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From Autoimmune Drugs to Tai Chi: the NIH’s Approach to Fibromyalgia

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Reprinted with the kind permission of Cort Johnson and Health Rising.

The National Institutes of Health (NIH) is easily the biggest funder of medical research in the world. Many research groups depend on the NIH for the majority of their funding.
Health Rising’s recent review of NIH funded studies on chronic fatigue syndrome revealed a small (14 studies underway) but rich list of studies. From an analysis of the gut microbiome, to the effects of exercise on the immune system, to studies on Epstein-Barr virus infection, to cerebral spinal fluid studies, the NIH was looking hard for the cause of ME/CFS. If the NIH isn’t funding ME/CFS much, the studies it does fund are focused strictly on pathophysiology.
The fact that not one treatment study was funded suggests the NIH is still floundering in that area.
The opposite picture is present for FM. The NIH is placing very little emphasis, at least this year, on trying to understand why or how fibromyalgia occurs (5 studies) but is more focused on treating it (14 studies).
Lackluster Attempt at Understanding Pathophysiology
Fibromyalgia is the sole focus of only three of the (only) five pathophysiological studies the NIH is funding.  Two of the studies (immune study, SFN study) focused purely on FM could conceivably produce a breakthrough in our understanding of it. The other three studies (placebo effect/cognitive processing) are decidedly ho-hum matters.
The NIH did fund a small fiber neuropathy (SFN) study but with @40% of FM patients having SFN, it was surprising that three or four studies weren’t being funded.  With so many intriguing central nervous system findings, it was remarkable as well to see the NIH funding only two pure brain imaging studies – one of them very small.
A Mind/Body Alternative Medicine Approach to Treatment
A strong focus on treatment would seem to be good news. Treatment should be, after all, the end result of research.  Unfortunately, the NIH’s treatment studies don’t fare much better.  Half of the NIH’s treatment studies are on mind/body approaches to FM (CBT, emotional processing, MBSR, Tai chi, placebo).  Several more studies focus on alternative approaches to FM such as acupuncture, blue green algae and Chinese medicine.
Past studies have shown these approaches can be helpful, but are they effective enough for the NIH to put most of its eggs in the mind/body basket / alternative health basket? Apparently, fibromyalgia’s home Institute at the NIH, NIAMS, thinks so. NIAMS is funding studies on propanolol and TENS but is putting most of its money on behavioral approaches to FM (4/6 studies) to treatment. It’s not putting a dime into understanding FM pathophysiology.
NIH appears to be more reinventing the wheel in the treatment arena rather than moving forward. Dan Moricoli’s and other mind/body recovery stories attest to the fact that that these practices can be effective in the right person. Still, no less than five yoga, four MBSR/meditation and ten Tai chi FM studies have been done in the past five years.
This doesn’t mean the NIH is not funding good studies – it’s just not funding enough of them. The etanercept and propanolol studies could open new windows on treating FM.  Finding that either an autoimmune drug or a beta blocker is helpful in FM would be news.  Assessing the long-term effects of opioids in FM is important given the many FM patients using them.  We all want to know more about small fiber neuropathy, and finding an immune trigger for chronic pain would certainly open doors.
ME/CFS may not be funded as well, but many of the ME/CFS studies could result in legitimate breakthroughs. The same, unfortunately, can’t be said for most of the NIH’s FM studies. That’s a real surprise given how rich in possibilities the FM field is.
It’s possible that NIAMS is simply blocking, i.e., not funding studies on pathophysiology, but it’s not clear whether these studies are not getting funded because NIAMS is not interested – or if the research field is simply ignoring FM? Note that the neurological institute (NINDS) is funding half of the pathophysiological studies, while NIAMS, as noted earlier, is funding none.  Assessing the number of FM grant applications forwarded to the NIH would be a good place for advocates to start figuring out what is going on there.
Active NIH Funded Studies in 2015

Wanted: Patients In All Sorts of Pain – An Immune Pain Study
Funding Institute: National Institute of Dental & Craniofacial Research 
No moderate pain patients allowed. One part of this study requires participants to have at least three of the following disorders: temporomandibular disorder (TMD), episodic migraine (EM), vulvar vestibulitis syndrome (VVS), fibromyalgia (FM), and irritable bowel syndrome (IBS) – to participate.
They believe that microRNAs (miRs) are activating an immune receptor (involved in infection, interestingly enough) TLR8 and a protein complex called NFKB, known to enhance the pro-inflammatory cytokine response.  Ultimately, this research could lead to immune-based therapies for chronic pain.  Who can we thank for this study? People with TMD – the dental institute is funding this study.
Small Fiber Neuropathy in Adolescents with Chronic Widespread Pain 
Funding Institute: National Institute of Neurological Disorders and Stroke 
Louise Oaklander was one of the first researchers to identify small fiber neuropathy in FM patients. She found quite a bit of it, but she believes the current testing regimens significantly under-diagnose SFN in adolescents. In this big study (almost $700,000), Oaklander will assess different SFN tests AND try to get at the cause of SFN using blood tests and skin biopsies. The study will end in 2020 and is being funding by NINDS (who else?).

Clearing the Fog Around FibroFog? 
Funding Institute: National Institute of Arthritis and Musculoskeletal and Skin Diseases 

This ongoing and rather small ($121,000) study will a) measure the cognitive problems in FM and people with depression, and b) use an MRI to compare how their brains function during a cognitive test. The researchers anticipate FM patients and people with depression will have different kinds of cognitive problems, and the MRIs will reveal different patterns of brain functioning are present.
Risk Factors For Chronic Pain
Funding Institute: National Institute of Neurological Disorders and Stroke

Talk about a long-running study. This massive project, which began in 2003, seeks to identify the psychological and physiological risk factors, clusters and genetic factors that predispose people to fibromyalgia and other chronic pain conditions.  This project has produced about 100 studies thus far and it’s still going strong – it’s getting a cool $1,314,211 for this year.
Understanding the Placebo Effect in Fibromyalgia
Funding InstituteNational Center for Complementary & Integrative Health 
This study will give FM patients a placebo – an intravenous injection guaranteed to have pain reducing effects – and then use PET scans to monitor the activation of their opioid receptors. They will use the scans to assess the integrity of this pain reducing system and to find biomarkers that will enable researchers to better assess its activity. This ongoing study, last funded in 2014, is expected to wrap up in 2020.

Biological Approaches
An Autoimmune Drug to Reduce Pain in Fibromyalgia?
Funding Institute: The National Institute on Drug Abuse 
The hypothesis behind this intriguing study is that pro-inflammatory cytokines are dysregulating opioid neurotransmission in FM patients, i.e., they are knocking down the opioid-based system of pain relief in FM. First, the investigators are going to determine the status of MOR opioid neurotransmission in FM patients and then they are going to give them Etanercept, a drug used in autoimmune disorders. They predict that Etanercept will restore opioid neurotransmission and reduce pain in FM.  It worked in animal models. Let’s hope it works in FM as well. This $250,000 study ends in 2018.

Acupuncture – Sort of – to Reduce Pain in Fibromyalgia
Funding Institute:  National Center for Complementary & Integrative Health 
The proponents of this study believe that electro-acupuncture (EA) is better than traditional acupuncture in reducing pain. In fact, one study found that electro-acupuncture (EA) was more effective than placebo in reducing pain but traditional acupuncture was not. They believe this may be because the needles in acupuncture affect the ever so sensitive somatosensory system in FM.  They’re testing their hypothesis using (1) EA and something called (2) “mock laser (ML) acupuncture” – a newer form of sham acupuncture that does not affect the somatosensory system negatively.
This rather expensive study ($645,000) will end in 2018.
Blue Green Algae for Pain AND Depression?
Funding Institute:  National Center for Complementary & Integrative Health 

The authors of this mouse study propose that common pathways underlie both FM and depression. Calling this conjunction of pathways a “dangerous pathological situation,” they state that having FM can trigger depression and depression FM.
Their solution – affect serotonin receptor functioning using extracts, fractions, and purified compounds from marine blue-green algae collected off of Panama. They noted that the task of examining the marine environment for therapeutic compounds has only recently begun.
Traditional Chinese Medicine (TCM) Takes its Shot at Fibromyalgia
Funding Institute:  National Center for Complementary & Integrative Health 

This five-year study – which is ending next year – examines how effective ten weeks of TCM is for the treatment of fibromyalgia. The funder? Obviously NCCAM.
Opioids – Do They Help or Hurt in Fibromyalgia?
Funding Institute:  The National Institute on Drug Abuse 
Many people with FM rely on opioids but the long-term effects are uncertain. This Stanford study will determine what effects they have on the key neurological aspects of FM, i.e., the pain pathways in the brain and the spinal cord, as well as, interestingly enough, on the activity of the “reward system” in FM. Finally, a long term study will assess how effective they are at relieving pain over time.
Another Low Dose Drug for Fibromyalgia? 
Funding Institute:  National Institute of Arthritis and Musculoskeletal and Skin Diseases 

First there was low dose naltrexone. Now these Utah researchers – no doubt in concert with the Lights who explored propanolol’s use in ME/CFS – propose the low dose propanolol – a beta blocker – may be effective at reducing the delayed onset muscle pain seen after exercise.  In this big study (200 FM patients) –  they must have had some good preliminary data to score a study this big – they’re going to assess post-exertional malaise (PEM) and gene expression changes after propanolol.
This $330,000 study will last for two years and is beginning this month at the University of Utah. (Contact email: akiko.okifuji@hsc.utah.edu)

Electrical Stimulation to Reduce Pain
Funding Institute:  National Institute of Arthritis and Musculoskeletal and Skin Diseases 
You might not think that stimulation could reverse a hyper-excitable nervous system condition, but it’s the descending pathways from the brain to the spinal cord that inhibit pain that aren’t working well in FM.  Enter transcutaneous electrical nerve stimulation (TENS) to get those inhibitory pathways up and running again.
This five-year $700,000 (in 2015) study will determine if using a TENS unit will decrease pain and fatigue and increase functionality. It ends in 2018.
Combined Biological and Behavioral

The Drug and CBT Study
Funding Institute: NIAMS
National Institute of Arthritis and Musculoskeletal and Skin Diseases 

Both tramadol and CBT are used in FM to reduce pain and increase activity, but rarely are they used together. This study combines tramadol and a version of CBT adopted for FM to see if FM patients do better on both. It will also use actigraphy to see if poor sleep or increased activity are associated with increased fatigue and pain. Interestingly, they believe they won’t be. They will also evaluate psychological and neurophysiological variables.
This big 5-year study ($1,000,000 in 2015) ends next year.
Behavioral and Mind/Body
MBSR for Fibromyalgia
Funding Institute:  National Center for Complementary & Integrative Health
John Kabat Zinn developed Mindfulness Based Stress Reduction (MBSR) – a mindfulness and meditation-based approach to managing disease for people with chronic pain who weren’t able to tolerate pain drugs. That makes it a natural for fibromyalgia. This Yale University study is slated to end in 2017.
Yoga vs Exercise? 
Pain Outcomes Comparing Yoga Versus Structured Exercise
Funding Institute: Veterans Affairs
Mindful stretching and breathing vs graduated exercise (meditation vs aerobics)…this one is going to be interesting. The Veteran Affairs is funding this study ending in 2017.
Catastrophic Reductions in Chronic Pain?
Funding Institute:  National Institute of Arthritis and Musculoskeletal and Skin Diseases 
Catastrophizing – ruminating on the worst that could happen – definitely increases pain sensitivity but no one really knows why.  These researchers have an idea.  They believe that catastrophizing activates the brain areas that process the emotional aspects of pain (e.g., anterior insula and medial thalamus). (There’s apparently a brain area for everything.)
They are going to reduce catastrophizing by using cognitive behavioral therapy (CBT) and then see if pain drops and as it does, if the activity of the parts of the brain involved in the emotional response to pain reduces as well.  This very expensive study ($700,000 plus) ends in 2019.
Neuromuscular Training Plus CBT for Teens
Funding Institute:  National Institute of Arthritis and Musculoskeletal and Skin Diseases 
This small study seeks to use a different kind of exercise called neuromuscular training in conjunction with CBT to reduce pain and hopefully increase physical activity in teenagers with FM.  This type of exercise is believed to limit post-exercise muscle soreness. This “cheap” study ($165,000) ends in 2016.
An Upgrade to CBT? Emotional Processing For FM
Funding Institute:  National Institute of Arthritis and Musculoskeletal and Skin Diseases 
Stating that many people with FM have either increased rates of lifetime trauma or problems with stress or emotional regulation, this large study focuses on emotional processing. The authors propose that CBT’s inability to directly address stress and emotion dysregulation has blunted its effectiveness.
They also state they have “solid preliminary data” on the efficacy of “emotion regulation based interventions for FM.”  NIAMS apparently agreed; this is a big expensive study ($600,000) that’s been funded since 2010 (making it probably a $3 million or so study).
The study compares emotional exposure therapy (EET) and standard cognitive-behavioral therapy (CBT). It ends in 2016.
Tai Chi –
a First Line Treatment for Fibromyalgia?

Funding Institute:  National Center for Complementary & Integrative Health 
The authors are so excited about Tai chi for fibromyalgia that they believe their results will show that it should be a “first-line” treatment, i.e., it should be one of the first therapies doctors recommend.  That’s a tall order, but the same researcher has proposed that Tai Chi be used in other rheumatological disorders such as osteoarthritis and rheumatoid arthritis.
This study will assess the short and long term effectiveness of Tai Chi vs aerobic exercise in over 200 patients using a variety of Tai Chi instructors.
Bright Light Treatments to Restore Sleep Patterns (and reduce pain) – in Veterans
This is not a fibromyalgia study but given all the sleep problems in FM and ME/CFS, it may very well apply. The authors note that delayed sleep patterns (late sleep) is associated with increased anger, depression, anxiety, fatigue and physical function.  They will use a morning bright light treatment to try and restore normal sleep patterns and reduce chronic pain and improve PTSD symptoms, depression, anxiety and sleep in U.S. veterans.

About the Author: Cort Johnson has had ME/CFS for over 30 years. The founder of Phoenix Rising and Health Rising, Cort has contributed hundreds of blogs on chronic fatigue syndrome, fibromyalgia and their allied disorders over the past 10 years. Find more of Cort's and other bloggers' work at Health Rising.

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