Fibromyalgia - An Integrative Approach
DIAGNOSIS
- 3 or more months of widespread pain, present above and below the waist on the right and left side of the body and along the midline
- Report of pain at a minimum of 11/18 specified locations (Tender Points-TPs) throughout the body when palpated with 4 kg. of digital pressure; TPs are widely distributed, typically located in muscle bodies, over tendinous insertions and at bony prominences, clustering around the neck, shoulders, chest, hips, knees and elbows.
“The Manual Tender Point Survery” (booklet and video) is available from: Pain Evaluation and Treatment Institute, University of Pittsburgh Medical Center,
- “Real World” Criteria:
- Diffuse myalgias
- Chronic fatigue
- Sleep disorder
- Symptoms typically worse post-exertion
- Associated symptoms: cognitive dysfunction, irritable bowel, headaches, TMJ, interstitial cystitis, arthralgias, depression, dizziness.
Syndrome more common in women (80-90%), all ages are affected. Prevalence in the
Evidence for alterations in:
pain-related neurotransmitters (e.g., substance P and nerve growth factor—both markedly elevated in spinal fluid; serotonin, norepinephrine),
immune markers (especially elevated levels of cytokines),
growth hormone levels (decreased),
sleep physiology (alpha/delta sleep anomaly, excessive periodic limb movements),
hormonal irregularities (especially hypothalamic-pituitary-adrenal/thyroid dysfunction),
phosphocreatinine and ATP levels in muscle cells (decreased), impairing cellular calcium reabsorption, necessary for terminating muscle contraction,
capillary walls in muscles (thickened), impairing oxygen delivery.
Physical Exam:
Diffuse muscle spasm evident, positive tender point exam, orthostatic hypotension, signs of concurrent conditions
Laboratory Evaluation:
CBC w/ differential, electrolytes, LFT, RFT, RBC Mg, B12, folate, methylmalonic acid (rule out subclinical B12 deficiency), ANA, RF, ESR (typically low), TFT (TSH, FT4, FT3; consider TT3/rT3 ratio, BBT), IGF-1, DHEA-S, CPK, Lyme serologies (consider EIA, Western Blot, C6LPE; may require PCR, provoked urine dot-blot assay), Ehrlichia abs, Babesia abs, Bartonella abs. Consider Sjogren’s, PMR, and/or SLE evaluation if indicated. Consider sinus CT scan, Polysomnogram (rule out sleep apnea and/or Stage IV abnormality), allergy workup (particularly to molds), adrenal evaluation (
TREATMENT
- Sleep (generally better to use combinations in low doses than single remedy in high dose with side effects):
a. Natural remedies:
Calcium, magnesium, herbal combinations (valerian root, hops, passion flower, wild lettuce, Jamaican dogwood), Melatonin (low dose initially, consider controlled release form), 5-HTP (generally avoid if on SSRIs—also helps anxiety, depression), GABA, phosphatidyl serine, l-theanine (especially if anxiety)
b. Medications:
Unisom, Benadryl, Lunesta (2 mg for initiation, 3 mg for maintenance), Ambien, Sonata (very short-acting, so can take during the night if early awakening, as long as pt. has 3 hours or more until wakeup time), SSRI’s
For sleep initiation: clonazepam (Klonopin), alprazolam (Xanax)
For sleep maintenance: trazodone, tricyclics—amitryptaline, nortryptaline, doxepin, (start with very low doses, may need to take up to 12 hours before wakeup time)
For pain affecting sleep: neurontin, muscle relaxants—Flexeril, Soma, Zanaflex
For deeper sleep: Xyrem (GHB)--may help stage IV disorder, but must be taken twice nightly; tightly controlled and expensive
- Nutrition:
Protein, calories, omega 3 fatty acids, B vitamins, trace minerals, anti-oxidants, malic acid/magnesium, treat reactive hypoglycemia (with chromium and frequent protein, while avoiding simple CHOs and tapering caffeine), NADH, CoQ10, B12 (SL, SQ, IM), nutritional IVs
- Hormones:
Thyroid (combination T4/T3 since many have deiodination defect and/or elevated reverse T3; TSH unreliable in presence of hypothalamic dysfunction [cf. Demitrack,
Adrenals (salt/fluids, licorice root [follow BP and potassium]), B-complex, ginseng, ashwagandha, cordryceps, low-dose hormones (Florinef, DHEA, pregnenelone, hydrocortisone [cf.
Estrogen/Testosterone (bioidentical replacement)
- Infections:
Treat aggressively as indicated. Chronic sinusitis may be occult, and may be fungal (cf. recent Mayo Clinic studies). Rule out Lyme, Babesia, Ehrlichia, Bartonella, Hepatitis C.
- Irritable Bowel Symptoms:
Determine and address underlying cause: parasites, bacteria, Candida-related, hypochlorhydria, pancreatic enzyme deficiency, undiagnosed Inflammatory Bowel Disease (consider ASCA, ANCA, anti-OmpC testing), food allergies (goblet cell-mediated histamine release).
- Pain Relief:
Nutrients: calcium, magnesium, 5-HTP (relaxes muscles), dl-phenylalanine (raises pain threshold)
Medications: Tramodol, muscle relaxants (Skelaxin is less sedating), judicious NSAIDs, acetominophen, opioids, dextromethorphan (20-30 mg. TID)—blocks pain-amplifying NMDA receptors, reduces development of opioid tolerance.
Topical agents: ketamine, lidocaine/prilocaine, amitryptaline/doxepin, gabapentin, ketoprofen/ibuprofen—combination consisting of 10% each (apply TID, may take 2 weeks to show effect); LidoDerm patch; BioEntopic Cream (15% ibuprofen, devil’s claw root, yucca root)
Therapies: microcurrent stimulation, Trigger point injection (Travell protocol), myofascial release/therapeutic massage, chiropractic, osteopathic manipulation, stretching program, warm pool exercises, yoga
Lifestyle modification: regular relaxation periods/stress management, activity modulation, graded exercise as tolerated, regulation of sleep/awakening times, caffeine avoidance
- Possibly Useful Medications:
Guaifenesin (cf. St. Amand, UCLA); SSRI/SSNIs—Venlafaxine (Effexor), Duloxatine (Cymbalta)--start very low dose; Modafanil (Provigil)—fatigue; Pramipexole (Mirapex)—pain; Pregabalin (Lyrica)--pain, sleep
F I B R O M Y A L G I A
AN INTEGRATIVE APPROACH
By Barry D. Elson, MD
DIAGNOSIS
- 3 or more months of widespread pain, present above and below the waist on the right and left side of the body and along the midline
- Report of pain at a minimum of 11/18 specified locations (Tender Points-TPs) throughout the body when palpated with 4 kg. of digital pressure; TPs are widely distributed, typically located in muscle bodies, over tendinous insertions and at bony prominences, clustering around the neck, shoulders, chest, hips, knees and elbows.
“The Manual Tender Point Survery” (booklet and video) is available from: Pain Evaluation and Treatment Institute, University of Pittsburgh Medical Center,
- “Real World” Criteria:
- Diffuse myalgias
- Chronic fatigue
- Sleep disorder
- Symptoms typically worse post-exertion
- Associated symptoms: cognitive dysfunction, irritable bowel, headaches, TMJ, interstitial cystitis, arthralgias, depression, dizziness.
Syndrome more common in women (80-90%), all ages are affected. Prevalence in the
Evidence for alterations in:
pain-related neurotransmitters (e.g., substance P and nerve growth factor—both markedly elevated in spinal fluid; serotonin, norepinephrine),
immune markers (especially elevated levels of cytokines),
growth hormone levels (decreased),
sleep physiology (alpha/delta sleep anomaly, excessive periodic limb movements),
hormonal irregularities (especially hypothalamic-pituitary-adrenal/thyroid dysfunction),
phosphocreatinine and ATP levels in muscle cells (decreased), impairing cellular calcium reabsorption, necessary for terminating muscle contraction,
capillary walls in muscles (thickened), impairing oxygen delivery.
Physical Exam:
Diffuse muscle spasm evident, positive tender point exam, orthostatic hypotension, signs of concurrent conditions
Laboratory Evaluation:
CBC w/ differential, electrolytes, LFT, RFT, RBC Mg, B12, folate, methylmalonic acid (rule out subclinical B12 deficiency), ANA, RF, ESR (typically low), TFT (TSH, FT4, FT3; consider TT3/rT3 ratio, BBT), IGF-1, DHEA-S, CPK, Lyme serologies (consider EIA, Western Blot, C6LPE; may require PCR, provoked urine dot-blot assay), Ehrlichia abs, Babesia abs, Bartonella abs. Consider Sjogren’s, PMR, and/or SLE evaluation if indicated. Consider sinus CT scan, Polysomnogram (rule out sleep apnea and/or Stage IV abnormality), allergy workup (particularly to molds), adrenal evaluation (
TREATMENT
- Sleep (generally better to use combinations in low doses than single remedy in high dose with side effects):
a. Natural remedies:
Calcium, magnesium, herbal combinations (valerian root, hops, passion flower, wild lettuce, Jamaican dogwood), Melatonin (low dose initially, consider controlled release form), 5-HTP (generally avoid if on SSRIs—also helps anxiety, depression), GABA, phosphatidyl serine, l-theanine (especially if anxiety)
b. Medications:
Unisom, Benadryl, Lunesta (2 mg for initiation, 3 mg for maintenance), Ambien, Sonata (very short-acting, so can take during the night if early awakening, as long as pt. has 3 hours or more until wakeup time), SSRI’s
For sleep initiation: clonazepam (Klonopin), alprazolam (Xanax)
For sleep maintenance: trazodone, tricyclics—amitryptaline, nortryptaline, doxepin, (start with very low doses, may need to take up to 12 hours before wakeup time)
For pain affecting sleep: neurontin, muscle relaxants—Flexeril, Soma, Zanaflex
For deeper sleep: Xyrem (GHB)--may help stage IV disorder, but must be taken twice nightly; tightly controlled and expensive
- Nutrition:
Protein, calories, omega 3 fatty acids, B vitamins, trace minerals, anti-oxidants, malic acid/magnesium, treat reactive hypoglycemia (with chromium and frequent protein, while avoiding simple CHOs and tapering caffeine), NADH, CoQ10, B12 (SL, SQ, IM), nutritional IVs
- Hormones:
Thyroid (combination T4/T3 since many have deiodination defect and/or elevated reverse T3; TSH unreliable in presence of hypothalamic dysfunction [cf. Demitrack,
Adrenals (salt/fluids, licorice root [follow BP and potassium]), B-complex, ginseng, ashwagandha, cordryceps, low-dose hormones (Florinef, DHEA, pregnenelone, hydrocortisone [cf.
Estrogen/Testosterone (bioidentical replacement)
- Infections:
Treat aggressively as indicated. Chronic sinusitis may be occult, and may be fungal (cf. recent Mayo Clinic studies). Rule out Lyme, Babesia, Ehrlichia, Bartonella, Hepatitis C.
- Irritable Bowel Symptoms:
Determine and address underlying cause: parasites, bacteria, Candida-related, hypochlorhydria, pancreatic enzyme deficiency, undiagnosed Inflammatory Bowel Disease (consider ASCA, ANCA, anti-OmpC testing), food allergies (goblet cell-mediated histamine release).
- Pain Relief:
Nutrients: calcium, magnesium, 5-HTP (relaxes muscles), dl-phenylalanine (raises pain threshold)
Medications: Tramodol, muscle relaxants (Skelaxin is less sedating), judicious NSAIDs, acetominophen, opioids, dextromethorphan (20-30 mg. TID)—blocks pain-amplifying NMDA receptors, reduces development of opioid tolerance.
Topical agents: ketamine, lidocaine/prilocaine, amitryptaline/doxepin, gabapentin, ketoprofen/ibuprofen—combination consisting of 10% each (apply TID, may take 2 weeks to show effect); LidoDerm patch; BioEntopic Cream (15% ibuprofen, devil’s claw root, yucca root)
Therapies: microcurrent stimulation, Trigger point injection (Travell protocol), myofascial release/therapeutic massage, chiropractic, osteopathic manipulation, stretching program, warm pool exercises, yoga
Lifestyle modification: regular relaxation periods/stress management, activity modulation, graded exercise as tolerated, regulation of sleep/awakening times, caffeine avoidance
- Possibly Useful Medications:
Guaifenesin (cf. St. Amand, UCLA); SSRI/SSNIs—Venlafaxine (Effexor), Duloxatine (Cymbalta)--start very low dose; Modafanil (Provigil)—fatigue; Pramipexole (Mirapex)—pain; Pregabalin (Lyrica)--pain, sleep
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