Fibromyalgia is a challenging disorder – for patients and for doctors in terms of trying to find effective treatment.
Generally speaking once you have fibromyalgia you are stuck with it. In some rare instances it may resolve without treatment.
Standard medicine focuses on symptom relief and avoidance of symptom worsening.
Functional medicine takes a different approach.
Functional medicine asks two questions:
- What is the root cause of this particular patient’s fibromyalgia and
- What can we do to, insofar as it is possible, to ‘fix’ the root cause of the fibromyalgia and, insofar as possible, make the fibromyalgia go away so that they do not have to spend the rest of their days on antidepressants, sleeping pills and pain-killers.
Below is an article which I have written on fibromyalgia.
The first sections review the ‘standard’ medical information.
In the later sections I describe the functional medicine approach to fibromyalgia.
I have also included a typical case history of a patient with fibromyalgia.
Fibromyalgia is a common neurologic health problem causing persistent widespread pain and tenderness (sensitivity to touch). The pain and tenderness tend to come and go and move about the body. Most often, people with this chronic (long-term) illness are fatigued , frequently have sleep problems and also other associated symptoms. For a diagnosis of fibromyalgia standard medical screening laboratory tests must be normal and other diagnoses with similar symptoms must have been excluded..
Key descriptive points in Fibromyalgia
- The pain is widespread – both above and below the waist and on both sides of the body
- The pain is persistent – over three months duration
- There are multiple tender sites within the body
- There will be associated symptoms which may include fatigue, difficulty sleeping, on restorative sleep, cognitive problems (aka ‘brain fog’)
- The standard medical tests are normal and other possible diagnostic explanations have been considered and excluded
- The diagnostic criteria which needed eleven out of eighteen areas of the body to be tender to touch were abandoned some years ago
Who gets fibromyalgia and how common is it?
- Is estimated to affect 2 to 4% of the population
- Is much, much commoner in women
- Most frequently presents in midlife but also may present during the teenage years or in the elderly
- People who already have a rheumatic disease are at greater risk for fibromyalgia
Conditions which may be confused with fibromyalgia
It is important to determine whether your symptoms are caused by some other underlying problem. Joint pain is not a diagnostic feature of fibromyalgia. Other diagnostic possibilities which need to be considered include:
- Rheumatic diseases.Certain conditions — such as rheumatoid arthritis, Sjogren’s syndrome and lupus — can begin with generalized aches and pain.
- Mental health problems.Disorders such as depression and anxiety often feature generalized aches and pain.
- Neurological disorders.In some people, fibromyalgia causes numbness and tingling, symptoms that mimic those of disorders such as multiple sclerosis and myasthenia gravis.
Tests that may be needed to diagnose fibromyalgia
While there is no lab test to confirm a diagnosis of fibromyalgia but a doctor may want to rule out other conditions that may have similar symptoms and blood tests may include:
- Full blood count
- Erythrocyte sedimentation rate (ESR)
- Rheumatoid factor
- C- Reactive protein (CRP)
- Thyroid function tests
- Vitamin D levels
The cornerstone for a reliable diagnosis of fibromyalgia is a careful physical exam of the joints and muscles together with the neurological exam to look for other causes of the patient’s symptoms. Newer American College of Rheumatology guidelines no longer require an “eleven out of eighteen tender points”
The standard medical tests all will be negative i.e. normal in fibromyalgia
Other clues to a possible diagnosis of fibromyalgia
People who have fibromyalgia also often wake up tired, even after they’ve slept continuously for more than eight hours. Brief periods of physical or mental exertion may leave them exhausted as well as having problems with short-term memory and the ability to concentrate.
Fibromyalgia often coexists with other health problems including :
- Irritable bowel syndrome
- Jaw / temporomandibular joint pain
- Anxiety or depression
- Frequent or painful urination or interstitial cystitis
Fibromyalgia symptoms sometimes begin after a physical trauma, surgery, infection or significant psychological stress. In other cases, symptoms gradually accumulate over time with no single triggering event.
Risk factors for fibromyalgia include:
- People who have post-traumatic stress disorder appear to be more likely to develop fibromyalgia.
- Some infective illnesses appear to trigger or aggravate fibromyalgia
- Your gender.Fibromyalgia is diagnosed more often in women than in men.
- Family history and genetics.Because fibromyalgia tends to run in families, there may be certain genetic mutations that may make you more susceptible to developing the disorder.
- Many people who have fibromyalgia also have tension headaches, temporomandibular joint (TMJ) disorders, irritable bowel syndrome, anxiety and depression
- Other disorders.If you have osteoarthritis, rheumatoid arthritis or lupus, you may be more likely to develop fibromyalgia.
Below is an outline of the standard medical treatment for fibromyalgia
In general, treatments for fibromyalgia include both medication and self-care. The emphasis is on minimizing symptoms and improving general health. No one treatment works for all symptoms.
Medications can help reduce the pain of fibromyalgia and improve sleep. Common choices include:
- Pain relievers.Over-the-counter pain relievers such as acetaminophen (Tylenol, others), ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve, others) may be helpful. Your doctor might suggest a prescription pain reliever such as tramadol (Ultram). Narcotics are not advised, because they can lead to dependence and may even worsen the pain over time.
- Duloxetine (Cymbalta) and milnacipran (Savella) may help ease the pain and fatigue associated with fibromyalgia. Your doctor may prescribe amitriptyline or the muscle relaxant cyclobenzaprine to help promote sleep.
- Anti-seizure drugs.Medications designed to treat epilepsy are often useful in reducing certain types of pain. Gabapentin (Neurontin) is sometimes helpful in reducing fibromyalgia symptoms, while pregabalin (Lyrica) was the first drug approved by the Food and Drug Administration to treat fibromyalgia.
A variety of different therapies can help reduce the effect that fibromyalgia has on your body and your life. Examples include:
- Physical therapy.A physical therapist can teach you exercises that will improve your strength, flexibility and stamina. Water-based exercises might be particularly helpful.
- Occupational therapy.An occupational therapist can help you make adjustments to your work area or the way you perform certain tasks that will cause less stress on your body.
- Talking with a counselor can help strengthen your belief in your abilities and teach you strategies for dealing with stressful situations.
Lifestyle and home remedies
Self-care is critical in the management of fibromyalgia.
- Reduce stress.Develop a plan to avoid or limit overexertion and emotional stress. Allow yourself time each day to relax. That may mean learning how to say no without guilt. But try not to change your routine completely. People who quit work or drop all activity tend to do worse than do those who remain active. Try stress management techniques, such as deep-breathing exercises or meditation.
Get enough sleep. Because fatigue is one of the main characteristics of fibromyalgia, getting sufficient sleep is essential. In addition to allotting enough time for sleep, practice good sleep habits, such as going to bed and getting up at the same time each The timeline concept is really important: when did the illness begin was there any association with menopause or perhaps a gastrointestinal infection, and operation or an injury.
- day and limiting daytime napping.
- Exercise regularly.At first, exercise may increase your pain. But doing it gradually and regularly often decreases symptoms. Appropriate exercises may include walking, swimming, biking and water aerobics. A physical therapist can help you develop a home exercise program. Stretching, good posture and relaxation exercises also are helpful.
- Pace yourself.Keep your activity on an even level. If you do too much on your good days, you may have more bad days. Moderation means not overdoing it on your good days, but likewise it means not self-limiting or doing too little on the days when symptoms flare.
- Maintain a healthy lifestyle.Eat healthy foods. Limit your caffeine intake. Do something that you find enjoyable and fulfilling every day.
I see my role as helping patients especially when the standard medical treatment is not working for them.
My medical philosophy also differs from the standard medical approach.
Standard medicine for fibromyalgia concentrates on symptom management and helping the patient to, hopefully, not get worse
My approach is the functional medicine approach : Let us try to find out what is wrong and fix it.
“You have this disorder which is called fibromyalgia. The cause of fibromyalgia differs between patients. Let us try and see what is causing your fibromyalgia and see if we can actually ‘fix’ it . Let us see if over time by working together we can reduce or eliminate the painkillers, the antidepressants, the sleeping pills and the anxiety medicines and try to get you to a point where you are pain-free, energetic and are able to once more live a ‘normal’ life.”
It is a precondition of seeing me that patients have been investigated by their GP or consultant so I have the comfort of knowing that life-threatening disease has been excluded.
The completed health questionnaire is important – you and I need to work together as a team.
Please complete health questionnaire carefully.
Timeline is an important
An example of past medical history
birth to 10 years
aged 4- 8 lots and lots of sore throats
aged 8 tonsils removed
Do you / did you – some things which I always keep in mind when I am trying to assemble the ‘fibromyalgia jigsaw’. Issues which I am thinking about.
Is your digestion a possible trigger / do you suffer frequent gastrointestinal symptoms? Remember a huge part of the immune system resides in the abdominal cavity
What about persistent vaginal candidiasis /thrush or possibly gastrointestinal fungal overgrowth?
Do you live in a mouldy, damp environment?
Could this person have a deficiency of stomach acid or a deficiency of digestive enzymes.
Is it possible that this individual might be inefficient at absorbing zinc or maybe, despite supplementation, they might have persistent low magnesium levels
Might a patient with dental amalgam fillings which are leaking mercury have a system which is not efficient at excreting/ detoxifying mercury.
Have you experienced onset or worsening of symptoms since menopause?
Did a serious infective episode kick things off?
Maybe roestrogen levels may suddenly have dropped (partial ovarian failure) without periods is actually disappearing?
Is there as significant food intolerance?
Could you maybe have a methylation abnormality which would affect both ability to detoxify foreign compounds but also affects serotonin availability and how your body handles hormones
Might you possibly have elevated free copper
What about either elevated or else very depressed salivary free cortisol levels.
At the end of the first consultation we organise the investigations.
At the second consultation (usually about four weeks after the first consultation) we formulate an individualised initial treatment plan which addresses the likely causes your particular case.
How I treat fibromyalgia
Do not throw away the medicines prescribed by your GP or consultant if they are working for you. As you hopefully improve you can discuss tapering and eventually discontinuing the medicines in cooperation with your prescribing doctor
Fibromyalgia: A typical enough case history
The Patient and her symptoms
A 45-year-old female who has fibromyalgia with a history of hypothyroidism, is on Eltroxin, has low baseline energy which dips even more accompanied by sugar cravings for a week before her period. Energy is very poor during the period itself, and she also is experiencing very heavy menstrual bleeding which has been investigated and uterine fibroids. Energy recovers to its normal poor baseline on about the sixth-day have her cycle but the fibromyalgia goes on for all of the month but is definitely worse in the week preceding her menstrual period. This lady also suffers from vaginal dryness, cognitive issues (aka as ‘brain fog’) , abdominal bloating, constipation and vaginal candidiasis/thrush. Libido has been low for some time and she finds her mood is very low during winter –she has a problem from when the clocks go back at the end of October until the beginning of April.
The patient consultation process in fibromyalgia
A detailed patient history is the first priority.
During the first patient visit it should become obvious what the most important diagnostic leads to follow up on are.
Appropriate laboratory testing is then organised to either rule in or rule out the various diagnostic possibilities.
How to ‘think’ about fibromyalgia using a functional medical model
Part of the thinking process in the first visit would include:
This lady is a typical enough example. Having assessed the medical history I then will decide how to investigate
I will usually check oestrogen progesterone FSH and LH hormone levels during the menstrual period ( usually during days 2 to 5 )and also check oestrogen and progesterone later in the cycle probably around days 18 to 21. I will also look at, as well as general bloods, DHEA level, testosterone and free testosterone.
Standard laboratory tests for magnesium are meaningless because the majority of magnesium is within cells (intracellular) so measuring magnesium within the serum or plasma is a waste of time. Thankfully the patient’s symptoms of low magnesium are usually very obvious which is a great help diagnostically.
I also would be very concerned as to whether or not this lady has enough stomach acid and digestive enzymes to absorb minerals like magnesium and zinc and to maintain a normal microbiome /gut bacterial balance.
I will look at free thyroid hormone 3 (tri-iodo-thyronine) and three as well as free thyroid hormone 4(free thyroxine).
It would be important to consider whether or not to investigate urinary mycotoxins i.e.. get the urine tested for toxins made by fungi which may be an indication that there is an overgrowth of fungi.
If there are urinary mycotoxins present then, at some stage but probably further down the road, it may be important to consider whether mercury leeching from dental amalgam is playing a negative role.
It may also be important to consider testing for a methylation abnormality or elevated free copper there usually will be useful pointers usually in the medical history
Then let’s imagine that cortisol levels are very high showing a high level of stress on the adrenal glands.
In the real world it is not always possible nor is it cost-effective to investigate everything at once. One tries to pick out the action areas which will likely make the biggest contribution to the patient’s health.
The priorities in treatment
The second patient visit is devoted to three things: Review of initial symptoms and medical history to make sure nothing was missed at the first visit. By this stage all the results of laboratory investigations will be available and these need to be integrated with the clinical findings from history and examination. This process then needs to the organisation of an initial treatment plan:
So let us suppose that is now the second consultation and we have our blood results and other tests back which will help us in decision-making.
In my opinion it also is still worthwhile to test basics like vitamin B12 level all over again because, sometimes, an individual has a long-term illness although the basic investigations are often done in the beginning now, say, perhaps five years on from the initial diagnosis basic lab tests like B12 level may have been forgotten about and B12 may have, unbeknownst to all, slipped down to a low level
From history it sounds like this lady’s oestrogen levels have dropped but we also know she is having heavy periods (she probably is having anovulatory cycles and not producing adequate amount of progesterone) so giving her more oestrogen without balancing it with progesterone would be incorrect so she probably needs both oestrogen and progesterone supplementation – progesterone, by itself, would render our patient more tired, fuzzy-headed and more constipated and also likely make period heavier
Let’s suppose that on the thyroid testing we find that free T4 levels are up near the top of the range but that free T3 levels are at the low end of the range and the patient also feels quite cold a lot of the time with a slow pulse then I may suggest either strategies to improve conversion of T4 to T3 (T3 is biochemically significantly more potent thanT4) or else we may try adding in a little bit of T3 supplementation. Also important to remember that the half-life of T3 is much shorter than that of T4 so T3 – if it is being supplemented – will need to be dosed twice daily usually.
Let’s suppose that bicarbonate testing is suggestive of low stomach acid. So this will then this will need to be supplemented. Probably digestive enzymes will also need supplementation.
Magnesium and or zinc supplementation may be indicated from the medical history.
Because of the vaginal thrush we are suspicious that this lady has a reservoir of fungal overgrowth in her bowel. Hopefully supplementing with stomach acid and digestive enzymes and a probiotic will improve this without needing to use antifungal antibiotics. Hopefully also getting the fungus under control will reduce the level of inflammation in the body. Although official medicine states that fibromyalgia is not an inflammatory disease I consider to be an inflammatory/autoimmune disorder.
If we have found an elevated free copper then this will also need to be treated.
We will hope that having supplemented stomach acid provided good quality digestive enzymes and probiotics gastrointestinal function will hopefully improve, the constipation will go away, the gastrointestinal contribution to the ongoing inflammation which is at the root of the fibromyalgia will improve.
If this lady has been demonstrated to have a probable methylation abnormality then improving methylation chemistry will hopefully help with the sugar cravings and also improve or resolve the seasonal affective disorder component.
Some of the brain fog and the physical pain is possibly due to low oestrogen levels so hopefully the oestrogen supplementation will help resolve the tiredness before and during the period and also help significantly with the sore limbs.
Between all the above steps one would hope that this patient would have a significant improvement when reassessed in six weeks. hen, depending on response the treatment would need modification.
The third patient visit takes place 6 to 8 weeks after the second patient visit and this visit focuses on : how well is the initial treatment plan working for the patient. If, as we hope the treatment is working well, then what aspects of the treatment need to be improved. If the treatment is not making a a different then what has been missed diagnostically?
At that six week stage the treatment will need to be adjusted and fine tuned .
If, after six weeks stage there is no significant improvement will then all of the treatment would need to be seriously reviewed because, within a six weeks window, one would expect that any effective treatment given to a patient with fibromyalgia would have begun to bear some fruit – even if the response has not been dramatic there ought at least to have been some shift in how the patient is feeling e.g. even if the pain was still bad the patient might say “I’m sleeping better” or “I have more energy “ or their digestion or fatigue before their period has improved even though their baseline fatigue may remain the same. It’s then a matter of managing all the detail as one proceeds.