South Australian Fibromyalgia research

New discoveries about cerebral blood flow

In the largest project of its kind yet published, a team of Adelaide scientists used improved statistical brain scanning techniques to measure blood flow to the brains of women with Fibromyalgia. The researchers not only confirmed previous findings of reduced cerebral blood flow in FM, but with more accurate methods they were also able to pinpoint decreased activity in a previously unsuspected area of the brain.

JENNY FAULKNER of Fibromyalgia SA interviewed Dr Richard Kwiatek, head of the research team, in order to write this article explaining the significance of the results.

Congratulations to South Australia on the long awaited publication in December 2000 in the premier international rheumatology journal Arthritis & Rheumatism of world class seminal research into basic brain processes underlying fibromyalgia, conducted by the Departments of Rheumatology and Nuclear Medicine at the Queen Elizabeth Hospital (QEH), Adelaide.

This was the culmination of four years' dogged work in a study without any official funding. By performing a SPECT scan (which measures regional blood flow) and MRI scan (which measures structure) of the brain of each participant, the QEH team discovered that blood flow in the brain stem -- the primitive "reptilian" part of the nervous system that connects the brain to the spinal cord -- in 17 women with fibromyalgia (FM) was reduced by an average of 12% when compared with that of 22 age- and education-matched healthy women.

Originally the study was done to see if the findings of a study of the University of Alabama at Birmingham, published in 1995, could be replicated.

Improved methods

The QEH study used the state-of-the-art technique of Statistical Parametric Mapping on the SPECT scans to screen the whole of the brain for difference in blood flow between FM subjects and healthy controls. In fact the QEH team improved the technique for the purposes of this study by using the average of the SPECT scans of all the healthy controls.

The previous finding of blood flow reduction in the thalami, important relay-stations deep within the brain, were confirmed, but reduction in a region of the brain stem known as the pontine tegmentum was also demonstrated, the brain stem being an area never before investigated.

Moreover, the QEH research team confirmed their own findings by re-analysing the suspicious regions within the SPECT scans by discovering a way of aligning each participant's SPECT and MRI scans in cyberspace more accurately than ever done before, again from the average of all the SPECT scans of the healthy participants. The borders of structures of interest were then drawn on the MRI scan and thereby automatically drawn on the aligned SPECT scan, yielding an accurate measure of blood flow for the area of concern.

A surprise result

Reduction in regional blood flow presumably means the nerve cell activity in the region of interest is reduced, ie nerve cells are under-active. As explained by Dr Richard Kwiatek, head of the research team, other evidence suggests that the reduction in blood flow in the vicinity of the thalami in FM is probably a non-specific response of the body to chronic pain of any sort. The reduction within the pontine tegmentum was a surprise, said Dr Kwiatek. Circumstantial evidence suggests that the reduction here is a true reflection of reduced nerve cell activity, but the problem is that FM is classically regarded as not having any associated "objective" abnormalities on both neurological examination and standard neurological investigations.

Therefore the question is: what does this blood flow reduction mean? - not least because, as Dr Kwiatek explains, the precise location of the deficit is not currently recognised to be part of the well-known system within the brain stem which modulates pain messages as they travel up from the spinal cord through the brain stem on their way to higher brain centres.

A clue, says Dr Kwiatek, might come from recent brain imaging studies investigating the chronic fatigue syndrome, which have also shown reduction in brain stem nerve cell activity in a similar, but to date less precisely defined, area.

Physiological abnormalities

However, the point is that all studies so far published are unable to tell if the blood flow and/or nerve cell activity reduction is the cause and/or effect of the FM or CFS syndromes. More work is definitely needed, but Dr Kwiatek says the demonstrated defects within the brain stem offer tantalising suggestions as to where future research into these syndromes should be directed. He explains that the brain stem controls basic vital functions of the whole body, which could be critical in the development of the devastating syndromes of FM and CFS with their protean and multi-system symptoms.

Moreover, he suggests that the work of the QEH team can be regarded as contributing important additional evidence that physiological abnormalities do occur in FM; although confirmation that the blood flow deficits are unique to the FM state and not a non-specific response to chronic pain, chronic sleep deprivation or any other of the non-specific symptoms of FM is still needed.

Community support and co-operation

Fibromyalgia SA was intimately involved in the QEH research team's efforts both through direct support and through most of the FM participants being associated with the organisation's predecessor, the Fibromyalgia Interest Group.

Several of the healthy controls were individually recruited by FM subjects, but due acknowledgment is needed of the many otherwise unrelated healthy women who selflessly and courageously answered a local press advertisement to be involved (from as far afield as Mt. Barker and beyond!). All of these women can be proud to know that their involvement has led to significant advances in SPECT brain scanning methods, and that they have potentially contributed to a major advance in understanding the basic disease processes behind FM.

In fact Dr Kwiatek states that publication of the QEH research team's work satisfyingly demonstrates how much can be achieved, despite few financial resources,through careful strategic planning, intelligent insights and generous cooperation between multiple disparate groups, both professional and community-based.

He claims that the achievements of the South Australian group are even more significant as the QEH's study represents the largest published functional brain imaging study in chronic unrelenting pain, involving probably the largest homogeneous healthy control group. The SPECT scans of the healthy control subjects are already being anonymously used by several international centres as controls for other studies, in addition to having led to several significant advances in the analysis of SPECT brain scans.

South Australia can therefore be proud of what it has achieved. As has already been commented, it has elegantly applied and developed techniques of the United Nations' Decade of the Brain (1990-1999) to a problem which will hopefully become an increasing initiative of the United Nations' Decade of the Bone and Joint (2000-2010).

- January 2001

Reprinted with permission from "FM Tender-Points" the official newsletter of Fibromyalgia SA . To contact Fibromyalgia SA write c/o the Arthritis Foundation of SA Inc., 1/202-208 Glen Osmond Road, Fullarton SA 5063. Phone (08) 8379 5711, Freecall 1800 011 041.

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