APPROACHES TO FIBROMYALGIA
Traditional fibromyalgia treatments and diagnosis were presented in previous blog posts; This article touches upon two other novel techniques, both non-invasive and outpatient-based, that may become regular considerations in fibromyalgia treatment.
Transcranial Direct Current Stimulation (tDCS). tDCS is a simple and painless procedure involving the stimulation of the brain located between two electrodes placed on the scalp. The extremely small electrical current emanates from a 9-volt battery. Although not yet FDA-approved for transcranial use, preliminary studies of tDCS, particularly of the primary motor cortex of the brain, show some promise in the use of this non-invasive treatment for pain and sleep-related fibromyalgia (Fregni F, et al. Arthritis Rheum. 2006; 54(12):3988-98; Roizenblatt S, et al., Pain Pract 2007; 7(4):297-306; Short B, et al. Pain 2009).
Transcranial Magnetic Stimulation (TMS). TMS involves the application of magnetic pulses over the scalp without using electrodes or direct electrical stimulation. Unlike ECT (electroconvulsive treatment), patients remain awake and alert during each TMS treatment, and can drive to and from the office due to a lack of cognitive and other side effects associated with ECT. The procedure is well-tolerated with few side effects compared to medication treatment.
While TMS has been FDA-approved, safe, proven, and well tolerated in the treatment of depression, preliminary research suggest that TMS may be a potential off-label alternative for treatment-refractory fibromyalgia, particularly if associated with depressive symptoms.
Recent Studies on TMS and Fibromyalgia Treatment
Since research has demonstrated that TMS can diminish chronic pain, there has been considerable interest in the application of TMS to fibromyalgia-related pain. Preliminary and promising studies on the use of TMS to treat fibromyalgia have recently been published.
Three potentially different TMS approaches to fibromyalgia treatment have been studied:
- Two studies indicate that high frequency TMS of the left primary motor cortex could become a future standard of fibromyalgia treatment:
A 2007 randomized, double-blinded, controlled study of 10 daily sessions of TMS in 30 patients with fibromyalgia demonstrated that patients who received active TMS experienced significant pain reduction that lasted up to 2 weeks after the last TMS session (Passard A, et al, Brain 2007;130;2661-2670).
Another preliminary, randomized, double-blinded controlled study of 40 fibromyalgia patients (A. Mhalla et al. Pain 152(2011) 1478-1485) showed that, compared to the group that received sham (ie, fake) procedures, there was a significant and sustained improvement in pain, activity, sleep, fatigue, outlook and general quality of life in the TMS group with fibromyalgia.
- High frequency TMS to the left prefrontal cortex appears promising according to one recent randomized, controlled study:
10 patients with fibromyalgia received ten sessions of TMS over a two week period. Those who received active TMS experienced a statistically significant reduction of 29% of their daily pain, which was followed by a significant reduction in associated depressive symptoms two weeks later and continued pain relief. The patents who underwent sham procedures experienced only a 4% improvement in pain. The authors of the study point out that the rapid onset of pain reduction in this pilot trial approximates that of pregabalin and duloxetine, although with markedly fewer side effects (Short EB et al. 2011). Interestingly, in this study, it was clear that improvement in pain symptoms occurred prior to a reduction in depression.
¢ Although two very small preliminary studies have focused on the application of low frequency TMS to the right front side of the brain. More research is needed before conclusions can be made about the efficacy of this technique. (Sampson SM et al., Pain Med. 2006; 7(2);115-8; Short B, et al., 2009).
Although the use of the NeuroStar TMS device for depression has been FDA-approved, its use to treat fibromyalgia without depression would be an off-label application of this device. Clearly more studies with larger numbers of subjects are needed to better determine optimal treatment protocols, pulse frequency and location of treatment (motor cortex, prefrontal cortex, or both) for TMS to become a routine treatment for fibromyalgia.
TMS for Depression with or without fibromyalgia.
While medication and psychotherapy are usually the first-line treatments for clinical depression, TMS is a non-invasive, highly tolerated, FDA-approved outpatient procedure for treatment-resistant depression, shown to be as effective as medication plus an augmentation agent. Since depression often co-occurs with fibromyalgia, TMS should be considered for the management of treatment-refractory depression with associated fibromyalgia pain.
If you have concerns about depression and chronic pain, think you may be suffering from depression and/or fibromyalgia, and want to know more about possible treatment options, contact your general physician, a psychiatrist, or a rheumatologist.
The West Coast TMS Institute, located in Sherman Oaks, Los Angeles, approaches depression in a comprehensive manner and is very sensitive to the needs of patients suffering from depression with or without fibromyalgia.
If you found this blog on fibromyalgia interesting, check out our next behavioral health post on posttraumatic stress disorder, or PTSD.