain 2002
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- Last Updated: 23 January 2016 23 January 2016
by Dr. Robert Bennett
The 10th World Congress on Pain was held in San Diego CA August 17 to 22, 2002. This is a triennial meeting organized by the International Association for the Study of Pain (IASP), the leading world body for pain researchers and clinicians. It was a truly massive and overwhelming meeting with 1788 presentations of one type or another. I do not have a precise number for the attendees, but my estimate is about 3500.
The first day was devoted to refresher courses. I took part in one of these courses devoted to rheumatic pain disorders, giving a one-hour talk on fibromyalgia (FM). The other two speakers were from the UK; Professor Michael Doherty spoke on osteoarthritis and Professor Bruce Kidd spoke on rheumatoid arthritis. I was gratified to learn that at least some UK rheumatologists are focusing their attention on pain mechanisms—but as in many countries this continues to be an uphill battle. There were many sessions devoted to the basic mechanisms underlying chronic pain states such as FM. Indeed, FM was frequently referred to in many of these presentations as being the classical example of a "central pain state". By this is meant that peripheral tissue causes of pain cannot be readily identified in most FM patients and that most of the action is at the level of the spinal cord and above. The neurophysiological and biochemical basis of central sensitization is now being unraveled in minute detail. Much of this work relates to neurochemicals and their interaction with specific receptors. This is the basis of the transmission of sensory impulses from one nerve cell to another. In order to make advances in this field one must devote a large chunk of a research career to just one very specialized topic. Needless to say, the arcane nature of this work makes it very difficult to understand unless one is an "insider". However, understanding the detailed mechanisms of neurochemical receptor interactions will be pivotal in the creation of designer drugs for treating chronic pain, while minimizing the unwanted side effects that plague many of the currently available medications.
Glial cells lecture
A state-of-the-art lecture, by Professor Linda Watkins from the University of Colorado in Boulder was particularly noteworthy. For the past 10 years or so, she has studied glial cells. Until fairly recently glial cells were considered boring, as their only known role was to provide a skeletal type support for nerve cells of the brain and spinal cord. Prof. Watkins discovered that glial cells can be activated by infections and other stresses, and they then interact with nerve cells to produce chronic pain states via the secretion of small proinflammatory molecules called cytokines. For instance, 90 percent of patients with HIV infection have chronic pain. Prof. Watkins has shown that one component of the HIV virus (gp 120) interacts with glial cells to induce a chronic pain syndrome. This of course may be of relevant to FM patients who trace the onset of their problem to an antecedent flu-like illness. Furthermore she has recently shown to that the introduction of a cytokine called interleukin-10 into the nervous system of mice with an experimentally induced chronic pain syndrome, attenuates their pain. Interestingly, interleukin-10 inhibits the actions of the pro-inflammatory cytokines. This is obviously exciting and important work which may eventually have a relevance to FM patients—stay tuned.
Fibromyalgia and CFS
There was an interesting symposium entitled "The Biopsychosocial Approach to Fibromyalgia and Chronic Fatigue Syndrome". It featured researchers with differing views as to the nature of FM and CFS. Dr. Milton Cohen, from Australia, asserted that two fundamental errors have been perpetuated in contemporary research on the clinical phenomenon of widespread pain and fatigue. The first is the failure to distinguish a clinical feature from a disease process, without a unifying concept. The second major error is the failure to focus on the neurobiology of the defining clinical finding—i.e. increased pain sensitivity.
Dr. Lawrence Bradley from Birmingham AL contested Dr. Cohen's statement regarding the lack of research on the neurobiology of FM and presented impressive evidence for abnormal pain processing and dysregulation of neuroendocrine function in FM. He noted that disorders such as FM, CFS and irritable bowel syndrome (IBS) had a large degree of overlap. But he also noted that not all persons with CFS showed the abnormal pain sensitivity of typical FM patients. Dr. Bradley concluded that a better understanding of the natural history of these overlap syndromes, looking at genetic contributions, developmental stressors and triggering events, will be essential in unraveling the relationships of these common disorders.
Fibromyalgia posters
There were 27 individual poster presentations devoted to the topic of FM. Here I review the 9 that I consider to be most relevant and understandable for patients.
1—A study from France explored the efficacy of subcutaneous ketamine on improving pain in FM patients. Ketamine is a class of drugs known as NMDA receptor antagonists. In high doses it is used as an anesthetic. Activation of the NMDA receptor is a critical event in the biochemistry of chronic pain states. Fifty patients received subcutaneous ketamine (up to 50 mg daily) for ten days via an infusion pump similar to that used by diabetic patients. There was a significant improvement in pain scores in 78 percent of the subjects. At six months after discontinuation of the ketamine, 45 percent of the patients still showed improvement. This is an intriguing study but suffered from lack of a control group using a placebo.
2—There was a fascinating study from a New York group exploring the effects of the September 11th World Trade Center disaster on symptoms of FM. In a study prior to September 11th, this group had screened a population of 9000 women in metropolitan New York and New Jersey for FM symptomatology and psychiatric symptoms. In February and March of 2002 they re-contacted 1000 of the same women to determine whether existing symptoms had changed. Interestingly they did not find any major changes in FM like symptomatology, although there was a minor increased in anxiety-related symptomatology. Interestingly, there was a significant reduction in the number of doctor visits. I asked the author of this study for her interpretation of the reduced doctor's visits. She conjectured it was due to a changed perspective of their problems in the light of the devastation wreaked upon so many others.
3—There is an ongoing question as to whether FM may be set off by whiplash injuries resulting from motor vehicle accidents. A study from Switzerland applied an objective measure of increased central nervous system sensitization (the nociceptive withdrawal reflex) to 3 groups of subjects; one group with whiplash, another group with FM and a group of healthy controls. The FM and whiplash patients, but not the healthy controls, showed unequivocal evidence of increased central nervous system sensitization. This is an important study that brings some objectivity to this issue.
4—On the same subject, a group from Seattle looked at the onset of FM following whiplash injury. This is an ongoing NIH funded study which aims to eventually enter 400 whiplash subjects. To date 25 subjects have been studied and 20 percent have developed widespread pain, and 80 percent met the tender point criteria for a diagnosis of FM. The authors concluded that some of the findings of FM are common in women 2 to 3 months following whiplash injury. They suggest that part of this increased prevalence may be due to a clustering of tender points in the neck region—as expected in the soft tissue trauma following hyperextension/flexion injuries to the neck. But they also noted that the high prevalence of FM symptomatology is probably not entirely artifactual, as 68 percent of the whiplash subjects also demonstrated tender points in other parts of the body.
5—A psychophysical research study from Gainesville Florida studied FM patients and healthy controls with an objective measure of central sensitization called "temporal summation." They asked the question as to whether central sensitization could be modified by the placebo response, fentanyl (a long acting opioid drug) or naloxone (a drug that antagonizes the analgesic actions of opioids and the placebo response). They found that FM patients had increased levels of central sensitization compared to healthy controls. Temporal summation was attenuated by both placebo and fentanyl to a similar degree and was not influenced by naloxone. It was concluded that central sensitization, which is thought to be a critical component of increased pain sensitivity in FM, can be centrally modulated by both endogenous (i.e. placebo) and exogenous (i.e. fentanyl) manipulations. There is increasing evidence that one's own endogenous pain modulating apparatus, modulated by endorphins, involves the same neural pathways as opioid analgesics. Thus strategies aimed at activating a patient's own endorphin system, such as exercise, adopting positive coping strategies and having an optimistic outlook, are important tools in the effective management of FM.
6—Most physicians who specialize in managing FM patients believe that a multidisciplinary approach to treatment is an essential prerequisite for success. A Canadian group developed a ten-week program for FM patients which included education, group support, coping skills training, physical exercise in a pool, goal setting and daily activity diaries. Patients were seen in groups of 10 to 15. Overall 395 patients had been analyzed at the time this study was reported. Highly significant improvements were seen in the Fibromyalgia Impact Questionnaire (FIQ), a widely used outcome measure in FM studies. Women showed greater improvements than men, and women under 40 showed the most improvement.
7—A study from Brazil reported on the effects of acupuncture on pain and quality of life in patients with FM. Forty-eight women with FM were randomly allocated into 2 treatment groups. Group 1 received amitriptyline plus twice-weekly acupuncture sessions for 3 months. Group 2 received amitriptyline plus stretching and relaxation exercises twice a week. There was a significant reduction of pain intensity and improved function in both groups, but the acupuncture group had significantly better response than the other group. The authors concluded that acupuncture is an effective tool for treatment of FM patients.
8—A study from Salt Lake City attempted to evaluate whether FM patients would be more susceptible to pain experience during mammography and Pap smears. A questionnaire was sent out to 100 women who were randomly selected from a database of FM patients. Fifty- nine patients agreed to take part in the survey. They rated pain and anxiety during their last mammography and Pap smear on a scale of 0 to 10. The mean pain score was 4.32 for mammography and 2.45 for Pap smears. Mean anxiety scores were 2.33 during mammography and 2.2 to during Pap smears. It was concluded that women with FM experience a moderate amount of pain during mammography, and rate mammography as significantly more painful than Pap smears. Anxiety levels were comparable between the two procedures. As pain is a deterrent to women for undergoing mammography, the authors suggested that more effective pain management during this procedure should be considered for those women susceptible to discomfort during mammography, such as FM patients.
9—A study from the UK evaluated the use of a new antidepressant drug called Reboxitine in a study of patients with FM and neuropathic pain. Reboxitine is a class of drugs that selectively inhibits the reuptake of noradrenaline. Thus its mode of action is somewhat similar to fluoxetine (Prozac) but it inhibits noradrenaline reuptake rather than serotonin reuptake. One of the mechanisms whereby the brain can control the relay of pain impulses upwards from the spinal cord is via a descending pathway from the midbrain which uses noradrenaline as a neurotransmitter. Thus it was conjectured that Reboxitine would modulate pain via this descending noradrenaline system. Twenty-five women with FM and 14 with neuropathic pain (nerve pain arising from conditions such as diabetes or shingles) were included in the study. Eight (32%) of the FM patients had a very significant reduction in pain intensity and 6 elected to continue with Reboxitine after the trial ended. Six (43%) patients in the neuropathic pain group reported significant pain reduction but only one wished to continue using Reboxitine after the study ended. The reason for not continuing with the medication after the end of the study was the side effects of insomnia and agitation. However, in some patients the sense of agitation was interpreted as a feeling of increased energy, which was particularly welcome in some FM patients. This study did not contain a placebo control group and thus the specificity of the Reboxitine effect cannot be assessed.
Summary
Overall the 10th World Congress on Pain was a stimulating and somewhat exhausting experience. As is often the case with large international conferences one was subjected to intense information overload. However, I came away with a sense of awe at the magnitude and quality of the research which is being done worldwide to reduce the burden of chronic pain. As an FM researcher, I was gratified to see that the diagnostic term "fibromyalgia" is being used increasingly by pain researchers who often refer to it as a "classical example of central sensitization." As a rheumatologist, I am increasingly impressed that FM is primarily a neurological disorder which presents as a musculoskeletal pain syndrome. Having said that, I believe that rheumatologists will continue to be the major specialty who treat FM, as the correct diagnosis of musculoskeletal pain is complex, and furthermore there is often an overlap of FM with chronic rheumatic problems such as osteoarthritis, lupus, and rheumatoid arthritis. Interestingly, neurologists seem to be one of the last standouts in accepting the FM concept.
Dr. Bennett is an internationally known FM specialist, Professor of Medicine at Oregon Health Sciences University (OHSU), and Chairman of Arthritis and Rheumatic Diseases Division. Permission was granted to publish this article from the Fibromyalgia Information Foundation's website. © 2002 Robert Bennett M.D., FRCP.
Dr. Sam Donta: The Interface of Chronic Lyme Disease, CFS and FM
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- Last Updated: 28 February 2009 28 February 2009
by Bonnie Gorman RN
The Massachusetts CFIDS/ME & FM Association Fall 2002 UPDATE
Dr Sam Donta presented a comprehensive, compassionate, cutting-edge lecture to Massachusetts CFIDS/ME & FM Association members on November 3rd. His topic was "The Interface of Lyme Disease with CFS and FM: Diagnostic and Treatment Issues." Dr. Donta is a nationally recognized expert on Lyme disease. He is the Director of the Lyme Disease Unit at Boston Medical Center and a Professor of Medicine at BU Medical School. He is a bacteriologist and an infectious disease specialist, who views the Chronic Fatigue Syndrome/Chronic Fatigue and Immune Dysfunction Syndrome/Myalgic Encephalopathy (CFS/CFIDS/ME) and fibromyalgia (FM) from that vantage point. He is also a consultant to the National Institutes of Health (NIH), and presented at NIH's scientific meetings on CFS research.
What does Lyme disease have to do with CFS/CFIDS/ME and FM you might be asking? Some people believe that Lyme disease may be one of the causative factors in both CFS/CFIDS/ME and FM. Others believe that some CFS/CFIDS/ME and FM patients are really misdiagnosed chronic Lyme disease patients and vice versa. Some believe that there is no such thing as chronic Lyme disease, instead these patients actually have CFS/CFIDS/ME or FM. We asked Dr. Donta to help sort all this out.
Parallel Symptom Patterns
Dr. Donta presented the symptom lists for chronic Lyme disease, chronic fatigue syndrome (CFS), fibromyalgia (FM), and Gulf War Illness (GWI). He pointed out the similarities between them, and found there were few differences. He has treated hundreds of patients with these illnesses. He found that CFS and GWI have identical symptoms, and FM is only distinguished by a positive tender point exam, that is often positive in CFS and GWI as well. Clinically it is almost impossible to distinguish or differentiate these illnesses.
He has concluded that chronic Lyme disease is remarkably similar to CFS, FM, and GWI. These multi-symptom disorders have similar symptom patterns consisting of fatigue and neurocognitive dysfunction, along with numerous other symptoms that probably relate to altered neurological function. Musculoskeletal symptoms may be more frequent in FM and in some patients with chronic Lyme than in CFS, but the definition of CFS and GWI also includes muscle aches (myalgias) and joint aches (arthralgias).
Lyme Disease Symptoms
Flu-like illness, fever, malaise, fatigue, headache, muscle aches (myalgia), and joint aches (arthralgia), intermittent swelling and pain of one or a few joints, "bull's-eye" rash, early neurologic manifestations include cognitive disorders, sleep disturbance, pain, paresthesias (including numbness, tingling, crawling and itching sensations), as well as cognitive difficulties and mood changes.
The only symptom difference in Lyme disease is the expanding circular rash with a clearing area and center resembling a "bull's eye." He pointed out that Lyme has multiple types of rashes and half of the rashes are not typical, they may not even include the "bull's eye" rash. They can appear from two days after the bite, then go on for a week or so. Patients who are infected may not develop or see the rash, and may not develop any future symptoms. In studies, only one third of the patients were actually aware of their tick bites.
30-50% of acute Lyme disease patients went on to develop chronic Lyme disease. Additionally, some previously asymptomatic patients may reactivate their infection following various stressors such as trauma, surgery, pregnancy, coexisting illness, antibiotics treatment, or severe psychological stress. The Lyme vaccine can also reactivate their infection. Similar triggers such as trauma, surgery etc. are known to precipitate CFS, FM and GWI as well. This is not a new phenomenon with infectious diseases. We know infectious diseases (i.e. TB) will reactivate after illnesses or surgery—any stressor.
Dr. Donta reported on the effects of gender on host susceptibility in Lyme disease, CFS, FM and other multi-symptom diseases. In all these disorders, women appear to be more affected than men, usually at about 2:1 ratios. He noted that neural cells contain estrogen and progesterone receptors, and that herpes viruses can utilize estrogen receptors to gain access to the reservoir in the cell nucleus. Treatment of chronic Lyme disease also seems to be gender-dependent to some degree, with men generally having more speedy and complete recoveries compared to women. He concluded that gender relationships are known for a number of infectious diseases, so it would not be surprising that such a relationship exists for chronic Lyme disease, CFS, FM and other multi-symptom disorders.
Etiology
Lyme Disease:—A distinct difference between Lyme disease, CFS and FM is that the origin of Lyme is clear. Lyme disease is caused by spirochetal bacteria transmitted by the bite of an infected deer tick. This bacteria is the Borrelia burgdorferi bacteria. It was identified in the late 1900s in Europe. The US was late to recognize what Europe had described. Lyme disease was not formally identified by the CDC until 1977 when arthritis was observed in a cluster of children in and around Lyme, CT. Since that time Lyme disease has been identified in many states. The CDC reports that it causes more than 16,000 infections per year in the US. Some researchers feel that the prevalence is higher than that.
CFS and FM—Dr. Donta feels that Lyme disease is an important cause of CFS and FM. In addition to Lyme, there are a number of other possible causes. The evidence is still circumstantial though. Epstein-Barr virus (EBV), the major cause of infectious mononucleosis, continues to be debated as a cause of CFS. It is uncertain whether EBV can cause symptoms other than fatigue, such as myalgias and arthralgias that are not seen during acute or reactivated EBV infection in patients who are being immunosuppressed, but it remains possible that EBV could cause one type of chronic fatigue disorder. There are also other herpes viruses i.e. HHV-6 that are being evaluated as potential culprits.
Dr. Donta reported that recently recognized species of Mycoplasma (Mycoplasma fermentans, Mycoplasma genitalium) have been implicated in CFS, FM and GWI. These same bacteria have also been implicated as causative agents of rheumatoid arthritis, based on PCR-DNA evidence in patients with these disorders in which 50 percent are found to have the DNA of the Mycoplasma in circulating white blood cells, compared to 5-10 percent of a normal population. Whether the presence of this DNA represents past exposure or ongoing infection remains to be resolved. No long-term studies have yet been performed in patients with CFS and FM to determine whether the finding of Mycoplasma DNA persists over months or years or whether such patients have any evidence of other infection such as Lyme disease or infection with Chlamydia species.
Central Nervous System Involvement
Dr. Donta reported that in Lyme disease, the nervous system seems to be the primary target for the bacteria causing the disease. Patients with Lyme disease express many neurologic symptoms such as pain, paresthesias including numbness, tingling, crawling and itching sensations, as well as cognitive difficulties and mood changes. Even the joint pains and occasional arthritis appear to be neuropathic in origin, as anti-inflammatory agents such as ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDS) have little if any effect on the pain. Experimental evidence from animal models also affirm the localization of B. burgdorferi DNA to the nervous system. Dr. Donta postulates that the disease mechanisms could involve inflammatory responses, autoimmune responses or toxin-associated disruption of neural function. Any inflammatory responses appear to be weak, and there is no compelling evidence that Lyme disease is a result of immunopathologic mechanisms.
Commenting on his research, Dr. Donta speculated that if they are correct, and Lyme bacteria is a nerve toxin that interferes with the transmission of the nerve impulse, then that is all you need to impede the normal flow of information. There is a lot of cross-talk in the nervous system. This toxin will decrease that cross-talk causing delayed responses resulting in cognitive problems—the brain fog so commonly described in all these multi-symptom disorders.
Although the disease pathways for other possible causes of CFS and FM have not been defined, Dr. Donta postulates that the central nervous system would appear to be a logical target for other pathogens or other disease processes. These illnesses clearly affect the brain and are bound to cause many neurological manifestations. Any changes in immunologic function would not appear to be sufficient to explain the various symptoms, and are likely to be secondary to other disease processes.
He feels we have been thinking too simplistically about finding whole organisms replicating in chronic diseases. It is highly likely that there is no single cause for these illnesses. It's more likely that there are multiple causes—different organisms causing the same final set of symptoms. Researchers need a better algorithm to study these fatiguing illnesses. We need to be more inclusive, rather than trying to separate the illnesses. Sometimes in medicine, if an illness is too complex to study, research interest dwindles. We have the technology to do the research, but there hasn't been the will and the momentum to get it done.
Clinical Diagnosis
Dr. Donta reiterated that the diagnosis of Lyme disease is primarily based on clinical grounds, just as with CFS and FM. Once other disorders are ruled out, the combination of symptoms over months is sufficient to make a presumptive clinical diagnosis. The diagnosis of Lyme is made easier if a typical rash is present during the early phase of infection. After that, it is difficult to distinguish the flu-like illness that can occur a few weeks later, or can recur over a number of months.
Dr. Donta reported that some patients develop severe headaches and an aseptic (infection free) meningitis, which frequently is diagnosed instead as viral meningitis. If a Bell's palsy occurs (drooping of one side of the face), the possibility of Lyme disease is likely. If an unprovoked arthritis occurs, causing swelling of a single joint, especially the knee, but sometimes more than one joint, then the possibility of Lyme disease should also be given high consideration.
He emphasized that it is the chronic phase of the disease that causes most problems for physicians and patients, because of the lack of objective signs and the presence of so many symptoms that it causes some doctors to attribute psychological reasons for the patients' symptoms. Many patients then receive a diagnosis of CFS or FM, when they may have underlying chronic Lyme disease as the cause of their symptoms.
Diagnostic Tests
Tests for Lyme disease, like tests for other infectious diseases, are often confusing and circumstantial, and their analysis and interpretation has often been flawed. In infectious diseases you do a Western blot test to see if you have a specific reaction. Western blot separates out proteins antigens of an organism you are looking for. It tells you if a person has been exposed. It is not a direct measurement of the organism. It is a measurement of whether the person has antibodies to it. Antibody tests are useful in the early stages of illness as with other acute infectious illnesses. Once the illness is in a chronic phase, antibody tests are not useful.
Just as viruses change from year to year, we know the Lyme bacteria mutates. There are a number of organisms that can shift their surface protein in a matter of hours and that is how they evade detection and patients test negative. These organisms attach themselves to proteins and conceal themselves—creating a cloaking mechanism that defies detection. This allows them to get where they want to go—the nervous system. Once they are inside a cell, the immune system can't see them.
That said, Dr. Donta explained that lab tests have been helpful is some patients with Lyme disease, especially those with arthritis, in whom there are stronger antibody responses than in those with the chronic, multi-symptom form of Lyme. The criteria for the laboratory diagnosis has been patterned after the arthritic form of the disease, and not the chronic form; as a result, there are many physicians who are misinformed about the test's lack of value in chronic Lyme disease. The Lyme Western Blot is helpful when it shows reactions against specific proteins of B. burgdorferi, but can be negative in 25-30 percent of patients who otherwise have chronic Lyme disease.
PCR-DNA tests for Lyme in blood, urine and spinal fluid are rarely positive, most likely because the bacteria and their DNA are not present in those body fluids, but inside nerve cells. Additionally, PCR-DNA studies are very easy to contaminate.
In chronic Lyme disease, the MRI exam of the brain is positive in about 10-20 % of patients. It can show some white spots (unidentified bright objects—UBO) in various areas, similar to those seen in multiple sclerosis (MS), a neurologic disease of unknown cause that has some overlapping symptoms with Lyme disease, CFS and FM, such as the numbness and tingling or paresthesias. (There are also positive MRI findings in CFS and FM patients as well.)
Dr. Donta reported that the brain SPECT scan shows some changes in blood flow to various parts of the brain, primarily the temporal (cognitive processing) and frontal (mood) lobes in about 75 percent of patients with chronic Lyme disease. Patients with CFS have also been reported to have some brain SPECT scan changes, frequently involving the occipital lobe. No comparative studies have been made among patients with chronic Lyme disease, CFS and FM. The mechanisms underlying these changes remain to be defined, but may be due to a mild vasculitis (inflammation of blood vessels) or to a signaling problem within the nerve network of the brain in those specific areas. It is promising that these changes are reversible in most patients treated with antibiotics that appear to be effective in treating the chronic Lyme disease. These MRI changes are often slow and may take a year to reverse themselves.
These are covert organisms we are dealing with. We need more direct detection methods for blood, spinal fluid and other body fluids. How do you detect organisms in spinal nerve roots or brain? Right now we can't. Nobody is going to biopsy patients. We need an illness registry so we can do direct detection studies, particularly of the brain, after death.
Treatment: Persistence Pays Off
Dr. Donta reported that there are lots of drugs that are active against the Lyme bacteria in the test tube, but the big question is whether the drug can get to the bacteria? Lyme bacteria lives in the cells of the nervous system, perhaps other cells. Dr. Donta has experimented with various intracellular-type antibiotics. He reviewed his journey through various antibiotics. After listening to his patients he decided that some antibiotics were better than others. He then looked at clarithromycin (Biaxin) and azithromycin (Zithromax) which he found had powerful activity against Lyme bacteria in a test tube.
But the antibiotics, by themselves, did not seem to do any good. He found that you need to change the cellular pH (the degree of acidity or alkalinity), making it more or less acidic, to maximize the effectiveness of the antibiotic. This allows the antibiotic to work better i.e. doxycycline seemed to work better when the pH was higher. Dr. Donta has experimented with various agents to adjust pH—i.e. amantadine (used to treat flu) and plaquenil (used to treat malaria). He just submitted proposals to NIH to study various agents to determine which is most effective.
Dr. Donta emphasized that the most important aspect of treatment is that it must be long-term—12-18 months, sometimes 24-36 months. This length is not unusual in the treatment of infectious diseases i.e. TB. In the first few months of treatment patients can expect an adverse reaction—symptoms will increase and you'll feel worse. You need to be able to hang in through this period, and allow 3-6 months of a treatment trial to determine if it is working. The earlier in the disease process that you start on treatment, the more successful it is. The more chronic the condition the less successful it is, and you'll need to treat over a longer period of time. This treatment resulted in substantial improvement and cures in 80-90% of patients with chronic Lyme disease. There are 10-20% who do not respond— generally those with a strongly positive Lyme test.
Dr. Donta reported that similar results have been found in some patients with CFS and FM of unknown cause, supporting the hypothesis that some patients with CFS and FM have an underlying infection responsive to those antibiotics. Antibiotic trials in CFS and FM have been limited to one month, a duration that is inadequate to properly evaluate the potential of certain antibiotics to have a positive effect on the disease. Additional studies, examining both potential etiologic agents of CFS and FM as well as treatment trials should lead to a better understanding of both the cause and treatment of patients with CFS and FM.
Q&A
Q: If the Lyme lab tests are inadequate and the symptoms are the same as CFS and FM, why not just treat all CFS and FM patients with the Lyme protocol?
A: You want to be conservative with your medicines. I think we have enough info now to tell CFS and FM patients to consider going on a 3-6 month trial of antibiotics and see if you're better. Consider all the other meds you are already taking that just treat symptoms and not the cause of your illness. They all have side-effects that can be hazardous. Is it worth it to you to consider a primary treatment aimed at a cause? There will be resistance from some MDs. They need to be educated. Your primary MD will need to consult an LD specialist re the treatment protocol.
Q: Do patients with Lyme disease also have bowel and bladder problems like interstitial cystitis (IS) and irritable bowel syndrome (IBS)? How are they affected by treatment?
A: Yes, many patients with Lyme have IS and IBS. He was surprised how much the bowel disorders affected treatment. Tetracycline generally helps the IBS. Plaquenil can sometimes irritate the bowel.
Q: I have received different results for the Western blot Lyme test. Why?
A: Lyme test results are not reproducible from one lab to the next. You will get different findings from different labs. The Western blot is not a great test for Lyme since the responses to Lyme bacteria are already very small responses.
Q: I've been sick for 15 years with CFS and my Lyme test was negative. Is there any value in treating now?
A: If the test was negative but you have the complex of symptoms and there is no other obvious answer, why not give antibiotics a try?
Q: I had the Lyme vaccine then got Lyme symptoms. Why?
A: Lyme vaccine was pulled from the market because it was causing reactions and reactivating a slow onset of Lyme disease.
Q: What are the ocular problems in Lyme?
A: He sees optic neuritis, similar to that seen in atypical MS patients.
Q: Is there any Lyme connection to cutaneous lymphoma?
A: He has looked closely for any cancer/Lyme associations, but has not seen many.
Q: Is there a connection with thyroid problems?
A: Thyroid problems are a very common co-existing condition with Lyme, as they are with CFS.
Q: How do I differentiate itching from allergic reactions?
A: The same sensory nerve fiber pathways that carry pain carry itching, numbness, tingling etc. Rash is common symptom. Rashes could be caused by medications, especially if they are body-wide. Is it an allergic reaction or hypersensitivity reaction? Get a complete blood count (CBC) with differential. Eosinophils will be elevated if allergic reaction. If not, then it's a hypersensitivity reaction. Treatments are similar.
Q: How do we get funding for research to advance these illnesses?
A: He stressed how important it is to combine advocacy and research efforts. Ultimately it will be a political solution. Get active legislatively in DC. The CFS Coordinating Committee is a very good forum. Lyme does not have anything like that. Groups need to work together, not fight with each other. There should be a coalition of all these groups. We also need to show insurance companies the benefits of primary treatment to patients, as well as to insurer's bottom line.
What Is Strength?
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- Last Updated: 07 December 2015 07 December 2015
We don’t always have to be strong. Sometimes, our strength is expressed in being vulnerable. Sometimes, we need to “fall apart” in order to regroup and stay on track.
We all have days when we cannot push any harder, cannot hold back self-doubt, cannot stop focusing on fear, cannot be “strong." There are days when we cannot focus on being responsible. Occasionally, we don’t want to get out of our pajamas. Sometimes, we cry in front of people. We expose our tiredness, irritability, or anger.
These days are ok. They are, simply, ok.
Part of our taking care of ourselves means we give ourselves PERMISSSION to fall apart when we need to. We do not have to be perpetual towers of strength. We are strong. We have proven that. Our strength will continue if we allow ourselves the courage to feel scared, weak, and vulnerable when we need to experience these feelings.
Today, help me to know that it is okay to allow myself to be human. Help me not to feel guilty or punish myself when I need to fall apart.
(Source: Melody Beattie, The Language of Letting Go)
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Notice about names
The Massachusetts ME/CFS & FM Association would like to clarify the use of the various acronyms for Chronic Fatigue Syndrome (CFS), Chronic Fatigue & Immune Dysfunction Syndrome (CFIDS) and Myalgic Encephalomyelitis (ME) on this site. When we generate our own articles on the illness, we will refer to it as ME/CFS, the term now generally used in the United States. When we are reporting on someone else’s report, we will use the term they use. The National Institutes of Health (NIH) and other federal agencies, including the CDC, are currently using ME/CFS.
Massachusetts ME/CFS & FM Association changed its name in July, 2018, to reflect this consensus.