by R. Paul St. Amand, M.D.
About 35 years ago I began working with a strange illness in which patients had many common symptoms, but great individual variability. Each patient qualified for the diagnosis "anxiety neurosis." The disease was cyclic and progressive and produced variably disabling effects.
"Fibrositis" was described in 1843, but this name implied inflammation. When muscle biopsies showed none, the name "Fibromyalgia" was coined and went into common usage several years ago. We had, by then, treated several hundred patients using names such as "rheumatism" to cover the diagnosis. It was obviously a very common disorder that needed attention, especially since I, too, suffered from the problem.
Though we estimate we have treated over three thousand such patients, we have never seen a case of pure fatigue syndrome. In well detailed medical papers, the symptom overlap between fibromyalgia and chronic fatigue is obvious. For the purposes of this article, let me use "Fibromyalgia" to cover the subject.
The symptoms are well-known but bear repeating. They consist of fatigue, irritability, nervousness, depression, insomnia (frequent awakening), impaired memory and concentration. Headaches, dizziness, blurring of vision, eye irritation or dryness, inappropriate flushing, sweating or sudden cold spells continue this list. Equally frequent are nasal congestion, abnormal taste varying from bad to metallic, ringing or other ear sounds, numbness or tingling in various locations. The irritable bowel syndrome, or spastic colon consisting of gas, bloating, constipation with or without diarrhea are commonplace. There is a high incidence of transient burning on urination, strong pungent urine (often dark and foamy) and, in some patients, repeated bladder infections. Patients also note cyclic chipping, breaking or peeling of fingernails. The restless leg syndrome and frequent foot or leg cramps are often present, usually at night.
We usually elicit a history of arthritis or rheumatism especially in older family members In fact, it is quite uncommon not to find symptoms suggesting fibromyalgia in other relatives. For example, my father, two sisters, and my three daughters all have this illness.
A multigenetic disease is likely. We have treated patients as young as four and have seen onset in patients in their seventies. Women predominate 80 percent to 20 percent men. Belgian authors have reported three genes associated with fibromyalgia, and since none was located on the X chromosome, such linkage will probably be found. The age of onset and the severity of the illness may depend on the number of inherited gene defects. Thus, inheritance from both parents assures early onset of fibromyalgia.
Results of physical examination of patients places much emphasis on the finding of eleven out of eighteen predetermined "tender points." This has been a useful concept, though somewhat artificial. We easily find many more widely distributed areas of swelling, spasm, and tenderness scattered all over the body. We map such findings and sketch the approximate size and induration of each. This map does not depend on tenderness, but mainly on what trained examiners feel. This map serves as an easy reference on subsequent visits to assure clearing of lesions.
Our work began when a patient on gout medication announced he could strip tartar from his teeth with his fingernail. This effect of his drug suggested a possible abnormality in calcium phosphate metabolism. We wondered if similar deposits were occurring elsewhere. We wondered if this were related to some rheumatic problem, and with the help of observant patients, soon were struck by the similarity of symptoms in these "neurotics." It was as though they had gone to some mysterious course dealing how to be tired, nervous and achy! It seemed obvious we should try gout medications on this new syndrome, and we did. The older gout medications (Probenecid and Sulfinpyrazone), however, did have side-effects. It was a delight about three years ago when we discovered that the simple expectorant Guaifenesin (mucus loosening medication) worked best and without side effects.
Our premise is that the inherited enzyme abnormality leads to faulty urinary excretion of something that then accumulates in the body as an intracelluar, abnormal excess. From this there is a partial blockade to the formation of ATP, the source of "power" which energizes most functions of every cell. Only this or a similarly basic, total body problem would seem to account for all the symptoms of fibromyalgia. We have suspected an abnormality in excretion of phosphates as the cause of the ATP problem. In turn, calcium would follow phosphates into the cell, and when this sits free in the intracellular fluid, forces the cell into either action, or blocks its function. Calcium belongs in certain cellular reservoirs, and, when it is released into the fluid of a cell (cytoplasm) effects such as a continuous muscle contraction occurs. Since nothing other than calcium free in the muscular fluid can sustain muscular contraction, it follows that the spastic muscle parts we find in the so-called tender points are sustained by excess calcium in the wrong place.
Guaifenesin seems more powerful than our previous medications. It is capable of reversing the entire process of fibromyalgia in a cyclic progressive fashion. Treatment unfortunately reverses all disease symptoms in more intense cycling. This is due to a rapid attack on multiple areas simultaneously. An average reversal rate is about one year of "cleansing" for two months of proper dosage. This occurs faster for a lucky 25-30 percent of individuals.
We begin our patients at 300 mg. twice a day of long acting guaifenesin. This requires breaking a tablet in half to start because long acting tablets are 600 mg. After one week if a patient has not felt any change, he or she is asked to raise his or her dosage to 600 mg. twice a day. This latter amount suffices for 80% of patients. A few will obviously need more. We hold patients at the 1200 mg. a day for one month and if there has been no worsening of symptoms the dose is raised to 1800 mg.
Aspirin completely blocks the benefit of all medications we have used, including guaifenesin. The greatest source of patient error comes from taking aspirin-related agents, salicylate or salicylic acid, which interfere with guaifenesin at the kidney level. Skin readily absorbs these compounds. Almost all plants manufacture salicylates, often in large quantities. Patients can neither take these nor use any skin creams that contain plant products.
Many pain medications contain aspirin or have "salicylate" or "salicylic acid" as part of their contents. Tylenol, Advil, Darvocet-N and anti-inflammatory drugs are acceptable. One must avoid products containing aloe, ginseng, menthol, mentholatum, almond, grapeseed oils etc. Castor oil and camphor have recently appeared in many lotions, lipsticks and underarm deodorants--they are high in salicylates. Ingredients with plant names (butchers' broom, rosemary, geranium, St. John's Wort) must be avoided. Vitamin C derived from Rose Hips and vitamins from "natural" sources such as vitamin C with bioflavanoids, which may contain quercetin, are also a source of salicylates. These offending substances will block the effect of guaifenesin. No adverse reaction ensues but no benefit is attained.
Fibromyalgia requires the over-utilization of fuel--that is, foodstuffs. The constantly contracted muscles work day and night. We find some 50 percent or more of our patients have a sugar craving, especially during cycles of pain and fatigue. This will push some into the hypoglycemia syndrome, or worse, into panic attacks caused by the release of adrenaline. This complex must be treated dietarily. Only the removal of sugar, caffeine and heavy starches from the diet will control it. It would be the subject of another article to explain the interplay of fibromyalgia with the entity known as the hypoglycemia syndrome. These same hormonal, chemical and enzymatic disturbances may also explain some weight gain experienced by many fibromyalgics.
Life has charm for the healthy. There is hope for the fibromyalgics and fatigued of the world. Happiness has been defined as freedom from pain (mental or physical). I wish you all that happy state.
"Now at last, in well-detailed medical papers, the symptom overlap between fibromyalgia and chronic fatigue has been made obvious. Most physicians now believe they are the same malady."
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