Understanding Fibromyalgia And Chronic Fatigue

Fibromyalgia And Chronic Fatigue by Dr David Drier

Fibromyalgia (FM) and Chronic Fatigue Syndrome (CFIDS) are a relatively common clinical syndromes, with about 6-10 million diagnosed patients in the U.S. alone. The average patient is 20-50 years old, and 90-95% of the patients are female, for reasons that are not fully understood, although a hormonal connection may turn out to be the reason. Cultural causes (unexpressed frustration, depression, and sexual abuse) are also being considered as possible reasons for the gender disparity.

Regardless, FM and CFIDS are systemic disorders, not simple muscular inflammations. They are likely to be a secondary condition where another primary condition has produced ongoing pain for over three months. A single cause for FM or CFIDS is unknown at present, but possible factors and causes include:

* Poor thyroid hormone regulation

* Genetic causes

* Trauma (physical or emotional)

* Infections / Inflammation

* Muscle physiology problems

* Neurological causes

* Neurotransmitter abnormalities

* Autoimmune causes / Immune dysfunction

* Allergic factors

* Muscle structure changes

* Abnormal sleep patterns

* Glandular/hormonal dysfunction

* Biomechanical factors

FM or CFIDS are probable diagnoses for the patient who says they "hurt all over", and has had extensive medical testing, without a definitive diagnosis. Common symptoms include:

* Fatigue

* Poor sleep

* Muscle pain

* Multiple joint pain

* "restless legs"

* Morning stiffness

* Numbness and tingling

* Worse pain with extreme cold, heat or humidity

* Worse with exercise

* Irritable bowel, bladder

* Chronic headaches

* Depression, anxiety, mood swings

* Low body temperature

* Hypotension

The American College of Rheumatology lists criteria for FM, as follows:

the patient has many of these symptoms, for over 90 days, on both halves of the body, and both the upper and lower torso, covering at least three body regions. There is also spinal or midline body pain, front and/or back present. There are no other systemic conditions present, such as lupus, rheumatoid arthritis, gout or hyperthyroidism. Another secondary condition would not rule out FM, however.

Particularly important in the diagnosis of FM is the presence of tender points- areas of muscle tender to palpation- in at least 11 of the 18 sites listed by the American College of Rheumatology. There are major problems with these site criteria, as I will go into shortly.

These findings are often, though not always, present with CFIDS patients, as well.

Other conditions seen along with FM or CFIDS:

* Allergies

* Anxiety disorder, panic attacks

* Memory and concentration problems

* Chronic Fatigue Syndrome

* Depression

* Dry eyes syndrome

* Endometriosis, fibrocystic breast disease

* Headaches- tension, migraine, combination

* Irritable bowel syndrome, irritable bladder

* Mitral valve prolapse

* Restless leg syndrome

* Raynaud's syndrome

* TMJ dysfunction

Conditions which must be ruled out include:

* Osteoarthritis, rheumatoid arthritis

* Reiter's syndrome

* Ankylosing spondylitis

* Psoriatic arthritis

* Polymyalgia rheumatica

* Lupus

* Sjogren's syndrome

* Polymyositis, dermatomyositis

* Progressive systemic sclerosis

* Hypo/hyperthyroidism

* Hypoparathyroidism

* Adrenal disorders

* Myeloma, metastasis

* Drug or alcohol myopathy

* Myofascial pain syndrome

* Psychogenic rheumatism

* TMJ Dysfunction

* Tendonitis, bursitis (multiple sites)

* Lyme disease

* Epstein-Barr infection

* Other viral infections

As you can see, the chances of misdiagnosing FM or CFIDS are great. But the biggest diagnostic error is confusing FM or CFIDS with myofascial pain syndrome (MPS). They are similar in many ways, but FM and CFIDS create tender points, as discussed earlier, while MPS creates trigger points, which are irritated areas of muscle that refer pain away from themselves. They may not be tender, even when palpated. Confusing things further is the fact that, at present, these distinct syndromes have one diagnostic code. So a patient may be correctly diagnosed with myofascial pain syndrome, which the doctor calls fibromyalgia or chronic fatigue, since the coding is the same. Not to mention that doctors are using FM and CFIDS as a "waste basket", like carpal tunnel or bursitis, for many different syndromes.

Correct diagnosis is important, because myofascial pain syndrome responds excellently to deep myofascial release, while the tender points of FM or CFIDS require clinical skills, in order not to treat tender points with deep myofascial release, which may exacerbate these points. Tender points respond to other manual methods, and a good practitioner can treat each on the same patient with skill and discretion.

That’s the groundwork, but here are some of my concerns:

* The 18 "tender point" sites were arbitrary locations chosen by early researchers into FM and CFIDS, and many of them are also common trigger point sites. * Rheumatologists and physiatrists, especially, are using the diagnosis of FM for virtually any patient with unexplained symptoms, who may then go without necessary further testing and clinical exploration.

* Many of the non-specific symptoms involved have other causes (see the long "rule out" list ).

* Many of the symptoms are stress or depression-related.

One theory put forward to explain FM and CFIDS has focused on hypothalamic dysfunction. Sleep deprivation research has shown that such sleep loss can cause:

Immune dysfunction, and infection as a result.

Reduced metabolic activity, with reduced brain blood flow.

Suppression of thyroid hormones.

Temperature regulation dysfunction, with temperature sensitivity.

Hyperphosphatemia, with defective phosphate metabolism.

Allodynia (that is, pain with normally painless levels of touch), possibly from elevated substance P, and low serotonin levels.

Hypothalamus Dysfunction

The hypothalamus is the “master” gland, controlling most other glands. Effects of hypothalamus dysfunction include:

Low thyroid, with reduced metabolism, weight gain and low body temperature.

Low antidiuretic hormone, with increased thirst, urinary frequency and decreased adrenal function.

Autonomic nervous system dysfunction.

Low growth hormone, with low DHEA levels.

Reduced cortisol levels, with immune dysfunction and hypotension.

Reduced ovarian and testicular function, with immune dysfunction.

Elevated prolactin.

Regardless of the cause, the effects of immune dysfunction include, opportunistic infections, leading to chronicity of CFIDS and FM. This might include:

Chronic sinusitis

Prostatitis

Bowel infections, yeast infections and “leaky gut syndrome”.

Food sensitivities.

Liver overload.

Reduced adrenal function.

Rickettsia, mycoplasma, etc.

Viral infections, which may cause hypothalamus dysfunction.

The combination of liver overload, immune dysfunction and reduced adrenal function can combine to produce food, chemical and environmental sensitivities.

If the autonomic nervous system is malfunctioning (which can occur with hypothalamus dysfunction), it can cause:

Neurally mediated hypotension.

Night or day sweats.

Nasal congestion.

Fatigue.

If temperature regulation is altered, one may find:

Poor energy efficiency.

Reduced enzyme efficiency.

While this is still theory, even if the ultimate causes turn out to lay elsewhere, one can see how the cascade of multiple symptoms, and chronicity, might occur.

Nutritionist Jeffrey Bland has pointed out that fibromyalgia may well be a more extreme form of myofascial pain syndrome, with chronic fatigue syndrome as a more extreme form of fibromyalgia. That is, they are all on a continuum, all involving increasing amounts of mitochondrial dysfunction, leading to reduced ATP energy production, and the resulting fatigue. A number of other prominent doctors feel that FM and CFIDS are part of the same process.

In my opinion FM or CFIDS is mainly a physical manifestation of stress-induced central nervous system function changes. Specifically, overactivity of the sympathetic and gamma efferent motor systems. The reticular activating system, through the gamma efferent motor system, controls muscle tone. Under extreme emotional stress, over a period of time, the muscle tone may be set at a higher level, leading to multiple areas of pain and sensitivity.

As a result, a history of sexual or emotional abuse (which is disproportionately common in CFIDS and FM patients), physical trauma (such as a car accident or sports injury) or viral syndrome can begin a cascade of events. leading to impaired immunity and increased muscle tone.

Additionally, trauma and stress lead to increased cortisol output, taxing the body, and leaving the patient fatigued, and “achy all over”.

Finally, if the pituitary/adrenal/hypothalamus axis is out of balance (and trauma or viral syndromes can lead to such imblances), moodiness, sleep disorders and fatigue may ensue. Thyroid dysfunction may also contribute to these symptoms.

Whatever the trigger turns out to be, once the syndrome starts, it tends to be self-perpetuating. Treating many systems simultaneously is the answer.

Treatment Recommendations for Fibromyalgia and Chronic Fatigue

Chiropractic bodywork should be your first line of defense in treating FM or CFIDS, along with nutritional therapy. Key areas to work on are the immune system, reducing pain and inflammation, reducing work and personal stress, and eating lower down on the glycemic index.

I incorporate all of the treatment guidelines which follow, including deep myofascial release, lymph drainage therapy, massage, spinal manipulation, nutritional protocols, Emotional Release Bodywork, Relaxercise, Somatics and rehabilitative exercises. All of the involved systems are treated simultaneously, for maximum benefit.

Depending on the severity and chronicity of the condition, along with the age and gender of the patient, one should expect results in a reasonable period of time, although many patient need about three months before they see any “traction” in their improvements. This holds true no matter who is treating the FMS/CFIDS patient.

1- Counseling/therapy.

FM and CFIDS hypersensitize the body's pain threshold, and effects the nervous system so that pain lasts longer. Hearing and even emotions may become hypersensitive, as well. Many FM or CFIDS patients see their lives collapse, through job losses. A patient may have little support from one's employer, friends, or family, who don't understand a disease that has no obvious outward signs. They may start out supportive, but run into "compassion fatigue". Family life may be disrupted. One's personal achievement standards may have to be lowered. Support groups may also be needed. A continued social life with friends is important, to avoid isolation.

FM and CFIDS are poorly understood, painful conditions, but neither one is terminal, crippling, or progressive in nature. And it is definitely not "in your head" (it’s in your body!). I use Emotional Release Bodywork, a combination of bodywork, Bioenergetic techniques and verbal exchange, to work with the emotional issues of FM and CFIDS, whether they are causative factors, or the result of FM or CFIDS itself.

2- Bodywork.

Chiropractic adjustments relieve spinal pain, reset muscle tone at a lower setting, and improve overall body mechanics which may be causing pain. Also, specific recommendations are made regarding how to modify your work site and daily activities, to reduce pain.

Deep Myofascial Release (DMR) is especially valuable, in removing "trigger points" and tender scar tissue, often a source of chronic pain in FM and CFIDS patients. Improvements can be made in your movements & strength as a result.

Lymph drainage therapy is invaluable for reducing inflammation and pain, while boosting immunity and reducing tension and stress. Both manual and electrical methods are used.

Somatics technique quickly breaks up chronic muscle spasm, and helps to release faulty movement patterns that have developed.

Massage techniques relieve both personal and muscle tension, and relieve tender points. Moist heat over a topical coolant, such as Biofreeze, is often helpful, and can be done by the patient at home.

3- Exercise.

Strenuous exercise is intolerable for most FM or CFIDS patients, but low impact aerobics, walking, or swimming are often well tolerated, leading to pain and stress reduction, along with increased lymph drainage.

Relaxercise and Somatics exercises are valuable and relaxing, integrating body movements, while improving focus and movement patterns. Always begin with a mild workout, and work up from there: from 10 minute sessions, up to 30 minute sessions.

Yoga is also helpful, especially poses like the cobra posture. Finally, meditation will help you to "let go of the outcome", and allow whatever is for "the highest good" to happen, without judgement. (Some patients report good results using moist heat over topical coolants such as Biofreeze or Flexall 454)

4- Nutrition.

Nutritional supplementation, which can greatly aid FM and CFIDS patients, is made in part, based on lab results, and what symptoms the patient is experiencing. That is, which systems are most involved in the pathology.

FM and CFIDS seem to be connected to some digestive, hormonal and metabolic disorders. In terms of diet, a hypoallergenic diet is best, with no alcohol, caffeine, or sodas. Reduce sugar intake, but increase leafy greens, soy products, canola oil, and cold water fish. If you have joint pain, drink chicken broth (one cup, three times/day), as the hyaluronic acid in it is great for joint pain. (see the dietary recommendations list at the end of this article)

Anti-inflammatories/anti-infectives:

Barley green or Kyogreen, used in one's morning orange juice, or sprinkled onto a salad. Use 1-2 tablespoons daily. (If you prefer a tablet, use Allergy Research’s Pro Greens)

Powdered ginger capsules, 4 times a day with food.

Fish oils or flax oil, as directed.

Digestive enzymes (Wobenzym, Azeo-Pangen or other), as directed.

Antioxident blend, as directed.

MSM, at least 1500 mg./day. Using 500mg. capsules, go as high as 6 caps, 2x/day for 2-3 months, then as needed. (500mg. of vitamin C helps absorb it).

NAC, 500 mg./day.

Oral hydrogen peroxide, using one part 3% peroxide with 2-5 parts warm water, 1-3x/day. Use with several drops of Oil of oregano and/or tea tree oil added. Mix well before use. Either swish orally for 5 minutes, rinsing several times, or use in a Waterpik.

Hydrogen peroxide baths (see the appendix for this protocol, and a sponge bath alternative).

Pain reduction supplements:

Magnesium and malic acid reduce pain levels, if deficiencies have been found in lab studies, or if your T3 levels are low. Dosage varies from 1200-2400 mg. malic acid, and 400-800 mg. magnesium.

Shark cartilage (like Cartilade), for joint pain.

MSM, previously noted.

Ginger, dried or as capsules, 1000mg., 1-4x/day. If used as tea, boil 10gm. chopped ginger (about 1/4 inch slice).

Glucosamine sulfate, 500mg., 3x/day, for joint pain. Use six weeks for benefit, then reduce dose to lowest dose which still helps.

Hydrogen peroxide, as an enema, 1-4 TBSP. in 1 liter of water, instilled rectally.

Other important supplementation:

S-Adenosylmethionone (Sam-E), 200 mg., 1-4 times/day.

DHEA, 50 mg./day.

Calcium, 100mg./day.

Vitamin D, 400 iu/day.

B-Complex, as directed, at night.

Vitamin E, 400 iu/day.

For detoxification:

Nature’s Cleansing Program, as directed. Use for three months.

Lipoic acid, 200 mg./day (for the liver).

For sleep:

5-hydroxtryptophan (5-HTP), as directed.

Valerian root, 180-360 mg./day.

Melissa (lemon balm), 80-160 mg./day.

Passion flower (passiflora), 100-200mg., at night.

Melatonin, 3/10mg., at bedtime.

Kava kava, 30% extract, 250mg. capsules, 1-3 at bedtime (if rash develops, add 50mg. B-complex at night).

Delta Sleep System, CD/tape. Can be played through night, if needed. 1-800-333-5287.

For fatigue:

Coenzyme Q, 100-200mg./day.

L-Carnitine, 2000mg./day, for three months, then go to 1000mg./day.

L-Arginine, 2000mg., 2-3x/day.

Magnesium/potassium aspartate, 2 capsules, 2x/day.

Transfer Factor, 600mg./day, in three doses of 200 mg.

For indigestion:

Iberogast, an herbal digestive aid, 20 drops, 3x/day in warm water, with meals. Use 4-8 weeks.

Bismuth, 120-240mg. tablets (Thorne Research’s “Formula SF734” is good).

Angostura bitters, found in (of all places) most liquor stores. Use 1-2 tsp. in water, and sip.

For depression:

Sam-E, previously noted.

5 HTP, previously noted.

Passion flower (passiflora), previously noted.

Ginkgo biloba, previously noted, but use 2 capsules, 2x/day for depression.

Hypericum (St. John’s Wort), 300-625mg., 3x/day. Allow six weeks to take effect. Use standardized to at least .3% hypericum. Take 2/3 of dose at night, to help sleep.

Anti-yeast treatment:

Avoid sweets, (see dietary guidelines, at end of article).

Stevia, herbal sweetener, instead of sugar.

Cranberry concentrate tablets, use as directed.

Acidopholus, 3-6 billion units/day, refrigerated form is best. Don’t take within 6 hours of any antibiotic.

Garlic, 1 clove, 1-3x/day, with meals (or as capsule, such as Kyolic).

Oil of Oregano, enteric coated, 2 capsules on an empty stomach, 3x/day, for 3-4 months, then 2 capsules a day for yeast overgrowth.

Immunity stimulants:

Transfer Factor, as directed.

Echinacea, 300mg., 3x/day (three weeks on, one week off each month).

MgN3, 250mg. capsules, 2-4 capsules, 4x/day, for two weeks. Then take twice a day. Expensive, but amazing boost for natural killer cells.

Selenium, 200mcg./day, for six months.

For “brain fog”:

Ginkgo biloba, standardized to 24%, 60mg. capsule, once/day for brain fog.

Piracetam, 1200mg., 2x/day for two weeks, then 2400mg., 2x/day for two weeks. Then adjust to optimum dose (up to 4800mg./day). )Order from England, antiagingsystems.com)

Hydergine, 4-6mg. each morning.

DMAE, up to 400mg./day.

For migraines:

Feverfew, 250mg., 1-3x/day, to prevent migraine.

Vitamin B2 (riboflavin), 400mg./day, to prevent migraine. Check B-complex and multi-vitamin amounts. TOTAL of all should be 400mg./day.

For parasites:

Artemesia annua, an herbal anti-parasitic, 500mg., 2 tablets, 3x/day, for 20 days.

Trycyclin, an herbal anti-parasitic, 2 tablets, 3x/day after meals, for 6-8 weeks.

D-mannose, 1/2 tsp. in water every 2-3 hours during day, for 2-5 days during bladder infections (can use long term fot chronic infections). Available from BioTech.

Reverse osmosis water filter system.

Colostrum, 3 capsules, 3x/day, for 8-12 weeks. Then use lowest dose needed for symptoms (always lower dose if nausea or indugestion occur). Take on an empty stomach.

Grape seed extract (pycnogenol), 100mg./day.

Helpful I.V. therapies, for immunity, fatigue and infection/inflammation:

Myers cocktails.

Blood photo-oxidation, with UV light.

Hydrogen peroxide infusion.

High dose vitamin C.

Chelation with EDTA.

Ozone therapy.

The following measurements should be made, for possible supplementation:

Amino acid analysis Parasitology

Organic acid analysis Lyme disease

Plasma or membrane fatty acid Stool analysis

Red blood cell trace elements Lactulose/mannitol ratio

Food allergy panel Liver detoxification profile

DHEA and cortisol levels Thyroid- T3 & T4 levels (not TSH)

Chlamydia and mycoplasma tests

Hypothyroid symptoms can be subtle, and may include disturbed sleep patterns, “restless leg” syndrome, sensitivity to cold, fatigue, widespread achiness and headaches. Ideally, any thyroid supplementation is Armour thyroid, which is natural, and sustained release T3, if needed, according to labwork (many FM & CFIDS patients are resistant to normal thyroid doses). Hormone replacement (estrogen, pregesterone, or testosterone) may also be necessary, along with DHEA.

While I do not prescribe medications, there are select times when medication is helpful in FM and CFIDS patients. Hence, a list of some of the useful medications, and their applications in these conditions:

For pain:

I.V. Lidocaine, Robaxin, Daypro, Voltaren, Zanaflex, Dextromethorphan, Ultram, Skelaxin, Norflex,

For sleep:

Ambien, Klonipin, Soma, Remeron, Xanax (Flexeril & Elavil are also used at times).

Hormonal treatments:

Synthroid, Armour Thyroid, Thyrolar, sustained release T3 (all thyroid hormone).

Cortef (adrenal hormone).

DHEA

Florinef

Oxytocin

Estradiol, natural Progesterone, Testosterone (all natural HRT for men and women).

Somatomed (helps make growth hormone).

Antiviral agents:

Famvir, Lithium, Monolaurin.

Anti-yeast treaments:

Mycelex oral lozenges, Diflucan, Sporanox.

For parasites:

Metronidazole, Yodoxin, Tinidazole, Humatin, Zithromax, Albendazole, Amphotericin B, Bactrim DS.

For infections (bacterial, mycoplasma, chlamydia, bladder infection, etc.):

Cipro, Doxycycline, Ziythromax, Biaxin.

For mood stability:

Zoloft, Paxil, Prozac.

Other prescriptions used:

Dexedrine, , Heparin, Effexor, Serzone, Celexa, Wellbutrin, Coumadin.

Resources:

Fibromyalgia Network, P.O. Box 31750, Tucson, Az. 85751, (602) 290-5508, (800) 853-2929

Seattle Fibromyalgia International Team, P.O. Box 77373, Seattle, Wa. 98177-0373, (206) 362-2310

American College of Rheumatology, 60 Executive Park S., Suite 150, Atlanta, Ga. 30329, (404) 633-3777

Copyright Dr. David Drier is a chiropractor, working in Nanuet, NY and Morristown, NJ. He is a certified Vodder Manual Lymph Drainage Therapist, and a graduate of the Hakomi Institute of Experiential Psychotherapy. Dr. Drier also has advanced training in Deep Myofascial Release. Dr. Drier can be reached at 845-774-7378 or Bodyworks1@frontiernet.net.