Encouraging News on Namenda (memantine) for Pain

namenda for fibromyalgia pain
Pain in a woman’s body

I previously posted an analysis of a double blind study where Namenda, a medicine for Alzheimer’s, showed benefit for fibromyalgia pain.   In the previous study from Spain, Namenda was significantly better than a placebo for treating Fibromyalgia. But only a minority of patients improved. As importantly, it took a six-month’s long trial of treatment before the benefit from Namenda compared to placebo was statistically significant.

After reviewing that data, I had mixed feelings about recommending memantine for my patients. (I will now call Namenda “memantine,” the generic version which is much less expensive.)   Since then I’ve recommended memantine to five FMS patients. In a bow to reality, I suggested they try memantine for a two-month trial period, instead of the six months used in the double-blind study. The results; two patients improved meaningfully. One could not tolerate raising the dose. Two followed through but memantine did not help.

Now I’m writing to alert you to an encouraging study where memantine helped a very different kind of pain, the chronic pain that can occur from a mastectomy among women treated for breast cancer. (There have been no further studies on memantine and fibro.)    After mastectomy, 30% or more of women develop a burning or shooting pain in the chest, arm and armpit that lasts for three months or more. In a single blind study, 20 women received memantine for two weeks before and two weeks after their mastectomy. Twenty other women who had a mastectomy took a placebo.

After three months, the women rated the intensity of their pain on a scale of zero to ten. The results: Women who had taken memantine experienced substantially less pain than did the women who took placebo. The p value was 0.017. (Less than .05 is “significant”.) Memantine also reduced the need for prescription pain medicines. Only one of 20 women who had taken memantine needed a prescription compared to six of 20 women who had taken placebo. (Six months post operation memantine patients still had less pain, but the difference was no longer statistically significant.)

Take-Home Thoughts
Memantine is probably useful for some forms of pain. But we should keep in mind it might react differently for different forms of pain. Post-mastectomy pain results from obvious trauma to peripheral nerves. FM reflects abnormalities in the brain and the spine that are not classically “traumatic.”   Since we have only one controlled study for memantine and fibromyalgia, anecdotal experience might be our next most useful resource.

Some scientists doubt that anecdotes are useful. As a practicing physician, I strongly disagree. Anecdotal experiences can and should influence our judgments—especially if we can create a mechanism through which many, many individuals can share their experience.    The Internet has become such a mechanism. Our challenge: how to adapt this mechanism to the practical needs of clinicians, researchers and patients who care about Fibromyalgia, Chronic Fatigue Syndrome and related health problems.

memantine-graph
memantine results for pain

 

Two key questions: Who has the skill and the interest to create a practically useful forum on line? Who has the interest and ability to organize and/or provide the necessary funding?

Please feel free to comment especially if you have taken memantine for any type of pain.

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.