Sleep disturbance is a problem for every single patient I have ever encountered with Fibromyalgia. In fact, sleep deprivation is such a common symptom, I ask patients routinely about the quality of their sleep. The area of controversy within this theory is whether or not sleep deprivation is the cause or a symptom associated with Fibromyalgia. This controversy reminds me of the old adage, “Which came first, the chicken or the egg”. Nonetheless, current sleep pattern research exemplifies the fact that sleep deprivation actually appears to be one of the causes of Fibromyalgia, even though this is not overwhelmingly agreed upon. What we do know for certain is that patients with Fibromyalgia tend to experience a lack of the deeper stages of sleep, subjectively resulting in the perception of poor quality of sleep. The result is a myriad of complicating factors, beginning with the most obvious symptom of fatigue. There are a number of chemical alterations which occur with sleep deprivation, none of which are positive outcomes for the patient. One must obtain proper sleep in order for our bodies heal properly. Sleep provides time for the body to repair damaged tissue, reproduce cells, and replenish neurotransmitters in the brain and the rest of the body. These neurotransmitters are responsible for moods, memory, emotions, and immune function alike. Perhaps the most renowned neurotransmitter is serotonin. This naturally occurring chemical in the brain helps to create heightened moods and feelings of well-being. Serotonin is produced in the brain when we are in deep stages of sleep. As one might imagine deprivation of sleep can and will reduce the levels of serotonin, thus rendering depression.
In order to better appreciate the function of serotonin, consider Prozac. This drug is used for treatment of depression and is designed to decrease the natural re-absorption of serotonin in the brain. The result is a relative increase in serotonin levels, and an elevated mood. In the case of Fibromyalgia, depression is considered one of symptoms, but there is much debate as to whether or not it is a symptom, or a potential cause. Professional observations and clinical research lead me to believe that depression is one of several causes of Fibromyalgia, despite the fact that the American Arthritis Foundation disagrees with this. What we have witness is the fact that each patient experiences slightly different symptoms of Fibromyalgia, and therefore depression may actually be a symptom for some individuals, and one of many causes for another.
Sleep deprivation poses a serious complication of FMS. The ramifications associated with sleep deprivation span far and wide. During deep stages of sleep, our muscles become very loose and relaxed, allowing for increased blood flow, thereby eliciting the removal of toxins. When our muscles become relaxed, there is increased blood circulation to remove lactic acid, as well as other toxins within the muscle cells responsible in part for increased pain arriving from within the muscles. Muscle tissue is repaired and rebuilt. In addition, tired fatigued muscles and tendons can be repaired when there is increased circulation brought about by deep sleep. As also previously stated, deprivation of deep sleep results in lower levels of natural pain killers or “endorphins” which are normally produced in the brain during deep sleep. The result is an increased perception of pain through the entire body. Therefore, mild pain signals from muscles or other connective tissue will be perceived more intensely, and diffusely.
Sleep deprivation is also responsible in part for the feeling of depression associated with Fibromyalgia. Our brain produces serotonin during the deeper stages of sleep, and generally speaking, higher levels of serotonin are associated with heightened moods and a more cheerful outlook on life. What is the cause of sleep deprivation? The question can be answered in two words; “busy minds”. There is a constant internal dialogue most patients with Fibromyalgia experience. Every single patient I have ever interviewed with FMS will describe it as, “My mind is always busy” or “I have to plan my day tomorrow when I lay down for bed”. I also hear phrases like, “I am always thinking about something” and “It is difficult for me to relax, I feel like I should be doing something”. This is not necessarily a negative condition, until it is time to let go and allow the conscious mind to rest. The conscious mind tries to take control of every aspect of life, and sleep is no exception. However, one cannot sleep if one does not go into an unconscious state!
There are several reasons patients with Fibromyalgia may not want to give up conscious control. When we look back at family situations, a common theme is an abusive family situation. It is difficult for these patients to give up control, because somewhere in childhood, they had to be overly responsible, and maintain some sense of control in a family full of individuals with little or no self control. As they get older and life situations pile up, the sense of being out of control is overwhelming. Sleep patterns suffer, stress-induced metabolism becomes a dominate state, and sooner or later with no time for rest and repair, the machine we call a body wears out, and our gauge for wear and tear is body pain and fatigue. Our bodies repair when we are at rest, and resting the mind is equally important. With proper quantity and quality of sleep, the immune system can function optimally, brain chemicals are able to be replenished (particularly serotonin), and perception of pain is diminished. Therefore, in order to reduce symptoms of FMS, it is essential to re-train sleep patterns by any means necessary, even if it means medication. However, meds will not cure the overactive mind; they will only give minor temporary relief when it comes to associated symptoms of deep sleep deprivation. In order to fully recover from the symptoms of FMS, one must learn to quiet the mind by reducing mental chatter. This is the reason sleeping medication only helps to reduce the symptoms of FMS in some patients, and offers little or any relief for others. However, I always encourage patients to discuss a trial period of sleep medication while they are initially attempting to reduce symptoms of FMS. Ideally, the combination of reducing stress, quieting our minds, and changing the diet offer the best form of treatment for sleep disturbance.
Sleep deprivation combined with daily stress also creates another significant problem for muscle tissue. Continued activation and chronic tension of muscle fibers of skeletal muscle by means of stress and loss of deep stages of sleep deplete the muscle cells of a vital energy component known as ATP. With diminished ATP levels, the muscle cells cannot effectively remove calcium ions from the internal fluids of muscle cells. Under normal conditions, this active, continuous process requires ATP. Lowered ATP levels can induce an effect similar to rhabdomyolysis, a rare muscle disease often with accompanying muscle pain. Normally, a person diagnosed with Fibromyalgia is tested for rhabdomyolysis, and does not have any positive blood test results indicating this condition. However, symptoms of Fibromyalgia resemble a very mild case of rhabdomyolysis, where absence of positive blood chemistry findings would be possible. This is not to say a person with Fibromyalgia in fact has rhabdomyolysis, but the mechanism of muscle pain in Fibromyalgia appears to result from this mechanism. That being said, it is beneficial to consider some of the potential causes of rhabdomyolysis as well.
Rhabdomyolysis is caused form many different things. As previously discussed in this book in the section of heart disease, cholesterol lowering drugs are one cause. In addition, inhibition of acetyl cholinesterase, an enzyme which breaks down the neurotransmitter acetyl choline (ACH), can induce multiple stages of rhabdomyolysis. For therapeutic reasons, this information is helpful when we consider what other ways acetyl cholinesterase may be inhibited. It is known that certain pesticides of the organophosphate and carbamate types inhibit acetyl cholinesterase, and therefore any type of pesticides should be avoided when a person has Fibromyalgia. Of course, most individuals already are aware they are more sensitive to any noxious chemicals, so organic fruits and vegetables are the best choice. Recent studies have also indicated that Ginkgo can inhibit acetyl cholinesterase, and supports neurotransmission, therefore supplementation my indirectly help lower muscle pain associated with Fibromyalgia, as well as enhance mental clarity. Nevertheless, the ultimate goal is to reduce the chronic tension on muscles, enhance sleep quality, and diminish pain ultimately improving quality of life for all patients suffering from FMS.
In every case of Fibromyalgia I have encountered in a clinical situation, there is an emotional component. Emotional factors are one of the most controversial etiologies of Fibromyalgia, yet all of my clinical observation and research indicates that this is perhaps the largest contributor to Fibromyalgia Syndrome. As we previously stated in the section of Sleep Deprivation, the overactive mind plays a large role in sleep disturbance. Yet time and again I experience resistance when I approach this topic with patients, with some patients taking a defensive standpoint, assuming I am blaming them for “self-inflicted” symptoms. I find it very interesting how society often uses the word “hurt” when describing emotional distress, but somehow very few people are willing to see a correlation between physical “hurt” and emotional “hurt”. There is great misunderstanding and skepticism about this connection, largely due to the inability to admit that symptoms may possibly be self-induced. This process is largely unconscious and stems from learned behavioral patterns. Understand there is much more to Fibromyalgia than just a psycho-somatic ailment. A complex pattern of behaviors have been ingrained and conditioned in the mind of the person with FMS, all of which stem from abusive situations either presently compounding in the person’s life or from abusive childhood family situations. Before we talk about the behavioral and cognitive aspects of FMS, let us explore the physiology behind the real pain the patient perceives.
If we consider the fact that the locations of the tender points are actually common locations of pain in a non-FMS patient, then we must investigate why this is true. After being in practice as a Chiropractor for several years, I can tell you the locations of painful tender points in Fibromyalgia patients are locations typically found in the general population. They are called Myofascial Trigger Points or “Trigger Points” for short. Diagnosis of Fibromyalgia specifically states, “Tender Points are not Trigger Points”, and I would adamantly agree with this statement. Tender points actually feel different from a Trigger Point, in the sense that they feel somewhat swollen. However, tender points are predictable, common locations of pain, and most of them are located at a potential site of a Trigger Point. The interesting thing to note about this is that Trigger Points are innervated (nerves supplying the area) by the sympathetic nervous system. This is the automatic portion of our nervous system which is responsible for the “fight or flight” response to emotional or external stimulus. In other words, if you were being chased by a Lion in the Serengeti, your body would go heavily into “fight or flight” mode (more than likely flight in this case), with the external stimulus being the Lion, and fear would be the visceral or “internal” evoked response. In the above example, this type of response is appropriate, as it is designed to save our lives. However, as you can imagine, prolonged internal fear, anger, frustration, or tension will eventually cause damage or disease in the body, especially in areas the autonomic nervous system regulates. It just so happens that the autonomic nervous system responds to emotions, because the center for emotions in the brain is directly linked to the autonomic nervous system. Some of the systems and bodily functions involved and regulated by the autonomic nervous include blood pressure, blood flow and circulation through tissue, heart rate, breathing (both air flow, and respiratory rate), digestion and bowel movements, immune function/response, and muscle tone. In the situation where “fight or flight” or “stress” mode becomes dominant, an unhealthy balance occurs in the body, leading to excessive wear and tear on the adrenal glands, pancreas, liver, and the musculoskeletal system. When chronic low-grade muscle tension is present, chemical by-products of muscle metabolism build up in the locations of “Tender Points”. In the case with Fibromyalgia, we see inner turmoil, fear, anger, and emotional pain literally turned into physical pain by means of the nervous system, altering blood flow and perception of pain, creating chronic increased tension within the muscles leading to a buildup of lactic acid and other toxins of metabolism. In turn lactic acid, by- products of muscle fatigue, and inflammatory chemicals like prostaglandins produce a chemical irritant to surrounding pain receptors, rendering the famous “Tender Points” tender, and are indeed different than trigger points. It is therefore very important to understand that pain and symptoms of Fibromyalgia Syndrome are real. However, one of the potential causes of symptoms often does stem from emotions.
When we investigate the underlying causes of trigger points, we can then begin to better to understand the connection between Fibromyalgia pain and that of Rhabdomyolysis. In the situation of a trigger point, we find leakage of calcium out of a portion of the muscle cell called the Sarcoplasmic Reticulum. This organelle of the cell is responsible for muscular contraction, by leaking calcium in response to the neurotransmitter acetyl choline. The result is accumulation of lactic acid and hyaluronic acid in the form of a Trigger Point. In contrast, rhabdomyolysis is caused by calcium leaking from the bloodstream into the cell, due to extensive muscle fatigue caused by continuous stimulation and loss of energy in the form of ATP. The result is a sore, tired muscle cell with damage caused by leaking of calcium form the bloodstream (not the Sarcoplasmic Reticulum), and a painful pro-flammatory agent group known as prostaglandins, particularly PGA2. The inflammatory component of tender points are what differentiates them from trigger points. The sources of pain are different, and therefore think of tender points as a severe progression of a trigger point.
In order to further understand the condition of Fibromyalgia, let us consider the fact that there are a number of similarities found in patients with FMS, in terms of psychological profile. The first and foremost is the role of the victim. It is rather common to see very responsible people with this syndrome. In fact, the majority of the patients with FMS are the most responsible members in the family system in which they were raised. Many are from alcoholic or/or abusive backgrounds as previously stated, where one of the children assumes a very responsible role. They begin taking care of the rest of the family as a sort of pathological loyalty, and this continues to surface again and again throughout their lives. In addition, they will often go to great lengths to assume responsibility for an action or event in which they never truly had any responsibility for. They feel victimized, mostly due to feelings of guilt and feeling powerless, often by trying to maintain peace. There is constant turmoil as the individuals try to find a balance between seeming selfishness and giving too much of themselves. Guilt wins out every time, so they find themselves giving too much, and feeling anger toward the people demanding their attention and efforts. Ironically, the person truly does become a victim, but not to the other members in the family, but to their own feelings and emotions. The person with Fibromyalgia usually has issues of fear and feels intimidated by others. They will go to great lengths to avoid confrontation, and get angry with themselves when they are unable to stand up and state their own opinions. This is especially noted when the individual is the “peace keeper” of the abusive family, and not necessarily the oldest child takes on this role. When confrontation is evident, the person goes into retreat, and the power struggle is seemingly won by their “opponent”. Feeling defeated, powerless, and often drained of energy, depression sets in as anger is turned inward, and physical pain will follow directly from emotional pain. This cycle is repeated over and over again, until physical symptoms and pain become debilitating. Usually at this point a frustrated individual finally presents to his or her family physician in search of an explanation and cure. This is when we hear of the famous diagnosis “It’s all in your head”, or my all time favorite “You are just depressed, I will give you an anti-depressant and some sleeping pills”. While these medications tend to help somewhat, the answers to question still loom, and the real cause is buried deep within frustration and self-criticism, only perpetuating the cycle of the Fibromyalgia Syndrome. It is essential for the patient to understand how and why these symptoms are happening to them, in order for them to experience complete recovery. Realization of the fact that physically feeling better can take time, because it is also necessary to change your perception of social interaction and regain personal power again! However, self-criticism will not help you. These responses to life situations are learned patterns of behavior so give yourself a break and allow time for healing.
The first thing a person must recognize is the fact that they are producing their own symptoms, but not intentionally or for attention. The need to be overly responsible combined with being the peace-keeper is where a great deal of the emotional frustration comes from, which eventually turns into physical pain. One important step to take is to stop playing the role of the victim, and take responsibility in the correct area of your life, instead of taking responsibility for everyone else’s problems and emotions. Individuals with FMS will constantly do this, because they are very caring and sensitive people, and would rather take the blame and deal with the emotions themselves. They will sacrifice their own mental well- being, just to someone else from feeling emotional pain.
What is not commonly known is the fact that patients with Fibromyalgia are very intelligent. They have higher IQ’s than average, and tend to be overly self-critical. Admitting there might be an emotional cause for their ailment is very humbling. In addition to this, change can be challenging, but once one accepts responsibility, self-empowerment is the reward. Denial only covers up the wounds, leading to additional disease manifestation in the body, and the chronic pain associated with Fibromyalgia. For this reason, I always encourage patients to seek out a professional councilor when dealing with Fibromyalgia Syndrome, preferably one who is well versed in victims of abuse as well as a good understanding of mind-body holistic healing. This is essential for the healing process, because the mind and body are one, they cannot be treated as two separate entities. Consider, however, that this process of mind-body also means body-mind. As goes our nutrition, so goes our chemical make-up, and hormonal responses to stress and emotions. With this in mind, begin your changes for healing with simple things first. The next section on Nutrition will help guide you to taking your first steps of chemical change.
Daily Nutrition for the FMS Patient
Let us first begin with basic requirements of the body. If you are not meeting the body’s basic needs, all the pills and potions in the world will not help you. Even if we consider the emotional aspect of FMS to be significant, there are still basic chemical needs of the body which cannot be negated. The list is based on simple, yet essential factors to sustain a healthy body. Remember, you must heal the whole body, taking into consideration the chemical, physical, and emotional aspects of health. Many times, taking care of the true chemical imbalances caused by poor nutrition, will diminish the emotional factors associated with FMS.
Water First and foremost is to make sure you are drinking enough water. Remember, when it comes to health, keep it simple, with basic things first. Your body is about 60-67% water, and if you are not consuming enough water, there is not enough liquid to flush through your kidneys and efficiently remove toxins and by-products. Water is also essential for normal chemical reactions to occur in the body, in addition to the cleansing action. Think about trying to rinse off a car after it has been washed with only one cup of rise water! People with Fibromyalgia tend to be sensitive individuals, both emotionally and physically, especially in terms of chemical sensitivity to the environment. Increasing water intake effectively helps your body remove toxins and by-products of muscle metabolism, and environmental toxins as well. One of the first questions I ask a patient with Fibromyalgia is “how much water do you drink per day?” The response is always widely varied. Patients will often say, “I drink a lot of soda and iced tea, they both have water in them”. This is not the same. It is essential to drink at least 6-8 glasses of plain water per day. A good way to monitor if you are consuming sufficient amounts of water is to note the color of your urine. For the most part, urine should be almost clear, with just a faint yellow tint to it. If you are taking B-vitamins, your urine might be a bright yellow, but should never be a dull, dark yellow. Avoid drinking anything with caffeine, due to the diuretic effect on the body. Caffeine tends to cause your body to get rid of water, and can mildly dehydrate you. Reverse osmosis systems work very well for removing chlorine and many other contaminants. They can usually be installed under the sink for under $200. The other option is to purchase a Brita® water filter, for less than $25.
Protein If we consider the fact that your body has over 600 muscles it uses for locomotion, and muscle is mostly protein, then we realize our body has a large relative mass of protein. Therefore, if you are not consuming enough protein to repair this large portion of body mass, your muscles, ligaments and tendons are going to get sore. For some reason, many health care practitioners fail to see this correlation, probably because research does not demonstrate decreased protein levels in the blood tests of patients with Fibromyalgia. Common sense tells us we would not expect to find decreased blood protein levels, otherwise there would be other disease processes going on, instead of just muscle pain. There appears to be a “sub-clinical” deficiency of protein (not enough to show up on an objective blood test), with symptoms of muscle pain and a general “aching” sensation throughout the body, as well as general fatigue. In addition to the muscle pain, joint pain, and fatigue associated with decreased protein, there is a craving for carbohydrates. Excessive sugar and high density carbohydrate intake will cause increased levels of insulin, resulting in fatigue, muscle and joint pain, increase fat and cholesterol production, predisposing your body to diabetes and heart disease over time. If there is no craving for sugar and one is not consuming large amounts of sugar, then perhaps there is a craving for high density carbohydrates such as breads, pasta, and cereal.
One of my patient’s with Fibromyagia denied eating or craving sweets. She said she rarely had sugary things, candy, or sweetened carbonated beverages. However, when I asked her what her typical daily diet was, the first two meals of the day consisted almost entirely of high density carbohydrates. She was only getting about 30 grams of protein a day (well below USRDA minimum), and was on a fairly heavy exercise routine! It was no surprise this woman had muscle and joint pain, since her body was not getting the protein she needed to repair the active muscle tissue, connective tissue and joint cartilage. Unless there is a rare genetic condition limiting your body from making glucose from other sources, we can survive without eating sugars or carbohydrates ever again. On the other hand, our body cannot make protein without consuming certain essential amino acids from other proteins. Protein, water and certain fats are essential in the diet, but we need to decrease the levels of high density carbohydrates (such as grains and pasta), and replace them with servings of fresh or frozen vegetables. In doing so, blood sugar fluctuations will decrease, fatigue will decrease, and some of the physical pain associated with FMS will also diminish.
Blood Sugar levels, Protein & Stress
Not everyone realizes the effects of stress on blood sugar metabolism. As we have previously explained, it appears that fear is a driving force in the lives of a patient with Fibromyalgia, largely due to the toxic environment in which they grew up. Our bodies react to fear in several ways, but particularly the case with Fibromyalgia is the release of adrenalin. Adrenalin subsequently causes the secretion of insulin in order to bring needed sugars into the muscle cells and other cells of the body. Blood pressure increases, heart rate and respiration increase, muscle tension increases, and after the fear-induced episode is done, the person is left with “hypoglycemia” or low blood sugar. Symptoms of hypoglycemia include depression, fatigue, irritability, and altered sleep patterns with nightmares. The other marked symptom is a craving for carbohydrates, which in turn releases more insulin to lower blood sugar, and then creates a situation of chronic over secretion of insulin and the typical “roller coaster” effect for blood sugar. I have often heard patients complain of mood swings and chronic fatigue associated with FMS. For the patient with FMS, it is essential to stabilize blood sugars via diet in order to level out mood swings, depression, and fatigue. An unwillingness to do this results in persistent symptoms of Fibromyalgia Syndrome. I have heard many excuses from patients, explaining “I have a chemical imbalance”, simply dismissing responsibility for the way they feel. What these patients fail to realize is that the chemical imbalance is more than likely an insulin induced sugar imbalance! Balancing blood sugar levels will help improve many of the symptoms of FMS in a very short time. This can be done by increasing protein and lowering high density carbohydrates. This is the first step in reducing fatigue and curbing depression naturally. The amount of protein required varies greatly from person to person, and can even vary daily depending on emotional and physical stress levels. USRDA for protein is typically under that of what is needed for most patients with FM, and generally speaking, the more stress you are under, the more protein you will need to offset the negative effects of stress.
We have been told to lower fat intake and increase the amount of complex carbohydrates in the diet. The problem with this is the fact that fats help stabilize blood sugar levels by inhibiting the release of insulin. The American Diabetes Association states that high fat diets are in part responsible for diabetes. If this was true, following their recommendation for a low fat, high complex carbohydrate diet would virtually stop diabetes, or at least help reverse it. Instead, patients always get worse on this diet, and the amount of new individuals diagnosed per year is on the rise. Instead, a diet low in carbohydrates from bread, cereals, grains and pasta and sufficient amounts of protein combined with essential unsaturated fats will stabilize blood sugar, and reduce the amount of blood sugar fluctuations. This is why the Zone Diet works so well, because it supplies sufficient protein divided in smaller amounts throughout the day, supplies carbohydrates mostly from vegetables, and contains essential fatty acids necessary for blood sugar stabilization and decreasing inflammation in the body.
The Zone diet was developed by Dr. Barry Sears based on scientific research and human physiology. It fits all the requirements for patients with FMS, and is designed to create a healthier, age-defying body. The diet basically consists of eating three large meals per day, consisting of lean meat in a portion no larger or thicker that your hand, and the rest of the plate is filled with vegetables. A form of fat is also required, in the form of olive oil or some other unsaturated fats containing omega-3 fatty acids. Then, snacks of the same ratio, yet smaller portions are necessary in between meals, so blood sugar levels are maintained. I would highly recommend reading the book for more details.
In addition to basic nutritional considerations, it is also important to note the effects of cigarette smoking on blood sugar levels. The result is similar to an “adrenaline” type of response. Most individuals do not realize that tobacco contains 8-18% sugar. How is that for an additive? Ever wonder why we hear of people craving sweets when they quit smoking? With every cigarette comes a mild increase in blood sugar levels. There is also a mild adrenaline kick from the stimulatory effects of nicotine, causing the release of more insulin resulting in lowered blood sugar, and 20 minutes later a craving for another cigarette. In addition to this, there is also a reduction of blood flow to muscles and connective tissue. Caffeine is also a stimulant, having negative affects on insulin, an adrenaline response, and decreased blood flow to muscles and other connective tissues. Cigarette smoking, caffeine and FMS are like trying to mix oil and water.
I have heard reference “Leaky Gut Syndrome” associated with FMS as one of the causes. Although this may be a possibility, the reality is that increasing protein levels and decreasing or eliminating sugars will help to repair this potential problem. Since we live in a carbohydrate predominant society, most individuals do not know the difference anymore between a hunger for protein, and hunger due to low blood sugar. A hunger for protein is characterized by a deep hunger which is not curbed by simply eating some carbohydrates. After eating carbohydrates, the body quickly digests them, and 30 minutes later you are hungry again. The release of acid in the stomach, over and over again to digest something which requires very little begins to irritate the lining of the stomach. In addition, the sugars will allow yeast to multiply in the body, and this will also irritate all mucus membranes. By getting your diet on track, you will minimize any other secondary problems. This is why it is so important to keep things simple, and begin with the basics first. (continued on page 3...)