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National fibromyalgia & chronic pain association conference, October 9-10, 2015: a review.

About 120 people who work daily to alleviate chronic pain gathered in Crystal City, Maryland, just across the bridge from the nation's capital, for a jam-packed weekend of continuing education October 9 and 10,2015. Organized by the NFCPA (National Fibromyalgia & Chronic Pain Association), this was a unique gathering open to researchers, healthcare professionals, and patients. The attendee mix not only served to galvanize researchers to stay committed but also provided cutting-edge information to patients and helped unify stakeholders in advocacy work to remove bias against chronic pain sufferers.

Day 1 started off with an exciting presentation by keynote speaker Daniel Clauw, MD. Clauw is an internationally renowned chronic pain researcher and a professor of rheumatology at the University of Michigan. He updated us on how to think about fibromyalgia. "Forget about the 18 tender points." Any part of the body can be tender, and it's not a local, but a central phenomenon. Previously, we had thought of FM as a discrete illness with focal areas of tenderness and related psychological and behavioral factors.

The new thinking is that there is a final common pathway for the constellation of symptoms, namely the central nervous system. Clauw admonished us to think of FM as part of a larger continuum with many somatic symptoms that create diffuse tenderness. Further, FM is not about just pain but also impairments in memory, sleep, and mood. These other issues can actually be more problematic than the pain. Here's a tidbit of information: many FM patients feel that they have dry eyes; however, they have negative Schirmer's tests and do not test positive for Sjogren's disease (both known causes of chronic dry eye syndrome). However, FM patients are far more sensitive than nonaffected people, and a small breeze across the eyeball will cause pain in the FM patient but not in a person without chronic pain. Artificial tears can help quite a bit. FM patients who learn to "push through" living with pain do better because of maintaining a positive outlook. Clauw also started a small chain reaction over the weekend in using the analogy of an electric guitar to understand the new model of FM. The brain is the amplifier, and in FM patients this is turned way up. The body of the guitar is the body of the patient, and the strings are the nerves that connect the periphery (skin) with the spine and brain. Strumming on the strings of an FM patient will create a lot more "noise" (pain) than in the average person. Folks that have long-history central pain (for example dysmenorrhea in teen years, IBS in the 20s, low back pain starting in the 30s) clearly have the amplifier set high. They have central issues. The work in FM is to learn to turn down the amplifier and not pluck the strings so hard. I'm not sure if the speakers coordinated this point (I suspect not), but we heard about electric guitars from Dr. Wolfgang Bauermeister and Dr. Frank Rice on Sunday as well! Clauw recommended that we all avail ourselves of 10 empowering modules for reducing chronic pain at the website FibroGuide (www.fibroguide.com).

Alyssa Wostrel, MBA, of the DC-based Integrative Health Policy Consortium gave a brief update on section 2706 of the ACA (Affordable Care Act, or "Obamacare"), which has been law since 2010 and will eventually open many venues for reimbursable integrative care, such as acupuncture, trigger point therapy, health coaching, and cognitive behavioral therapy. The law empowers state insurance commissioners to require state-based insurers to comply with the nondiscrimination language, which forbids discrimination against provider types, as long as the providers are properly licensed in their state. Wostrel encouraged us to contact our state insurance commissioners if our health insurance has not been covering a certain type of provider--because technically this is now illegal. Consider this talking point: The US has the most expensive, and one of the least functional, healthcare systems on the planet. There is excellent evidence that patients who engage with integrative care have better outcomes, and cost less. Check out the consortium's booklet "Integrated Health and Medicine: Today's Answer to Affordable Healthcare," available online. (See also Pathways to Healing on page 23.)

Next up was Dr. Lynn Webster, who presented on the impact on patients of the FDA's moving oxycodone from a Schedule III to a Schedule II drug. Although overdose deaths have gone down, patients have suffered because the higher schedule requires much closer physician monitoring, which of course increases costs and delays in refills. Some prescribers are "narcophobic," meaning that they are loath to be seen as too free with the prescription pad. This has left some patients high and dry, and suffering. The reschedule is important nevertheless as part of the solution for reducing opioid addiction, which is rampant in the US, and for driving us all to find better pain solutions. One such solution may come in the familiar weed grown by many of the founders of this country: hemp. Webster gave a brief overview of the state of phytocannabinoids in the US today and emphasized that while medical marijuana won't solve all our problems, the non-"high" portion of the plant, CBD (cannabidiol), holds significant promise for not only pain but also immune regulation and even improving cancer prognoses. In the states (23 plus Guam) that have legalized marijuana to some degree, a recent survey shows that there has been a 25% reduction in deaths by opiate overdose, and also significantly less use of the ER for pain, despite the lower availability of oxycodone, the most prescribed pain narcotic in the US by far.

After a quick stretch break, we were treated to what was for me the most novel information at the conference, which is the role of neck problems in chronic pain syndromes. A sleep specialist (neurologist Victor Rosenfeld, MD), a rheumatologist (Andrew Holman, MD), and a cervical spine specialist (Cory Kingston, DC) helped us understand how a kink in the neck creates hyperarousal of the central nervous system, with concomitant lowering of the pain tolerance threshold. Rosenfeld led us through normal and disordered sleep architecture, and we could see from the graphs that FM patients have much more "alpha intrusion," which basically means less, often much less, deep delta-wave, restorative sleep. Deep sleep is where tissue repair can occur. Holman explained that it's not good enough to image a neck in a neutral upright position only. What's required to assess spinal compression are neck images (plain X-ray or MRI) in flexed and extended positions as well. If you feel bad or dizzy, or get a pain flare from tilting your head back or forward, it's quite likely that you have some impingement on your spine which inhibits optimal cerebral spinal fluid (CSF) flow, thus chronically sending pain signals to the brain. Kingston described an all-too-common modern poor-posture stance, forward head posture, which he dubs a syndrome; and he aptly demonstrated the unfortunate biomechanics which result from poor posture. Text neck is a term that he coined for a common activity that throws our spine out of alignment and ultimately causes chronic tightening of the upper back and neck muscles.

After lunch, NFMCPA board member and passionate pain prevention advocate Dr. James Fricton (a dentist by trade) presented an overview of the prevalence and impact of chronic pain in the US, as well as his innovative work to empower both providers and patients.

Dr. William Collinge spoke about how mindfulness, cognitive behavioral therapy, and self-awareness can reduce pain symptoms, especially when used as part of a comprehensive, holistic approach to ameliorating pain.

Dr. Kim Dupress Jones, nurse practitioner, PhD, and associate professor at OHSU (Oregon Health & Science University), led us through ideas for exercise modification so that we don't give up but keep movement in our lives every day. The basic idea is to start low, go slow, but keep going.

The day wrapped up with two more informative speakers with lots of practical tips on modifying your kitchen and bathroom or even car; how to find community exercise classes that work for you; and how to ration your energy sensibly, so you don't crash early in the day. Barbara Kornlau, JD, OTR, and certified pain educator presented on "Living and Buying with FM and Chronic Pain"; and Mary Biancalana, MS, CMTPT, LMT, and owner of the Chicago Center for Myofascial Pain Relief, cheerfully demonstrated dozens of trigger-point releasing tips using simple tools such as a tennis ball.

Day 2 started early with a series of presentations followed by breakout sessions. First we heard from researcher Dr. Frank Rice, one of the world's leading experts on skin innervation and epidermal chemistry. Rice definitively expanded our thinking about what part of the body can feel pain. His research has uncovered "small fibers" capable of sensory transmission (nerve activity) in all cells: skin cells, even the pigment producing keratinocytes, and hair follicles and blood vessels, even the tiniest in the capillary beds. These small nerve fibers affiliated with all cells not only sense pain, but also can respond to light, thermal cues, and nutrient detection and cause reflexive movement away from pain via neurotransmitters and other chemicals within the adjacent cells' environment, which responds 24/7 to threatening or helpful stimuli through a constant feedback mechanism.

Rice differentiated beneficial acute pain, which is transient and due to mechanisms that are responding appropriately to a transient noxious condition, from nonfunctional chronic pain. Chronic pain is inappropriately prolonged pain due to "neuropathic" alterations in the widespread tissue sensory mechanisms. Again, every part of the body has neural fibers (axons) that react to pain. Peripheral nerve cells bring sensory information to the dorsal root ganglion cells, which then feeds into the dorsal cortex of the spinal cord, then up to the somatic sensory cortex in the cerebrum. Small fibers are the thinnest fibers within larger fibers (axon chains) that are not immediately involved with gross pleasurable sensation but often involved in painful stimuli. Some fibers respond to all sensation; say, warmth. Separate fibers (the small fibers) give different signals when the warmth intensifies to dangerous levels of heat. Our bodies interpret pain as an obvious threat to homeostasis.

Chronic pain patients are often frustrated by negative EMGs because small fibers don't have sufficient signal strength to be picked up with this testing. With more sophisticated tools, we now know the skin is loaded with small fibers. Paradoxically, chronic pain conditions are typically associated with a loss of epidermal nerve endings. Small fiber neuropathy by definition means loss of epidermal axons. However, the remaining fibers are apparently overly sensitive.

Small fibers are associated with the vasculature, which converge with the sympathetic nervous system. The sympathetic nervous system (fight or flight) fibers regulate the sensory fibers. Maybe drugs such as SNRIs work not on the brain, but in the periphery? Rice postulates that FM may involve a pathology of the convergent sensory and sympathetic innervation on cutaneous arterioles. Women have twice as many sympathetic fibers along their blood vessels than do men, and these fibers seem to be estrogen sensitive, which could explain why many more women than men have chronic pain and Raynaud's syndrome.

What started this mismanagement of vascular flow which characterizes Raynaud's and other pain syndromes? Likely stress to the brain, which creates more sensitive sensory input.

There is normally a finely tuned interaction among the CNS, peripheral nervous system, and the body that maintains homeostasis and normal perceptions.

There is increasing evidence that there are measurable biological pathologies occurring in peripheral tissues. This offers potential new targets for therapeutic intervention and to improve diagnostics.

There is a tremendous capacity for the nervous system to find a solution to solve adverse physical and psychological challenges. We are lucky to have such a dedicated pain researcher as Frank Rice.

Next we heard Michael Sorrell, MD, a veteran NIH researcher, who presented on myofascial pain. Pain is caused by disturbance of myofascial trigger points (TPs), which are hyperirritable spots in skeletal muscle or in the fascia associated with skeletal muscle. We know that TPs are electrically different from surrounding tissue. They have spontaneous electrical activity. If you stick a needle in, more response is generated than if stimulating a non-TP area. TPs have altered biochemistry; reduced pH, higher levels of bradykinin and acetylcholine. TPs are usually located in taut bands of muscle. When a taut band is stimulated (plucked or strummed), it often contracts, causing a local twitch response, which is a spinal reflex. TP pain can mimic radiculopathy, migraine aura, bony, abdominal, or cardiac pathology, and other symptoms. If the TP does not respond to myofascial therapy, look again for a primary source of the pain.

Sorrell presented several case studies. One concluded that 85% of patients with migraine without aura improved at least 50% with myofascial therapy.

Next on the agenda we were captivated by German physiatrist Wolfgang Bauermeister, MD, PhD, who started his lecture by emphatically proclaiming his love of rock and roll (and electric guitars). Dr. B. gave us a sneak preview of his innovative work using a special ultrasound technique (elastography) to identify tissue texture changes and confirm the very real presence of TPs.

The last segment before lunch and the break-outs was a more in-depth look at the work of Fricton. He presented a dynamic, colorful PowerPoint full of cartoons, quotes, and humor--but also many dire facts. For example, pain is the No. 1 driver of cost in the US health-care system, according to a 2012 American Pain Association analysis, costing $635 billion or more annually. Pain is also the main cause of disability. As part of how to address these huge problems, Fricton directed us to a free, online class called "Prevention of Chronic Pain: A Human Systems Approach," available through Coursera (www.coursera.org).

I chose to learn more about Kingston's approach to correcting cervical stenosis for the first breakout after lunch. The weather in DC was beautiful, sunny with just a touch of a fall breeze.

Kingston said we could contact him (his practice is in Logan, UT) with questions about referrals: Coryk73@ yahoo.com.

Our first exercise was to assess a patient visually for compensation around optimal alignment.

Eyes will always want to be level with horizon so the body will find a way to make the eyes stay level. The ear holes should lineup directly over the shoulders in a side view. Shoulders should be equally level. Hips should be level. The ability to rotate head left and right should be equal.

Good frontal alignment puts the sternal notch directly below the middle of the forehead. FM is not just muscle pain; it's a whole raft of comorbid symptoms. The neck is so important because it's where the brain connects to the body. The function of the bony vertebrae is to keep us upright against gravity. Along with eye "righting" reflex, upright posture differentiates us from monkeys. Further, the bony vertebrae protect our spinal column, which is most vulnerable at the neck. The spine has series of 45[degrees] spring-loading areas: neck, thoracic, lumbar. Our necks need to balance the weight of head. Having a "military neck" wrecks ligaments at back of neck and smashes anterior cervical discs.

Here are the diagnostic criterion for Chiari syndrome, a congenital spinal stenosis:

1. headache/neck pain

2. dizziness/vertigo

3. vague pains throughout body

4. impaired balance

5. foggy thinking

6. urinary incontinence

7. IBS

8. voice changes

Maybe FM is not, a rheumatologic or infectious problem. Maybe it's spinal stenosis, but not necessarily Chiari syndrome. Kingston made a good case for why chronic pain patients often have bad necks. Modern life sets us up for upper spinal injury. Consider that acceleration as slow as 5 mph can cause whiplash.

The suboccipital muscles are part muscle (stretchy) and part ligament (not stretchy). They lock the head in extension in situations causing rapid forward movement of the head. Righting reflexes cause the forward moved head to lift chin and push butt back, especially in women, who carry their weight low. In men, weight is abdominal, pulling weight forward, causing neck to compensate forward, actually opening cervical spaces. Men are less prone to neck problems. Intermittent abutment of the spinal cord causes massive autonomic arousal. In FM this situation is chronic. It feels to the FM patient as if the tiger is constantly in the room. Forward head posture affects CSF flow and leads to not only local but also central pain. The good news is, this can be corrected, but you may have to spend 3 weeks or so in Utah.

Next I attended the exercise/nutrition module. Kim Jones presented new research showing that physical inactivity and poor muscle strength are linked to all-cause mortality. She discussed growth hormone (GH), a small peptide with a 20 minute half-life, secreted by pituitary in pulses throughout day. FM patients don't make enough because it's mostly secreted during stage 3 and 4 sleep. Unfortunately, administering GH is very expensive and did not help FM patients much.

Insulin-like growth factor (IGF-1) holds more promise. It is also a small peptide but with a much longer (21-hour) half-life. Serum levels reflect pulsatile secretion of GH over the previous 48 hours.

FM patients have low IGF-1. Replacement (with intramuscular injections) works to bring up levels, and folks feel better. However, there are potential side effects such as weight gain and fluid retention.

Other option is exercise. Yay! That sounds better. At peak aerobic capacity, GH is maximally stimulated. The drug pyridostigmine (Mestinon) restores growth hormone to normal levels in exercising FM patients. However, good results were really only seen in patients taking the medicine and exercising. Eccentric movement seems best: maximize big muscles. Big steps going uphill; baby steps going down. Seek warm water options. Water adds natural resistance, thus mimics strength training. Jones did give an exercise caveat. Many FM patients are hypermobile and at risk of overstretching using weights, especially during water aerobics.

She closed with some general advice for exercise and FM:

1. Find a program that you can do.

2. Seeing others like you being successful can help.

3. Observe and track functional improvements. Keep a journal to chart progress. Functional improvement comes before symptom (pain) improvement.

4. Speak kindly to yourself.

5. Start low, go slow ... but get there.

She shared this resource: the Fibromyalgia Information Foundation website, which offers videos (http:// myalgia.com/VIDEOS/Video_lntro duction.htm)

Dr. Kathleen Holton, nutrition researcher with the NIH, presented accessible information about the power of vegetables (loads of minerals) and good fats. She emphasized that dietary choices absolutely can affect neurotransmitter function. In general, high-carb diets reduce GH and high-protein diets promote GH. She states, and I agree, that nutrition is the single most important factor in optimizing your health.

Positive choices include produce and "clean" meat high in vitamins, minerals, protein, essential fatty acids, and fiber. Negative food choices include fast food and processed edibles that contain additives, pesticides, herbicides, trans fats, heavy metals, and other chemicals.

Holton introduced the idea of health-robbing excitotoxins. These are food additives such as glutamate, carrageenan, aspartate, and L-cysteine, which add shelf-life and addictive potential. Carrageenan is used to induce pain in lab rats. Glutamate is a nonessential, negatively charged amino acid found in nature. The bound form in meat digests slowly and in a balanced way, so it is OK. The free form is mostly found in soy products (soy sauce naturally contains high amounts)--and spikes blood levels of glutamate quickly after ingestion. Chronic pain patients, or any patients with neurodegenerative diseases such as ALS or Parkinson's, should avoid soy sauce. Glutamate is also a neurotransmitter, the most ubiquitous one in the body, and a major player in pain transmission. Disordered glutaminergic neurotransmission has been implicated in FM. FM patients have higher brain and CFS levels of glutamate. Doritos have 11 excitotoxins.

Seizures and migraines are caused by excess glutamate. The important nutrients vitamin C (500 mg daily), vitamin E (400 IU daily, found in nuts, seeds, olives), vitamin D (4000 IU daily but check serum levels because this might not be enough) and omega-3 fatty acids (salmon, sardines), and zinc (mostly from meat) were discussed briefly. More time was spent on magnesium. Fifty percent of the FM population is deficient. Stress lowers magnesium levels. Magnesium deficiency causes neuromuscular excitability, high blood pressure, dizziness, seizures, and tachycardia. The best food sources of magnesium are buckwheat flour, bulgur, semisweet chocolate, halibut, spinach, and white and black beans.

In summary, the optimal diet contains only real food, and is naturally low in additives and trans fats and high in nutrients and fiber.

I then jumped over to learn a bit more about the TP-locating ultrasound technique pioneered by Bauermeister. He uses a "shock wave" device--similar to lithotripsy--to reorganize the dysfunctional "neurotransmitter soup" that defines the milieu of a TP. The therapeutic effects of shock waves have been studied extensively. They change the neurobiology of the tissue. TPs create the ongoing nociceptive input from the periphery that creates the centrally appreciated pain. Breaking up TPs can provide immediate and often enduring relief. Other effective modalities include acupuncture and dry needling.

Not wanting to miss some of the self-care tips presented by the energetic Mary Biancalana, I spent the last hour of the conference using hand-held self-massage tools and lying on the floor watching short videos. A perfect closing!

Let us take what we have learned out into the world to help reduce suffering.

www.DrEmilyKane.com

www.AKANP.org

www.naturopathic.org

by Emily Kane, ND, LAc
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Author:Kane, Emily
Publication:Townsend Letter
Article Type:Conference notes
Geographic Code:1USA
Date:May 1, 2016
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