Fibromyalgia is an illness characterized by severe muscle pain
which is associated with poor sleep and often depression. It shares
some of the features of chronic fatigue syndrome (CFS.) Indeed, 70 %
of patients diagnosed with fibromyalgia meet all of the diagnostic
Criteria for Chronic Fatigue Syndrome. The major difference between
the two is the presence of musculoskeletal pain in FS. In medicine,
a disease exists when an illness has very specific symptoms,
physical exam, and laboratory findings. An illness which cannot be
as definitively defined and may mimic other conditions is called a
syndrome. FS is such an illness.
Fibromyalgia is one of the more common problems seen in a general
family medical practice. It is characterized by muscle pain which
may be generalized and tender points which are localized to known
specific locations. Unlike arthritis, there is no inflammation
present and joints are not directly affected. The associated pain
may cause aching or burning and is unpredictable in nature. In some
people, the pain can be severe and disabling , in others there is
only mild discomfort.
Although there is no known cause of FS, its onset may be related
to physical or mental stress, inadequate sleep, injury, exposure to
cold and dampness, infections, and occasionally rheumatoid
arthritis. The condition seems to run in some families although no
genetic component has yet been identified. Current thinking suggests
that patients with the disease may have lower levels of serotonin
which explains the problem with sleep and an exacerbation of the
response to pain. It may affect 4% of the general population.
The stiffness and pain associated with FS usually appear
gradually with worsening due to fatigue, physical straining, and
overuse. The soft tissue and muscle of the neck, shoulders, chest
and rib cage, lower back, and thighs are especially vulnerable. The
diagnosis requires that all three and four or more of the following
major and minor criteria be present:
Major Criteria:
- Generalized aches or stiffness of at least three anatomical
sites for at least three months
- Six or more typical, reproducible tender points
- Exclusion of other disorders that can cause similar symptoms
Minor Criteria:
- Generalized fatigue
- Chronic headache
- Sleep disturbance
- Neurological and psychological complaints
- Numbing or tingling sensations
- Irritable bowel syndrome
- Variation of symptoms in relation to activity, stress, and
weather changes
- Depression
The following is a more detailed list of potential symptoms that
patients may experience:
- Sleep disturbances: Sufferers may not feel refreshed,
despite getting adequate amounts of sleep. They may also have
difficulty falling asleep or staying asleep.
- Stiffness: Body stiffness is present in most patients.
Weather changes and remaining in one position for a long period of
time contributes to the problem. Stiffness may also be present
upon awakening.
- Headaches and facial pain: Headaches may be caused by
associated tenderness in the neck and shoulder area or soft tissue
around the temporomandibular joint (TMJ).
- Abdominal discomfort: Irritable bowel syndrome
including such symptoms as digestive disturbances, abdominal pain
and bloating, constipation, and diarrhea may be present.
- Irritable Bladder: An increase in urinary frequency and
a greater urgency to urinate may be present.
- Numbness or tingling: Known as parathesia, symptoms
include a prickling or burning sensation in the extremities.
- Chest Pain: Muscular pain at the point where the ribs
meet the chest bone may occur.
- Cognitive Disorders: The symptoms of cognitive
disorders may vary from day to day. They can include "spaciness",
memory lapses, difficulty concentrating, word mix-ups when
speaking or writing, and clumsiness.
- Environmental Sensitivity: Sensitivities to light,
noise, odors, and weather are often present as are allergic
reactions to a variety of substances (see below).
- Disequilibrium: Difficulties in orientation may occur
when standing, driving, or reading. Dizziness and balance problems
may also be present.
Substantial overlap between chemical sensitivity, fibromyalgia,
and chronic fatigue syndrome exists. The latter two conditions often
involve chemical sensitivity and may even be the same disorder.
Those agents associated with symptoms and suspected of causing onset
of chemical sensitivity with chronic illness include gasoline,
kerosene, natural gas, pesticides (especially chlordane and
chlorpyrifos), solvents, new carpet and other renovation materials,
adhesives/glues, fiberglass, carbonless copy paper, fabric softener,
formaldehyde and glutaraldehyde, carpet shampoos and other cleaning
agents, isocyanates, combustion products (poorly vented gas heaters,
overheated batteries, etc.), and medications (dinitrochlorobenzene
for warts, intra nasally packed neosynephrine, prolonged
antibiotics, and general anesthesia with petrochemicals, for
example).
Multiple mechanisms of chemical injury that magnify response to
exposures in chemically sensitive patients can include neurogenic
inflammation, kindling and time-dependent neurologic sensitization
and auto-immune activation. The scientific literature suggests that
there may be a marked correlation between the body's ability to
effectively detoxify xenobiotic substances and the presence of
chronic disease processes such as fibromyalgia.
Epidemiological studies have shown that the tendency toward
depression in patients with fibromyalgia may be a manifestation of a
familial depressive spectrum disorder (alcoholism and/or depression
in the family members), and not simply a "reactive" depression
secondary to pain and other symptoms.
Diagnosis
There is currently no diagnostic or
laboratory test to identify FMS. A diagnosis is made by first ruling
out other conditions that may mimic its symptoms such as thyroid
disease, lupus, Lyme disease, and rheumatoid arthritis. A study of
thyroid function showed that 63% of a group of FS patients suffered
from some degree of hypothyroidism. This percentage is much higher
than for the general population. Fibromyalgia patients were shown
either to suffer from a thyroid hormone deficiency or from cellular
resistance to thyroid hormone. (Refer to the Thyroid
Deficiency protocol for suggestions that could correct a thyroid
hormone defect as a possible underlying cause of fibromyalgia.)
The diagnosis is made based upon the patient's historical and
physical findings. A history of generalized muscle pain and malaise
coupled with the finding of the specific tender points is
suggestive. The patient will often state that the symptoms developed
after a viral infection. A history of poor sleep is also suggestive.
It is important to consider other conditions including depression
and chronic viral infection. It is the latter that overlaps with
chronic fatigue. Sometimes treating the poor sleep resolves the
condition which would not be true for depression. On physical exam,
in addition to tender points, the patient may have a particular type
of skin and soft tissue consistency which may be best described as
"doughy."
One may recall that both FMS and Chronic Fatigue not only have an
overlap, but describe a vague constellation of symptoms. That is why
one of the major criteria is exclusion of other disorders that can
cause similar symptoms. A truly thorough work up including things
that most conventional physicians do not look at such as the Yeast
Syndrome (see the Yeast
Protocol) for example is very comprehensive. The author's
colleague, Dr. Ed McDonagh, has a very extensive protocol for the
diagnosis and treatment of both FMS and Chronic Fatigue which he
groups together.
His work up includes: dark-field (specialized) microscopy of the
blood, routine blood chemistries, sedimentation rate for
inflamation, anti-nuclear antibody test, for lupus, antioxidant
Assay, intracellular mineral diagnostics for mineral status,
Comprehensive digestive stool analysis for digestion, DHEA level,
ELISA-ACT for T cell mediated allergy, hair analysis for minerals
looking for heavy metals, amino acid analysis of urine, basal
temperature for thyroid function (see the Thyroid
Protocol), antibodies for candida, antibodies for Epstein Barr,
CMV, herpes, chlamydia, Helicobacter to look for chronic infection,
and other testing as needed.
Treatment
Treatment consists of managing the symptoms
to the greatest possible extent. It may be necessary to try several
approaches before a satisfactory regimen is found. Various
medications and nutritional supplements that have been studied in
clinical trials have provided pain relief and improved sleep quality
in FMS patients.
One study found that 55% of FMS patients suffered from sleep
disturbances, and that these sleep disturbances were not caused by
pain. Alleviating insomnia with antidepressant medication,
melatonin, and/or prescription sleep-inducing drugs could alleviate
pain.
Antidepressant drugs have been used with varying degrees of
success in treating fibromyalgia. The author begins with
5-hydroxytryptophan, 25 to 100 mg at night. If this does not improve
sleep and other symptoms, a tricyclic antidepressant (see the
Insomnia Protocol) is added. If this does not work, an SSRI
antidepressant such as Celexa 20 to 40 mg replaces the tricyclic.
Celexa has a much better side effect profile than Prozac. Tryptophan
is now available from some compounding pharmacies and may be taken
by itself up to 3000 mg per day. If it is combined with either a
tricyclic or SSRI antidepressant, the dosage must be reduced.
One European study showed that the combination of monoamine
oxidase (MAO)-inhibiting drugs such as Nardil or Parnate along with
the nutrient 5-hydroxytryptophan, significantly improved
fibromyalgia syndrome, whereas other antidepressant treatments
yielded poorer benefits. The doctors who conducted this study stated
that a natural analgesic effect occurred when serotonin levels and
norepinephrine receptors were enhanced in the brain. The monoamine
oxidase-inhibiting drugs did produce some side effects. European
doctors combine 5-hydroxytryptophan with a decarboxylase inhibitor
in order to make it available to produce serotonin in the brain. It
is difficult for Americans to get 5-hydroxytryptophan with a
pharmaceutical decarboxylase inhibitor. The vitamin B6 Americans use
also inhibits the ability of 5-hydroxytryptophan to enhance brain
levels of serotonin. One of the reasons these agents work is by
improving the quality of sleep which is also mediated by serotonin.
Please note that anyone who has been taking a tricyclic or SSRI
antidepressant such as Prozac or Celexa must wait at least 14 days
(this is called wash out) prior to beginning an MAO inhibitor. Fatal
reactions have occurred when MAO inhibitors have been mixed with
these antidepressants. Additionally, patients taking MAO inhibitors
must avoid certain foods and medications. Your doctor or pharmacist
will give you a list of these items. It is also very important
to boost magnesium levels by supplementation.
Continuation of FIBROMYALGIA
