FIBROMYALGIA


Fibromyalgia is an illness characterized by severe muscle pain, that 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 CFS. The major difference between the two is the presence of musculoskeletal pain in fibromylagia. In medicine, a disease exists when an illness has very specific symptoms and physical exam and laboratory findings. An illness that cannot be as definitively defined and may mimic other conditions is called a syndrome. Fibromylagia (FMS) 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, no inflammation is 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 fibromylagia, 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 FMS 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 major and four or more of the following minor criteria be present: Major Criteria

1. Generalized aches or stiffness of at least three anatomical sites for at least 3 months
2. Six or more typical, reproducible tender points
3. Exclusion of other disorders that can cause similar symptoms

Minor Criteria

1. Generalized fatigue
2. Chronic headache
3. Sleep disturbance
4. Neurological and psychological complaints
5. Numbing or tingling sensations
6. Irritable bowel syndrome
7. Variation of symptoms in relation to activity, stress, and weather changes
8. 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 contribute 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 parasthesia, 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, intranasally 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 autoimmune activation. The scientific literature suggests that there may be a marked correlation between the body's ability to effectively detoxify xenobiotic (foreign) 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 fibromylagia. 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 FMS 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 that may be best described as "doughy."

Both fibromylagia and CFS not only 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 workup would include things that most conventional physicians do not look at, such as the yeast syndrome (see the Candida protocol ), for example. A complementary physician, Dr. Ed McDonagh, has a very extensive protocol for the diagnosis and treatment of both fibromyalgia and CFS, which he groups together.

His workup includes dark-field (specialized) microscopy of the blood; routine blood chemistries; sedimentation rate for inflammation; antinuclear antibody test for lupus; antioxidant assay; intra- cellular 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 Deficiency protocol ), antibodies for candida; antibodies for Epstein Barr, CMV, Herpes, Chlamydia, and Heliobacter to look for chronic infection; and other testing as needed.

Drug 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. Begin with a tricyclic antidepressant. If this does not work, a 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 a 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.

CAUTION: 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.

The whole article can be found at:
http://www.lef.org/protocols/prtcl-050.shtml

Abstracts for Protocol can be found at:
http://www.lef.org/protocols/abstracts/abstr-050.html#1