Low Dose Naltrexone (LDN): Possibly a Major Breakthrough

Background

Naltrexone is an FDA approved medicine used to block the effects of opiate pain medicines such as codeine, oxycodone or OxyContin.  At its usual dose of 50 mg Naltrexone tends to increase sensations of pain because it also blocks the action of the body’s own natural opiate-like compounds. But at much lower doses, in the 3-4 mg range, LDN has long been used by alternative medicine-minded clinicians as a treatment for pain, fatigue and other symptoms. The key insight here is that very low doses of Naltrexone don’t harm our body’s natural opiates. Rather, at low doses, Naltrexone seems to act to reduce our sense of pain.

LDN and pain
LDN and pain

LDN helps a meaningful proportion of FM patients—perhaps 40%. And, its side effect profile has been relatively benign—almost certainly more favorable than our standard FM drugs. As importantly, LDN’s proposed mechanism, suppression of inflammatory chemicals (cytokines) within the central nervous system might lead toward a new approach for a broad range of diseases.

 

Study

double blind study was conducted by Jarred Younger PhD, and Sean Mackey, M.D., PhD  from the Stanford Medical School’s Division of Pain Management. Thirty one women with Fibromyalgia were each treated with 4.5 mg of naltrexone in the evening for 12 weeks and a placebo for 4 weeks.

Results

Reduction in pain scores compared to baseline were significantly greater during the LDN period compared to placebo. (28.8% reduction versus 18% reduction; P=0.016). LDN was also associated with improved general satisfaction (P=.045) and better mood (P=0.039). Thirty two percent of participants had an improvement in both pain and either fatigue or sleep while on naltrexone in contrast to an 11% response rate during placebo (P=0.05). The #1 “side effect” was increased dreaming, which some subjects felt were disturbing.

Other than a small pilot trial done earlier by the Stanford group, I believe that Younger and Mackey’s study is the only academically sound test of LDN for Fibromyalgia.  However, I and at least one other CFS-ME/Fibromyalgia specialist (Nancy Klimas, M.D, PhD personal communication) have found LDN useful. LDN is not a cure-all, but it seems to help a substantial proportion of patients. Dramatically exciting is LDN’s proposed mechanism, suppression of cytokines and brain immune cells called microglial cells. This brain-anti-inflammatory approach might also apply to other difficult to treat neurological conditions.

Fibromyalgia is known to have an element of central nervous system inflammation as do other brain related diseases including Multiple Sclerosis, Parkinson’s and Alzheimer’s.  Would LDN also help these conditions? Hopefully, more research will follow.

Take Home Thoughts

Low dose naltrexone helps relieve pain in a substantial proportion of people with Fibromyalgia. In some people it might also help with fatigue and mood, although that part has not been formally tested in studies.  Not all patients tolerate LDN but the most frequent side effects, increased dreaming and headache, are not dangerous and often decrease over time. Except for people who regularly take narcotics, it is reasonable to consider a trial of LDN.  For these reasons, clinicians who treat FM and/or CFS/ME should consider themselves obligated to learn more about LDN and, with informed consent, consider offering it to selected patients.

Exercise and FM/CFS – Segment 3

This post is the final segment with Kim Jones, RN, PhD associate professor at the School of Nursing of the Oregon Health and Science University and one of the world’s leading experts on Fibromyalgia. The main goal of this 3-part series is to provide tips on how to exercise safely and effectively so that people with symptoms of Fibromyalgia (FM) or Chronic Fatigue Syndrome (CFS) can feel better. This segment includes valuable information on specific gym equipment and exercises and thoughts on the what to look for the right instructor and workout environment. If you have FM or CFS, feel free to post any personal experiences you may have from following the tips that are provided in this video.

Part 3 of 3:

 

Go to Segment 1 video and Segment 2 video.

Exercise and FM/CFS – Segment 2

This post is the second segment of three with Kim Jones, RN, PhD associate professor at the School of Nursing of the Oregon Health and Science University and one of the world’s leading experts on Fibromyalgia.  The discussion continues from the first segment providing practical advise on how to successfully exercise with Fibromyalgia (FM) or Chronic Fatigue Syndrome (CFS).  If you have FM or CFS, feel free to post any personal experiences you may have from following the tips that are provided in this video.

Part 2 of 3:

 

If you have not viewed Segment 1 yet, link to it here,
Part 3 is coming soon!

Exercise and FM/CFS – Segment 1

Exercise is the BEST REMEDY—but only if you do it not too much, not too little, but JUST RIGHT!

If you have Fibromyalgia (FM) or Chronic Fatigue Syndrome (CFS)—you know it’s not easy to do just right. This post is part of a three-part video series focusing on when and how to exercise. Our expert in the video, is Kim Jones, RN, PhD associate professor at the School of Nursing of the Oregon Health and Science University. Dr. Jones is one of the world’s leading experts on Fibromyalgia. She has published more than 50 research papers and worked closely on FM research with Robert Bennett, M.D., former chairman of the division of arthritis and rheumatology at the affiliated medical school. Dr. Jones also serves as President of the Fibromyalgia Information Foundation. Although Dr. Jones’ main focus is on Fibromyalgia, patients with Chronic Fatigue Syndrome should also benefit from her advice.

Part 1 of 3:

Part 2 is coming soon!

Medical Marijuana Use of Fibromyalgia Patients

I had the pleasure of interviewing Dr. Ginevra Liptan, internist from Portland, Oregon. She is one of the nation’s leading experts on Fibromyalgia. As Oregon has a very active Medical Marijuana Program, Dr. Liptan is also an expert on how to apply medical marijuana to treat Fibromyalgia.

The first video from this interview addresses the positive and negative aspects of treating Fibromyalgia with medical marijuana.

Part 1:

As an aside, in New Jersey where I practice, persons who have Fibromyalgia and have not responded adequately to standard treatments will often qualify for the NJ Medical Marijuana Program. More information on this program and my direct experience can be found on my website.

The second video from this interview explains the practical do’s and don’ts of using medical marijuana for people enrolled in a medical marijuana treatment program.

Part 2:

To view all of my videos, go to my YouTube Channel.

Dry Needling Plus Physical Therapy: A Major Advance for Fibromyalgia Treatment

Background

Dry needling is a technique used by specially trained physical therapists, physicians, and dentists to treat several forms of musculoskeletal pain.  Controlled studies show benefit for regional myofascial pain, temperomandibular joint dysfunction (TMD), and chronic tension headache. It 42424315_stypically uses an acupuncture type needle to enter into and disrupt localized spots of intense muscle spasm called trigger points. This may allow almost immediate relaxation of the involved muscle which often relieves pain. It also allows concurrent physical therapy to be done more effectively.

The needling is called “dry” because no medicines are injected. Several studies show that dry needling alone is as effective as injecting a local anesthetic or corticosteroids into the trigger point.  Three years ago, the New Jersey State Board of Physical Therapy authorized physical therapists to treat with dry needling.  Since the excellent physical therapy group I refer to added dry needling to their tool kit, their results for my Fibromyalgia patients have greatly improved.

Today I’m pleased to report on a double blind study that confirms the benefits from adding “dry needling” to standard treatments.  Researchers from the Rheumatology Services at the Specialist Clinic of Cantabria in Santander, Spain added six weekly one hour sessions of dry needling to the standard treatment of 60 Fibromyalgia patients. Another 60 patients (controls) continued with standard treatment alone.  Unlike the usual practice of inserting needles into palpable trigger points within any symptomatic muscle, the Santander group inserted their needles specifically into the site of the 18 standard Fibromyalgia tender points. These anatomical locations were defined by the American College of Rheumatology.   Clinically, we find the standard tender point sites often also contain trigger points.

Findings

After six weeks of treatment the patients treated with dry needling improved considerably more than the control patients who did not have dry needling.  Several measures of pain and fatigue status showed major benefit.  Improvement was found for each of the following: The Visual Analogue Scale for Pain (P=0.002), the Visual Analogue Scale for Fatigue (p=.02), the SF-36 health questionnaire (p=.0001), the degree of pain elicited by pressing six specified sites with a dolorimeter (pain inducing device )(p=0.0005), the amount of pressure needed to induce pain (p=.002) and a survey of global subjective improvement (P=.00001).   (The P values indicate the probability that the advantage of dry needling was due to chance. A P value of .05 or greater is considered to be statistically significant. A P value of .01 or greater is highly significant

No dry needling was done during the next six weeks. Then outcomes for both groups (treated and controls) was measured again. Most impressively, six weeks later—12 weeks after the study started—the advantage for the dry needling group over the controls, continued to be high

Training

Now for the “bad” news. In the United States, although dry needling by physical therapists is authorized in about half the states, only a modest number of physical therapists, physicians or dentists have major experience with dry needling.  As with any therapeutic technique, training and experience are important.  For many Fibromyalgia patients the simplest way to locate a trained or experienced practitioner will be contact the programs that train clinicians in this technique. They can refer you to their graduates.  They also might know other experienced clinicians

In the Northeast United States the main training program is run by Robert Gerwin, M.D., a professor of neurology together with Jan Dommerholt, PT, PhD, an outstanding physical therapist.  I most often refer patients seeking this technique to North Jersey Physical Therapy Associates.

Is dry needling related to acupuncture?  Except that both use a similar tool, the theory and practice of dry needling  have little in common with acupuncture. They are fundamentally different.  A few acupuncturists have also trained in dry needling. Unfortunately, a guild mentality may have developed among acupuncture organizations.  In New Jersey and several other states, the acupuncture professional society is attempting to ban physical therapists from doing dry needling on the grounds that dry needling by physical therapists is the “illegal practice of acupuncture”. Good grief

Take Home Thoughts

Dry needling done alone without concurrent physical therapy is more likely to relapse if posture problems and weak or tight muscles remain. The best results should occur if dry needling and physical therapy are done at the same time.   Contact the physical therapy association in your state (e.g. Delaware Physical Therapy Association) and ask if physical therapists are allowed to do dry needling in your state. If so and you suffer from Fibromyalgia, Headache, Temperomandibular Joint Disorder TJD or other chronic muscle-related problems, consider consulting a physical therapist with training and experience in this potentially useful technique.

Can the “MIND Diet” Reduce “Brain Fog” Due to Chronic Fatigue Syndrome and Fibromyalgia?

The short answer is we don’t know, because research on “brain

mediterranean diet vs mind diet
fruit, nuts and vegetables

fog” has been extremely limited–to say the least. (For specifics, see research by Anthony Ocon.)

 

Therefore, I hope our readers will be encouraged to learn that a relatively simple diet change is probably effective for reducing or delaying another currently “untreatable” form of brain fog—that due to Alzheimer’s Disease.

Diet fads versus Diet Science

For many decades we’ve faced an army of dietary fads. Each has claimed the ability to improve health. But, almost all claims are based mainly on anecdotes. Scientific studies have largely been absent. Fortunately, that’s changing.

Mediterranean Diet

The best research has focused on the “Mediterranean Diet” as a preventive treatment for heart disease and stroke. For this study, researchers recruited more than 7,000 Spanish men and women who were at high risk for heart disease or stroke. Each person was assigned to follow either the “Mediterranean Diet” plan (high in unsaturated fats such as olive oil and/or nuts, high in fruits, vegetables and whole grains, but low in saturated fat) or the “control” diet (the standard low fat diet such as the American Heart Association might advise).

The results showed that the Mediterranean Diet:

  • Had 30% fewer heart attacks and strokes compared to those on a low fat diet.
  • Is practical. People were able to follow it for more than 5 years.
  • Can help significantly within only 5 years.

These researches continued the study and applied neuro cognitive testing to 522 persons from within the main study. After six years, results further showed that the group on the Mediterranean Diet scored significantly higher in the cognitive testing compared to those in the low fat diet even after adjusting for risk factors.

Findings

The Mediterranean Diet, not only prevents heart attacks and stroke, but also helps maintain cognitive skills leading to the possibility of delaying or preventing the onset of Alzheimer’s dementia. But, since baseline cognitive scores were not measured, a true controlled study was still needed.

In 2015, Valls-Pedret and the Mediterranean Diet study group reported the results of a small controlled study that used 447 60+ year old Spanish volunteers who followed either a Mediterranean-style Diet or a low-fat diet. After 4.1 years, the results showed:

  • The Mediterranean Diet can reduce cognitive decline
  • Cognitive test and memory scores were higher for the Mediterranean Diet group compared to the low fat diet group

Further work on diet and Alzheimer’s comes from Martha Morris, Ph.D. and her research team at Chicago’s Rush University Medical Center. Dr. Morris’ team may be the world’s leading experts on the effects of nutrition on cognitive decline due to aging. She modified the Mediterranean diet to take into account other research on dementia and named it the MIND Diet. This was used in a study of 923 Chicago men and women, age 58 to 98. Each person did not have Alzheimer’s at the start of the study and their current eating pattern was scored against the key principles of the MIND Diet.

After 4.5 years, the following was found:

  • 144 of 923 (16%) were diagnosed with Alzheimer’s
  • Participants whose MIND Diet compliance scores were initially in the top third were only 47% as likely to develop Alzheimer’s compared to those in the bottom third
  • Those in the middle third did better than those in the lowest third, but not as well as those in the upper third
  • The Mediterranean Diet pattern also predicted a low Alzheimer’s rate but not quite as well as did high scores for the MIND Diet
  • A separate paper by Dr. Morris’s group reported the difference in cognitive skills between the top third on the MIND Diet and those in the bottom third were equivalent to the top third being “7.5 years younger in age” compared to the bottom third”—although chronologically in fact their average age was the same.

Take Home Thoughts

Evidence is increasing that the Mediterranean Diet, not only prevents heart attacks and stroke, but likely also helps maintain cognitive skills. We are not certain if the Mediterranean Diet would also help patients with brain fog due to ME/CFS or FM but we can probably reject as outdated the long-held “cliché it must be a “placebo effect” when people report that symptoms improve after a change in diet.

The strength of the MIND DIET study was that the statistical analysis was controlled for life style behaviors, illnesses and genetic risks for Alzheimer’s. However, researchers did not actively assign subjects to each diet. They simply scored how closely each subject’s self-chosen diet compared to the MIND Diet ideal. So, we can’t be sure whether high adherence to the MIND Diet caused the lower rate of Alzheimer’s or whether other factors might have been at work.

So, which diet should one follow if we have brain fog due to Fibromyalgia (FMS) or Chronic Fatigue Syndrome (CFS)? At this time, we have no easy answer. Ideally, someone would fund a study where patients with CFS or Fibromyalgia would take a cognitive test, then go on either the MIND Diet (or Mediterranean Diet) or their usual way of eating. (Readers who have major wealth, might consider this project!) Aside from this, people who adopt the MIND Diet or the Mediterranean on their own, can report their experience to their doctors to our blog and/or to a widely read health support website such as Prohealth.com.

For those interested in the Mediterranean Diet, consider a book by Nick Nigro and Bay Ewald, Living the Mediterranean Diet: Proven Principles and Modern Recipes for Staying Healthy. See links for a brief summary of the MIND Diet and a more detailed summary in pdf format.

For either diet, plan on a minimum 3 to 6 month trial before judging it’s effects.
We welcome comments from any patient or doctor who has useful information to share about diets in this context.