Dr. Daniel J. Clauw, MD, explains his approach to treatment of Fibromyalgia patients, and offers a vision of the future.
Healthcare professionals may also wish to review Dr. Clauw's course for CME/CE credit, launched May 29, 2008 – "Fibromyalgia: A Label for Chronic, Widespread Pain."
Daniel Clauw, MD, is a physician dedicated clinical care and research on the mechanisms and most effective treatments of patients with FM, CFS, and related conditions such as Gulf War Illnesses and multiple chemical sensitivities. At the University of Michigan, Dr. Clauw is Professor of Medicine in the Division of Rheumatology, and Director of the Chronic Pain and Fatigue Research Center and Michigan Center for the Advancement of Clinical Research. He leads a national team in the study of these illnesses at U-Mich, Georgetown University, the NIH, DoD, VA, and other academic medical centers.
Question: Dr. Clauw, when did you first become aware of Fibromyalgia as a valid illness with real symptoms?
Dr. Clauw: While in training as a rheumatology fellow [at Georgetown University. Most of my mentors believed that Fibromyalgia was a real illness and taught me that. I was lucky in that regard, because many rheumatologists of that era (and some of the present era) did not believe that Fibromyalgia was a “real” problem, and certainly would not recommend that their junior faculty do research on this condition.
Q: Do you have a standardized treatment protocol for your FM patients?
Dr. Clauw: I use a combination of low-impact aerobic exercise, symptom-based pharmacologic therapy, and cognitive behavioral therapy. Not all patients need all three.
n I usually begin by prescribing medications to target the two or three most prominent symptoms that a patient has. In most cases pain is one, but poor sleep, fatigue, memory problems, or other symptoms sometimes interfere more with function than pain.
n I only use one treatment at a time, and see if it works before deciding whether to continue with the treatment, or discard it. One of the biggest problems I see in practice is that doctors and patients try too many things at once, and then they have limited ability to tell if something is working, or whether a new symptom is a side effect of a treatment.
n After I find the correct one or two medications to reasonably control many of the symptoms, then I will add aerobic exercise, and sometimes cognitive behavioral therapy (CBT). Both exercise and CBT can either be done simply (with simple instructions for exercise or a workbook or Arthritis Foundation course for CBT) or with more professional guidance (e.g., with a physical therapist, personal trainer, social worker, or psychologist).
These treatments take many months to work (in contrast to medications, which usually work within a month or so if they are going to work at all), but the benefits are more durable than the benefits obtained from medications.
n If this combination of treatments doesn’t work, I will sometimes add complementary and alternative therapies at this point.
Q: What are your recommendations for the following important issues for FM patients (as applicable)?
n Sleep (unrestful sleep; insomnia) – Sleep hygiene (avoiding caffeine/alcohol, exercising near bedtime, etc.), followed by tricyclic medications (e.g., FlexerilR, ElavilR in very low doses given a few hours before bedtime), or sedatives (e.g., zolpidem [AmbienR]). LyricaR and NeurontinR can also help this symptom. When using the tricyclic drugs or any medications, Fibromyalgia patients should “start low, go slow.” I usually begin at 5 to 10 mg of Flexeril or Elavil taken two hours before bedtime, and increase the dose by 5 to 10 mg per week.
n Pain – Tricyclics, duloxetine (CymbaltaR), pregabalin (Lyrica), gabapentin (Neurontin), venlafaxine (EffexorR), tramadol (UltramR)
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n Low energy (combating fatigue) – Buproprion (WellbutrinR), duloxetine (Cymbalta) venlafaxine (Effexor)
n Depression (drugs prescribed, etc.) – See above recommendations, plus selective serotonin re-uptake inhibitors (e.g., ProzacR, ZoloftR, PaxilR, often in higher doses that work for depression).
n Brain fog (inability to concentrate, memory problems, etc.) – Same as for low energy, plus occasional use of Central Nervous System (CNS) stimulants.
n Diet– I don’t think there is any diet than can be recommended except a sensible, healthy diet.
n Supplementation (how to address any deficiencies) – There are a few supplements that may be helpful for FM such as magnesium supplements, or SAM-e, but patients should understand that these are drugs when taken in this way. I am always somewhat amused when a patient comes in to me taking eight different nutritional supplements, and says that he/she doesn’t want to take any drugs. A drug is anything that is ingested to change the body’s physiology – nutritional supplements are drugs.
Q: What is your recommendation regarding exercise for FM patients?
Dr. Clauw: Just as with medications, a “start low, go slow” approach is most effective. Focus on low-impact exercises, begin at a very low level (5 minutes 3 to 4 times per week) and slowly increase by a minute or two per week.
In some patients who are very intolerant of exercise because it worsens their symptoms, warm water aquatic therapy can be a good way of starting an exercise program. I try to eventually get patients to do 20 minutes per day of aerobic exercise, and tell them it will typically take 3 to 4 months to reach this point.
Q: Are you currently involved in any research studies?
Dr. Clauw: Yes, many. We are doing research into both the mechanisms, and most effective treatments, for Fibromyalgia and related conditions. With respect to mechanisms, our group is particularly interested in the pain amplification mechanisms in Fibromyalgia. We and others have uncovered clear evidence that there is some process causing normal pain signals to be amplified in Fibromyalgia, almost like the volume control is set too high in the nervous system. We also study other components of the nervous system, such as the hypothalamus, and autonomic nervous system.
With respect to treatment, we are very interested in whether and how non-drug treatments work in FM. We have ongoing trials of cognitive behavioral therapy, exercise, and acupuncture in FM. We are also working on trials of drugs being developed especially for FM.
I feel that all of the above areas are very promising.
Q: What do you think the future looks like for FM patients? Are we moving forward in dealing with this debilitating disease – as patients, practitioners, and as a society?
Dr. Clauw: Perhaps the most promising thing for patients is that the pharmaceutical industry is getting much more interested in FM than in the past. The pharmaceutical industry ultimately will be responsible for putting Fibromyalgia “on the map,” both with respect to the “legitimization” of this illness, and to finding more effective treatments. That is how validation has happened with other illnesses like irritable bowel syndrome, and migraine headaches.
For more information about the diagnosis and management of Fibromyalgia offered by the Chronic Pain & Fatigue Research Center at the University of Michigan – and to read about the Center’s current pain research studies – go to http://www.med.umich.edu/painresearch/pro/over.htm
Note: This information has not been evaluated by the FDA. It is generic and is not meant to diagnose, prevent, treat, or cure any illness, condition or disease. It is very important that you make no change in your healthcare plan or health support regimen without researching and discussing it in collaboration with your professional healthcare team.