By Ian Anderson, B.Sc., DC
HOW COMMON IS IT?
Fibromyalgia is no joke! It is estimated that up to 4% of the U.S. adult population has fibromyalgia. If this information is correct and can be extrapolated to the Ottawa region, then approximately 10 000 to 15 000 people could have this condition in Ottawa. Women are more often affected by the condition than men by a 5 to 1 ratio.
WHAT ARE THE SYMPTOMS AND SIGNS OF FIBROMYALGIA?
The following chart shows the most common signs and symptoms of fibromyalgia:
| Age (years) | 49.5 (24-65) |
| Number of history criteria fulfilled | 5.6 (3-7) |
| Number of tender points | 9.7 (4-14) |
| Duration of muscle pain (years) | 11.5 (2-40) |
| Symptoms worsened by cold, damp weather | 78% |
| Symptoms worsened by physical activity | 93% |
| Poor sleep | 68% |
| Fatigue during daytime | 95% |
| Subjective swelling | 86% |
| Irritable bowel syndrome | 18% |
| Morning stiffness (>30 mins.) | 74% |
WHAT ARE THE FACTORS THAT AGGRAVATE FIBROMYALGIA SYNDROME (FMS)?
PRIMARY FMS
| SOCIAL AND ENVIRONMENTAL FACTORS |
NEUROENDOCRINE FACTORS |
| Home and job stress | Low energy, easily fatigued, |
| Pending litigation | reduced stamina |
| Cold intolerance | Neuroautonomic imbalance |
| Unemployment, lack of productivity | Nonrestorative sleep |
| Unrealistic goals | |
| BIOMECHANICAL FACTORS | PSYCHOLOGICAL FACTORS |
| Hyperlaxity | Affective spectum disorders |
| Overuse, overload | Anxiety disorders |
| Physical deconditioning | Depression |
| "Tight body" | Helplessness behaviours |
CAUSES OF FIBROMYALGIA UNDER INVESTIGATION
The exact cause of fibromyalgia is unknown at this time; however, the following areas are presently under investigation.
Sleep Disturbances:
Smith and Moldofsky report a profound stage 4 sleep deprivation due to intrusions of alpha rhythms among the normal non-REM delta pattern. REM sleep is normal. Patients with fibromyalgia (FM) are often unaware that their sleep has been interrupted. Lack of adequate sleep has been suggested as a cause for increased morning symptoms of pain and fatigue.
In a study, six FM patients were deprived of stage 4 sleep and seven of REM sleep. The group deprived on stage 4 sleep reported more musculoskeletal symptoms, significantly increase in muscle tenderness, and an increase in morning symptoms compared to the REM-deprived group.
Lack of Exercise:
Regular aerobic exercise, appears to protect against developing fibromyalgia. Three quite physically fit FM subjects had no pain symptoms nor change in dolorimeter (tenderness to touch) scores with deprivation of sleep 4 sleep.
Lack of conditioning may cause the pain, weakness, and fatigue after exertion. Poor conditioned muscles cannot be restored as quickly as conditioned muscles due to less glycogen storage and low ATP (the energy for muscles to work). Patients with fibromyalgia tend to be sedentary and below the level of average physical fitness. It is not clear whether lack of conditioning promotes pain or vice versa.
The profound exhaustion and increased pain after exertion gradually leads to less exercise and activity. Seventy-five percent of FM patients reported exhaustion following minimal activity.
Microtrauma:
Microtrauma caused by or resulting from hypoxia, ischemia, stress, prolonged muscle spasm,local muscle abnormalities was suggested after studies showed nonspecific ultrastructure changes in the muscles of fibromyalgia patients. Muscle biopsies taken from fibromyalgia (FM) patients showed no evidence of inflammation, but there were significant changes indicative of chronic muscle spasm and ischemia.
A sustained contraction of even 4% of a maximal voluntary contraction impairs circulation. Metabolites accumulate causing a drop in muscle pH. The result is abnormal muscle enzyme function with the inhibition of ATP. Muscle energy depletion can occur. Thus postural abnormalities and muscle imbalances can result in microtrauma and eventually pain.
Posture:
Apart from local muscular pain caused by overuse or inflammation (with local irritation of nociceptors) and apart from referred pain (with pain radiating in a segmental pattern), there may be a third type of pain in the muscular system: centrally controlled tendomuscular pain (CCTMP) called tendomyose.
CCTMP might develop by a defined loss of central inhibition to neural impulses and this is how intact muscle might become painful by way of a guarding mechanism of the nervous system. It is my belief that muscular pain does not have to be caused by overstressed or ischemic muscles, but could be regulatory pain functioning as a guarding mechanism to avoid a position (in the case of FM a flexed position). A study by Hiermeyer found that in patients with pain in the neck, shoulder, or back; the pain very often disappeared after local anaesthesia in the sternocostal joints or in the pubis symphysis - which might prove that the origin of widespread pain could lie in these regions, which are overstressed in flexed position.
12 tender points of FM lie on erecting muscles and another 4 points lie at sternal joints, both of which are overstressed in a flexed position (FP). These findings may indicate the influence of posture on fibromyalgia syndrome. Studies show that posture has an influence on palpatory pain at trigger point (TP) sites. (see diagram below).
Chemical Imbalances:
Growth hormone is critical in maintaining and repairing muscle. The secretion of growth hormone occurs primarily during stage 4 sleep and this in turn results in a rise in somatomedin C. Serum levels of somatomedin C were found to be significantly lower in 70 fibromyalgia patients compared to 55 healthy controls. Persistently low levels of growth hormone secretion may predispose to muscle microtrauma and/or impair normal healing after muscle microtrauma or ischemia.
A tryptophan-serotonin deficiency has been proposed. Tryptophan is a precursor to the neurotransmitter serotonin. Serotonin regulates deep, restorative non-REM sleep, affective status, circadian release of adrenocorticotropic hormone (ACTH), and the interpretation of painful stimuli. A lack of serotonin or its precusor could account for many of the symptoms reported by FM patients. Serum serotonin and tryptophan were significantly lower in FM patients than matched controls. On an interesting note, supplementing patients' diet with tryptophan improved sleep, but worsened the musculoskeletal pain.
A number of other chemicals and their effects have been poorly studied, but they help explain the increased perception of pain, and the irritable bowel syndrome which oftens accompanies FM.
These include:
Emotional States:
Emotional stress, anxiety, or depression may be a common etiology pathway.
Catecholamine levels rise during stress responses and have been found elevated in the urine of FM patients. No correlation has been found between the clinical features of FM and the psychologic status of the patient. Fibromyalgia does not appear to be depression, anxiety, or stress, although all of these contribute to enhanced pain. Fibromyalgia, chronic fatigue, irritable bowel syndrome, and depression may share a common physiologic abnormality.
Some doctors believe repressed guilt may play a role in this syndrome also.
Viral:
Some FM patients report onset after infections or viral exposure. Up to 54% of FM patients reported prior Lyme disease. Other infectious agents associated with FM include human immunodiciency virus, Coxsackie virus, Epstein-Barr, Streptococcus, and Parvovirus. FM and chronic fatigue syndrome have failed to demonstrate tissue invasion by any microorganism. However, viral exposure may activate cytokines which might produce the symptoms.
A compromised gut mucosa can lead to hyperpermeability allowing small, foreign proteins like antigens and possibly viruses into the systemic circulation (leaky gut syndrome). This could lead to recurrent fibromyalgia. Treatments to improve gut health have been tried for similar conditions like CFS (Chronic Fatigue Syndrome). Since CFS patients report good results, the same treatments have been proposed for fibromyalgia.
Nutritional Deficiencies:
Lack of dietary substances needed for ATP synthesis and for mitochondrial respiration may cause FM. A malate deficiency may cause physical exhaustion since malate is the common mediator of increased mitochondrial respiration.
Magnesium is crucial for glycolysis, so a deficiency in magnesium could cause hypoxia. A magnesium deficiency is associated with muscle cramps upon exertion and upon awakening. Calcium in proper balance with magnesium, allows normal muscular muscle function. In excess, calcium will inhibit magnesium absorption and metabolism.
TREATMENTS
Studies find that 70% will have significant improvement in pain symptoms and functional capacity if the syndrome is identified early and the patient is well motivated. Management programs must focus on modalities to reduce pain, instruction in posture, manipulation to restore proper biomechanics, stretching and exercise, stress reduction, life-style changes to improve sleep, naturopathic techniques and appropriate pharmaceuticals. The most successful programs emphasize the patient's active participation.
Manipulation:
Any abnormal biomechanics or trauma (microtrauma) could result in abnormal biochemical function and impaired performance leading to pain and disability. A study reports reduction in headaches and joint pain following manipulation of a patient with chronic fatigue syndrome. Since both FM and CFS present with significant chronic musculoskeletal pain, a course of manipulation may be warranted. Manipulation does not appear to "cure" the condition.
A significant number of FM patients tried manipulation for relief of their discomfort with 37%-45% reporting moderate to great improvement.
This was more successful than the two most recommended drugs for FM. Chiropractic was reported as giving no relief in 16.2% of cases, while drugs were of no benefit in 45% of patients. A study done by Wolfe reports that chiropractic treatment scored among the most effective treatments. The use of chiropractic treatments has been in recent literature to help control pain in the FMS patient.
Pharmaceuticals:
In a patient survey, amitriptyline, the most commonly prescribe drug for FM, provided moderate to great improvement in only 30.2% of cases, with 56.6% reporting no improvement. Cyclobenzaprine, the second most commonly prescribed drug, was reported to be effective in 39% of cases, with no improvement noted by 46.3% of patients. Taken as a whole most pharmacotherapy was reported as ineffective by more than 45% of patients.
Lithium therapy may work in FM by enhancing the effects of tricyclic antidepressants. There are three case studies utilizing lithium carbonate at 300 mg. two to four times daily as an adjunctive treatment.
All patients experienced a prompt and marked reduction of pain and stiffness. Laboratory parameters in these patients showed no evidence of lithium toxicity to the thyroid or kidneys.
Exercise:
Exercise is a key aspect of management. Many FM patients are afraid of increasing the pain and fatigue if they exercise. When done properly, there is no exacerabation of symptoms. Sherman recommends a low-impact, low-load, repetitive activity, such as brisk walking, biking, or swimming, starting at 5 minutes a day and gradually building to 30 minutes three to four times weekly. Such exercise will enhance general fitness, posture, flexibility, improve blood flow to muscles, and contribute to a general sense of well-being.
Nutritional:
Oral malate and magnesium at 1200 - 2400 mg and 300 - 600 mg respectively, reduced tender point pain by 41% after 4 weeks and 67% after 8 weeks. Vitamin E is necessary for the prevention of the particular type of abnormal connective tissue changes which occur in primary fibrositis and for the cure of the condition. Three of four patients with FM and associated fluid retention syndrome followed a low-carbohydrate, low sodium, low-calorie diet to reduce water retention and promote weight loss. All three noted relief from edema, diurnal weight gain, and the aches and pains. Prior drug therapy of the three patients was unsuccessful.
Animal studies have shown that deprevation of essential fatty acids in the diet can lead to generalized defect in connective tissue synthesis and thus may cause pain in FM patients.
Homeopathy:
Rhus toxicodenfron 6c (tincture of poison oak diluted in ethanol) was the most commonly indicated homoeopathic medicine for 42% of FM. In a double-blind, placebo-controlled, crossover design trial, the treatment group did better in all variables compared to placebo. The number of tender spots reduced by about a quarter. A significant improvement in pain and sleep was reported. Constitutional homeopathic treatment is indicated for sustained improvement.
Tropical Irritants:
Capsaicin, a compound found naturally in chilli peppers, has been shown to specifically target type C sensory neurons and impact their ability to synthesize, store, and release substance P. Patients treated with 0.025% cream four times daily reported significantly less tenderness in the tender points than controls at week 4.
Biobehavioral Therapies:
Sixty-nine FM patients met in small groups for 10 weekly sessions to learn relaxation techniques, stress reduction, and coping strategies. Of the 44 completing the program, 96% felt the program was valuable.
Moderate clinical improvement was noted in 57% and marked improvement in scores reported in 18%.
Patients treated with EMG-biofeedback showed a signigicant improvement in pain scores, morning stiffness, and the number of tender points when compared to the sham biofeedback group. The improvement remained at 6 months posttreatment.
Sleep:
The patient should create a relaxing environment using a comfortable mattress and temperature, no noise or lights, no pets in the room, and no late evening alcohol, liquids, meals, caffeine, or exercise.
Psychological Therapy:
Psychological therapy or a support group may be warranted to reduce depression, anxiety, stress, anger, and so on.
Food Intolerance Assessment:
According to Dr. Carrol, elimination of a person's constitutional food intolerances may significantly reduce their health difficulties. Thus, patients with FM may notice a significant improvement in pain, energy and sleep with certain foods eliminated from their diet.
Acupuncture:
Traditional acupuncture has been used for centuries for pain management. Proper techniques and point selection can significantly reduce pain, improve quality of sleep and improve energy. Dr. Bruce Pomeranz at the University of Toronto along with Dr. Jacque Beneviste have done numerous studies showing the efficiency of acupuncture in pain management.
IN CONCLUSION
Even though the cause of fibromyalgia remains unknown. Most chronic acquired diseases are believed to result from the interaction of multiple factors related to the host, environment, and precipitating agents. Comprehensive approaches combining clinical and laboratory methods promise to unravel the currently obscure relationships in this complex disorder.
Further information and references can be acquired by calling 829-7100.