AUSTRALIAN NATUROPATHIC NETWORK
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Definition

Fibromyalgia (FMS) has only recently gained recognition as a distinct clinical entity. It superficially resembles other disorders such as Rheumatoid Arthritis and has often been dismissed as an imaginary or psychiatric problem. FMS is considered a nonarticular (soft tissue) rheumatic syndrome characterised by chronic musculoskeletal aches, pains and stiffness that occur primarily in muscles and their attachments and are associated with specific sites of exaggerated tenderness on palpation, called tender points.[i] The muscle symptoms are also accompanied by a variety of other symptoms including fatigue, headaches & sleep disturbances, just to name a few.[ii] FMS is considered primary in the absence of musculoskeletal pathology and other rheumatic or organic diseases (ie trauma, cancer, thyroid and rheumatic diseases), and secondary or concomitant when associated with certain systemic or rheumatic diseases. It has also been associated with more than 46 infectious, metabolic, neurologic and neoplastic diseases.1

Causes

Despite intensive research, the pathogenesis of FMS remains unclear.[iii] Clinical heterogeneity is pronounced, and multiple factors are likely to relate to its development and chronicity. There is no concrete evidence of overt inflammatory or structural abnormality and the problem appears functional rather than pathological.1 3 A number of etiologies for FMS have been investigated, including:

Relationship with Chronic Fatigue Syndrome (CFS)

FMS sufferers exhibit similar symptoms to CFS sufferers, except in FMS muscle pain predominates over fatigue.[iv] [v] Studies have shown that 80% of FMS sufferers meet the criteria for CFS.5

Stress

A multi-factorial etiology, with stress being the common pathway has been proposed.[vi]

Abnormalities in Muscle Physiology

Abnormalities discovered in some FMS patients include tissue hypoxia and deteriorated muscle fibers at the sites of tenderness.6 [vii] [viii] There is some scientific evidence to support the theory of chronic hypoxia as a cause for FMS. Proponents for this theory postulate that FMS symptoms (particularly pain) are predominantly caused by enhanced gluconeogenesis with breakdown of muscle proteins, resulting from a deficiency of oxygen and other substances needed for ATP synthesis.7 Studies have revealed FMS sufferers have decreased ATP levels. [ix] In addition, the low serum amino acids in FMS patients in spite of increased muscle proteolysis suggest a very active gluconeogenesis in FMS patients.7

Magnesium & Malate Deficiency

Magnesium plays a critical role in key enzymatic reactions for both aerobic and anaerobic glycolysis. Studies have shown that patients with low magnesium levels often exhibit most of the common symptoms of FMS sufferers.7 Magnesium deficiency causes swelling and disruption of the cristae of the mitochondria, with a decreased number of mitochondria per cell. Similar abnormalities have been noted in the muscle biopsies of FMS sufferers. Many FMS sufferers have also displayed lower than normal Mg levels[x] and treatment with supplementary malate and Mg has shown to improve FMS myalgia in several trials conducted to date.7

Abnormal Neurohormonal Function

·         The most popular and widely accepted model for FMS pathogenesis of the moment is related to CNS mechanisms like nociception and alloynia.[xi] Several studies have shown the levels of platelet & brain serotonin, and cerebro spinal fluid substance P to be abnormal in FMS sufferers in directions that could amplify pain perception.11 There is also evidence of decreased flux through the serotonin pathway in FMS sufferers.[xii] Several clinical studies have confirmed the effectiveness of 5-HTP tryptophan in increasing pain tolerance and improving sleep patterns in FMS sufferers.5

·         Hypothalmic-pituitary-adrenal stress axis abnormalities have also been researched as a possible cause for FMS. [xiii] There may be some basis to this theory on the grounds that growth hormone deficiency has been reported in as many as 30% of FMS patients and studies have shown supplementation with synthetic growth hormone has relieved tender point pain in some FMS patients. [xiv]

Sleep Disturbance

·         Chronic non-restorative sleep has been suggested as a possible cause of FMS. Various factors (such as regional pain syndrome, bereavement and anxiety) cause reduced deep sleep, with resultant somatic symptoms and fatigue. Once reduced sleep has been established, reduced activity, declining activity and pain encourage perpetuation of aberrant sleep pattern.3

·         The severity of pain of FMS correlates with sleep quality; when patients with CFS have a good night’s sleep, pain is reduced.5

Chronic/Acute Viral Infection

A number of infectious agents have been associated with the onset of FMS including Lyme disease, Influenza A virus,[xv] Human immunodeficiency virus, Coxsackie virus, Epstein-Barr, Streptococcus, and Parvovirus.2 However, evidence for triggering viral infections in most FMS patients is lacking.3

Chemical/Food Sensitivities & Parasitic Infections

Some researchers believe chemical/food insensitivities and parasitic infections may trigger the onset of FMS.4 Studies have shown that 20 to 47% of FMS sufferers have severe environmental chemical intolerance.[xvi] They also commonly show reactions to a number of foods including: MSG [42.5%], candida albicans yeasts [37.5%], Caffeine [35%], Chocolate/cocoa [35%], Food Colourings [35%], cola beverages [35%], crustaceans [35%], dairy products [25%], Sulfites [22.5%], Yoghurt [22.5%], Aspartame [20%], Orange [20%].[xvii]

Prevalence

FMS is nine times more common in women between the ages of 30 – 50 than in men.3 5 6 It is now recognised as one of the most common rheumatic complaints with clinical prevalence of 15-20% in rheumatoid practice.7 It is estimated to affect around 4 percent of the population.5 Six million people in the USA are believed to suffer with FMS.[xviii]

Signs & Symptoms

In the majority of cases, the symptoms are severe enough to interfere with normal daily activities and a significant number of people are disabled by FMS.

·         The most prominent symptoms are localised to the muscles and include pain, aching, stiffness, tension and muscle fatigue.[xix] Proximal muscle groups (neck, shoulders, elbows, hips, knees and back) are most widely affected.6 The pain may be of two kinds; a dull ache which is more or less constant or a sharp, shooting pain. For many, muscle fatigue and weakness are incapacitating.19

·         Irritable bowel and bladder symptoms in 34-53% of patients1 6

·         Functional dyspepsia4

·         Candida4

·         Sense of swelling and parasthesias of the extremities1

·         Leg cramps (42%)3

·         Restless legs3

·         Raynauds phenomenon (30%)6

·         Chest pain3

·         Chronic tension and migraine headaches (28-58%)6

·         Insomnia (86%) and sleep disturbances are common with many patients waking several times during the evening and typically feel unrefreshed after sleep (96%).1

·         Symptoms aggravated by cold or humid weather, excessive physical activity, physical or mental fatigue (60-90%), anxiety and stress1

·         Pain is often relieved or modified by warm or dry weather, hot showers or baths, restful sleep, moderate activity, stretching exercises and massage1

·         Frequent infections (colds, flu)5

·         Many patients with fibromyalgia have coexistent osteoarthritis (there is no evidence that the osteoarthritis is related the fibromyalgia in such circumstances1

·         Psychological symptoms: depression (20%), anxiety, panic attacks, anger, agitation, irritability, forgetfulness, impaired concentration (41%), frustration1

·         Primary dysmenorrhea7

Less common symptoms include:

·         Mitral valve prolapse7

·         Tachycardia6

·         Hypermobility syndrome19

·         Vertigo6

·         Tendonitis & bursitis6

·         Skin mottling6

·         Temporomandibular joint dysfunction6

·         Sciatica6

·         Systemic lupus erythematous (SLE)1

·         Dry mouth and eyes8

Orthodox Investigations

To date, no clinical, biochemical, serologic, inflammatory, immunologic or structural pathologic findings have been consistently implicated in FMS.1

Diagnostic criteria for Primary FMS includes:

Major Criteria (required)

1.        Widespread pain for at least 3 months

2.        Multiple tender points in at least 6 or more of 18 tender sites3 5 6

3.        Absence of underlying disease as a cause for FMS

Minor Criteria

1.        Alpha intrusion in nonREM sleep EEG

2.        Nonrestorative sleep

3.        Overnight increase in morning stiffness and fatigue

4.        Daytime fatigue or tiredness

5.        Unpleasant abnormal sensations (dysesthesias)

6.        Pain in response to normally inocuous stimuli (eg light touch, movement, posture) called allodynia

7.        Excessive skin reddening provoked by stroking or palpating the skin (dermatographia)

8.        Aggravation with cold, stress of activities

9.        Improvement with rest, heat, increased level of physical fitness

10.     Chronic headache (migraine, tension)

11.     Functional bowel disorder (Irritable bowel syndrome)

A classification of FMS is helpful in diagnosis and management1

Despite the relatively simple criteria, the diagnosis of fibromyalgia is one of exclusion. In the presence of myofascial pain, underlying disease must be ruled out. Investigations typically conducted by a physician include:

·         Complete medical history, including rheumatologic and neurological problems

·         Complete physical examination, including a rheumatologic examination focusing on neuro-muscular function, musculoskeletal function, examination for pathology of the muscles and spine, and palpation of soft and bony tissues to identify tender points.

·         Positive findings indicative of fibromyalgia include:

·         Multiple tender points at specific anatomical sites.3 Common sites include:

·         Low cervical spine (C4-C6 interspinous ligaments)

·         Low lumbar spine (L4-S1 interspinous ligaments)

·         Suboccipital muscle (posterior base of skull)

·         Mid-supraspinatus

·         Mid-point of upper trapezius

·         Pectoralis insertion – maximal lateral to second costochondral junction

·         Lateral epicondyle

·         Gluteus medius

·         Greater trochanter

·         Medial fat pad of knee3

·         Mild soft swelling particularly in the fingers7

·         Skin pinch tenderness especially over the trapezius but also in the upper arms and legs3

·         Hyperaemia1

·         Negative findings typically include:

·         No pathologic muscle weakness3

·         No evidence of joint swelling, periarticular muscle wasting or mechanical limitation of movement often associated with rheumatic or articular disease3

·         Neurologic examination is usually negative, however it is not uncommon to note the presence of tender peripheral nerves, including radial, ulnar, and median nerves1

·         General physical examination is usually negative3

·         The presence of other physical findings suggesting organic disease should direct the examiner to the possibility of an underlying illness causing or associated with manifestations of fibromyalgia1

·         Laboratory studies to rule out other pathologies as follows:

·         Full blood count, erythrocyte sedimentation rate, blood viscosity and antinuclear factor to rule out SLE3

·         Thyroid function tests to rule out hypothyroidism1

·         Creatine kinase concentration to rule out Inflammatory myopathy3

·         In selected cases, other tests may be necessary, including kidney function

·         Sleep laboratory test which are usually normal1

·         Radiographs, EMG (Electromyographic studies) & nerve conduction studies (usually negative in most fibromyalgia sufferers)1

Naturopathic Investigations

·         Detailed case study to determine causative factors and determine treatment protocols and priorities.

·         Physical examination to check for any anatomical, structural or mechanical anomalies of musculoskeletal system

·         Observation, physical examination of tongue and fingernails, zinc tally test may be useful to indicate vitamin and mineral deficiencies

·         If digestive disturbance and IBS are prominent symptoms, Urinary indicans test may be useful to test gut toxicity. A stool analysis test may be also useful to determine whether infestations or parasites are present

·         Iris diagnosis

·         Urine test to determine if heavy metal contamination is a problem.

Orthodox Treatment

There is no cure for FMS and the prognosis for FMS sufferers is poor. Some cases clear up on their own, some become chronic and some go through cycles of flare ups alternating with periods of apparent remission. Studies conducted have shown that less than 1 in 10 patients diagnosed in hospital lost their symptoms within five years.3

Although FMS is a chronic condition, patient’s quality of life can be improved when symptoms such as fatigue and pain are reduced.

Orthodox medical treatment protocols include:

·         Serotonin substrate supplementation via L-tryptophan or 5-hydroxytryptophan. This has been shown to improve symptoms of depression, anxiety, insomnia, and somatic pains in many patients.5 12 [xx]

·         NSAIDS such as Ibuprofen, aspirin and acetaminophen are often prescribed for symptomatic pain relief, but are rarely effective.6 7

·         Tricyclic antidepressants such as amitryptyline (10-30mg at bedtime) improve sleep patterns by prolonging stages 3 and 4 of the sleep cycle.7 They also potentiate the action of endogenous and exogenous opioids, producing an analgesic effect.6 Long term use is discouraged due to the severe side effects associated with long term use.6

·         Muscle relaxants such as cyclobenzaprine has been shown to improve the symptoms of FMS with patients reporting a decrease in pain and evening fatigue and an increase in sleep6

·         Benzodiazapines are often prescribed to treat the depression/psychological component of the disease6

·         Emotional support & education is of the utmost importance to help individuals understand and manage their perplexing array of symptoms and undertake necessary lifestyle changes. Support can be obtained informally from fibromyalgia self-help and support groups. Professional assistance is also encouraged for those having a difficult time adjusting to life with FMS.

·         Treatment with recombinant growth hormone has improved several clinical features, including tender point pain14

·         Lithium therapy may work in FMS in conduction with tricyclic antidepressants by enhancing their effects7

Nutritional Treatment & Rationale

Aims

·         Symptom relief (pain, fatigue, depression, anxiety)

·         Patient reassurance and education is vital. Address psychological component, stress and lifestyle issues.

·         Support the endocrine & nervous systems (adrenals, thyroid, pancreas, etc to improve metabolic processes for energy production). Treatment outcome will depend upon presenting symptoms

·         Improve immune system status (especially important if infections or viral component)

·         Correct nutritional deficiencies/imbalances

·         Increase energy output

·         Reduce Oxidative Stress as free radicals promote inflammation and cell damage17 [xxi]

·         Ensure proper digestion is occurring  and improve general circulation in order to get more nutrients to cells

·         Check for environmental, chemical and food sensitivities or allergies.

·         Improve bowel waste elimination

·         Correct dysbiosis as many FMS sufferers have leaky gut & malabsorption problems4

·         Support liver detoxification and improve liver function

Dietary Recommendations

·         Look at food intolerances/allergies; follow a grand elimination/rotation diet.

·         Eat a well balanced diet consisting of whole foods with emphasis on protein, essential fatty acids and low glycaemic index carbohydrates. This diet should consist mainly of vegetables (raw or lightly steamed, juiced, fruits, whole grains (millet, brown rice, quinoa, buckwheat), raw nuts and seeds, legumes, deep sea fish to renew energy and build up immunity

·         Eat four or five small meals per day to keep a steady supply of protein and carbohydrates available for muscle function.4

·         Educate the patient on good eating habits

·         Provide some nutritious, tasty and easy to prepare recipes

Avoid

·         Stimulants such as alcohol, nicotine and caffeine (disruptive to sleep patterns)

·         Limit consumption of solanine containing foods (green peppers, eggplant, tomatoes and potatoes) as these interfere with enzymes in muscles and may increase pain and discomfort4

·         Avoid red meat, dairy products, highly refined foods, fried foods or other foods high in saturated fats as they promote pro-inflammatory and pain producing prostaglandins

·         Reduce intake of sugars, refined carbohydrates, gluten and yeast products.

Take

·         Increase fluid intake to help flush out toxins (spring/filtered water, herbal teas)

·         Increased intake of foods containing the following vitamins and minerals are recommended:

·         Tryptophan: soy beans, fish, eggs, nuts, dates, banana, alfalfa, fennel, carrots, spinach, broccoli

·         Magnesium: almonds, buckwheat, tofu, millet, pecans, walnuts, rye, beet greens, spinach, brown rice, avocado, dry beans, green peas, sweet potato, bananas, blackberries, broccoli, cauliflower, carrots, celery, asparagus, cabbage, mushrooms, onions, apples, dried apricots, chlorophyll

·         Malate: prunes, pears, cherries, passionfruit, apricots, strawberries, plums, peaches, nectarines, fennel

·         B1: sunflower seeds, pine nuts, soy milk, sesame seeds, buckwheat, lima beans, pinto beans, mung beans, peas, egg yolks, brazil nuts, lentils

·         Phenylalanine: soy beans, fish, eggs, almonds

·         Antioxidants: garlic, onions, leeks, eggs, carrots, beetroot, turmeric, ginger, green tea, berries, green beans

·         If digestive and liver function is poor:

·         Lemon juice in warm water in the morning to stimulate bile flow

·         Apple cider vinegar in water before meals to stimulate digestive enzymes

·         Bitter foods: radicchio, endive, nasturtium, rocket, dandelion leaves

·         Enzyme containing foods: papaya, pineapple, alfalfa, cucumber, kiwifruit, avocado

Supplements

Given the complexity of FMS a wide range of supplementation may be required depending on the severity and range of symptoms.

·         Pain and depression –

·         dl phenylalanine5

·         Malate (1200 - 2400 mg/day) & Mg (300 - 600 mg/day): shown to reduce tender point pain significantly1 4 [xxii]

·         Tryptophan (300mg/day)7 [xxiii] (refer Causes above)

·         B1: FMS patients found to have low vitamin B1 status and reduced activity of some thiamin-dependant enzymes [xxiv]

·         B5, B6

·         Sleep and anxiety – Mg, B3, B5, B6, tryptophan, vitamin C5 21

·         Antioxidants -  vitamin C, E, A, Se, glutathione, cysteine, glutamine, glycine, Mn, Cu, Zn, Co-enzyme Q10

·         Lipotropic agents - Methionine, vitamin B6, B9, B12, choline to improve liver function

·         Energy production – Mg, malic acid, Co Q 10, B complex21

·         Improve energy output –Creatine phosphate21

·         Immune system: vitamin C - 1000mg tds, bioflavonoids, A, E, Zn

·         Probiotics - L acidophilus, bifido bacteria powder and fructooligosaccharides to recolonise the gut with beneficial intestinal flora populations.

·         Essential fatty acids - evening primrose oil and fish oils to protect against cell damage and help reduce pain and fatigue

·         Vitamin E 100-300iu/day has improved some FMS symptoms

·         Calcium to prevent imbalance which may result from high Magnesium intake