FIBROMYALGIA Carolyn McMakin, M.A.,D.C. 5 Hours Continuing Education INDEX Fibromyalgia: Definition 3 Myofascial Pain Syndrome 3 Fibromyalgia; Symptoms and diagnosis 4 Differential Diagnosis 5 Onset and course 5 Features and Testing 6 -7 Therapeutics: Prescriptions 8 - 9 Therapeutics: Non prescription 9 - 11 Note to Patients 11 My personal hypothesis 12 - 13 Our Treatment Protocol 14 - 17 Bibliography 18 - 20 Appendix: Diet for Depression Allergy Elimination Diet Fibromyalgia Syndrome is a chronic pain disorder characterized by diffuse musculoskeletal soreness, stiffness, non-restorative sleep and psychological disturbance. At present the etiology, pathological mechanisms, and course of fibromyalgia are unknown. It used to be known as "fibrositis" implying an inflammation of fibrous or connective tissues, but research has failed to demonstrate inflammation as a significant component of either the clinical presentation or muscle biopsy specimens of patients with "fibrositis" symptoms. The general term "Fibrositis" has now been redefined as two more distinct clinical categories, Myofascial Pain Syndrome, and Fibromyalgia Syndrome. Myofascial Pain Syndrome vs. Fibromyalgia Syndrome Myofascial Pain Syndrome was described in Janet Travell's book, Myofascial Pain and Dysfunction - The Trigger Point Manual. MPS is now defined as musculoskeletal pain arising from one or more trigger points. Trigger points are hyperirritable spots within the belly of the muscle, tendon, or ligament which, when directly stimulated, may give rise to pain in a distinctive distribution, as well as to paresthesias and autonomic symptoms. Definition of Myofascial Pain Syndrome (MPS) 1. Pain occurring in a regional distribution which can be reproduced by pressure over a trigger point. 2. A trigger point is defined as: a) A tender area within the belly of a muscle b) Pressure applied to a trigger point causes pain and/or tingling in a characteristic distribution. c) The muscle harboring the trigger point is shortened resulting in a reduced range of motion; either stretching or contracting the muscle causes pain. d) The muscle with the trigger point feels taut in the location of the TP. e) Stimulating the TP by snapping or needling often causes the muscle to contract. f) Injection of the TP with a local anesthetic abolishes both the local and referred pain. We use microcurrent applied with graphite/vinyl gloves to remove trigger points. Definition of FMS FMS is associated with the presence of widespread aching pain and tender points. Tender points do not occur exclusively in muscle and are considered to be anatomic sites of excessive local tenderness. FMS patients may also have coexisting trigger points. Dr. Bennett (OHSU) defines FMS as: 1. Widespread aching and pain in all four quadrants 2. Eleven or more tender points out of a total of 18, defined by palpation with approximately 4-kg pressure with the pad of the thumb over nine paired locations. We use an algometer to assure precise pressure application ICD code: FMS - 729.0, MPS -729.1 Most commonly noted Tender points Midpoint upper trapezius 84-90% Medial fat pad of the knee 74-90% 2 cm distal to the lateral epicondyle 62-86% Upper gluteal area, below iliac crest 60-65% Midpoint SCM 46-65% Just distal to medial epicondyle 50-57% 2nd costochondral junction 32-42% Symptoms: Wolfe (1990) Widespread Pain 97.6% 11/18 Tender Points 90.1% Fatigue 81.4 Morning Stiffness 77.0% Sleep Disturbance 74.6 Paresthesias 62.8 Headache 52.8 Anxiety 47.8 Dysmenorrhea 40.6 SICCA (dry eye) Symptoms 35.8 Prior depression 31.5 Irritable Bowel Syndrome 29.6 Urinary urgency 26.3 Raynaud's 16.7 Other symptoms found listed in various papers: affective dysfunction, articular pain, subjective (objectively undetectable) swelling of the hands/knees/feet, reticular skin discoloration, dizziness, memory problems, difficulty with concentration, rashes, chronic itching, allergic rhinitis, multiple environmental and chemical sensitivities, hypersensitivity to heat and cold. Associated disorders: Migraine and non-migraine headache (28-58%) Irritable bowel syndrome (34%-53%) Raynaud's syndrome (30%) Mitral valve prolapse Chronic Fatigue Diagnostic Features: 1) Predictable pattern of tender points which may be elicited by palpation - 11 out of 18 potential tender points (Tender to less than 4 lbs./in) 2) Chronic non-restorative sleep pattern 3) Present for at least three months Fibromyalgia is no longer a diagnosis of exclusion. The more associated symptoms from Wolfe's list, the more secure the diagnosis. Differential Diagnosis: (may be accompanied by Fibromyalgia) Chronic fatigue Syndrome - associated with a positive Epstein-Barr titer - some question whether EBV causes CFS or is opportunistic, some support for the idea that CFS is an advanced form, or variant of FMS. In CFS fatigue and cognitive problems are overwhelming complaints, along with non-exudative pharyngitis, swollen cervical lymph nodes, low-grade fever. Hypothyroidism - early in its course often causes diffuse myalgias. Inflammatory muscle diseases - usually have weakness and elevated concentration of muscle enzymes Lyme Disease - other symptoms include red, hot, swollen joints, rash (seven days after the bite) 60%, unexplainable neurological problems, heart palpitations. Blood antibody test will be positive after one month, with 20% false positives. Parkinsonism - causes stiffness Polymyalgia Rheumatica - generally pain and stiffness in the shoulder and pelvic girdle without weakness, generally older than 50 years, usually sed rate greater than 50mm/h; often treated with cortisone derivatives. Rheumatoid arthritis, lupus, systemic sclerosis - fatigue and myalgia sometimes occur before overt articular symptoms develop. Silicone Implant Reaction- other symptoms include dry eyes and mouth, Raynaud's 60%, positive ANA test 70%, painful joints (shoulders, fingers, knees) Tendinitis - the major areas of tenderness are primarily in the tendons where they attach to bone rather than in the muscles. Yeast Infections - candida infections seem to have similar symptoms and may be associated in some FMS patients Symptoms of FMS are often present in a variety of diseases. These include allergies, blood disease, cancers, infection, hormonal problems and reaction to drugs. Fibromyalgia is a distinct syndrome, whether occurring alone or with other conditions. The idea of secondary Fibromyalgia is no longer valid. (Janet Hulme, MA, PT, Women's Health Seminars, Missoula, MT) Onset: Usually (55%) gradual adult onset 55% of patients could not recall a precipitant to their symptoms 24% attribute onset of symptoms to trauma -auto accidents, surgeries 14% attribute onset to psychological factors such as "stress, emotions, family change" Average age of onset: 29-37 years old Average age of presentation: 34-53 years old Course: Once symptoms manifest they are likely to persist to some degree for the rest of the patient's life. Articular disability does not generally occur. Patients are likely to experience profound fatigue, stiffness, paresthesia, and subjective muscle tension chronically. There may be periods of remission and exacerbation. Even with optimum treatment and good initial results brief relapses are common often caused by temporary sleep disturbance. Miscellaneous: Fibromyalgia patients tend to remain employed and stay employed despite significant disability. Employment status was not significantly different from the national average. In one study 30% had to change jobs, 17% had to quit work because of symptoms. 44% needed help with household tasks, 24% were supported by disability pension. Prevalence: 3 to 6 million Americans suffer from fibromyalgia. In Rheumatology clinics the prevalence is from 3.7% to 20% In general medical clinics 5.7% to 9% 92-100% Caucasian 73-88% Female Age adjusted figures show 1% overall incidence below age 60, 4% above age 60 Age range 14 -68 No information about prevalence in chiropractic offices Testing: Normal CBC, Sed rate, thyroid, negative RA screen, chem screen Depending on the model of pathogenesis and treatment you use, hepatic detoxification evaluation, gastrointestinal permeability testing, digestive stool analysis, serum food allergy testing can be done. Features Aberrant serotonin metabolism - reduced levels of serotonin in spinal fluid - antibodies against serotonin have been found in FMS patients. Delta sleep interference - alpha wave intrusion leads to decrease in growth hormone, which is secreted during delta sleep - alpha EEG NREM sleep anomaly. You can induce FMS in healthy patients by depriving them of NREM sleep for three consecutive nights, unless they are highly fit and conditioned. (Moldofsky) FM patients have a significantly lower level of tryptophane and 6 other amino acids (one study found that tryptophane supplementation had no effect on fatigue, mood or pain) - tyrosine, leucine, and isoleucine also low Increased norepinephrine excretion, reduced levels of dopamine, norepinephrine, and serotonin in the CFS of FMS patients. DHEA and cortisol are significantly lower in FMS patients. Moth eaten type I muscle fibers, ragged red fibers, swollen mitochondria, atrophy of type II fibers, abnormal mitochondria, glycogen deposits in the muscle cells, mucopolysaccharide alterations. Changes are non-specific and inconsistent among patients. A network of elastic fibers not seen in healthy controls connects muscle fibers of FMS patients. Decreased intramuscular ATP and phosphocreatinine - alteration in mitochondrial oxidative phosphorylation (Mathur &Gatter). Compromised microcirculation - ultra sound decreases microcirculation in FMS patients, opposite the effect seen in normal patients. But, there is no difference in capillary density. No consistent EMG changes. Alcohol consumption increases FMS symptoms, and increases conversion of tryptophane to kynurenine. Elevated substance P in spinal fluid - 3-6 times normal. Auto-immune dysfunction doesn't seem to be a feature - FMS patients do not tend to get other autoimmune diseases Fatigue, emotional distress makes it worse. 44% of men with Fibromyalgia have co-existent obstructive sleep apnea. There is a genetic predisposition - it is runs in families, more common in relatives of patients with depression. Patients with FMS have low somatostatin levels, low levels of GH - probably due to sleep disturbance and low serotonin levels. There is a symptom overlap between FMS and chronic fatigue syndrome, and some support for the theory that they form a continuum of one condition. Female predominance - during premenstrual portion of the cycle, there is a substantial increase in conversion of tryptophane to kynurenine, so it doesn't go to serotonin and leads to increased sleep disturbance. It is postulated that this estrogen dependent shift in tryptophane metabolism is a feature in the female predominance of FMS. Therapeutics Prescription Drugs: Amitryptoline - Elavil - 12.5-75 mg -low doses help reduce symptoms and minimize side effects. If it is going to work it will do so in the first two weeks. (N=23) Jaeschke, et al, Clinical usefulness of Amitryptoline in Fibromyalgia, results of 23 randomized control trials. Journal of Rheumatology 18(3) 447-51, 3/91 Paxil and Trazadone - serotonin re-uptake inhibitors - anecdotally useful - I couldn't find papers on it. Ibuprofen and Xanax (Alprazolam) are useful when used together. N=78, 4 groups - I, A, IA, Placebo. IA group responded well, N=52 8 weeks - same results. McBroom, Hester, Treatment of Primary FMS with Ibuprofen and Alprazolam, double blind, placebo controlled study. Arthritis and Rheumatism 34(5) 552-60, 1991 May Hypnotics: Halcion, Restoril, Dalmane - 14 pts, 10 of 14 had complete resolution of symptoms in one to 4 weeks (mean = 3 weeks), 2 had reduction of symptoms, 2 unresponsive patient responded to electro-acupuncture. Side effects can be a problem. Rothschild, B, Retrospective assessment of Fibromyalgia therapeusis. Comprehensive Therapy, 20(10): 545-9, 1994 Clomipramine (Anafranil) - a serotonergic anti-depressant better at relieving pain than depression, Amitriptyline is effective at doses lower than those used in major depression. Goodrich, PJ, Sandoval, R. Psychotropic treatment of CFS and related disorders (review); J of Clinical Psychiatry 54(1): 13-20, 1993, Jan. Cyclobenzaprine (Flexaril) 10 mg at night works as well as 30 mg (10 TID) in reducing symptoms and 30 mg significantly increases side effects. Santandrea et al, "A double blind cross over study of two Cyclobenzaprine regimens in primary FMS." J of International Medical Research 21(2), 74-86, 1993, April Cyclobenzaprine (Flexaril) and Ibuprofen - N=32, 15 pts - 10 mg Flexural, 17 pts 10 mg Flexural and 600 mg Ibuprofen. C+I better for morning stiffness, all symptoms improved to the same extent S-Adenosylmethionine is helpful with pain, fatigue, morning stiffness. It is an anti-inflammatory, analgesic, antidepressant. N=44 Jacobsen, S; "Oral s-Adenosylmethionine in primary fibromyalgia", Scandinavian J of Rheumatology, 20(4) 294-302, 1991) Thyroid- Cytomel-T-3 -The hypothesis is that T3 receptors are resistant to T3 hormone. Increased cortisol levels, as seen after an accident or surgery or during emotional trauma, lead to a decrease in TSH and a shift from beta-receptors to alpha-receptors. Patients resistant to T4 and desiccated thyroid responded to T3 with elimination of their FMS symptoms. Euthyroid patients (patients with normal thyroid function blood tests) treated with T3 experienced relief of their FMS symptoms. Supraphysiologic doses (150-250mcg) were sometimes required and patients experienced no stimulation side effects at this dosage. Lowe, DC, Eichelberger, MD, et al; Improvement in Euthyroid Fibromyalgia Patients treated with T3; Journal of Myofascial Therapy, Vol1, No2 July1994. Unpublished- Oxytocin and DHEA in Fibromyalgia and Chronic Fatigue Oxytocin is produced in the retina, pineal, ovary, adrenals, thymus, and pancreas as well as the posterior pituitary. DHEA -dehydroepiandosterone is produced by the adrenals. The adrenals produce 30-50 mg of DHEA a day, and 2-3 mg of Cortisone per day. DHEA helps stimulate production of muscle and muscle repair. Dr. Jon Russell showed that fibromyalgia patients have a lower level of DHEA sulfate. Oxytocin is active in cell membranes and activates cyclic AMP, and the inositol triphosphate system, which is DHEA dependent. DHEA sulfate levels are measured and DHEA and Oxytocin supplemented. Dr.Stodinger in Spokane has 200 patients on this protocol. 66% of patients have had complete remission of symptoms. Dr.Flechas, who did the work on Malic acid and magnesium, developed this protocol, is looking for someone to do a large controlled trial on it, as it appears promising. Side effects include water retention and weight gain. RX that don't work: Zopiclone - helps with fatigue but not pain - 33 pts, double blind Fluoxetine (Prozac) has no effect, N=42, double blind (anecdotally useful) Chlormezanone (Trancopal) - double blind - no beneficial effect Benzodiazapines - Valium, etc. - contraindicated - they interfere with stage 4 sleep. Imipramine (Tofranil), steroids, non-steroidal anti-inflammatories don't help Steroids and Narcotics are contraindicated Non- Prescription programs that work Magnesium and Malic Acid - reduces muscle pain - 15 pts, 8 weeks, 1200-2400 mg Malate, 300-600 mg magnesium. Tender point index went from 19.6 to 6.5(p <. 001). Subjective improvement in myalgia occurred within 48 hours of supplementation. 6 patients mean TPI =6.8 after Malic acid/Mg after two weeks on placebo TPI increased to 21.5(p<. 001). Worsening occurs within 48 hours of placebo administration. Abraham MD, Flechas, MD, MPH, Journal of Nutritional Medicine (1992) 3, 49-59 (We use Metagenics product Fibroplex.) Detoxification: Metagenics/ Jeff Bland Ph.D. program. Theory is that the problem is one of toxicity, dysfunctional oxidative phosphorylation, intestinal dysbiosis, increased gut permeability causing problem with amino acid transport and utilization - i.e. if the liver is using amino acids for detoxification systems there are reduced amounts available for neurotransmitter synthesis. Sustain, Ultra-Clear, Ultra-Clear Plus, Hypoallergenic diet, Hypoallergenic diet, supplemental digestive enzymes, gut flora replacement, candida treatment. (4R- remove, replace, re-inoculate, repair. Metagenics/Jeff Bland, Ph.D.) In some of our patients the diet alone has reduced symptoms dramatically. Tyler Protocol: same theory as Metagenics - gut permeability, de-tox, enzymes, flora - capsules instead of powder. 5-Hydroxytryptophan 90 day trial, 50 patients - number of tender points, anxiety, quality of sleep, fatigue all showed significant improvement (p=<. 001) good/fair =50%, no one removed from treatment due to side effects. Puttini PS, Caruso, I; Primary Fibromyalgia syndrome and 5-hydroxytryptophan-90 day open study, Journal of International Medical research 20(2): 182-9, 1992 April. (5-HTP is available in USA) Electro-acupuncture - Deluze, C; Bosia, L; Zirbs, A - 7/8 outcome parameters showed significant improvement in active treatment group; none improved in sham group. 50% had satisfactory improvement, 25% had dramatic improvement - almost complete disappearance of symptoms. Points included: Stomach 36, Large intestine 4 (bilaterally) and six other points not described but chosen "depending on the patient's pain pattern and according to the empirical efficacy of the sites in the treatment of pain." (See Melzack, Still, Fox; "Trigger points and acupuncture points for pain: correlation and implications." Pain 1977; 3:2-23) In-office trials, my office, we have similar results, excellent response. We have stimulated different points on the stomach and bladder meridian. Refer to an acupuncturist you trust. Deluze, C; Bosia; Zirbs; Electro-acupuncture in Fibromyalgia, British Medical Journal, Nov., 1992, 305(6864) 1249-52 Waylonis MD, Ohio State Medical Journal - 46% of patients treated said the best most long lasting relief was obtained from electro-acupuncture. Simms, Controlled trials of therapy in Fibromyalgia Syndrome, Baillieres Clinical Rheumatology 8(4): 917-34, 1994 Nov. Aerobic exercise - results are inconclusive - it helps some patients, but makes the seriously impaired patients worse - they are so close to the anaerobic threshold that exercise puts them over the edge. (Patients scored lower on five of the seven measures used, higher on the physical disability profile on the Sickness Impact Profile, (N=19). Mild physical activity seems beneficial - warm water swimming Gentle low impact aerobic exercise seems to help. Patients need to get above the aerobic threshold by exercising parts that don't hurt. Nichols DS, Glenn, "Effects of aerobic exercise on pain perception, affect, and level of disability in individuals with Fibromyalgia", Physical Therapy 74(4): 327-32 1994 April. Improving physical fitness can result in decrease symptoms and improved function. (McCain) NSAID's useful for simple analgesia, but not otherwise effective; this is not primarily an inflammatory condition. Can cause bladder irritation. Niacin - time release Niacin 250 mg/day increases peripheral circulation Guaifenesin - Available in tablets, it is an expectorant - reduces phosphate and uric acid deposits. OTC - dose 300 - 600 mg bid/tid Dr.St. Amand (UCLA) has been working with FMS for 20+ years. He found that medications that cause the excretion of uric acid are effective in reversing the symptoms of FMS. His working hypothesis is that people with FMS have an inherited abnormality in phosphate excretion, which causes deposits to form inside the mitochondria. He uses Guaifenesin 600mg twice a day. Three weeks treatment reverses one year of deposits. We have used it successfully on two patients whose Fibromyalgia symptoms disappeared after four weeks use. Hypnosis works better than physical therapy - In refractory FMS patients N=40 12 week treatment period with follow-up at 24 weeks - "Compared with patients in the physical therapy group, the patients in the hypnotherapy group showed significantly better outcome with respect to their pain experience, fatigue on awakening, sleep pattern and global assessment at 12 and 24 weeks. Haanen et al, "Controlled trial of hypnotherapy in treatment of refractory fibromyalgia." Journal of Rheumatology 18(1): 72-5, 1991 Jan. Imagery, progressive muscle relaxation Juvenile patients (N=7) 8.6-17.7 years old "In majority of patients such techniques were effective in reducing pain and facilitating improved functioning." Walco, Ilowite "Cognitive-behavioral intervention for juvenile primary Fibromyalgia Syndrome, Journal of Rheumatology 19(10): 1617-9, 1992 October. Treat for Candida - muramyl dipeptides produced by healthy bowel flora help induce sleep, candida may be a feature of IBS symptoms. Fluconazole (Diflucan), and Garlic oil capsules are effective. Stool sample testing for candida overgrowth will do sensitivity testing to determine effective agent. Tell your Patients Take it easy - Tell patients to simplify their lives as much as possible, take time to meet their own needs, use their time and energy to do the things they find most rewarding and fulfilling. Recommend: Education, stretching, massage, support. Medicate for symptomatic relief, use visualization, meditation, relaxation tapes, cold/heat, streamline your life, pace yourself. Avoid: Repetitive exercises, swimming crawl or breast stroke especially in cool water, immobility, yoga (holding postures is stressful), weight training, narcotics, steroids, stairs, uphill climbing, and emotional distress. Final Note There are so many therapies available, both prescription and non-prescription, that are effective in Fibromyalgia it should be possible to find some combination of treatments which will make a patient comfortable and reduce symptoms to a tolerable level. I encourage you and your patients to be positive, patient, gentle, persistent and determined. My Personal Hypothesis When you put together all of the features of Fibromyalgia and all of the things that are effective in its treatment a certain group of amino acids becomes prominent. They are the branch chain or neutral amino acids, tryptophane, tyrosine, leucine, and isoleucine. They are all found in reduced levels in FMS patients. These branch chain amino acids are all transported in the gut by the same amino transport molecule. There are four different amino acid transport molecules in the small intestine, one each for acidic, basic, branch chain, and proline has its own. It is a sodium co-transport system susceptible, according to Guyton, to disturbance by toxicity. When you "clean up" the gut in some patients - their FMS symptoms go down. The hypoallergenic diet, detox program, and antioxidant supplements would reduce intestinal inflammation and improve function of the transport proteins. Leucine: Each of the four types of thyroid hormone receptor has a "leucine zipper"- 10 leucine molecules in a row-right in the middle of the thyroid hormone binding domain. If leucine is not available, reproduction of the receptors would stop, resulting in a reduced number, or there can be a frame shift in the RNA molecule and the receptors may be made incorrectly. Tryptophane: Serotonin is made from tryptophane. If you supplement 5-hydroxy tryptophane, which, because of its positive charge, would use a different protein carrier molecule, patients improve. Supplementing tryptophane doesn't seem to help. If tryptophane levels were low because it was being used up in liver de-tox reactions then tryptophane supplementation should help. This suggests that the transport system is the problem. Leucine/isoleucine: Oxytocin seems to be effective in certain patients. Oxytocin is only 10 amino acids long and there are only two essential amino acids in it, leucine and isoleucine. Tyrosine: Tyrosine is a precursor to epinephrine, nor epinephrine, and dopamine which are reduced in FMS patients. Electro-acupuncture seems to work well. If you think of protein molecules, such as the amino acid transport molecules, as existing in a certain thermodynamically stable configuration, which can shift to a different configuration when an electromagnetic current is applied along a specific axis, it provides a model as to how electro acupuncture might work. The transient elevation of endorphins may also be helpful, but doesn't explain the long-term improvement seen with electro-acupuncture. The ragged red fibers seen in FMS could be caused by scavenging of the muscle tissue for essential amino acids unavailable through transport. Guaifenesin is the only therapeutic agent that doesn't fit this model, but we're not really sure how it works. The Uric acid reduction hypothesis begs the question of why uric acid is elevated in the first place, or how Uric acid elevation influences the amino acid deficiencies and other problems seen in FMS. Guaifenesin has been reported to improve brain function and minimize damage following a stroke. The mechanism isn't understood and there are obviously some features of Guaifenesin's actions we don't understand. The problem in Fibromyalgia may be either in the transport, utilization or conversion of amino acids. The transport proteins seem to me to be the most likely problem, but no one has done studies to evaluate them yet. Dr. I John Russell at University of Texas has a similar hypothesis, and has explained the difficulties associated with verifying the hypothesis. Radioactive tagging of amino acids to study transport is too toxic for patients, and unethical since it makes them radioactive for life. Studying amino acid metabolic byproducts, as suggested to me by Dr.Jeffrey Bland, still leaves the basic questions of transport unanswered. If the body were scavenging the amino acids from muscle tissue the amino acid excretion products would be the same as if they were ingested. Tissue culture study of amino acid transport would accomplish the study goal but arranging for a GI tissue sample from a living or deceased Fibromyalgia donor patient would require some persistence and good luck. Stress, emotional trauma, or physical trauma such as surgery or an auto accident, cause a rise in serum cortisol. In creases in cortisol cause thinning of the intestinal lining and reduction in protein production as well as a reduction in TSH and a shift from beta stimulatory receptors to alpha receptors. (Guyton). If the increase in cortisol lasts long enough the thinning it causes in the gut lining and the reduction in protein synthesis could be responsible for a shift in the transport proteins. This mechanism could explain the posttraumatic and emotional stress cases of FMS. The cases of gradual onset FMS could be caused by genetic susceptibility and borderline function of the amino acid transport proteins complicated by modern diet and chronic exposure to low level toxicity in the food, air, water, and dental fillings. Guyton states that the amino acid transport molecules are susceptible to inactivation by toxicity. This mechanism would explain the cases that arise following some chronic or acute toxic exposure. The "amino acid transport" model is the only model I can find which accommodates and explains the various causes of FMS, its features and treatments. Any comments or corrections would be most appreciated. Our Treatment Protocol We have been treating Fibromyalgia patients at our clinic based on this information for the last two years. The results have been most encouraging. One of the naturopathic student interns in our office conducted a survey of our patients for her senior thesis. Of the 25 Fibromyalgia patients treated in the last 10 months with our new microcurrent myofascial pain protocols, 24 had their pain reduced from an average of 7-8/10(VAS), to a 3-4/10. She asked many open-ended questions about specific changes, improvements, and remaining symptoms. Copies of her thesis are available upon request. Our treatment protocol consists of the following: Diet Modification: We have observed that patients who remove the allergenic foods from their diet have significant improvement. We use serum allergy testing for IgG and IgE antibodies. In general, irritable bowel symptoms are significantly reduced or eliminated, and the overall fatigue and muscle tenderness usually improves. The allergy testing is done through National BioTech (now Great Smokies) Laboratories and costs $225 to $390 for the basic food and inhalants panel. The lab provides a kit with instructions and the patient can have the blood drawn at any local lab. The lab processes the blood and ships the serum to Seattle. We have the results and comprehensive diet recommendations back in about 10 days. Supplements/Detox: We have observed that most Fibromyalgia patients, when questioned, have a history of some toxic exposure. They were raised on or near farms or orchards, near chemical plants or pesticides, worked as welders, hairdressers, manicurists, near nuclear power plants, or some other source of organic chemicals, prescription drugs, or radiation. We hypothesize that this exposure compromises the ability of the liver to process the toxic load and creates a sub clinical dysfunction in the liver detox pathways. Standard liver function tests are usually normal, but testing for liver detox pathway function is usually abnormal. We supplement, as tolerated, products that supply the necessary liver nutritional support and detoxification pathway intermediates such as lipoic acid, glutathione, Silymarin, methionine, cysteine, and carnitine. The trade products we choose from are: Metagenics "Mitochondrial Resuscitate", combined with "Oxygenics" an antioxidant supplement; Tyler, Detoxification Factors, and Lipotropic factors; Biotixx Research, Livotrit Plus, a combination of herbs and Silymarin and MCS- Metabolic Clearing Support, and Pure Encapsulations, Lipoic Acid(100mg). Many patients need just good basic nutrition but have absorption difficulties. We use a liquid colloidal mineral supplement, "Mineral Toddy", which seems to raise energy levels and is well tolerated. The company which produces the "Mineral Toddy" also produces a "Total Toddy" containing vitamins. I don't have enough experience with this formula to know if it is going to be as useful as the mineral supplement, but it sounds good. We use a low dose multiple vitamin made by NF formula, "Spectrient", which has a generous complement of herbs and botanicals thought to be helpful, is well absorbed and usually well tolerated. Even tender stomachs don't seem to get nauseated. We start with one capsule twice a day and increase as tolerated to two three times a day. We use "Fibroplex" made by Metagenics as a source of Manganese, Magnesium, and Malic Acid. There are other companies who supply this combination and any similar combination should work equally well. This combination is useful in preventing the recurrence of the myofascial trigger points as we work on them. It can be useful in reducing myofascial pain, but it doesn't remove trigger points or address the systemic, metabolic problems associated with fibromyalgia. The most common side effect is diarrhea, which is dose related. We use Pycnogenol as an antioxidant and Silymarin/Milk Thistle for liver support and repair. I began prescribing these after I saw a patient who had been diagnosed with Fibromyalgia eight years earlier. She came to me for treatment of myofascial trigger points and during her history stated that she had Fibromyalgia and exercised two hours a day either walking, riding bicycle, or swimming. Algometer testing of her "tender points" showed that none of them were tender to less than four pounds per square inch. She no longer had Fibromyalgia and I asked her how she had done it. She stated that she had been exercising, taking Silymarin and Pycnogenol for one year, and receiving regular massages. I have since recommended this regimen to patients who are willing to try it. 5-HTP has been useful in treating the sleep difficulties. It is available; you just need to ask around. Pure Encapsulations now carries a 50 mg capsule. Dose:100-500mg, 1hour before bedtime with some carbohydrate(not protein) and B-6 50-100mg. Prescriptions: We have medical physicians we refer patients to when they need a prescription. The medications which have proven most useful have been Trazadone, when a short term SSRI seems indicated and Cytomel, when hypothyroid symptoms are most pronounced. The patients who are on the least medication are the ones who seem to have the best results. Exercise: We recommend that patients begin exercising as tolerated. If they tolerate five minutes a day, we start there and increase as much as possible gradually. The best exercise seems to be warm water exercise, either swimming or just paddling around as vigorously as tolerated. Walking is excellent in the absence of a warm water pool. Do all the sensible things advised in the FMS self-help information - avoid repetitive upper body exercise and heavy weights. Gentle aerobic conditioning as tolerated seems to be most beneficial. Be consistent. Exercise three to five days a week doing something. Massage: We treat patients twice a week with massage, microcurrent and light force or drop table adjusting as necessary and tolerated. We use Russian massage technique, but any technique, which stimulates circulation, gently addresses the trigger points and doesn't hurt, will be helpful. Microcurrent: We have developed specific microcurrent frequencies that are useful for treating the myofascial trigger points found in FMS patients. Microcurrent trigger point therapy applied with graphite/vinyl gloves has the advantage of requiring little pressure and working fairly quickly. We are able to treat large sheets of myofibrosis and myofascial trigger points with gentle pressure, letting the current do the work. Seminars are being taught in various locations to medical, chiropractic and Naturopathic physicians with an interest in the treatment of myofascial pain. If a physician expresses an interest we'll be happy to share the information by setting up a seminar in a convenient location. Visualization: Encourage the patients to see themselves as well. Don't build "false" hope, but once the pain starts to come down, encourage the patient to focus on where they want to be instead of focusing on the fear of the pain coming back. Relaxation visualizations, visualizing comfort, warmth, peaceful surroundings have been shown to be helpful, and we encourage and instruct patients in such imagery. Pain Psychology: When a patient has been in pain for a long period of time, pain becomes a part of how they define themselves. "I'm 5'4" tall, brown hair, blue eyes, and I'm in pain (8/10) most of the time." When you change the pain it is a welcome change, but it also changes who the patient "is", and how they define themselves. We talk about this because the transition is easier on the patient if they understand the process and are ready for it. As patients get better, and the pain becomes less disabling, they have to find other ways of doing for themselves what the pain was doing. As much as I hate the concept of "secondary gain" (As if being in constant pain was worth it because of all the good things it does for you. Right!), it is a real feature in chronic pain, especially as the patient recovers. When the patient recovers they no longer have FMS as an excuse for not doing things they don't really want to do. They need to learn to say "no" when they don't have FMS as an excuse. While the patient was disabled, they probably had help with difficult tasks from family or friends. Once they recover, they need to find other ways to experience support and connectedness from those close to them. When they recover, it is important to find other ways to nurture and care for themselves now that they are not taking care of their illness. I suggest that if they just hate doing windows, once the FMS improves - do something fun and hire the windows done, or learn to leave them dusty! Counseling, assertiveness training, or a good women's support group can be helpful in this process. Attitude: The patients who have the best results are the ones who are determined to recover. They acknowledge that they have Fibromyalgia but are absolutely determined to do whatever they have to do to recover and have a life again. They exercise, they take their supplements, they follow the diet and avoid allergenic foods, and they commit time and energy to their treatment and well being. For example, if stresses occur, they handle them and move on. Stress makes their symptoms worse and they can't afford to deal with stress that way. We encourage this attitude in our patients. I am absolutely committed, tenacious, determined, creative, inventive, and persistent when it comes to helping our patients recover. I do not assume that anyone has to "live with the pain." I will do whatever it takes to get a patient well. We have had four patients who went from having algometer-confirmed Fibromyalgia, to having no tender points or trigger points, exercising regularly and sleeping just fine. They are the exceptions, but if four can, more can. Almost all of our FMS patients have had significant reductions in their pain, with reductions in pain from an 8/10 to a 3-4/10 being most common. The patients who do the best are determined. Those that do the worst whine a lot, take narcotics, and use their FMS to manipulate their families. I put so much intention and energy into helping our patients recover that we really don't have many "whiners". Prayer: Larry Dosey, MD has documented in his books the power of prayer to help the healing process. I routinely appeal to a higher power, God, however you think of Him or Her, for help in healing the patient, especially as I sit down to do the myofascial work. The worse a patient is, the more I pray. The better the patient gets, the more thankful I am. We have seen results that are truly humbling. It is an honor to be allowed to participate in someone's healing. And, in our clinic, we are all really clear about where the healing power comes from. I pray internally and don't presume to impose my spiritual practices upon my patients. If the patient is praying too, I assume it's helpful. I encourage you to try it. (Warning: I suggest that you pray for healing or peace, but never patience. You always get what you pray for. Prayers for patience result in conditions that require you to develop patience!) BIBLIOGRAPHY 1. Goldenberg DL. 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