Liebe Forumteilnehmer:
Diese Texte (auf Englisch)
erhielt ich von einer Freundin in England. Diskussion über Fibromyalgie, ob es sich um Geisteskrankheit, Posttraumatische Störung oder Autoimmunerkrankung handelt. Die Theorie von Dr. Amand hat sich noch nicht durchgesetzt. Sie ist wahrscheinlich zu einfach.
Der Rest folgt im nächsten Beitrag.
Liebe Grüße
miriam
http://localhost/www.medscape.com
Authors and Disclosures
Author
Bret Stetka, MD
Editorial Director, Medscape Features Group
Disclosure: Bret Stetka, MD, has disclosed no relevant financial
relationships.
From Medscape Rheumatology
What Is Fibromyalgia? Medscape Readers Weigh In
Bret Stetka, MD
Posted: 02/28/2011
What Is Fibromyalgia? Introduction
"Fibromyalgia is a name in search of a meaning."
-Anonymous Canadian rheumatologist
What is fibromyalgia, aside from being a major frustration to patients and
clinicians? And what causes it?
Medscape recently published a debate posing these questions to Dr. Charles
Argoff, a neurologist specializing in pain, and Dr. Jonathan Kay, a
rheumatologist. Tempers flared throughout (respectfully of course), with Dr.
Argoff taking the position that fibromyalgia is itself a distinct condition
associated with widespread reduction in a patient's pain threshold, and thus
a heightened sensitivity to pain. Dr. Kay held a different view, arguing
that fibromyalgia is merely a symptom complex with a number of possible
causes.
Etiology aside, progress has been made: There are currently 3 US Food and
Drug Administration (FDA)-approved treatments for fibromyalgia. These are
duloxetine, milnacipran, and pregabalin: all of which appear to be at least
partially effective. Still, managing the condition remains a major challenge
to clinicians, and disagreement continues as to what exactly fibromyalgia is
and how one should approach diagnosis and management.
In response to our debate, readers -- including physicians, nurses, and
patients -- flooded Medscape's open discussion forum with their own
thoughts, theories, and management tips (plus a few tirades). On the
following pages, we've highlighted some of the more interesting, thoughtful,
and strong reader opinions.
Medscape Readers Weigh In
A number of clinician readers made it clear: If there's one thing that we
know about fibromyalgia, it's that we don't know much about fibromyalgia. A
rheumatologist cautioned, "Fibromyalgia is an invention, not a diagnosis.
It's a grab bag of puzzling symptoms, not all of which may be related.
Calling it a syndrome is premature and unhelpful...; symptomatic treatment
is offered until we know more."
A psychiatrist then took an etiologic stab: "I would suggest that
fibromyalgia is a neurophysiologic condition, and we may do a disservice to
persons with psychiatric diagnoses by trying to separate "mental" from the
rest of the functions of the brain. I believe we remain a long way from
understanding adequately the complexity of the nervous system and how
"abnormalities" are manifested in individuals. The pain and discomfort is
real in that patients subjectively experience pain and discomfort, which is
a function of neurolophysiologic activity ultimately registering in the
brain."
He/she went on to suggest potentially effective therapies in addition to the
approved medications, including talk therapy, exercise, improved sleep
hygiene, nutrition, and avoidance of stressors.
An internist took a harsher stance and proposed a solution: "Having been
practicing primary care internal medicine for 30+ years, I feel like
fibromyalgia snuck in the back door while practitioners were looking the
other way. I know that sufferers defend their disease vigorously, but it is
hard to buy an entity with no diagnostic lab, imaging, pathology, or other
objective findings. Physical findings despite attempts to codify them are
shaky at best, and a significant number of sufferers improve on
antidepressants. What are we treating here? I propose a nationwide poll of
practicing primary care physicians, neurologists, rheumatologists, and
orthopaedists asking whether they think that this is a real entity. I bet
the answer is no. When that is settled, we can get to the business of
figuring out what really ails these folks instead of disabling them with an
illness and telling them that they will never get better."
There Is Some Evidence
Sleep disorders. Inflammatory cell abnormalities. A small fiber neuropathy.
There is evidence suggesting that these conditions, along with many others,
are associated with what is often diagnosed as fibromyalgia. In particular,
sleep apnea and chronic hypoxia to the brain's pain centers were frequently
proposed by readers as potential inciters of fibromyalgia symptoms, and a
number of commenters recommended ordering a sleep study in patients in whom
the condition is suspected.
A family practice doctor of osteopathy wrote: "After finishing residency I
was bombarded with patients who had tender points and the diagnosis of
fibromyalgia. I started to screen [them] for sleep apnea and was
flabbergasted at the number of patients who had hypoxic/apneic episodes at
night. Now, after several years of screening patients, about 75% of my
patients diagnosed with fibromyalgia have nocturnal oxygen or a CPAP
[continuous positive airway pressure] machine."
And then there was inflammation. As one reader pointed out, a 2010 article
from Clinical Rheumatology [1] suggests that mast cells (MCs) may play a key
role in the condition. The study reported significantly increased MC counts
in the papillary dermis of patients with fibromyalgia. The authors wrote:
"MCs are present in skin and mucosal surfaces throughout the human body, and
are easily stimulated by a number of physical, psychological, and chemical
triggers to degranulate, releasing several proinflammatory products which
are able to generate nervous peripheral stimuli causing CNS [central nervous
system] hypersensitivity, local, and systemic symptoms."
A recent abstract presented at the International Association for the Study
of Pain's 2010 conference in Montreal, Quebec, Canada,[2] reported that
patients with fibromyalgia have more symptoms of depression and alterations
in peripheral and central nervous pain pathways compared with healthy
individuals. A neurologist commented, "[Fibromyalgia] symptoms are the same
as in small fiber neuropathy, and amenable to the same treatments. [This]
study reports that patients with fibromyalgia have decreased epidermal nerve
fiber density, as in small fiber neuropathy." Another neurologist suggested
"testing patients for small fiber neuropathy before telling them anything."
The 4 D's: Depression, Diet, Drugs, and Vitamin D
The complexity of fibromyalgia became more evident with still more reader
input. "Fibromyalgia may be a name to sum up symptoms, but the symptoms are
vast and varied. They come and they go; they overlap other ailments; and
they present in multiple. However, I suspect in all of those with this
'syndrome,' there is a commonality of symptoms that are unique," stated one
physician reader who, along with many others, believes that fibromyalgia is
linked with numerous potential confounders, including pain, sleep disorders,
psychiatric illnesses, and diet. Dormant viruses, trauma, stress, and the
medical community's recent culprit du jour -- vitamin D deficiency -- were
also proposed.
So, Is It Depression?
One MD wrote, "I believe that fibromyalgia is, in most cases, a somatic
presentation of anxiety or depression. It is real, with pain and
inflammation in some cases. But I believe in its essence that it is a form
of depression and anxiety in most cases."
Other readers weren't sold on the psychiatric theory. An MD cautioned,
"Psychiatry does nothing to treat the cause of pain. To tell a patient with
postherpetic pain to see a psychiatrist and not treat them for their pain
would be ridiculous. Rather than dig deeper into the true depth and breadth
of the illness, it's much easier and cheaper to dismiss the patient with
antidepressants with follow-up by a psychiatrist." He cited a recent
Canadian consensus document on fibromyalgia,[3] which states that
fibromyalgia is not synonymous with mental illness, pointing out that many
fibromyalgia symptoms are not common features of depression.
A cardiologist commenter recalled developing a fibromyalgia-like syndrome
following a fall in which he hit his head: "I had no psychological triggers
for this syndrome; the illness to me is dysfunction of the pain signaling
system."
What About Diet and Vitamin D Deficiency?
One anonymous commenter reminded the forum of evidence linking chronic pain
and autoimmune conditions, such as fibromyalgia, with vitamin D
deficiency[4-6]: "I've seen patients with fibromyalgia who turned out to be
severely vitamin D deficient. Within a couple of months of starting a
large-dose supplement (easy and inexpensive), their pain levels were
significantly less." A neurologist chimed in, "Give high doses of vitamin D
a chance!"
Another physician wrote: "I know many with fibromyalgia who have wheat and
dairy intolerance...; people with fibromyalgia, like people with chronic
fatigue syndrome, develop these digestive tract symptoms. I have found that
control of diet is critical for most people with fibromyalgia if they want
to avoid diarrhea. I am not suggesting [that the condition] is caused by
Helicobacter pylori, but the enteric microflora [might play a role]."
Rest folgt.
======================================