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Fibromyalgia: proper diagnosis is half the cure.

Your Patient Tells You That They Have Fibromyalgia; Now What?

So your patient says that they have fibromyalgia (FM) and were told that there is no known cause or cure. The best that their family physician can do is suggest that they take some prescription medications and learn to live with the pain. Should they, and you, accept this diagnosis and prognosis?

Before we answer that question, read a few real-life stories from these patients below:

* I was diagnosed with fibromyalgia and suffered with widespread pain, fatigue, and inability to lose weight. After two years of unsuccessfully trying different pain and antidepressant medications,

I finally got a second opinion and was diagnosed with a previously undetected thyroid problem. My fibromyalgia pain went away completely after I was put on thyroid hormone replacement.

* I suffered with terrible fatigue and achiness throughout my body, but especially in my legs. My doctor told me that I had fibromyalgia and gave me an antidepressant. At the same time, one of my best friends told me that she had the same symptoms, but that her pain turned out to be related to her cholesterol medication. I asked my doctor about this and he took me off Lipitor, and within 2 months my fibromyalgia pain went away.

* I suffered with pain in multiple joints and my doctor checked for rheumatoid arthritis, which was negative. I was told that I had fibromyalgia and was put on pain medications. After a few months, I went to a rheumatologist who did new blood tests and found that I had inflammation somewhere in my body. More blood tests confirmed that I had Lyme disease.

I was put on an antibiotics protocol and my fibromyalgia pain went away completely.

* I was diagnosed with fibromyalgia after my doctor ran numerous blood tests and could not find any medical problem that could explain my severe fatigue and widespread pain. I did notice that my symptoms got much worse around the time that my husband was diagnosed with prostate cancer. I was not sleeping through the night and started to develop panic attacks. My doctor recommended that I take a muscle relaxant before bedtime to improve my sleep and a low-dose antidepressant to help reduce my anxiety. In addition, I decided to take some yoga classes and cut back on the amount of coffee that I was drinking, both of which seemed to help reduce my stress levels. Now my fibromyalgia pain is greatly reduced and I am starting to feel normal again.

Each of these stories had a happy ending. Why? Because the doctor eventually figured out what was causing symptoms that were labeled, correctly or incorrectly, as fibromyalgia. Proper diagnosis is half the cure. If the diagnosis is not correct, how can the treatment be correct?

Proper Diagnosis

So, was the diagnosis of fibromyalgia correct in all these cases? If all of the patients suffered from the same condition, why did they require such different treatments? In the first three cases, the patient was incorrectly given a diagnosis of FM, and then another medical condition was eventually found that accounted for the symptoms of widespread pain and fatigue. The pain and fatigue went away in each of these cases, because proper diagnosis led the doctor to prescribe the proper treatment and medication.

FM is the correct diagnosis only when truly global pain and persistent fatigue are present, along with other centrally mediated problems such as anxiety, depression, irritable-bowel-like symptoms, and unrefreshed sleep, and other medical conditions that may explain the symptoms have been ruled out. As we can see in the first three cases above, the doctor gave the diagnosis of FM prematurely - before exploring all other possible causes for the pain and fatigue. Only in the last case was the patient correctly given a diagnosis of FM, after all other medical conditions were excluded and eliminated.

This last patient fits the classic profile of a FM patient as first described by the American College of Rheumatology in 1990, when the criteria for making a diagnosis of FM were first published. (1) These diagnostic criteria were revised in 2010 and again modified in 2011.2 We have decided to use the term classic FM to describe this type of patient who has undergone extensive medical testing to rule out all possible medical diseases, as well as functional and metabolic issues, that could be causing the symptoms of widespread pain and fatigue. This is a very important and critical point: that the diagnosis of classic FM can only be made when there is no other disease(s) or disorder(s) present that could account for the symptoms.

In our previous examples, the patients clearly had other medical problems that were causing their symptoms of widespread pain and fatigue. The first patient had an underactive thyroid condition and was not suffering from classic FM. The second was experiencing a reaction to cholesterol-lowering medications and was not suffering from classic FM. The third patient had Lyme disease, and was not suffering from classic FM. Essentially those three patients were misdiagnosed with FM when in fact they had other medical problems that accounted for their symptoms.

So why do we have a dilemma? Doctors often use the single word fibromyalgia to diagnose a complex of symptoms that can have multiple causes. Worse yet, doctors often prescribe the same treatment package to all the patients whom they label with fibromyalgia. It is like using the term back pain and prescribing muscle relaxants to all patients with back pain. Some may have strained muscles, some may have arthritis, some may have herniated discs, and a few may even have a hidden fracture or dislocation. Sometimes the one-size-fits-all prescription may help patients get better, but not usually.

As a standard course in treating classic FM, most doctors will prescribe a combination of the following three treatments: (1) medications for sleep, pain, anxiety, and/or depression; (2) mild exercise for relaxing the muscles and to promote better blood flow; and (3) psychological counseling or relaxation techniques for reducing the emotional distress associated with fibromyalgia. (3)

In fact, these three treatments can be very helpful for a patient who is truly suffering from classic FM. We'll talk a lot more about classic FM in the next page or two, but for now it is important to know that only a small number of patients diagnosed with FM actually suffer from this classic variety of the syndrome. Most people who are told they have FM are really suffering from another problem. A study by Fitzcharles et al. revealed that patients diagnosed with FM by primary care physicians and rheumatologists ended up with an incorrect diagnosis a staggering 66% of the time when evaluated subsequently by a panel of FM experts. (4) There are three broad categories of these conditions--other than classic FM--that are most often the cause of widespread pain and fatigue: (5)

1. Medical problems that may cause widespread pain and fatigue: examples are thyroid disease, diabetes, Lyme disease, cancer, and other medical diseases;

2. Musculoskeletal problems that may cause widespread pain and fatigue: examples are trigger points or "muscle knots," spinal joint problems such as disc degeneration and pinched nerves.

3. Functional/metabolic problems that may cause widespread pain and fatigue: examples are subtle functional hypothyroidism, inefficiency of energy production in the cells of the body due to mitochondrial dysfunction, nutritional deficiencies (including vitamin D, CoQlO, carnitine, B vitamins, magnesium, etc.), chemical and food sensitivities, reactions to medications, and other problems with body metabolism and biochemistry.

Unfortunately, the standard treatment approach for classic FM will not help patients with pain and fatigue caused by conditions within any of these three categories. (6) So what's the solution to this dilemma? Actually the answer is simple. The doctor needs to find the cause of the widespread pain and fatigue, and prescribe treatments that eliminate the cause. It doesn't help to have a doctor tell the patient they have fibromyalgia without first ruling out a condition in one of these other three categories of medical problems. However, if the doctor has performed an extensive medical history and laboratory tests, and still cannot find a cause for these symptoms, the patient may indeed be suffering from classic FM. We will now provide a brief explanation of classic FM.

Classic Fibromyalgia

The actual cause of classic FM is unknown, but is theorized to be an unusually strong response by the nervous system to physical and/or emotional trauma. Some people develop classic FM after a severe car accident, work-related injury, serious surgical procedures, physical or emotional abuse, or witnessing a horrific event. These traumatic events may lead to a heightened and prolonged pain response to many sorts of stimuli that would not normally be perceived as painful, such as bright lights, sounds, changes in temperature, moderate pressure on the skin or muscles, or household chemicals. Many researchers now believe that there is a strong genetic predisposition to the development of classic FM, because it tends to run in families, but clearly the right constellation of environmental factors also have to be present. (8)

In addition to living with chronic pain and fatigue, many classic FM patients have extraordinary amounts of stress in their lives or may have experienced intensely emotional events that have caused their nervous systems to have heightened responses to pain (similar to people who experience posttraumatic stress disorder [PTSD]). It is important to realize that these patients are not suffering from some sort of psychological defect; classic FM patients are not "imagining" their pain. The pain is quite real, and researchers can see abnormal changes in pain processing in the brains of classic FM patients with a special type of MRI scanning known as functional MRI (fMRI). (9)

For some unknown reason, the brains of classic FM patients do not process pain in the same way as healthy patients without FM. Research has also shown that there is a lower amount of certain chemicals in the brain fluids of classic FM patients, which could explain the heightened pain responses and lead to failure of the descending antinociceptive system (DANS). (7) (See Figure 1.) This is why certain prescription medications and nutraceuticals can help to reduce these chemical imbalances and thereby relieve the chronic pain of FM. (3) Because the underlying cause of classic FM seems to be related to emotional stress or previous traumatic experiences, the most effective treatment is a combination approach that incorporates medication/ supplementation, exercise, and relaxation techniques. (10)

Here's a checklist of symptoms found most commonly in patients with classic FM:

* Unrefreshing sleep

* Extreme sensitivity to touch

* Difficulty with concentration

* Widespread pain/tenderness

* Extreme fatigue/low energy

* Migraine headaches

* Inability to tolerate exercise

* Grinding/clenching teeth

* Irritable bowel syndrome

* Multiple chemical/food sensitivity

* History of depression/anxiety

* Irritable bladder syndrome

If your patient has experienced widespread pain for more than 3 months and has at least 4 of the above symptoms, they may very well be suffering from classic FM and may be a candidate for the standard medical approach. Certain medications, or nonmedication neurotransmitter precursors such as 5-hydroxytryptophan (5-HTP), can be helpful to reduce the level of pain, unrefreshing sleep, and emotional stress. (11) However, other approaches can be helpful to "retrain" the nervous system and the body's responses to pain. These include activities such as mild aerobic exercise, yoga, tai chi, meditation, and self-relaxation techniques. (12) Sometimes psychological counseling that uses a cognitive behavioral therapy approach is also quite beneficial to classic FM patients.

If your patient does not have at least 4 of the symptoms noted above, then you should look for some other cause of their FM symptoms. It is likely that instead of having classic FM, they are suffering from some other medical problem that may mimic FM. The first thing is to make sure that their symptoms of widespread pain and fatigue are not caused by some undiagnosed medical problem, which we will discuss in the next section.

Common Medical Problems That May Be Confused with Classic FM

In patients who complain about generalized pain and fatigue, it is imperative that the doctor rule out the presence of any medical condition or disease known to cause many of the symptoms associated with classic FM. Hypothyroidism, anemia, rheumatoid arthritis, Lyme disease, rheumatic autoimmune disorders such as ankylosing spondylitis (AS) or scleroderma, multiple sclerosis, and cancer are some possible causes for symptoms of vague and diffuse musculoskeletal pain associated with pronounced fatigue. (5) Most of the medical assessments appropriate in this type of situation come in the form of laboratory testing, to include any or all of the following screening tests:

* Complete red and white blood cell count with white cell differential

* Thyroid function tests (total and free T3 & T4, TSH, and thyroid antibodies)

* Standard blood chemistry

* C-reactive protein and/or erythrocyte sedimentation rate (ESR)

* Lyme test, rheumatic/autoimmune profiles (as necessary)

As simple as these screening tests may be to perform, it is not uncommon for doctors to fail to have any laboratory tests performed on their patient and still render a diagnosis of FM despite the fact that according to American College of Rheumatology (ACR) guidelines and criteria, a diagnosis of FM should not be rendered until all lab tests come back negative and fail to detect any obvious medical reason for the symptoms. (2)

The doctor should employ a simple, rational approach to laboratory assessment, which includes an initial complete blood count (CBC) as a screen for common forms of anemia (unhealthy or low levels of critical oxygen-carrying red blood cells), and an assessment of white cells to rule out infection or marrow disease. (13) More specifically, obvious reasons for excessive fatigue, such as anemia, can be ruled out on the CBC by screening for low RBC count, altered hemoglobin and abnormal RBC indices such as MVC, MCH, and MCHC tests. An erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) test can help to confirm the presence or absence of inflammation or infection. Although the ESR and CRP tests are nonspecific, extremely high values found on these tests may indicate the need for further laboratory testing for underlying autoimmune rheumatic diseases or possible undiagnosed serious illnesses, including malignancy (cancer).

Thyroid blood tests should be routinely performed in patients who present with the complaints of widespread pain and fatigue in order to rule out obvious hypothyroidism as the cause of these symptoms. While the classic signs and symptoms of low thyroid function, including fatigue, weakness, cold intolerance, low temperatures, weight changes (usually weight gain), and depression are routinely considered by doctors, common musculoskeletal signs and symptoms of hypothyroidism including muscle pain, stiffness, muscle cramping, muscle weakness, numbness and tingling, and joint pain are often not considered. The incidence of muscle and joint symptoms with hypothyroidism has been reported to be as high as 30% to 80%. (14) These facts are extremely important since it is precisely these vague muscle or joint symptoms that may drive the patient to you initially. Many patients suffering from these symptoms will likely be unaware that they have a thyroid condition, and if missed by the physician, their symptoms may inadvertently be misdiagnosed as FM. More information will be provided on thyroid conditions in the later section on functional metabolic disorders often misdiagnosed as FM.

The doctor should also order a standard blood chemistry panel, as it is very useful to evaluate the general health of a patient experiencing widespread pain and fatigue. This panel should be done after an 8- to 10-hour fast and generally includes serum blood sugar, liver enzymes (liver function tests), cholesterol, blood lipids (fats), and kidney function tests. Of course these laboratory tests should be correlated with physical examination findings and other diagnostic tests. If the physical exam findings suggest that the patient may be suffering from joint pain and/or obvious soft tissue inflammation, not simply increased pain perception in the soft tissues, additional laboratory studies such as a rheumatoid panel and Lyme disease and coinfection screening tests may be warranted.

It is highly important to note that if laboratory studies are positive for any of the above noted medical conditions or diseases, a diagnosis of FM may very well be inappropriate. In the author's clinical experiences, patients who have diseases that go undetected due to a shoddy examination and investigation are often misdiagnosed as having FM in an attempt to explain or justify their constellation of symptoms. As a general rule, no patient should ever be given a diagnosis of FM without a complete physical examination and basic screening laboratory testing to rule out the underlying medical conditions.

Muscle and Joint Conditions That May Be Confused with Classic FM

One of the most common reasons for a mistaken diagnosis of classic FM is pain that is actually arising from several muscles and joints of the body. Widespread pain is often caused by a few different painful conditions that all put together feel like just one big painful condition. For example, a patient might have injured the lower back in a work-related accident 2 years ago, had a whiplash to the neck from a car accident, and also twisted the knee while walking down the stairs. When this patient makes an appointment, the doctor asks, "Where do you hurt?" The response might be, "My lower back, neck, and knee ... geez, Doc, I just seem to hurt everywhere." The busy doctor may quickly make the diagnosis of classic FM and not take enough time to sort out the fact that this patient actually has three separate problems: a low back problem, a neck problem, and a knee problem. Sure, the patient may be thought to have "widespread pain," but it is actually caused by three distinct muscle and joint problems and not classic FM.

This happens quite frequently with older patients, who often have some degree of arthritis in several joints and come to their doctor with a complaint of widespread pain. Most primary care doctors simply don't have the time or training to perform a comprehensive physical examination of the muscles and joints, and may be quick to label a patient with classic FM. Many older patients have an overlap of general widespread pain from arthritis, but also have one or two localized muscle or joint problems that could respond well to treatment by a physical therapist, chiropractor, or massage therapist.

It might seem simple, but there is a basic principle of diagnosis that can quickly determine if the pain is coming from a muscle or joint. Movement should reproduce the pain if the pain is coming from a musculoskeletal structure. For example, if the patient has pain between the shoulder blades coming from the neck or shoulders, movements of the neck or shoulders should cause it to get worse. If there is absolutely no movement or position that makes the pain worse, it may not be coming from a muscle or joint, and other sources should be considered.

A certain type of muscle pain is often mistaken for classic FM. To talk about this, we first need to clear up a very common mistake that is made in medical clinics. This is the mistaken belief that the tender points found in FM are the same as the trigger points found in another condition known as myofascial pain. (15) Most doctors know about trigger points; they are the "knots," "lumps," or "taut bands" found in painful muscles after too much exercise or remaining in a poor posture for too long.

It is really important not to confuse trigger points and tender points. These are not the same condition. Tender point is used with the classic type of FM wherein the patient reports widespread pain and multiple areas that are extremely painful to even the lightest touch. In classic FM, these tender points are painful but generally not lumpy, hard, or nodular; they are simply "tender." However, the trigger points found in myofascial pain have a very distinctive texture; they feel hard and lumpy. Some people describe the way trigger points feel as "cords" or "guitar strings." All of these words are simply attempts to describe the observation by patients and doctors that trigger points have a distinctive texture to them, whereas tender points have no such distinctive texture.

As a patient, you can figure out for yourself whether your painful areas are tender or trigger points. Gently rub the muscles over the areas of your pain. Close your eyes and let your fingers tell you what you feel. Does the area of painful muscle feel different from the same area on the opposite side of the body? If you roll across these painful "knots," does it reproduce your pain and cause a "twitch" in the muscle? If so, you may very well be suffering from trigger points and myofascial pain, not tender points and FM.

Of course, trigger points can be successfully treated with deep massage, ischemic compression techniques, and stretching methods that are commonly used by chiropractors, physical therapists, physiatrists, and massage therapists. Acupuncture can also be used to treat trigger points. But remember that the tender points found with classic FM are generally not going to respond to manual massage or therapies, because the tender points are centrally mediated alterations in pain perception and not really areas of true muscle problems. They are just painful areas due to abnormal processing of pain signals by the brain and nervous system. That's why deep pressure massage techniques don't seem to work as well with classic FM patients.

It is also possible that your patient's pain is coming from joints that lie deep to the muscles. In this case, you will not feel any lumps, knots, or taut bands in the muscles because the painful joint is much deeper. However, you should still be able to provoke the pain with certain movements and positions. For example, if the patient has pain in the neck area that is coming from the joints of the cervical spine, the pain should get worse when rotating the neck fully to the right and left, looking up toward the ceiling and down toward the floor. If there is pain in the shoulder that is coming from the shoulder joint, the pain should worsen with full elevation of the arm toward the ceiling or reaching back behind the back.

Functional Problems with Metabolism That May Confused with Classic FM

More subtle functional disorders may represent various types of subclinical disease states and disorders involving dysfunction of internal organs and individual metabolism, rather than true pathology. These functional disorders are often not on the busy traditionally trained clinician's radar screen and range the gamut from simple vitamin and mineral insufficiencies, to more hidden functional disorders such as energy metabolism disorders (mitochondrial dysfunction), subtle endocrine imbalances (subclinical thyroid disorders, abnormalities in stress physiology, etc.), opportunistic intestinal infections (dysbiosis), blood sugar abnormalities (reactive dysglycemia), postviral immune suppression, and other conditions that are not readily apparent on standard laboratory screening tests.

Energy Metabolism

Several nutritional deficiencies have been identified in patients with fatigue and widespread tenderness, including coenzyme Q10 (CoQlO) and carnitine, both absolutely critical in the cellular production of energy, proper cognitive function, and muscle function and metabolism. (16,17) Studies also suggest that the use of supplements to include B vitamins, magnesium, and malic acid (malate) have shown positive results in FM patients. (18-20) However, there is speculation that these interventions mainly aid in the biochemistry of energy production within the mitochondria of cells, including in muscles, which may alleviate the fatigue and muscle soreness often reported by patients diagnosed with FM, but they may not really be addressing issues specific to classic FM. In the author's experiences, in mild to moderate cases of fatigue and widespread achiness, supplementation with the above nutrients may have a significantly positive clinical effect. However, patients with severe fatigue usually do not respond adequately to these supplements alone, and require a more comprehensive functional approach. All of these functional disorders, and many more not mentioned, have the common denominator of potentially causing symptoms of low energy, fatigue, and widespread achiness, which are difficult to diagnose and often lead to an inappropriate diagnosis of FM.

The Importance of Optimal Thyroid Function

The thyroid gland is responsible for synthesizing several hormones that have vast effects on overall body metabolism. It is unique among endocrine glands in that large amounts of hormones are created and stored in the thyroid and then released very slowly. Iodine ingested from food and water is concentrated by the thyroid gland and combined with the amino acid tyrosine in various chemical configurations to create the active thyroid hormones triiodothyronine (T3) and thyroxine (T4). The numbers 3 and 4 are used to identify the number of iodine units incorporated into the hormone's structure. All reactions necessary for the formation of T3 and T4 are influenced and controlled by thyroid stimulating hormone (TSH), produced in the pituitary gland in the brain (see Figure 2).

As stated previously, thyroid function laboratory tests should be routinely performed in patients who present with complaints of widespread pain and fatigue in order to rule out overt hypothyroidism as the cause of these symptoms, including thyroperoxidase and thyroglobulin antibody tests to screen for cases of autoimmune thyroid conditions such as Graves' disease and Hashimoto's thyroiditis. However, more subtle presentations of thyroid dysfunction should also be considered, even when standard lab values are within normal range. Many cases of hypothyroidism will respond well to the use of common hormone replacement medications, such as Synthroid, Levothroid, or Levoxyl. However, these medications only contain synthetic L-thyroxine (T4). Many patients suffer from and inability to efficiently convert the relatively inactive T4 hormone to the much more active T3 hormone, often instead producing more of the relatively inactive reverse T3 (rT3) (see Figure 3).

This condition is sometimes referred to as euthyroid sick syndrome, low T3 syndrome, or thyroid peripheral conversion disorder. One possible reason for this can be elevations in the adrenal hormone cortisol due to acute or long-term stress. In these situations, patients often do not feel relief of their symptoms when placed on T4 thyroid hormone replacement therapy alone. The use of a combination of thyroxine (T4) and triiodothyronine (T3) therapy together (e.g., Armour Thyroid, Nature-Throid, or combination therapy of Synthroid and Cytomel) is very often required to adequately manage patients who do not adequately respond to T4 therapy alone. These patients may not have overt abnormalities on standard thyroid laboratory studies and may have been told that their thyroid is fine. Doctors need to pay close attention to patients' clinical symptoms and temperature, and also utilize closer inspection of laboratory testing and consider a trial of thyroid treatment for patients with clinical symptoms of hypothyroidism who have laboratory results in the lower part of the normal range for both total and free T3 and T4 and/or a TSH result in the upper part of the normal range. Since only the free (unbound) hormones can enter cells and bind to the thyroid hormone receptors on the cell nuclei, the free T3 and T4 hormones should be ordered and evaluated for comprehensive thyroid evaluation, something which is often not done by many conventional doctors, including endocrinologists. When these free hormones, particularly free T3, bind to the nuclear hormone receptor in a cell, they regulate DNA (genetic) control of various biochemical processes, thereby altering metabolism throughout the entire body. Lowered function of the thyroid gland, regardless of the cause, can result in profound physiologic effects throughout virtually all systems of the body. General signs and symptoms include fatigue, weakness, cold intolerance, low temperatures, weight changes (usually weight gain), and depression. Generally speaking, lower levels of thyroid hormone entering cells will slow overall metabolism and energy, while higher levels will increase overall metabolism and energy. (14)

Here's a checklist of symptoms that may be found in patients with a hypothyroid condition:

* Extreme fatigue/low energy

* Weakness

* Weight gain

* Muscle cramps/aches

* Difficulty with concentration

* Joint pain

* Inability to tolerate exercise

* Numbness/tingling

* Cold all the time

* Hard time remembering things

* Constipation

* Carpal tunnel syndrome

* Chronic infections

* High blood sugar

* Frequent postnasal drip

* High blood fats (cholesterol)

* Swollen look to face

It is the author's experience that undiagnosed subtle thyroid issues are one of the most prevalent reasons for complaints of fatigue, achiness, and cognitive dysfunction and the eventual misdiagnosis of FM, particularly in women. To learn more about functional hypothyroid disorders, please see the "Media/Articles" tab at DrDavidBrady. com.

Stress and the Adrenal Glands

It is also important for doctors to evaluate how the body responds to stress in all patients complaining of fatigue. This is often done by evaluating the status and functioning of the adrenal glands. This is necessary due to the fact that increases in adrenal catecholamines, the "fight-or-flight" stress hormones produced by the adrenal glands, and increases in the activity of the sympathetic nervous system have been implicated in FM. Evaluation of cortisol, another stress hormone produced by the adrenal glands, should also be assessed when screening for adrenal dysfunction. The pattern of low cortisol and elevated catecholamines is common in those diagnosed with FM and has also been associated with (PTSD, which may explain the common emergence of FM diagnoses in people who have undergone significant stress, life-altering events, and trauma. (21) In patients with this classic pattern, psychological counseling and stress-reducing lifestyle modifications and cognitive behavioral therapy techniques are imperative.

In summary, there appears to be a certain subset of patients who may receive an inappropriate diagnosis of FM and do not display the entire spectrum of clinical elements indicative of classic FM, do not show any positive laboratory findings indicative of overt organic medical pathology or disease, yet have significant functional deficits in their metabolism and certain organ systems. The functional medicine approach to the treatment of these patients is not based on any one infectious agent or treatment modality as the curative, or even palliative, solution. It is based on the principle that restoration of proper cellular biochemistry and metabolism, in a manner unique to the individual's needs, through balancing the endocrine system, correction of nutritional deficiencies, and the reduction of cumulative toxic load and oxidative stress will allow normalization of mitochondrial function and cellular energy production, and ultimately lead to a reduction in the signs and symptoms of low energy, fatigue, and widespread achiness. (23) Many of these factors can be addressed with simple lifestyle changes by the patient, including eating a varied and balanced fresh-food diet, consuming reasonable but targeted vitamin, mineral, and herbal supplements, and engaging in stress management techniques such as regular light exercise, proper sleep, adequate recreation and relaxation, deep-breathing exercises, guided imagery, yoga, meditation, prayer, biofeedback, and other forms of cognitive behavioral therapy. (3)

The old adage "diagnosis is half the cure" is certainly true. Very targeted and individualized treatment intervention is also key.

Basic General Supplementation Plan for Those Diagnosed with FM

This protocol can be helpful whether you actually have classic FM or not.

* Magnesium: 500-1000 mg per day in divided dosages (glycinate or malate form preferred)

* B-complex: 50-100 mg twice daily

* CoQ10 (oil-based soft gel): 100 mg twice daily

* L-carnitine: 500 mg 2-3 times daily

* 5-hydroxytryptophan (5-HTP): 50-100 mg 2-3 times daily (only under supervision)

* Melatonin (sustained release preferred): 3-6 mg 30 minutes prior to bedtime if patient is experiencing insomnia or unrefreshed sleep.

Dietary Modifications

1. Avoid food allergens and caffeine.

2. The consumption of nonprocessed whole foods is critical in order to avoid chemical food additives as much as possible. Simple sugars should be limited as much as possible in the diet. A low allergy-sensitivity diet (avoid gluten, dairy, corn, etc.) should be followed for several weeks followed by reintroduction of foods one at a time in order to determine if any of these specific foods contribute to a worsening of symptoms. Variation in food consumption patterns should be strived for. Artificial sugar substitutes and caffeine should be entirely eliminated.

Lifestyle Modifications

* Keep predictable sleep patterns (in bed by 10 p.m., don't oversleep in morning)

* Get moderate exercise, but do not overexercise

Current Drug Therapies

Treating all symptoms of central sensitization is the key focus of the three FDA-approved medications for FMS pain, including pregabalin, duloxetine, and milnacipran. In 2007 pregabalin (Lyrica), an alpha-2-delta (a2[delta]) ligand, became the first medication to gain FDA approval for treatment of FMS pain. Although, as with each of the three approved FMS medications, the exact mechanism of pregabalin's pain-relieving action is not yet clear, it is currently believed to function via reducing nervous system hyperexcitability. Pain reduction may also result from decreased release of pro-pain neurotransmitters in the spinal cord and through modulating pain transmission in the spinal cord. (3)

New Emerging Therapies

A recent Stanford University study using very low doses (3-4.5 mg at bedtime) of the medication naltrexone, an opiate blocker, demonstrated a 30% reduction in pain for all 10 of the patients in this small trial. (23) Further research is called for, especially given the low cost and side-effect profile of this medication. Its mechanism of action is suspected to not be through its known opiate modulation capabilities, but instead may be through its pleomorphic anti-inflammatory and immune modulation capabilities and the possibility of its reducing the microglial inflammation deep in the brain now being reported in classic FM, though this still is yet to be clarified. (24)

Remember, Proper Diagnosis is Half the Cure

It is very important to know whether the patient is really are suffering from classic fibromyalgia (FM). You should never issue a diagnosis of FM unless you have fully explored all other possible causes for your patient's widespread pain and fatigue. This includes careful consideration of all other medical conditions, musculoskeletal problems, and functional metabolic issues. These other causes of widespread pain and fatigue are actually more common than classic FM and must be excluded or eliminated.

Notes

(1.) Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Arthritis Rheum. 1990;33:160-172.

(2.) Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. Arthritis Care Res. May 2010;62(5):600-610. doi:10.1002/acr. 20140.

(3.) Arnold LA. Biology and therapy of fibromyalgia. New therapies in fibromyalgia. Arthritis Res Ther. 2006;8:212. doi:10.1186/arl971.

(4.) Fitzcharles MA, Boulos P. Inaccuracy in the diagnosis of fibromyalgia syndrome: analysis of referrals, rheumatology. 2003;42:263-267.

(5.) Schneider MJ, Brady DM, Perle SM. Differential diagnosis of fibromyalgia syndrome: proposal of a model and algorithm for patients presenting with the primary symptoms of widespread pain. J Manipulative Physiol Ther. 2006,29:493- 501. Available at www.jmptonline.org/issues.

(6.) Dadabhoy D, Clauw DJ. Fibromyalgia - different type of pain needing a different type of treatment. Nat Clin Prac Rheumatol. 2006;2(7):364-372.

(7.) Abeles MA, Pillinger MH, Solitar BM, Abeles, M. Narrative review: the pathophysiology of fibromyalgia. Ann Intern Med. 2007;146:726-734.

(8.) Buskila D, Neumann L, Hazanov I, Carmi R. Familial aggregation in the fibromyalgia syndrome. Semin Arthritis Rheum. 1996;26:605-611. doi:10.1016/S0049-0172(96)80011-4.

(9.) Lourengo-Jorge L, Amaro E. Brain imaging in fibromyalgia. Curr Pain Headache Rep. 2012;16:388-398.

(10.) Yunus MB. Editorial review: an update on central sensitivity syndromes and the issues of nosology and psychobiology. Curr Rheumatol Rev. 2015;ll(2):70-85.

(11.) Sarzi Puttini P, Caruso I. Primary fibromyalgia syndrome and 5-hydroxy-l-tryptophan: a 90-day open study. J Int Med Res. 1992;20:182-189.

(12.) Kelley GA, Kelley KS. Exercise improves global well-being in adults with fibromyalgia: confirmation of previous metaanalytic results using a recently developed and novel varying coefficient model. Clin Exp Rheumatol. 2011 Nov-Dec;29(6 Suppl 69):S60-S62. Epub 2012 Jan 3.

(13.) Kis AM, Carnes M. Detecting iron deficiency in anemic patients with concomitant medical problems. J Gen Intern Med. 1998 July;13(7):455-461.

(14.) Khaleeli A, Griffith DG, Edwards RH. The clinical presentation of hypothyroid myopathy and its relationship to abnormalities in structure and function of skeletal muscle. Clin Endocrinol. 1983;19:365-376.

(15.) Schneider MJ. Tender points/fibromyalgia vs. tender points/ myofascial pain syndrome: a need for clarity in terminology and differential diagnosis. J Manipulative Physiol Ther. 1995;18:398-406.

(16.) Cordero MD, Cotan D, del-Porto-Martin Y, et al. Oral coenzyme Q10 supplementation improves clinical symptoms and recovers pathological alterations in BMC's in a fibromyalgia patient. Nutrition. 2012:28.

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by David M. Brady, ND, DC, CCN, DACBN

Author of The Fibro-Fix, with Michael J. Schneider, DC, PhD

Dr. Brady's new book, The Fibro Fix, provides a wealth of information on how to negotiate your way toward rendering the proper diagnosis and the proper treatment for symptoms of widespread pain and fatigue. Preview the book at FibroFix.com. Also, learn more about the Fibro-Fix Summit, where Dr. Brady interviewed 30-plus experts on FM and related disorders often misidentified as FM at FibroFixSummit.com.

Dr. David M. Brady has over 25-years of experience as an integrative medical practitioner and academic. He is a licensed naturopathic medical physician in Connecticut and Vermont and a board-certified clinical nutritionist. Dr. Brady is also a prolific author of medical papers and research articles on fibromyalgia and has dedicated a large part of his professional career to helping people recover from this mysterious disorder.

He currently serves as the VP for the Division of Health Sciences, director of the Human Nutrition Institute, and associate professor of clinical sciences at the University of Bridgeport in Connecticut. He maintains a private practice, Whole Body Medicine, in Fairfield, Connecticut, and is also the chief medical officer for Designs for Health Inc. and Diagnostic Solutions Labs LLC. You can learn more at DrDavidBrady.com and FibroFix.com.

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