Treatment of the Month

Did You Know?

As of 2008, Fibromyalgia affects an estimated 10 million Americans each day, with female patients between the ages of 20 and 50 tragically comprising the vast majority of patients. For most patients, Fibromyalgia is characterized by diffuse, widespread pain in the myofascial network of soft connective tissue as well as within skeletal, digestive, and cardiac muscles.  In addition to pain Fibromyalgia also presents with a predominant symptom of uncharacteristic fatigue. In fact, approximately 70% of patients diagnosed with Fibromyalgia meet the diagnostic criteria for Chronic Fatigue Syndrome.

          Additionally, there are several accessory symptoms that often occur in conjunction with this disease process: 1) Disrupted Sleep Patterns, 2) Irritable Bowel Syndrome, 3) Depression, 4) Brain Fog, 5) Migraines, 6) Skin Rashes and 7) Poor Digestion.

The Anatomy of Fibromyalgia – Substance P, Fascia & Scarring

Perhaps, the most common symptom among Fibromyalgia patients is pain. Pain reveals one inescapable truth, that damage is occurring within the body at the cellular level. Pain is one of the body’s most essential mechanisms because it acts much like a beacon. Pain signals immune cells precisely where to go once a pro-inflammatory healing response has been initiated (7 Stages of Healing). Without the pain stimulus the immune system would neither be called into action nor know where to go. Thus, as natural medicine is concerned, both pain and inflammation are essential components of the cellular healing process. However, chronic pain and inflammation are indications that the underlying causes of cellular tissue damage have yet to be adequately addressed. The gift of natural medicine is its ability to discover the root causes of cellular damage and then to treat the person by addressing the root cause rather than falling prey to the symptom.

It is said with respect to Fibromyalgia that research suggests an elevated level of a neuropeptide, Substance P. Substance P is a neurotransmitter working within the nervous system that modulates our perception of pain. As Substance P increases within our Central Nervous System (Spinal Cord and Brain), so should our perception of pain. In this way, Substance P acts as the intermediary between the site of the cellular damage and our Central Nervous System (CNS) so that the CNS can launch the pro-inflammatory process and the immune responses that ensue. However, too often we are conditioned to look at pain as the problem when it is actually part of the solution. Of particular interest is research that has detected up to 3 times the normal level of substance P in the cerebrospinal fluid of fibromyalgia patients.  Most researchers have concluded that the body is functioning in error, that it is incorrectly overproducing Substance P…but is this accurate?

What if the nervous system for the Fibromyalgia body is acting correctly? What if the amount of Substance P is elevated because the amount of cellular damage is elevated, thereby triggering the increase in Substance P? When pursuing natural healing a good place to begin is the assumption that the body is indeed working properly. With this assumption in place it allows us to practice Occum’s razor, the thought process that the obvious solution is probably the correct solution. So it goes, we must discover the causes that may be obvious to the body, but for whatever reason have not been obvious to most modern research.

Our bodies are comprised of a fascinating soft connective tissue, known as fascia, that surrounds and penetrates every muscle fiber in the body. Fascia acts as a carrier tissue for the 4 Vital Tissues: 1) Nerves, 2) Arteries, 3) Veins, and 4) Lymphatic Vessels. Simply speaking, arteries deliver oxygen and nutrients to the cell.  Veins carry carbon dioxide and waste away from the cell. Lymphatic vessels host immune cells and also siphon off cellular waste water, while nerves monitor and guide each of these physiologic processes. In doing so, each of these 4 Vital Tissues plays an instrumental role in the management of healthy alkaline pH. 

When injured, the body employs quite an amazing mechanism for advanced healing. Regardless of the cause (4 Considerations) of the injury, the body heals the same exact way.  Thanks in large part to the participation of the immune system and the formation of scar tissue we are able to overcome injury. However, if too much scar tissue is formed due to repetitive injury then it creates an obstacle to the optimal functioning of the 4 Vital Tissues. In essence, excess scar tissue can trap nerves, prevent the flow oxygen and nutrients to the cell, disrupt the removal of carbon dioxide and waste away from the cell, and even hinder immune cell penetration into the affected areas. At this point scar tissue, essential to healing, now becomes part of the problem. So, herein we discover the accumulation of scar tissue to be a potential cause of Fibromyalgia.

The Physiology of Fibromyalgia – Environmental Pollution, Adrenal Fatigue &  Hypothyroidism

          In addition to pain, most Fibromyalgia patients also experience symptoms of uncharacteristic and unrelenting fatigue. Simply stated, walking around the block can have the potential to completely exhaust the Fibromyalgia patient for several days, to say nothing of what a full day at work might do. While pain is certainly no day at the beach, fatigue is of infinitely more concern clinically. Without energy cells cannot regenerate. Additionally, the immune system cannot clear either environmental pollution or infections. Without energy the body simply will not heal.

          To understand the role that fatigue plays we must first note that every cell in the body should be able to produce energy based upon the body’s situational energetic needs. When we are calm the body requires significantly less energy as when compared to when we are under stress. When we are under stress the situation demands that the body engage the Sympathetic Division of the Autonomic Nervous System (Autonomic NS). The Sympathetics are responsible for a protective ‘Fight or Flight’ response and under stress are utilized in favor of our Parasympathetic Division. The Parasympathetic Division is responsible for healing the body and known as our ‘Rest & Digest’ nervous system. These divisions comprise two parts of a whole, and counter balance each other to the extent that when one is active the other takes a more subordinate role. 

Believe it or not, our bodies are designed to live the vast majority of a 24-hour day in Parasympathetic ‘Rest & Digest’ mode and only access our Sympathetic ‘Fight or Flights’ for short, infrequent bursts throughout the day. However, 21^st century living does not often afford us the basic luxury of living a life free from stress. Today, many people are fortunate to experience 4-6 hours of Parasympathetic living each day, let alone the optimal 21 to 23 hours. While this may seem somewhat deflating because we may not be able to readily change our life circumstances, we do maintain the power to change how we view our life and the choices we make. In this light, we have the ability to transform our perception from one that views life for its stresses (Sympathetics) into one that views life for our successes (Parasympathetics).

Therefore, as a result of situation, the lifestyles we create, and our perceptions, the Sympathetics tend to dominate our body’s physiologic functioning. The result is the correct increase of our cellular performance by ensuring that adequate fuel sources such as Glucose, Glycogen, Triglycerides, and Amino Acids are available for energy production. Remember, the more stress we are under the more energy our bodies need. Hormonally, the Sympathetics stimulate the mobilization of two very important substances, Cortisol & Thyroid hormone. 

In order to turn fuel into energy, cells require specific vitamins and minerals as catalysts and Cortisol and Thyroid hormones to drive the biochemical reactions. However, under prolonged periods of sustained stress, such as degenerative disease, chronic pain, pollution accumulation, infection, and sleep deprivation, the Sympathetics remain dominantly active leading to glandular overuse and eventual burnout. Without the necessary components to drive the production of energy, energy cannot be produced and disease processes tragically spiral out of control. Deficiencies of Cortisol and Thyroid hormone are like having wood, but no fire to burn it.         

          Cortisol is a hormone secreted by our Adrenal Glands and essential to cellular energy production and thus the promotion of life. It is a substance that can be equated to Jing in Traditional Chinese Medicine, otherwise known as our essence. In addition to being essential for energy production, Cortisol is remarkable for its profound anti-inflammatory effect upon the body. Of note is that Cortisol is our waking hormone, meaning that it is at a higher availability while we are awake. Conversely, Cortisol should be at its lowest in the evening so that one can experience effectual sleep. In fact, it is during sleep, while Sympathetic stimulation and Cortisol levels are low, that the immune systems and cellular regeneration is typically the most active. For many Fibromyalgia patients they have exhausted their Adrenal Glands, yet still possess a Sympathetically Dominant nervous system. A body that can neither achieve sleep nor maintain it cannot heal. Thus, for patients experiencing disrupted sleep patterns with elevated Sympathetic and Cortisol stimulation at night this can become a potentially devastating combination.

          With the results of sleep lab tests, researchers have found that the majority of Fibromyalgia patients fall asleep with minimal trouble indicating low Cortisol levels; however, their deep level (stage 4) sleep is constantly interrupted by bursts of awake-like brain activity indicating Sympathetic activation and Cortisol stimulation most likely due to Substance P proliferation. Basically, patients are not achieving the type of restful sleep one’s body needs for recuperation and upon waking the next morning they often describe feeling stiff, sore and quite unclear mentally. This associated sleep disorder is called the alpha-EEG anomaly and is rooted in how Circadian Rhythms are disrupted by damage leading to Sympathetic stimulation and elevated Substance P levels.  Couple this with fatigued Adrenal glands and it’s not hard to see how one would have a difficult time achieving effectual, healing sleep.

Thyroid Hormone functions similar to Cortisol in that it is essential for the cellular production of energy and optimal temperature regulation within the body. In fact, Thyroid Hormone works in conjunction with Cortisol to optimize cellular performance and metabolism, including that of Immune Cells. If either too much or too little of these essential hormones is present then the body’s ability to create the energy necessary for detoxification and ward off infection becomes severely hindered. Thus, the physical accumulation of more environmental pollution and sub-acute microbial infection. With the presence of pollution and infection taking hold, it is little wonder why Fibromyalgia patients develop secondary symptoms such as Irritable Bowel Syndrome or Acid Reflux. 

The Biochemistry of Fibromyalgia – Mitochondrial Dysfunction

What’s more, Mitochondria have the unique ability to multiply within each cell in response to regular physical activity such as created by Pranayama Breathwork, Meditation, Yoga, Tai Chi, and Cardiovascular Exercise. The more a body is active the more energy it is able to generate. It is for this reason that the more we move our bodies, the better we tend to feel. 

Mitochondria possess the ability to grow in number within our cells thanks to having their own DNA. In fact, at one time during our evolution Mitochondria were not part of our cell’s organelles. At some point during the evolutionary process, a symbiotic union was formed between our nascent cell and the Mitochondria. Essentially, we feed the Mitochondria air and food and they in turn feed us ATP. Today, it is said that all of the Mitochondria in our bodies come exclusively from our mother. If mom’s Mitochondria were healthy at the time of conception then so will ours be, and, of course, the opposite is true as well, unfortunately.

The Energetics of Fibromyalgia – Deficient Kidney, Triple Heater & Liver Congestion

          Understanding the Anatomy, Physiology, and Biochemistry of the problem let’s now look at the energetics of Fibromyalgia from a Traditional Chinese Medicine perspective. We have already noted that the Fibromyalgia patient often experiences severe fatigue evidenced by deficient Cortisol and Thyroid hormone. Energetically, this indicates deficient Kidney energy (low Cortisol) and potentially stagnant Triple Heater and Liver energy. Triple Heater because it is analogous to the pituitary gland and help to regulate all glandular function. Liver because it is responsible for purifying the blood and managing our emotional state. It is no accident that Fibromyalgia patients often experience depression as stagnant Liver energy when coupled with deficient Kidney energy often creates this very reality.

The Kidneys and the Liver are the primary organs of blood filtration. Again, take the perspective that the body is functioning properly and that the blood is tainted with pollutants. If these organs are doing their job then clearing the pollutants we are exposed to should be of little consequence. However, what do these organs need to fulfill their responsibilities? How about energy and all the co-factors that go into its creation along with some effectual sleep. When they have an abundance of energy they are able to continually purify the blood by preparing waste for clearance from the body via the p450 Cytochrome System. When they have energy they are able to clear waste through one of the 4 Elimination Channels: 1) Large Intestine - Pooping, 2) Skin - Sweating, 3) Lungs - Breathing or 4) Urinary Bladder – ‘Going Number 1’. When they have energy they are able to flow energy through their meridians, which can be found in the myofascial channels of the legs. And herein lies the connection between the Anatomy and the Energetics.

If the energy to detoxify is available AND our elimination channels are functioning optimally, then waste can be cleared before it adversely impacts the body. If energy is deficient and the channels are closed then the body must store the waste preferentially within the fascia, fat tissue, and ultimately in the organs of filtration. The body does this, stores waste, so as to minimize its adverse effects. We simply can’t afford to have high levels of environmental pollution circulating through the blood. It either must be  cleared or stored. For a body there are no other alternatives.

The Emotion of Fibromyalgia – Depression, Serotonin, & Sunlight

          In order to now come full circle in understanding the toll that Fibromyalgia takes upon the body, mind and soul, let’s now investigate the emotion of this degenerative process. Certainly fatigue leads to a sluggish, slow affect and pain can easily skew ones perspective of life. Both make it very challenging to look at life with optimism and hope, particularly when a patient has been told that what they feel is all in their head or that the best they can hope for is a life of pain meds. Imagine hearing that over and over again? It’s little surprise that many people dislike doctors. We certainly have a lot of work to earn back the trust of our society. But I digress…

          When the perspective of life is skewed toward negativity, hopelessness, fatigue, and pain we can quantify this as depression. The best way I can describe depression for those of you who have been fortunate to never have experienced it is…it’s as if you want someone to reach out and give you a big hug, tell you everything is going to be alright, and then all the problems disappear. It’s like this and with one important addition, you don’t want to have to ask for someone to do it.  Depression is more than a lack of desire or drive. It’s a longing for someone to take interest in what you are going through, to know without it having to be explained.

          Biochemically, it has much to do with a deficit of the neurotransmitter Serotonin. Here comes something really cool. Did you know that Serotonin is an immediate biochemical precursor to Melatonin, the sleeping hormone/antioxidant? And did you know that the vast majority of Serotonin and Melatonin are produced in a healthy digestive tract? And you may have known that Serotonin is stimulated by moderate amounts of daily sun exposure. You wanted answers, well here are a few. The key to healing still revolves around some foundational Naturopathic principles: Energy, Sleep, Sunlight Detoxification, and a Healthy Digestive Tract.

          So then what might disrupt Serotonin production besides the above mentioned? Studies have reported a greater number of severe experiences of emotional and physical abuse in patients with fibromyalgia, compared to the general population. Most often, the abuse came from family members or partners. This suggests that post-traumatic stress disorder (PTSD) or chronic stress may play a strong role in the development of fibromyalgia in some patients. PTSD is an anxiety disorder that is a reaction to a specific traumatic event. The symptoms characterized by PTSD can last for years after the traumatic event and include emotional withdrawal, hopelessness, irritability, mood swings, sleep problems, inability to concentrate, and an excessive startle response to noise. Some evidence is suggesting that PTSD actually results in changes in the brain, possibly from long-term over-exposure to stress hormones.

Additional Patient Resources

   National Fibromyalgia Association – www.fmaware.org

   Fibromyalgia Network - www.fmnetnews.com

   Environmental Health Perspectives – www.ephonline.org

   Environmental Working Group – www.ewg.org

References

Crofford L. J., Simpson S., Young Jr, J. P., et al. A Six-month, Double-blind, Placebo-controlled, Durability of Effect Study of Pregabalin for Pain Associated With Fibromyalgia. American College of Rheumatology Annual Meeting, Presentation # L44.

Denko CW, Malemud CJ. Serum growth hormone and insulin but not insulin-like growth factor-1 levels are elevated in patients with fibromyalgia syndrome. Rheumatol Int. 2005;25(2):146-51.

Gill JM, Quisel A. Fibromyalgia and Diffuse Myalgia. Clin Fam Pract. 2005; 7(2); 181-190.

Harris RE and Clauw DJ. How Do We Know That the Pain in Fibromyalgia Is "Real"? Current Pain and Headache Reports. 2006;10:403-7.

Lemstra M, Olszynski WP. The effectiveness of multidisciplinary rehabilitation in the treatment of fibromyalgia: a randomized controlled trial. Clin J Pain. 2005; 21(2): 166-74.

Mease P. Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment. J Rheumatol Suppl. 2005;32(10):2063

National Institute of Arthritis and Musculoskeletal and Skin Diseases. Fast Facts: What is Fibromyalgia? Last accessed on 29 November 2006.

Cypress Bioscience, Inc. Milnacipran: Results of first Phase III Trial. Last accessed on 29 November 2006.

Sigal LH, Hassett AL “Contributions of Societal and Geographical Environments to Chronic Lyme Disease” Environmental Health Perspectives Supplements Volume 110, Number 4, August 2002

Ziem G, McTamney J “Profile of Patients with Chemical Injury & Sensitivity.” Environmental Health Perspectives Volume 105, Supplement 2 March 1997, p 417-436.

Additional Medical Information

Classifications

There are two categories of Fibromyalgia:

1. Primary (idiopathic); causes are unknown
2. Secondary: causes can be identified

Additional Suspected Causes of Primary (Idiopathic) Fibromyalgia

The most common type of the two is primary fibromyalgia. Many experts believe that fibromyalgia is not a disease but rather a chronic pain condition induced by several abnormal body responses to stress. Many attribute and theorize the onset of primary fibromyalgia to physical injuries, emotional trauma, or viral infections such as Epstein-Barr, but none have been proven to be the cause of primary fibromyalgia. Research published in the December 2006 issue of Current Pain and Headache Reports found that the areas in the brain that are responsible for the sensation of pain are different in fibromyalgia patients from the same areas in healthy people.

Additional Suspected Causes of Secondary Fibromyalgia

Secondary fibromyalgia is caused by a specific cause, unlike primary fibromyalgia. Possible causes include:

1. Physical injury
   1. In one study, secondary fibromyalgia developed in over 20% of patients who had neck injuries. The symptoms are identical to those of primary fibromyalgia but are harder to treat. Another study reported a high rate of fibromyalgia in workers who had repetitive stress injuries, although it is not clear which condition came first.
2. Ankylosing spondylitis (arthritis affecting the spine)
3. Surgey
4. Lyme disease

Diagnosis

In 1990, the American College of Rheumatology (ACR) set the following criteria for the classification of fibromyalgia:

1.    Widespread pain must be present for at least 3 months. This pain must appear in all of the following locations:

2.    Pain in at least 11 of 18 specific areas called tender points on the body. The pain experienced when pressing on a tender point is very localized and intensely painful (not just tender). Tender points are located in the following areas:

The ACR classification provides a guideline, but doctors will also use a patient's medical history and other symptoms in reaching a diagnosis. Fibromyalgia is often diagnosed when other diseases have been excluded. Long-term symptoms that may indicate fibromyalgia include: