Fibromyalgia Syndrome (FMS)

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 Fibromyalgia, 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:

1. Sleep disturbances. Sufferers may not feel refreshed, despite getting adequate amounts of sleep. They may also have difficulty falling asleep or staying asleep.
2. 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.
3. 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).
4. Abdominal discomfort. Irritable bowel syndrome including such symptoms as digestive disturbances, abdominal pain and bloating, constipation, and diarrhea may be present.
5. Irritable bladder. An increase in urinary frequency and a greater urgency to urinate may be present.
6. Numbness or tingling. Known as parasthesia, symptoms include a prickling or burning sensation in the extremities.
7. Chest pain. Muscular pain at the point where the ribs meet the chest bone may occur.
8. 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.
9. Environmental Sensitivity. Sensitivities to light, noise, odors, and weather are often present, as are allergic reactions to a variety of substances (see below).
10. Disequilibrium. Difficulties in orientation may occur when standing, driving, or reading. Dizziness and balance problems may also be present.

Diagnosis
There is currently no diagnostic or laboratory test to identify Fibromyalgia. 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.”

The lab evaluation 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(hair analysis); comprehensive digestive stool analysis for digestion; DHEA level; amino acid analysis of urine; basal temperature for thyroid function, antibodies for candida; antibodies for Epstein Barr, CMV, Herpes, Chlamydia, and Heliobacter to look for chronic infection; and other testing as needed. Not everyone needs all the above tests.

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 such as amytriptiline (Elavil). 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 European antidepressant drug S-adenosylmethionine (SAMe) has been shown in several published studies to be specifically effective as a therapy to reduce the chronic pain and depression associated with fibromyalgia. The suggested dose is 400 to 800 mg twice a day.

SAMe is currently sold as a dietary supplement in the United States.

Recently, in a study conducted on 12 fibromyalgia and chronic fatigue syndrome (CFS) patients, researchers found a vitamin B12 deficiency in all test subjects, which correlated positively with an increase in homocysteine levels found in their cerebrospinal fluid. They concluded that the elevated homocysteine levels are directly related to symptoms of fatigue found in both FMS and CFS patients.

In addition to drug and nutritional supplementation, certain approaches may help patients feel better and improve the quality of life:

1. physical therapy including massage, myofascial release, cranio-sacral therapy, mild electrical stimulation, the application of heat or cold, ultrasound, posture and movement training, and chiropractic treatment;
2. gentle exercise to ease sore muscles by increasing blood circulation and range of motion;
3. alternative approaches such as biofeedback, yoga, Tai chi, stress management, nutritional counseling, and acupuncture.
4. Swimming in a heated pool allows for greater mobility with greater ease than most other activities.
5. Massage properly done is also helpful.
6. Hot soaks with one half pound of Epsom salt added to the hot bath water are great for pain.

Acupuncture may be of variable benefit with its greatest impact upon treating painful muscle. In the experience of many complementary physicians, orthomolecular therapy with the intravenous administration of up to 50 mg of vitamin C 2 to 3 times a week for 4 to 24 weeks may be helpful. Some patients benefit from chelation therapy. Oral or intravenous NADH has also been found to be clinically useful. The ultraviolet irradiation of blood (UBI) has been found to be useful for some patients.

Also consider natural hormone replacement, DHEA, immune enhancers such as thymus and rejuvenators such as cell therapy, medications to control yeast or other bacteria if present, allergy desensitization if indicated, thyroid replacement if necessary, and Heidelburg testing if gastric dysfunction is suspected.

A Pain-Suppressing Drug
For patients with persistent symptoms or those with severe symptoms at the outset, one may prescribe the drug buprinorphine, a mild narcotic with agonist and antagonist properties that has a very low addiction liability, if any. Patients can use it for a long time without developing serious withdrawal symptoms when the drug is discontinued. The drug is virtually unknown among most physicians.

Of special interest, particularly since depression compounds and confounds FMS, buprinorphine 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. This makes buprinorphine particularly useful in FMS where pain, sleep abnormalities, and depression predominate the constellation of symptoms. The dosage is variable. The drug is commercially available only as an injectable .3 mg ampule, which is a small dose even for injection.

Since the drug is poorly absorbed orally, larger dosages must be used. When used orally, the liquid is withdrawn or shaken from the ampule and held under the tongue as long as possible. Compounding pharmacies can make up buprinorphine for sublingual use as a troche. Both forms, the ampules and the troches, are expensive. For pain that prevents sleep, start with two to six ampules sublingually or .5 to 2 mg of a sublingual troche. For treating pain associated with depression throughout the day, begin with two to six ampules or .5 to 2 mg every 4 to 6 hours. As with most medications, begin with a low dose and increase until the smallest dose that proves effective is reached. Do not worry about addiction.

Summary

1. Try addressing the sleep problem first.
2. S-adenosylemethionone (SAMe) 400 to 800 mg, twice a day (the most important single nutrient or drug therapy according to the published studies)
3. If 2 fails, add one of the tricyclic antidepressants (see the Insomnia protocol).
4. If 3 fails, consider combining 5-hydroxytryptophan with an SSRI antidepressant such as Celexa 20 to 40 mg
5. Tryptophan up to 3000 mg a day may be substituted for the 5-hydroxytryptophan
6. If the above suggestions fail, consider combining an MAO inhibitor such as Nardil, 15 to 75 mg a day, with 5-hydroxytryptophan, 20 to 100 mg a day. The MAO is taken in divided doses throughout the day and the 5-hydroxytryptophan is taken at night. CAUTION: The dosing must be carefully supervised by a physician. Discontinue any tricyclic or SSRI antidepressant at least 14 days prior to beginning an MAO inhibitor. Fatal reactions have occurred when MAO inhibitors have been combined with certain antidepressants and drugs. Your physician or pharmacist will advise you of potential MAO food and drug interactions.
7. Magnesium supplementation with a good chelated product.
8. Gentle daily exercise, in particular, swimming.
9. Consider acupuncture.
10. Consider massage.
11. Homocysteine.
12. Nightly hot soaks in bathtub with one half pound of Epsom salt.
13. Consider orthomolecular therapy with intravenous vitamin C, 50 mg 2 to 3 times a week.
14. Oral or intravenous NADH.
15. DHEA. Dosage is best titrated by blood or saliva testing in concert with a physician knowledgeable about DHEA.
16. higher dose pregnenolone, 100 to 400 mg a day.
17. buprinorphine, two to six ampules sublingually or sublingual troches .5 to 2 mg before bed for night pain and poor sleep.
18. buprinorphine two to six ampules sublingually or sublingual troches .5 to 2 mg every 4 to 6 hours for daytime pain and depression.