THURSDAY, 14 JUNE 2018
Hyperbaric oxygen therapy (HBOT) treatment in fibromyalgia
Background Chronic pain conditions, such as fibromyalgia(FM), are among the most common health problems managed by general practitioners, rheumatologists, clinical psychologists.FM is characterised by multifocal pain, fatigue, non-restorative sleep, cognitive complaints high levels of distress, associated with greater affect intensity. There’s evidence from randomised controlled trials that some treatments like pharmacotherapy, patient education,behavioural therapy and physiotherapy are effective in reducing symptoms;however the majority of the patients aren’t satisfied with the current treatments. HBOT showed some clinical effects that may induce a significant improvement of the FM symptoms.
Objectives The goal of this work was to evaluate the effect of HBOT on FM symptoms.
Methods 33 female patients aged 29–63 y, with FM were included in this work. Patients initially pharmacologically treated(Pregabalin 150 mg/die, Duloxetine 60 mg/die) with unsatisfactory clinical improvement, were enrolled at the Rheumatology Unit San Cesario-Italy. The HBOT protocol comprised 20 sessions,3d/w,90 min,100% oxygen at 2.5ATA.
Patients were randomly assigned to treated and control groups and evaluated every month for the next 4 months: patients in group A were treated with 20 sessions of HOBT in the first 2 months and evaluated for the following 2 months: patients in group B used the pharmacological treatment for the first 2 months and then were treated with 20 session of HBOT in the last 2 months. During HBOT no pharmacological treatment was allowed. The treated group patients were evaluated at baseline and after 10 and 20 HBOT sessions. Evaluations consisted of physical examination, including tender point count, and socio-demographic and clinimetric questionnaires: Fibromyalgia Impact Questionnaire(FIQ), Functional Assessment of Chronic Illness Therapy, Pittsburgh Sleep Quality Index, Quality of life, Beck Depression Inventory, State Trait Anxiety Inventory, Pain Catastrophizing Scale.
Results: 5 patients withdrew from the HBOT treatment for claustrophobia. HBOT led to significant amelioration of all FM symptoms, with significant improvement in life quality. HBOT leads to a reduction in the number of tender points in the 2 groups. This reduction occurs in the group A without changing during the following 2 months of observation. In the group B the improvement is more related to the HOBT than to the therapy. The FIQ score improves in group A. No improvement was observed in the control group.
Conclusions: The analgesic effects of HBOT have been studied in nociceptive, in inflammatory and neuropathic pain models, and may be useful for the treatment of various chronic pain syndromes. Excessive pain in FM may be due to hyperexcitability of the pain processing pathways and under-activity of the pain inhibiting pathways in the brain.
It has been shown that HBOT increases cell metabolism, reduces apoptosis, alleviates oxidative stress, increases neurotrophin and nitric oxide levels by enhancing mitochondrial function in neurons and glial cells, it may even promote the neurogenesis of endogenous neural stem cells.
HBOT-induced neuroplasticity also leads to the repair of chronically impaired brain functions.
Our data confirm the efficacy of HBOT in treating FM. Further studies are required to evaluate the protocol and to understand the duration of the clinical effect.
Disclosure of Interest None declared
Researchers at the Sagol Center for Hyperbaric Medicine and Research at the Assaf Harofeh Medical Center and Tel Aviv University were studying post-traumatic brain injury patients when they realized hyperbaric oxygen treatment (HBOT) could help patients with fibromyalgia.
"Patients who had fibromyalgia in addition to their post-concussion symptoms had complete resolution of the symptoms," said Dr. Shai Efrati, who noted his own mother suffers from the syndrome. Efrati is lead author of the study, head of the research and development unit at the Assaf Harofeh Medical Center and a member of the Sagol School of Neuroscience at Tel Aviv University.
Hyperbaric oxygen chambers that expose patients to pure oxygen at higher-than-atmospheric pressures are commonly used to treat patients with embolisms, burns, carbon monoxide poisoning and decompression sickness (known to divers as "the bends"), among many other conditions.
One effect of exposure is to push more oxygen into a patient's bloodstream, which delivers it to the brain. Efrati's earlier trials found HBOT induces neuroplasticity that leads to repair of chronically impaired brain functions and improved quality of life for post-stroke and mild traumatic brain injury patients, even years after the initial injury.
Ben-Jacob said two patients spearheaded the push for the study. One was an Oxford graduate student who developed fibromyalgia after suffering a traumatic brain injury in a train crash. "By chance, the secretary of the department where she worked is the mother of the nurse in charge of the HBOT. She said you have to go and try to do it," he recalled.
The other, he said, is a professor of sociology who specializes in post-traumatic stress disorders due to child abuse. The professor had suffered from fibromyalgia for many years. Her symptoms got worse through the initial treatments - a common experience for other patients in the study who she said had suppressed memories due to child abuse - before they got better. But by the end of treatment both women showed remarkable improvement, Ben-Jacob said.
Efrati said some patients will likely require follow-up sessions. "The abnormalities in brain regions responsible for the chronic pain sensation in fibromyalgia patients can be triggered by different events," he said. "Accordingly, the long-term response may be different.
"We have learned, for example, that when fibromyalgia is triggered by traumatic brain injury, we can expect complete resolution without any need for further treatment. However, when the trigger is attributed to other causes, such as fever-related diseases, patients will probably need periodic maintenance therapy."
The clinical trial involved 60 women who had been diagnosed with fibromyalgia at least two years earlier. A dozen left the trial for various reasons, but half of the 48 patients who completed it received 40 HBOT treatments five days a week over two months. Half of the 48 patients who completed the trial received 40 HBOT treatments five days a week over two months. The 90-minute treatments exposed patients to pure oxygen at two times the atmospheric pressure.
The other half were part of what Ben-Jacob called a crossover-control group. They were evaluated before the trial and after a control period that saw no improvement in their conditions. After the two-month control, they were given the same HBOT treatment as the first group and experienced the same relief, according to the researchers.
The researchers noted the successful treatment enabled patients to drastically reduce or even eliminate their use of pain medications. "The intake of the drugs eased the pain but did not reverse the condition, while HBOT did reverse the condition," the researchers wrote.
Efrati said the findings warrant further study. "The results are of significant importance since, unlike the current treatments offered for fibromyalgia patients, HBOT is not aiming for just symptomatic improvement," he said. "HBOT is aiming for the actual cause—the brain pathology responsible for the syndrome. It means that brain repair, including even neuronal regeneration, is possible even for chronic, long-lasting pain syndromes, and we can and should aim for that in any future treatment development."