~Fibromyalgia

~Fibromyalgia
Reprinted with permission of Life Extension®.

  • Diagnosis
  • Effects of Sleep Deprivation
  • Chronic Inflammation
  • Supplements
  • Pain-Supression
  • Candida
  • Lifestyle Changes
  • Summary


Fibromyalgia is a condition characterized by severe muscle pain. The term fibromyalgia means pain in the muscles and fibrous connective tissues (tendons and ligaments). Fibromyalgia is associated with poor-quality sleep and is often accompanied by depression and anxiety. It is also referred to as a syndrome because fibromyalgia is a group of symptoms. It shares some of the features of chronic fatigue syndrome (CFS), with 70% of patients diagnosed with fibromyalgia also meeting the diagnostic criteria for CFS.

Fibromyalgia syndrome (or fibromyalgia) is one of the more common presenting problems seen in a general family medical practice. It is often characterized by muscle pain and flu-like symptoms. Unlike arthritis, the joints are not directly affected. Associated pain may cause aching or burning. The nature of the condition is unpredictable. In some people, pain can be severe and disabling. In others there is only mild discomfort.

Although there is no known cause of fibromyalgia, its onset may be related to physical or mental stress, inadequate sleep, injury, exposure to cold, dampness, infections, and occasionally rheumatoid arthritis. Fibromyalgia seems to run in some families, although no genetic component has yet been identified (Yunus et al. 1999). Current thinking suggests that persons with the condition may have lower levels of serotonin which may explain the difficulty with sleep and exacerbation of response to pain. Fibromyalgia potentially affects 4% of the general population.

DIAGNOSING FIBROMYALGIA

  • Symptoms
  • Challenges
  • Mycoplasmal Infection


Symptoms: The stiffness and pain associated with fibromyalgia appear gradually, worsening with fatigue and physical exertion. Soft tissue and muscles of the neck, shoulders, chest and rib cage, and lower back and hips are particularly vulnerable. A diagnosis of fibromyalgia requires that three or more of the following criteria be present (Barkhuizen 2001):

  • Sleep disturbance. Upon waking, the person may feel unrefreshed, despite getting an adequate amount of sleep. There may also be difficulty in falling asleep or staying asleep (Crofford et al. 2001).

  • Chronic fatigue and flu-like symptoms. Debilitating fatigue and associated symptoms are present, lasting at least 6 months and primarily affecting women (Crofford et al. 2001). Aching also accompanies the fatigue. Aching is one of the first symptoms that usually appears at the onset of fibromyalgia (Leventhal et al. 1991).

  • Stiffness. Body stiffness is present in most persons. Weather changes and remaining in one position for a long period of time contribute to the problem. Stiffness may also be present upon awakening (McCain et al. 1989).

  • Headaches and facial pain. Headaches may be caused by associated tenderness in the neck and shoulder areas or in soft tissue around the temporomandibular joint (TMJ) and surrounding muscles (Aaron et al. 2000).

  • Abdominal discomfort. Irritable bowel syndrome including symptoms such as digestive disturbances, abdominal pain and bloating, constipation, and diarrhea may be present. These symptoms may also be caused by "leaky gut" syndrome or the lack of pancreatic enzymes in the digestive system (Aaron et al. 2000).

  • Irritable bladder. An increase in urinary frequency and a greater urgency to urinate may be present. Typically these symptoms appear without the presence of a bladder infection (Clauw et al. 1997).

  • Numbness or tingling. Known as parasthesia, the symptoms include prickling or burning sensations in the extremities (Guler et al. 1992).

  • Chest pain. Muscular pain at the point where the ribs meet the chest bone may occur which is sometimes diagnosed as costrochondritis (Wise et al. 1992).

  • Cognitive disorders. The symptoms of cognitive disorders may vary from day to day, including "spaciness," memory lapses, difficulty concentrating, word mix-ups when speaking or writing, and clumsiness. These symptoms can also be indicative of candidiasis (Glass et al. 2001).

  • Environmental sensitivity. Sensitivity to light, noise, odors, and weather are often present, as are allergic reactions to a variety of substances. However, when these symptoms occur, there is usually no measurable immune system response like that found in true allergies (Stevens et al. 2000).

  • Disequilibrium. Visual confusion and nausea may be experienced when driving a car, reading a book, or otherwise tracking objects because fibromyalgia is thought to affect the tracking muscles of the eyes. Difficulties with smooth muscles in the eye may also cause additional difficulty with focus (Thomas et al. 2001).

  • Depression and anxiety. Although persons with fibromyalgia are frequently misdiagnosed as having depression or anxiety disorders, research has repeatedly shown that fibromyalgia is not a form of depression or hypochondriasis. However, when a person is chronically ill, onset of depression is not unusual (McCain et al. 1989).


A flare-up of fibromyalgia symptoms seems to be triggered by three common factors: physical, emotional, and environmental (Miller 1999). A most in-depth study of fibromyalgia was done over a 4-year period. This study has been documented in The Metabolic Treatment of Fibromyalgia by Dr. John C. Lowe. This book explores in detail the many avenues that this "syndrome" might take and the mechanisms and actions in the body that might potentiate it.

The Challenge of Diagnosing Fibromyalgia

Substantial symptom overlap exists between chemical sensitivity, fibromyalgia, and chronic fatigue syndrome as well as many other degenerative, autoimmune, and viral diseases. Fibromyalgia and chronic fatigue syndrome often involve chemical sensitivity that is also associated with leaky gut syndrome. Not only do fibromyalgia and chronic fatigue syndromes overlap, but they include a vague constellation of symptoms. That is why the major challenge in diagnosing fibromyalgia is exclusion of other disorders that can cause similar symptoms.

There is currently no specific diagnostic or laboratory test to identify fibromyalgia. Therefore, as noted earlier, diagnosis is made by ruling out other conditions that often mimic the symptoms of fibromyalgia (thyroid disease, lupus, Lyme disease, and rheumatoid arthritis). For example, an early study of thyroid function reported that 75% of a group of fibromyalgia patients had some degree of hypothyroidism (Wilke et al. 1981). This percentage is much higher than that of the general population. Fibromyalgia patients were shown to have either a thyroid hormone deficiency or a cellular resistance to thyroid hormone (Neeck et al. 1992) (refer to the Thyroid Deficiency protocol for suggestions that could correct a thyroid hormone deficiency as a possible underlying cause of fibromyalgia).

The antipolymer antibody (APA) assay, introduced in 1999, does not diagnose fibromyalgia, but it does detect APAs in the blood of most patients with fibromyalgia or fibromyalgia-like symptoms. Research showed that the titers of these antibodies correlate with nine separate clinical measures of fibromyalgia severity (Wilson et al. 1999). The APA assay is performed by Autoimmune Technologies, LLC in New Orleans. A request form, which must be requested by a physician, can be accessed at http://www.autoimmune.com/ForP&RIntro.html.

Because the list of possible symptoms in fibromyalgia is long, making a differential diagnosis is difficult. First, patients with suspected fibromyalgia should have a comprehensive medical evaluation as part of a workup. A workup might include routine blood chemistries; C-reactive protein and sedimentation rate to detect systemic inflammation; antinuclear antibody test for lupus; antioxidant assay; intracellular mineral diagnostics for mineral status; comprehensive digestive stool analysis to rule out leaky gut syndrome; DHEA level; enzyme-linked immunoabsorbent assay (ELISA-ACT) for T-cell-mediated allergy; hair analysis to test for the presence of heavy metals; amino acid analysis of urine; basal temperature for thyroid function (see the Thyroid Deficiency protocol); antibody assays to diagnose chronic infection from Candida (a yeast-like fungus), the Epstein Barr virus, cytomegalovirus, Herpes virus, Chlamydia (microorganisms living as parasites which are classified as specialized bacteria), and Helicobacter (bacteria); and others as indicated. A truly thorough workup includes testing that is often overlooked by conventional physicians: the yeast syndrome (see the Candida protocol). In older patients, a sedimentation rate (ESR) may be useful to exclude polymyalgia rheumatica (see the protocol on Polymyalgia Rheumatica). Patients with symptoms of hypothyroidism require studies of the thyroid.

In addition to ruling out other conditions that mimic symptoms of fibromyalgia, diagnosis is also based on the patient's historical and physical findings. A history of generalized muscle pain and malaise combined with the finding of specific tender points is suggestive. Often the patient will state that the symptoms developed following a viral infection or trauma. Because fibromyalgia has a syndrome diagnosis, any patient fitting the diagnostic criteria of aching all over and the presence of at least 11 of 18 tender points has fibromyalgia by definition. However, accurate diagnosis by tender-point examination requires knowledge of how to perform this examination. Tender-point examination is not a diagnostic criterion of exclusion. Therefore, if a patient has typical symptoms of fibromyalgia, but does not meet the tender-point criterion, a diagnosis of "possible fibromyalgia" may be assigned and a therapeutic trial of standard treatment offered. Tender points should be re-examined on a return visit because they are present on some days and not on others and often change body locations.

A history of poor-quality sleep is also suggestive of fibromyalgia. When patients report poor-quality sleep, it is important to rule out other conditions that could be responsible, including depression and chronic viral infection. Sometimes treating poor-quality sleep resolves the symptoms of fibromyalgia, but this would not be the case for depression and chronic viral infection.

Mycoplasmal Infection: A Possible Cause That Has Been Overlooked?

One possible cause being explored is mycoplasmal infection (MI). Patients with fibromyalgia and CFS have been reported to test positive for mycoplasmal blood infections (Nasralla et al. 1999). Mycoplasma is a group of microorganisms (intermediate between a bacterium and a virus), the smallest capable of free existence. Unlike viruses, Mycoplasma can reproduce outside living cells. Mycoplasma pneumoniae is responsible for atypical pneumonia, particularly in immunodeficient individuals (treated with antibiotics). Mycoplasma organisms are found in soil, water, and many other locations in nature. We cannot avoid contact with Mycoplasma. Fortunately, most of us mount an effective immune response when coming in contact with these organisms, thus preventing them from invading our body. People with dysfunctional immune systems, whether genetic, suppressed because of stress or other illnesses, or associated with CFS/fibromyalgia, cannot mount an effective defense and therefore they become infected. Testing for MI is done in a combination of direct culture on Mycoplasma media and an indirect, or noncultural, blood test (IGM and IGG antibody test). Eradication of MI requires long-term use of specific antibiotics. Then repeated testing is required to be certain that Mycoplasma has been eliminated. This process typically takes from 3 months to 1 year, and often antibiotics must be rotated to prevent development of resistance.

FIBROMYALGIA AND THE DETRIMENTAL EFFECTS OF SLEEP DEPRIVATION

As you will learn in the following section, fibromyalgia is associated with elevated levels of proinflammatory cytokines. At the annual meeting of the Endocrine Society in San Francisco (June 22, 2002), researchers reported that sleep deprivation markedly increases inflammatory cytokines (Vgontzas et al. 1999). This finding may help explain why pain flare-ups occur in response to lack of sleep in a variety of disorders, including fibromyalgia.

According to researchers, even a modest lack of sleep adversely affects hormone and cytokine levels (Vgontzas et al. 1999; 2001). In a carefully controlled study, two potent proinflammatory cytokines, IL-6 (interleukin-6) and TNF (tumor necrosis factor), were affected. Vgontzas and colleagues at the National Institutes of Health studied 25 young healthy men and women who agreed to spend 12 consecutive nights in a sleep laboratory. The results of this study were presented by Dr. Alexandros Vgontzas (Professor of Psychiatry at Pennsylvania State University in Hershey) to the annual meeting of the Endocrine Society (June 22, 2002). Dr. Vgontzas reported that sleep deprivation caused a 40-60% average increase in the inflammatory marker IL-6 in men and women, while a 20-30% increase in TNF was shown in men alone.

Additionally, in a statement to Reuters Health, Vgontzas said that the study findings indicate that getting a full night's rest of 8 hours is not a nice bonus, but is necessary to overall health and functioning. Vgontzas said: "There is no optional sleep. Those two to three hours on top of the 6 hours of base sleep are important for functioning during the day." He also stated that persons who miss even 2-3 hours of sleep function poorly the next day (Schorr 2002).

In addition, Dr. Vgontzas stated that study findings indicating that a lack of sleep may stimulate an increased chronic, low-level inflammatory response are worrisome because inflammation has been linked to so many degenerative conditions (such as high blood pressure, heart disease, and diabetes). Vgontzas also warned: "Restriction of sleep (of) a few hours is a major risk for public safety" (Schorr 2002).

The Vgontzas study has significant implications in the treatment of fibromyalgia. For many persons who have difficulty sleeping, following the recommendations in the Insomnia protocol could provide considerable relief from pain by preventing the increase of proinflammatory cytokines.

FIBROMYALGIA AND CHRONIC INFLAMMATION

Chronic inflammation is related to numerous diseases that are seemingly unrelated. These include rheumatoid arthritis, atherosclerosis, cancer, diabetes, and Alzhei-mer's disease, among others. Destructive cell-signaling chemicals known as inflammatory cytokines are also contributory factors in many of these diseases. As noted earlier, fibromyalgia is associated with elevated inflammatory cytokines.

Interleukin-8 (IL-8) is a cytokine with multifunctional actions that enhance inflammation by enabling immune cells to migrate into tissue. IL-8 also promotes sympathetic pain. Elevated levels of IL-8 are seen in fibromyalgia patients (Wallace et al. 2001).

IL-6 is another inflammatory cytokine known to attack bone and cause formation of fibrinogen which is associated with heart attack and stroke. IL-6 induces muscular hyperalgesia, a condition in which the slightest exertion can cause extreme pain.

A cytokine blood profile test can reveal if you have excess levels of certain inflammatory cytokines.

A number of natural products have been shown to be effective in reducing cytokine levels. These include the hormone dehydroepiandrosterone (DHEA) which has been shown to inhibit IL-6 production (Straub et al. 1998; Kipper-Galperin et al. 1999); fish oil supplements containing docosahexaenoic acid (DHA); and borage oil containing gamma-linolenic acid (GLA) (Harbige 1998). Methylsulfonylmethane (MSM) is a sulfur-containing molecule found in plants and body tissues that is also known to inhibit inflammation (Herschler 1990; Jacob et al. 1999).

Pentoxifylline (PTX) is a low-cost prescription medication primarily prescribed to treat peripheral artery disease. However, it has also shown remarkable cytokine-lowering ability in a number of degenerative diseases (see the protocol on Chronic Inflammation for additional information about PTX).

NATURAL SUPPLEMENTS

Melatonin is the most effective antioxidant yet studied because it easily penetrates cell membranes (especially in the brain) to provide protection against free radicals throughout all of our cells. Melatonin also crosses the blood-brain barrier very effectively. It appears to protect the central nervous system against injury, disease, and aging better than any other substance. Melatonin is used to induce drowsiness and improve sleep patterns and more physicians are recommending melatonin as a safe and effective insomnia therapy (Shochat et al. 1998). Melatonin not only helps most people sleep better, but it has been shown to alleviate pain (Jeong et al. 2000; Yu et al. 2000; Dauvilliers et al. 2001; Gagnier 2001; Pekarkova et al. 2001).

S-adenosylmethionine (SAME) is an antidepressant supplement that has been shown to be specifically effective as a therapy to reduce the chronic pain and depression associated with fibromyalgia.

FM Formula (now called Fibrex from Herbal Research) is a mixture of Chinese and Western herbs formulated specifically to combat the symptoms of fibromyalgia. One study (although not peer-reviewed) showed that when taken for a minimum of 9 months, FM Formula helped to combat a viral condition that a group of British researchers believe is linked to fibromyalgia. This product should be taken while following the Candida control diet to further detoxify the body. Some people may experience the Herxheimer reaction when taking this product, meaning that a temporary increase of symptoms may be felt when drugs and/or alternative treatments are administered (Thomason 2002).

L-Theanine is an amino acid found in green tea that produces tranquilizing effects in the brain. In Japan, soft drinks and chewing gum contain theanine for the purpose of inducing relaxation and easing anxiety. Although theanine creates a feeling of relaxation, allowing the ability to concentrate, it does not shut down the brain (Sugiyama et al. 2001).

Cetyl Myristoleate is a medium-chain fatty acid that is mainly used for inflammation related to the treatment of arthritis. It has been known to reduce the effects of fibromyalgia. Cetyl myristoleate is synthesized from cetyl alcohol and myristoleic acid and affords good protection against adjuvant-induced arthritic states (Diehl et al. 1994).

Malic Acid plays a key part in the metabolism of carbohydrates as well as the formation of adenosine triphosphate (ATP). Malic acid is a fruit acid that is synthesized as part of the Krebs's citric acid cycle (also called Krebs's cycle) in human metabolism. In the Krebs's cycle, a series of enzyme reactions use carbohydrates, proteins, and fats to yield carbon dioxide, water, and energy. Energy is produced from the burning of pyruvic acid without the associated buildup of lactic acid. Less lactic acid helps to relieve muscle pain associated with fibromyalgia (Russell et al. 1995).

B Vitamins In a study conducted on 12 patients with fibromyalgia and chronic fatigue syndrome (CFS), researchers found a vitamin B12 deficiency in all test subjects that correlated positively with an increase in homocysteine levels found in their cerebrospinal fluid. The researchers concluded that elevated homocysteine levels are directly related to symptoms of fatigue in both fibromyalgia and CFS patients (Regland et al. 1997). Supplementing with methylcobalamin (vitamin B12), vitamin B6, folic acid, and trimethylglycine (TMG) will help to lower levels of homocysteine and increase energy levels.

Digestive Enzymes have been shown to assist with the breakdown and proper absorption of food and to increase the effectiveness of supplements taken to alleviate irritable bowel and leaky gut syndromes. Both of these conditions are associated with fibromyalgia (Palm et al. 2000; Lubrano et al. 2001).

A PAIN-SUPPRESSING DRUG FOR FIBROMYALGIA

Physicians may prescribe the drug buprenorphine for patients with persistent symptoms or patients with severe symptoms at the outset of fibromyalgia. Buprenorphine is a mild narcotic with agonist and antagonist properties that has a very low addiction liability, if any. Patients can use buprenorphine for a long time without developing serious withdrawal symptoms when the drug is discontinued. This drug is virtually unknown among most physicians.

Because depression compounds and confounds fibromyalgia, it is particularly interesting that buprenorphine is a very rapidly acting antidepressant that works when other antidepressants fail. In addition, it helps patients sleep, probably as a result of pain reduction. These qualities make buprenorphine particularly useful in the treatment of fibromyalgia because pain, sleep abnormalities, and depression predominate in the constellation of symptoms. The dosage is variable. Buprenorphine is also available commercially as an injectable, 0.3-mg ampule, a small dose even for injection.

Since buprenorphine is poorly absorbed orally, larger oral dosages must be used. When taken orally, the buprenorphine liquid is withdrawn or shaken from the ampule and held under the tongue as long as possible. Compounding pharmacies can make up buprenorphine for sublingual use as a troche. Both forms, the ampules and troches, are not inexpensive. For pain that prevents sleep, start with two to six ampules sublingually or 0.5-2 mg as a sublingual troche. For treating pain throughout the day that is associated with depression, begin with two to six ampules (or 0.5-2 mg as a sublingual troche) every 4-6 hours. As is common with most medications, begin with a low dose and increase slowly until the smallest dose that proves effective is reached. Do not be concerned about addiction (see the protocol on Pain for more information).

Candida Control Diet

Many persons with fibromyalgia state that they experienced improvement after starting the Candida control diet. To control Candida (a yeast-like fungus), this diet provides a list of foods to include or avoid. Avoiding sugar (canned, bottled, or frozen fruit juices; processed foods; sweeteners; candy; dried and candied fruit) is particularly important because Candida feeds on sugar (see the protocol on Candida for additional information). Studies also demonstrate that sugar will deplete energy. Therefore, eliminating sugar from your body might help to eliminate the chronic fatigue that is associated with fibromyalgia (Kaartinen et al. 2000). Also important is avoiding fresh or prepared foods that contain yeast and fungi. There are a number of tests available to detect Candida. Testing is available for anti-Candida antibodies in the blood; how much Candida is present in the stool; and even skin testing for allergy to Candida. A copy of the Candida control diet can be accessed on the Web at: http://www.normanallan.com/Med/candiet.html.

LIFESTYLE CHANGES

In addition to drug and nutritional supplementation, certain lifestyle approaches might help patients with fibromyalgia to feel better and improve their quality of life (Dykman et al. 1998):

  • Physical therapy, including massage, myofascial release, craniosacral therapy, mild electrical stimulation, application of heat or cold, ultrasound, posture and movement training, and chiropractic treatment

  • Gentle exercise to ease sore muscles by increasing blood circulation and range of motion

  • Alternative approaches such as biofeedback, yoga, tai chi, pilates, stress management, nutritional counseling, and acupuncture

  • Swimming in a heated pool to allow for greater mobility than can be obtained from many other activities

  • Hot soaking baths with a half pound of Epsom salt added to the water

  • Acupuncture (may be of variable benefit with its greatest impact being on treating a painful muscle)


In the experience of many complementary physicians, orthomolecular therapy with intravenous administration of up to 50 grams of vitamin C 2-3 times a week for 4-24 weeks, may be helpful. Some patients benefit from chelation therapy (see the protocol on Heavy Metal Toxicity for a description of chelation therapy and its various applications). Ultraviolet irradiation of blood (UBI) has been found to be useful for some patients.

Summary

The following supplements may help to improve the many symptoms of fibromyalgia:

  1. Melatonin for a sleeping disorder, 300 mcg-3 mg at bedtime. Some people use a time-release melatonin supplement to avoid early morning awakening.

    Note: Correcting a sleep disorder is extremely important (refer to the Insomnia protocol for suggestions).

  2. SAMe to alleviate depression, 400-1600 mg daily.

  3. Cetyl Myristoleate (CM Plus) for inflammation, three 1500-mg softgels daily, taken on an empty stomach.

  4. Malic acid to help with muscle aches, three 350-mg capsules daily.

  5. Life Extension Mix, for broad-spectrum antioxidant protection and immune enhancement, 9 tablets daily as directed.

  6. Super Digestive Enzymes to aid in digestion and absorption of nutrients, 1-2 capsules before every meal.

  7. DHEA, to reduce levels of IL-6. (The usual dosage of DHEA is 25-50 mg daily. Blood testing is highly recommended to establish baseline serum levels and to eliminate the possibility of hormone-related cancers.)

  8. Super EPA/DHA contains fish oil extract known to reduce levels of inflammatory cytokines softgels twice daily.

  9. MSM reduces pain and inflammation in some people, 1000-3000 mg daily.

  10. Supplements known to reduce homocysteine levels that are often elevated in fibromyalgia patients: methylcobalamin (sublingual vitamin B12), 1-5 mg daily; vitamin B6, one 250-mg capsule daily; folic acid, 800 mcg daily in combination with 300 mcg of vitamin B12; TMG, 500-1000 mg daily.

  11. L-theanine to promote relaxation, 100-400 mg daily.

  12. Fibrex to fight symptoms or a virus or fungus (as directed) (Fibrex 200 Vegi Caps are a product of Herbal Research.)

  13. The Candida control diet, particularly if Candida is present.

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