Fibromyalgia Syndrome (FMS) is a fairly common disorder characterized by general body pain, fatigue, muscular pain/soreness, irritability and sleep disturbance. Millions of Americans suffer from this syndrome, and the number of diagnosed patients appears to be on the rise, according to some recent studies. This is a painful, frustrating syndrome leaving the person with numerous symptoms which remain difficult to diagnose by even a knowledgeable health care practitioner. Once diagnosed, the prognosis is vague at best, and most treatment protocols are less than adequate.
In a clinical situation, Fibromyalgia presents in a wide range of severity and length of symptoms. It is estimated that FMS affects between 2-4% of the U.S. population, and occurs more commonly in women than in men. Men can have symptoms of fibromyalgia, but most research suggests the symptoms do not present with the severity that they do with women. Despite this, fibromyalgia is the second most common rheumatic syndrome, and according to the American Arthritis Foundation, the exact cause is unknown at this time. The variation of presentation is something of special interest, since FMS is typically only categorized into two types; Primary and Secondary. Primary Fibromyalgia is the most common presentation, with no actual known cause. On the other hand, secondary Fibromyalgia means there is some other disease-like process occurring in the body, giving rise to the symptoms associated with Fibromyalgia. Obviously, the cause of Fibromyalgia is known in the case of secondary presentation, because the symptoms arise due to an underlying condition, such as mononucleosis, cancer, infection (viral or bacterial) or any other chronic disease. Although our treatment approach will help to lesson the symptoms of secondary Fibromyalgia as well, this article describes primary Fibromyalgia.
Presentation of the Syndrome
FMS is characterized by a myriad of symptoms, and can look like many different disease processes. Therefore, in 1990 the American College of Rheumatology developed guidelines to help physicians diagnose Fibromyalgia. According to these guidelines, a person has Fibromyalgia if he or she has a history of widespread pain of at least three months’ duration, in addition to pain above and below the waist on both sides of the body, and pain in at least 11 or more of 18 specific tender point sites. The tender points are in predictable locations of the body, and are not always painful to a person until pressure is elicited during a physical examination. The locations of the tender points are illustrated on this chart:
Symptoms associated with FMS can begin gradually or suddenly. I have treated many patients with FMS and most symptoms begin gradually. Frequently, patients are undiagnosed or misdiagnosed because symptoms fluctuate and can be rather vague at first. It is not common for a patient to go several years before a conclusive diagnosis of Fibromyalgia Syndrome is given by a qualified physician. Ironically, this is not the end of the frustration for the patient, this is only the beginning.
For a syndrome that has been around for many centuries, there is very little conclusive treatment-related research. There has been a tremendous amount of speculation on the topic, but a specific cause of the syndrome has yet to be found. Hundreds of studies have been conducted on the syndrome, but only there is only one commonality: there is no known cause. Because of this, Fibromyalgia is currently referred to as a syndrome (a collection of signs and symptoms), and not a disease process. This concept is important to understand, since patients can often become quickly discouraged when they are diagnosed with FMS. However, we will begin to fully divulge the complex nature of the syndrome. Since the best form of treatment for chronic conditions always begins with education about the condition itself, let us proceed with a list of criteria for diagnosis and more specific symptoms associated with FMS.
Diagnosis and Symptoms of Fibromyalgia
When we consider the wide spectrum of signs and symptoms associated with Fibromyalgia Syndrome, it is important to understand that not everyone has all of these symptoms. However, the first four symptoms must be present in order to have a diagnosis of Fibromyalgia Syndrome.
Generalized body pain of 3 or more month’s duration.
Widespread pain on both sides of the body, in areas above and below the waist
Pain at 11 out of 18 predictable “tender points”
“Restless Leg” Syndrome
Diffuse muscle and joint pain which increases with activity
Fatigue often accompanied by a “hazy” or “foggy” sensation
Inability to concentrate often leading to anxiety and frustration
Numbness in various body regions (often transient).
Irritable bowel can be part of the syndrome as well as digestive problems.
Tension headaches and/or migraine headaches can also accompany Fibromyalgia
Temporomandibular joint (TMJ) syndrome
Generalized body pain of three or more month’s duration is one of the first criteria for diagnosis. In other words, a patient must have pain located in various parts of there body for at least three months. For a person with true Fibromyalgia, this is not an issue. In fact, I think this symptom goes without saying, since this is the main complaint for all patients. Technically, this pain is supposed to be located on both sides of the body, in areas above and below the waist. There are also 18 predictable “Tender Points” associated with Fibromyalgia as illustrated on the previous page. These tender points are assessed by a physician using approximately 4 kg of pressure with a finger. There must be at least 11 out of 18 tender points present, otherwise the patient does not have true FMS, according to the American College of Rheumatology guidelines.
The last critical symptom that must be present in order for there to be a diagnosis of Fibromyalgia symptom is sleep disturbance. Every patient will experience this to some degree. Poor sleep quality is a serious attribute to FMS, and one that has been in the spotlight of investigation when it comes to finding the cause. Medical treatment has been heavily focused on the problem of sleep disturbance, and therefore one of the treatments of choice thus far has been administration of sleeping medication to enhance quality of sleep. Results have been somewhat favorable, but less than desirable in most cases.
Most patients explain that they “hurt all over” and “it feels like every joint in my body hurts”. However, it is different than they have ever felt before. Some patients will say it feels similar to when they have been sick with the flu, but they do not feel sick. I often hear of patients saying their legs feel restless at times, especially when sleeping or sitting for long periods of time like in a movie theatre. Several patients experience a “hazy” or “foggy” sensation at times, and an inability to concentrate. Nearly every patient I have every questioned with FMS will experience increased muscle pain with even mild activity, which can last for several days. Fatigue is always present, and will leave the patient feeling anxious and frustrated, because this is not what is typically “normal” for them. Other symptoms such as transient numbness in hands, feet and even the face can be experienced. Irritable bowel often accompanies FMS, as well as tension headaches, migraine headaches and Temporal Mandibular Joint Syndrome, or TMJ as it is commonly referred to. All of these symptoms can accompany Fibromyalgia, but not all of them have to be present, or present at one time. Symptoms frequently fluctuate from day to day, week to week, and month to month. Of course, the question at hand is; why does this happen?
History and Theories
It is believed that this syndrome was originally diagnosed in the early 1900’s, but some literature suggests findings of similar symptoms as far back as the medieval era. Apparently, descriptions of similar symptoms have been written in medical literature in the mid 20th century, and some theories suggest what was being described could have been FMS. As previously stated, Fibromyalgia can begin gradually, or suddenly. Physical trauma can and often will provoke FMS, such as a car accident or a fall. However, not everyone will experience FMS after a physical trauma. There is great debate over the exact cause of Fibromyalgia; some researchers suggest a viral origin, while others hypothesize sleep disturbance as the primary cause. Although viral etiology seems logical, blood tests have not shown this to be consistently factual. Research has repeatedly demonstrated a reduction or interruption of deep stages of sleep in almost everyone with Fibromyalgia, but some researchers and medical professionals feel this is a potential symptom, while others feel this is one of the primary causes. One other study involving muscle biopsies found low levels of carnitine within the muscle cells of FMS patients, when compared to the “normal” population levels. Nevertheless, no one can agree on the exact cause of Fibromyalgia, and therefore treatment has been less than successful, for the most part. Perhaps the reason for the poor response to traditional medicine and manual forms of therapy is due to the fact that it has not been approached from a holistic standpoint.
As a general rule, chronic disorders tend to evade traditional medical treatment methods, and FMS is no exception. Most physicians and researches focus on one cause, thereby administering “one cure”. Consider the fact that chronic conditions are researched and treated using only one single approach. This is done primarily because research can only focus one variable, yet all chronic disorders of health have three basic variables or components to them; Chemical, Physical, and Emotional. Holistic health care practitioners call this the “Triad of Health”, or the complete approach to treatment of a person, not the treatment of a disease or syndrome. To treat a disease or syndrome without taking into consideration this triad is to miss a very important aspect of health care. The result is inefficiency of treatment, frustrated patients, expensive health care, and an inadequate approach to finding the true cause or causes of the ailment. Clearly, society is already feeling the need to expand our consciousness in order to enhance health care for everyone. When we consider the case of Fibromyalgia Syndrome, we can begin to understand that this syndrome is just one small component of a more serious health care problem at large.
Approaching health care from a “Holistic” standpoint seems like common sense. However, most individual health practitioners will focus only on one aspect of health. For example, Medical practitioners focus mainly on the chemical aspect of FMS, and tend to prescribe medications such as anti-depressants and sleeping pills in the case of FMS. Chiropractors focus mainly on structural or physical changes within the spine and muscles. Naturopaths and Herbologists lean toward herbal remedies and vitamin/mineral needs of the body, while psychologists concentrate on the emotional aspects of disease and syndromes. In reality, all three aspects of the Triad of Health need to be considered, in every case of an unhealthy human being. Without this larger perspective, tunnel vision will blind health care practitioners, rendering less effective treatments and reduced healing for the patient. In the case of Fibromyalgia Syndrome, it is important to treat every aspect of the ailment, and attempt to unveil emotional, physical and chemical causes of the syndrome. Obviously, this is not an easy task, but is absolutely essential for the well-being of the patient.
Far too often a distraught patient suffering from FMS will present to our office with a history of lingering symptoms and poor response to traditional medical management. Typically this patient was treated like a disease, and not a person. A thorough medical history and interview commonly reveals a large emotional component to their symptoms of FMS, which is why treatments aimed at physical or chemical components have been ineffective to say the least. Another individual may discover chemical conditions related to insufficient dietary needs, or structural changes within the spine and muscles following physical trauma. The key is to find what is causing your symptoms, and take the best corrective action or remedy. In reality, it is necessary to cover basic needs of the body first, in all three categories. This can take some time, energy, some self-discipline and responsibility, but the outcome is certainly worth the effort.
For many years, there has been great speculation regarding a viral etiology for FMS. Considering the fact that the viral theory surfaces when medical research is unable to prove the origin of a chronic syndrome or chronic disease, then it is no surprise Fibromyalgia has been blamed on a virus. When researchers and specialists cannot pinpoint a direct cause of a condition, speculation leads to theories, and the viral theory is high on the list of hypotheses. The ever elusive virus poses a high probability, due to the prevalence, and can be difficult at first to recognize. It goes without saying that FMS could in fact stem from a virus not yet recognized, however, blood viral titer tests are vague, and have yet to show any signs of an infectious virus associated with primary Fibromyalgia. With a viral infection, laboratory tests would demonstrate increased levels of certain chemicals within the blood stream, and there would also be increased numbers of specific white blood cells. So far, there is no such indication of either one of these in mainstream medical research. There are also many specific viral tests which can be performed, but so far these tests have not shown positive, despite the fact that symptoms a patient might be experiencing are significant. In fact, one of the criteria for the diagnosis of Fibromyalgia is to demonstrate negative laboratory findings, in order to rule out rheumatoid arthritis, under-active thyroid, mononucleosis (mono), Lyme disease, Hepatitis, Lupus, Cancer, and a couple other connective tissue disorders. This is why it is difficult to diagnose FMS, and the diagnosis is actually one of exclusion. In addition to the fact that there is very little objective laboratory evidence supporting a viral cause, the syndrome would also be contagious, and this also has not been proven. Although a viral cause is certainly possible, we have to wonder why only certain individuals remain vulnerable to such a virus, and why we can’t rid the virus from our bodies. With this in mind, let us consider how to enhance our own immune system through natural means.
We do know that boosting the body’s own immune system seems to be the best defense in terms of long-term reduction of infections and enhancing overall health. One way of doing this is to ensure proper nutrition and vitamin/mineral balance (which will be discussed in detail shortly). For example, it has been know for many years the role of Vitamin C when it comes to boosting the immune system, and helping to reduce vulnerability to infections and even the common cold viruses. Perhaps is it even more beneficial to combine the function of Vitamin C and reducing the intake of sweets and sugars in an attempt to enhance immune function. By simply reducing the amount sugar we place in our mouths, we reduce the amount of bacteria in this area as well. Proper oral hygiene is also essential for keeping bacteria growth in the oral cavity and throat to a minimum. Our mouths are the perfect breeding ground for bacteria, especially when sugars are readily available. The excess bacteria produce toxins and irritation to the normal tissue within the mouth and throat, rendering them vulnerable to opportunistic viruses. If the growth of bacteria is kept to a minimum, the tissue integrity is more easily maintained, and these opportunistic viruses will be less likely to invade healthy cells. In addition to this, the immune response triggered by our tonsils will cause a release of chemical irritants to tissues throughout the entire body. Interferon is one of the chemicals the body releases in response to viral infections, and the result is generalized body pain with fatigue. Prostaglandin release will also create generalized swelling and inflammation. Since these are symptoms relating to Fibromyalgia, it becomes apparent that high intake of sugars can have a negative overall effect on the immune system, and create a situation of increased body pain. I am unaware of any scientific research regarding the subject of high levels of simple sugar ingestion, but we have been exposed to clinical relevance such as the next case discussion.
As I was taking a case history of a patient in my office, the topic of muscle pain and painful menstrual cramps came up. Evidently, the patient used to experience a lot of cramping and heavy bleeding during her menstrual period, until her tonsils were removed when she was in late teenage years, due to a history of chronic sore throats. Until this point in time, the patient was unable to logically come up with an explanation for this phenomenon. Upon further questioning, she was also experiencing generalized fatigue, generalized body pain, and some moderate occasional joint pain as well, prior to the tonsillectomy. After several minutes of consideration, we came to the conclusion that the tonsils were constantly becoming inflamed, fighting off a mild infection in the mouth. Since the tonsils are the immune system’s first line of defense, they were producing chemical messengers for the rest of the body, triggering interferon release and prostaglandin release. More than likely, they were fighting to keep higher than normal levels of bacteria in check, and possibly fighting off an opportunistic virus as well. They responded by releasing interferon and small levels of prostaglandins to help the rest of the body begin preparation for battle, but the result was muscle and joint pain from interferon, and excess contraction of the uterus from the release of prostaglandin. The above case observation supports the theory of bacteria overgrowth in the mouth creating vague body pains, and even painful menstrual cramps. However, it is not logical to have your tonsils removed to test out this theory, but instead simply decrease your intake of sugar to suppress bacterial growth in the oral cavity.
There is some supporting clinical evidence relating to the above theory in terms of bacterial overgrowth. Numerous alternative health practitioners have had remarkable results in terms of symptom reduction for patients following herbal cleanses and probiotic supplementation to stimulate the growth of healthy bacterial in the intestines. Acidophilus and pre-biotic supplementation (namely fructoligosaccharrides or FOS) has also helped to control yeast overgrowth, which can manifest in the oral cavity, as well as any other mucous membranes in the body. Acidophilus is naturally found in yogurt and is referred to as “active cultures”. It can also be purchased at a health food store, but may not always contain live bacteria. A recent study published regarding pro-biotic supplements suggests that supplementation with fructoligosaccharrides actually help restore healthy levels of acidophilus within the intestines, because it is the main source of food for the healthy bacterial. The theory is based upon the premise of providing the optimum environment for the bacteria to naturally multiply, thus restoring colonization.
Many experts agree yeast overgrowth is partially responsible for symptoms of FMS, but concrete evidence is yet to be found to support such a theory. Since we have very little substantial objective evidence for the cause of Fibromyalgia syndrome itself, we cannot overlook yeast overgrowth as a potential cause. Moreover, this theory does have a physiological basis supported by the “oral bacterial overgrowth” concept described earlier in this chapter. “Leaky gut” syndrome has become a buzz word frequently linked with abnormal immune function and auto-immune disease like processes. The idea is based upon the precept that the intestinal lining or “mucosa” has been compromised by diet and malnourishment. There is a resulting increased permeability between the cell walls within the lining, allowing larger proteins (normally broken down into amino acids) and sometimes bacteria to seep into the blood stream. Since these foreign substances are recognized as such, the immune system launches an attack, and the attack is not localized to the protein and small amounts of bacteria. The result is overall body pain, fatigue, sore joints, that being said, we promote herbal cleansing of the body and GI tract, and encourage pre-biotic and pro-biotic supplementation as a part of the holistic treatment program for Fibromyalgia. (continued on page 2...)