Matthew Hogg BSc (Hons) mFNTP mNNA mABH mABNLP
Registered Nutritionist, Hypnotherapist & NLP Practitioner
Fibromyalgia is a chronic condition affecting around 2% of the population in developed countries. Patients experience widespread musculoskeletal pain and fatigue, often to a disabling degree, as well as many other distressing symptoms.
The official definition of fibromyalgia syndrome (FMS) that is most commonly referred to is that published in 1990 by the American College of Rheumatology (ACR). According to this definition fibromyalgia patients must have:
- Widespread pain in all four quadrants of their body for a minimum of three months.
- At least 11 of the 18 specific tender points.
Although this definition hasn't been revised and still stands today, 35 FMS experts recently came to a consensus that a person does not need to have the required 11 tender points to be diagnosed and treated for FMS.This now means that people who may not previously have been diagnosed and received treatment for Fibromyalgia will now do so.
Although the above definition is mainly concerned with pain and tenderpoints, there are a lot more symptoms that may be present in Fibromyalgia, just as fatigue is by no means the only symptom in CFS. Below is a list of common FMS symptoms:
- Fatigue - This can be both physical and mental fatigue. It is a pronounced fatigue that leads to a significant reduction in ability to carry out normal tasks and live your usual lifestyle. The fatigue is usually ever present to some degree and is not relieved by sleep; in fact it may be a lot worse upon waking, especially after a lot of activity the previous day.
- Post Exertional Malaise - A general feeling of being ill. It can be described as a 'flu-like' or 'hangover' feeling.
- Muscle and Joint Aches - These can occur anywhere in the body but the most common sites are the lower back and legs. The aching can be severe and is aggravated substantially by any exertion, physical or mental.
- Cognitive Dysfunction - Symptoms of cognitive dysfunction are a common problem in fibromyalgia patients. They include poor concentration, memory loss (constantly forgetting simple information like names and numbers), inability to take in information (having to read the same thing over and over) and a general reduction in cognitive ability and IQ.
- Jaw Pain - Pain in the jaw and facial muscles that can be severe. There is significant crossover here with myofascial pain syndrome, and temporomandibular joint syndrome (TMJ).
- Morning Stiffness - Stiffness is any of the major joints just as is experienced in other types of arthritis.
- Chronic Headache - As would be expected in someone who feels "ill all over" and achy in general, headaches are a common complaint in fibromyalgia. They are different to headaches experienced before the onset of the illness and their severity usually varies inline with other aches and symptoms.
- Balance Disturbance - An unusual but common symptom is a loss of balance or sensation of dizziness. This most often occurs upon standing up and the sufferer may feel faint and even black out. This is often referred to as 'neurally mediated hypotension (NMH)' or 'orthostatic intolerance' and is most likely due to low blood pressure or abnormal blood flow to the brain.
- Mood and Sleep Disturbances - Depression, anxiety and irritability are often present which frequently leads to misdiagnosis by doctors. Sleep disturbances are common and may present as hypersomnolence (sleeping more than normal), sleep reversal i.e. sleeping all day and awake at night, or insomnia (inability to sleep). Sleep apnea and restless leg syndrome (RLS) are also common.
- Abdominal Pain/Digestive Disturbances - These are symptoms similar to irritable bowel syndrome and fibromyalgia sufferers are often diagnosed with IBS.
- Nausea - Particularly apparent when other symptoms feeling particularly ill in general.
- Skin Sensitivity - This is another unusual symptom. Some CFS sufferers experience a sensation where patches of skin become very sensitive to touch and may feel like they are burning. Some people describe this as a "crawling sensation". There are many different skin care products available that may or may not alleviate some of this ailment. The effectiveness of certain products vary from person-to-person.
- PMS type symptoms - Painful menstrual periods (dysmenorrhea) and painful sexual intercourse (dyspareunia)
Unlike CFS the only symptoms required for diagnosis are those relating to pain. As you can see from this list however, there is much more to the illness and significant overlap with CFS. Symptoms vary greatly in severity with factors such as stress, physical activity and time of day playing a part amongst others.
Pain IS the main symptom however, specifically, pain and tenderness in certain areas of the body when pressure is applied to them. These are what are termed 'tender points'.
Areas where pain my be present include:
- Back of the head
- Upper Back
- Upper Chest
The pain is often worse in the morning, improves throughout the day, and worsens at night. It can be experienced as aching, throbbing, burning or migratory (moving around the body). It is common for patients to also experience muscle tightness, soreness and spasms.
The presence of tender points is currently used to diagnose fibromyalgia. In addition, researchers use a questionnaire known as the Fibromyalgia Impact Questionnaire (FIQ) to determine the severity of a particular patients condtion and how it affects their ability to live their life.
The cause, or causes, of fibromyalgia are still not known. There are a number of theories that have been put forward by researchers. The following are the main candidates:
- Viral Infection
- Immune or Endocrine System Dysfunction
- Autonomic Nervous System Dysfunction
- Substance P
- Candida Overgrowth/Gut Dysbiosis
- Physical Injury/Trauma
- Accumulation of phosphate due to enzyme deficiency
- Chronic Sleep Disorders
Viral infection has often been suggested as a possible trigger of fibromyalgia in susceptible people, just as it has in CFS, due in part to the fact that both illnesses often start with a flu-like illness. Early studies looked for the Epstein-Barr as symptoms of both CFS and fibromyalgia are similar to those of Epstein-Barr infection. Studies however generally found positive results for the virus to be no higher in fibromyalgia patients than in the healthy controls (1). More recently a study involving two groups of fibromyalgia patients, one group whose illness started quickly another whose illness developed gradually, were tested for IgM antibodies to enterovirus. The study found that in the acute onset group 50% tested positive whereas only 15% tested positive for enterovirus antibodies in the gradual onset group. The researchers suggest this may indicate the virus is either involved in causing the illness or that the immune response in the acute onset group is simply different (2). It may be that viral infection is just one of many triggers that can lead to the development of fibromyalgia. This would account for the differences between patients whose illness began with an acute episode and those whose illness developed gradually. Further research may reveal more about the role of viruses in fibromyalgia.
There has so far been less research into immune dysfunction in fibromyalgia than there has with chronic fatigue syndrome. Studies that have been done have hinted at multiple abnormalities in immune function but the exact mechanisms have not been elucidated. Many of the results obtained from research so far parallel findings in CFS including elevated levels of T lymphocytes and certain cytokines accompanied by decreased numbers of natural killer cells (3, 4, 5). Recent research has looked at how immune dysfunction may be causing the soft tissue pain associated with fibromyalgia. One 2004 paper proposed that an autoimmune reaction to vasoactive peptides, molecules that act as hormones, neurotransmitters, immune modulators and more, may lead to the development of the disease state of fibromyalgia. The authors write "The proposed mechanism of action is that inflammatory cytokines are provoked by tissue injury from unaccustomed exercise or physical injury. This may trigger a response by certain vasoactive neuropeptides which then undergo autoimmune dysfunction as well as affecting their receptor binding sites." (6).
Endocrine dysfunction is thought to play a significant role in fibromyalgia. The feeling is that the dysfunction centres around the hypothalamus-pituitary-adrenal (HPA) axis, although other hormones also seem to be involved. Research has shown that the HPA axis in fibromyalgia patients is underactive compared to healthy people with the result of smaller amounts of adrenal hormone being excreted. In one study fibromyalgia patients and healthy controls were given a dose of ACTH, the hormone that tells the adrenal glands to release cortisol. The results showed that 95% of fibromyalgia patients showed a lower response than the lowest recorded result from the control group (7). Clearly this shows significant underactive adrenal glands in fibromyalgia patients. Another study found significantly lower levels of DHEA-S, another adrenal hormone, in fibromyalgia patients compared to healthy individuals (8). Although the researchers didn't link this finding to levels of pain in the fibromyalgia patients, it could well play a role in other aspects of illness, as both cortisol and DHEA are stress hormones, low levels of which can compromise the body's ability to deal with stress of any kind. This same study did correlate low levels of testosterone (male sex hormone) with "poor health status", meaning the lower the level of testosterone, the more severe the patients condition.
Nervous System Dysfunction
Both fibromyalgia and CFS patients suffer from strange cognitive difficulties. Often feeling overwhelmed by sounds, smells and other sensory information, especially when in busy public places such as a mall or office. Skin often feels very sensitive to the touch as well. Dr. Jay Goldstein believes these and the other symptoms of fibromyalgia can be explained by neurological dysfunction. When the brain receives sensory information such as this, the prefrontal cortex decides on the importance of the information before passing it on to the rest of the brain for processing. In fibromyalgia sensory information that should be classified as low importance is given high importance. As a result, the brain is overwhelmed by all this "important" information all at once and the patient feels overwhelmed and exhausted. At the root of this information processing problem may be deficiency of certain neurotransmitters, most importantly glutamate, norepinephrine and dopamine (9).
Of course, this could also explain the pain of fibromyaglia with the sensation of touch being amplified into that of pain. Touch and pain are on the same spectrum of sensation after all.
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Related to the idea of sensory overload is the finding of high levels of substance P in fibromyalgia patients (9). Substance P is a neurotransmitter, found only in the spinal fluid, which has the effect of increasing the importance the prefrontal cortex assigns to sensory input, thus worsening the situation described by Dr. Goldstein. Injection of substance P into the cerebrospinal fluid of healthy volunteers has been shown to give them diffuse body pain similar to that seen in fibromyalgia. Substance P therefore, has the effect of amplifying pain signals. In fibromyalgia patients, the higher levels of substance P turn touch or small pain sensations into the excruciating pain that many experience.
Around 30 years ago a handful of physicians, most notably Dr's Crook, Truss and Trowbridge described a syndrome characterized by a wide range of symptoms very similar to those of fibromyalgia which they suggested was caused by overgrowth of the normal intestinal yeast such as Candida albicans which proliferated due to antibiotic usage and other factors. They treated their patients with antifungal drugs with reportedly good results. A small amount of subsequent research seems to validate their theories with it becoming clear that antibiotic drugs adversely affect intestinal flora and allow Candida sp. to become prevalent (10, 11). There are studies that appear to show successful treatment of intestinal candidiasis with antifungal drugs as well (12, 13). Strangely, although Dr. Crook in particular connected intestinal yeast overgrowth with CFS/fibromyalgia decades ago there has been little material published regarding this since, apart from a few papers again suggesting the link due to the observed similarities between supposed yeast related illness and CFS/fibromyalgia (14). The most likely reason for this is the still pervasive view that there are no definitive tests for intestinal yeast overgrowth. Testing of urine or blood for 'tartaric acid' would appear to offer just this definitive test however. Tartaric acid is a product solely of yeast and is not produced as part of human metabolism, therefore any detected in blood or urine must have originated from the yeast that inhabit the intestinal tract. Studies could, and should, be undertaken to compare tartaric acid levels between healthy controls and patients with fibromyalgia. Patients of all the illnesses on this site as well as other unexplained chronic illnesses should also be tested to establish the role of yeast overgrowth in these conditions. An important study recently published has shown the link between antibiotic alteration of gut flora, candida proliferation and the initiation of allergic illness (15). Since allergies are prevalent among fibromyalgia sufferers this research is further evidence that the link between this illness and intestinal yeast should be investigated. Despite the lack of published research, all the major diagnostic labs that serve functional/integrative medicine physicians consistently report a correlation between yeast markers such as tartaric acid, elevated blood ethanol and Candida antibodies in samples from fibromyalgia patients. A large number of physicians specializing in the treatment of fibromyalgia and related illnesses include anti-fungal agents as a major part of their treatment protocols. A search of online forums, chat rooms and blogs also reveals a large number of fibromyalgia patients who have had success self-treating with an anti-fungal protocol. Further research in this area is long overdue.
With more published research behind it is the idea that small intestinal bacterial overgrowth (SIBO) might play a role in fibromyalgia (16). A very interesting 2004 study showed that 100% (42/42) of fibromyalgia patients had SIBO, shown by positive lactulose breath test results (17). Even more startling was the fact that the more severe the SIBO detected, the more pain patients suffered from. On this evidence, lactulose breath testing should be an important diagnostic tool for fibromyalgia patients and SIBO should be treated when detected. SIBO can be treated with targeted antibiotic drugs or with antibiotic herbs.
Learn more about Candida & gut dysbiosis
'Leaky gut syndrome' is thought to be a result of gut dysbiosis and food allergies, amongst other things, and could contribute to the disease process in CFS and a number of other chronic illnesses.
Learn more about leaky gut syndrome
Physical Injury or Trauma
The theory that physical injury can trigger fibromyalgia is a controversial one. A number of published papers have reviewed all available research in this area (18, 19). It was found that the strongest evidence supporting an association between trauma and FM is a recently published Israeli study in which adults with neck injuries had greater than a 10-fold increased risk of developing FM within 1 year of their injury, compared with adults with lower extremity fractures. The authors of one of these papers concluded "although there is some evidence supporting an association between trauma and FM, the evidence is not definitive. Further prospective studies are needed to confirm this association and to identify whether trauma has a causal role".
Elevated levels of phosphate may be behind some of the muscular aches and pains in fibromyaglia. Dr. St. Amand believes that fibromyalgia is the result of an inherited biochemical abnormality resulting in poor excretion of Phosphate (and oxalate to a smaller degree). Dr. St. Amand believes that fibromyalgia sufferers fail to process phosphate properly so it is retained rather than excreted by the kidneys. He believes this is probably due to deficiency of an enzyme or enzymes involved in this process. According to Dr. St. Amand, the symptoms of fibromyalgia are a result of the accumulation of the excess of phosphate and oxalate within the body's cells. This leads to impairment of energy production within the mitochondria and may also directly cause the pain and stiffness in the muscles and soft tissue experienced in the illness. There has also been published research that suggests this may be the case. Research back in the 1980's involving 15 fibromyalgia patients showed they had elevated levels of adenosine monophosphate and creatine (20). The study also showed the patients had decreased levels of adenosine triphosphate, adenosine diphosphate and phosphoryl creatine. This would suggest that adenosine monophosphate and creatine are accumulating in tissues instead of being converted to these more active substances.
Dr. St. Amand discovered that guaifenesin, a common ingredient of cough medicine could increase the excretion of phosphate and oxalate. Guaifenesin has since proven to be an effective treatment for many fibromyalgia sufferers.
Learn more about guaifenesin treatment
Chronic Sleep Disorders
A common problem in fibromyalgia is disturbed sleep. Sufferers often wake feeling tired and unrefreshed despite getting plenty of sleep. One explanation for this is the finding that patients don't experience sufficient deep REM sleep, instead remaining in a light unrestorative sleep for most of the night (21, 22). EEG testing has also shown that brain activity is higher in fibromyalgia patients whilst asleep. Whenever the deep REM sleep state is approached, electrical activity within the brain increases to prevent it. Patients may also experience waking many times during the night as a result of these abnormalities.
Fibromyalgia patients also have a higher incidence of specific sleep disorders such as restless leg syndrome and sleep apnea:
Restless Leg Syndrome (RLS): This is a condition in which a persons legs feel extremely uncomfortable, with relief only being achieved by constant movement. It is usually described as "deep-seated, creeping, tingling, burning or aching" feelings in the calves, thighs, or feet. It normally is most prominent when in bed and makes the sufferer feel like getting up and moving around. The exact cause of restless leg syndrome is unknown and it can occur at any age. In fibromyalgia patients restless leg syndrome is often another source of interupted sleep.
More about restless leg syndrome
Sleep Apnea: Sleep apnea is defined as the cessation of breathing during sleep. Sufferers may actually stop breathing for a period of time with the result that they are awakened by the automatic reflex to start breathing again. This situation can occur many times during the night resulting in the patient getting very little sleep, not to mention the stress of such a frightening condition. There are two main causes of sleep apnea, the first obstructive sleep apnea (OSA) being caused by obstruction and/or collapse of the upper airway (throat), the second being neurological sleep apnea (NSA) in which the brain ceases to stimulate breathing.
Clearly, sleep disorders play a major part in fibromyalgia, contributing greatly to levels of fatigue and even pain. Whether sleep disturbance is a primary cause of the illness or is itself a symptom is a matter of debate.
More about sleep apnea
It is clear that there are a large number of abnormalities in multiple body systems in fibromyalgia patients. These abnormalities centre around the nervous, endocrine and immune systems and the way these interact with each other. Although these abnormalities have been identified it is still unclear which are causes and which are effects. New research will hopefully shed more light on this but until then doctors who are seeing the best results with patients seem to be those who take a multifactorial approach and try to correct as many of the abnormalities discussed as they possibly can, using currently available treatments.