Persistent Pain This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
From The October 1999 Issue of Nutrition Science News
By Marcia Zimmerman, C.N.Searching for the cause of fibromyalgia and natural sources of relief
On Sunday, May 10, 1999, famed ballerina Evelyn Cisneros retired from the San Francisco Ballet after 25 years of performing. Asked during an interview what she would most enjoy about retirement, Cisneros said it would be waking up every morning without excruciating pain. She explained that she can barely crawl out of bed each day. For years she battled her joint and muscle pain -- the result of a lifetime of dancing.
An estimated 10 million Americans share the daily pain Cisneros described. They drag themselves out of bed and begin their day while coping with extreme pain, spasms, stiffness and decreased physical ability. Although Cisneros could look forward to the end of her pain, people with fibromyalgia have little hope of escaping their condition.
Fibromyalgia syndrome (FMS) is a chronic debilitating disease. It affects 2 to 4 percent of the U.S. population, with women sufferers outnumbering men by a ratio of 10:1. [1] Some experts estimate FMS is second only to osteoarthritis as the most common rheumatic condition. [2] The women affected are between the ages of 20 and 60--most are 45 to 55. Women in this latter age range are typically experiencing perimenopause or menopause, with shifting hormone levels that can affect the degree of pain experienced. [3 ]In the end, fibromyalgia is an often misunderstood condition--and there is no cure.
A Delicate Diagnosis
Fibromyalgia is described as fatigue, stiffness and widespread musculoskeletal pain that varies in type and intensity. The pain usually starts in one spot then progresses to other locations. The intense pain waxes and wanes, often seeming to be everywhere. In many cases, patients are unable to get an accurate diagnosis and have no idea what causes their painful condition. To further complicate diagnosis, other symptoms such as sleep disturbances, fatigue, headaches, irritable bowel syndrome, lowered cortisol and neurotransmitter imbalances can occur along with FMS pain. [3]FMS can also be accompanied by other disorders including chronic fatigue syndrome, osteoarthritis, systemic lupus erythematosus (SLE or lupus) and psoriatic arthritis. [4]
Although FMS is often confused with the equally painful rheumatoid arthritis (RA)--a chronic inflammatory joint disease--it differs in that there is no damage or deformity to the connective tissues, joints or muscles. FMS is not an inflammatory condition, but both FMS and RA are classified as rheumatic disorders--those that cause pain in the muscles, joints and connective tissues. Current research indicates FMS-related pain is a result of faulty muscle function involving both contraction and relaxation. A decrease in available energy for muscle contraction and an inability of muscles to relax after contraction is thought to be the underlying cause. Eventually, the thin membrane (sarcolemma) that surrounds groups of individual muscle fibers becomes tight and thick, causing further pain within the muscles. [5]
To be diagnosed with FMS, patients must meet the criteria established in 1990 by the American College of Rheumatology. These criteria require that pain persist for at least three months, be present in all quadrants of the body, and occur in at least 11 of the 18 specific trigger points on the back of the head, base of the neck, between the shoulders, under the shoulder blades, on top of the buttocks, inside the knees and outside the elbow joint (see diagram). [4] These points must be extremely painful even to slight pressure.
Tracking the Pain
Two types of FMS have been identified: primary, stemming from an uncertain origin; and post-traumatic, resulting from a physical injury such as a fall or whiplash. In either case, the symptoms are the same.
The difficulty of getting an accurate diagnosis often leaves patients depressed and anxious, and leads physicians to conclude the condition is psychological rather than physical. Antidepressants are commonly prescribed regardless of whether an FMS diagnosis is reached or not. Even after diagnosing FMS, physicians often prescribe antidepressants to treat the anxiety, depression and sleep disorders that usually accompany the condition. To mitigate pain, patients often use over-the-counter pain killers such as acetaminophen and nonsteroidal anti-inflammatory drugs. Other pain treatments include muscle relaxants or injections of corticosteroids or pain killers into the painful spot. [2]
Doctors and researchers seeking the elusive cause of FMS have suggested various theories. Sleep disturbances, which are extremely common in FMS patients, are considered the primary cause of the disorder. FMS patients appear to lack delta wave sleep--the deepest and most relaxing sleep phase. [4] Lacking restful and restorative sleep, patients experience disturbances in biological rhythms, which affect virtually all bodily systems. [6,7]
Researchers at the Rheumatology Unit at the L. Sacco Hospital in Milan, Italy, have studied the effects of serotonin levels in FMS patients. They say levels of the neurotransmitter, which influence mood, pain and sleep, are significantly lower in FMS patients. This, they suggest, is responsible for the changes in muscle structure and metabolism. In addition, they propose that the low serotonin levels combined with elevated levels of two peptides involved in pain perception alter immune responsiveness. In two 50-patient trials, researchers gave 100 mg 5-hydroxytryptophan (5-HTP) three times daily to each patient, which resulted in a 50 percent reduction in all symptoms measured. Moreover, patients retained the beneficial effects for up to 90 days after treatment. Oral forms of 5-HTP, a serotonin precursor, are well absorbed into the brain and quickly converted to serotonin. [8,9]
A consensus among neuroendocrinologists who presented papers on FMS at a National Institutes of Health scientifc workshop in Bethesda, Md., in July 1996 was that FMS patients have an altered stress response system as evidenced by lowered cortisol levels and an abnormal adrenocorticotropic hormone (ACTH) response. The resulting abnormalities in biological rhythms affect the pain response, secretion of reproductive hormones, and immune and nervous system functions. [10 ]
Complementary FMS Treatments
Leslie Mason, Ph.D., from the department of psychology at the University of North Carolina, Charlotte, reviewed the few studies that have been published on FMS treatment outcomes. She found that combining conventional treatments with complimentary therapies such as biofeedback, chiropractic, exercise, massage therapy, meditation, physical therapy and stress reduction techniques have been most successful for long-term FMS management. [6] Other common adjunct therapies include increasing flexibility and fitness through stretching, and gentle exercise such as bicycling, swimming and walking. [4]
In addition to physical therapies, people with FMS should pay close attention to their diets. Emphasizing whole, fresh foods and eliminating processed foods is a sound nutritional strategy for any disease condition. Specific dietary modifications for FMS have not been published, but scientists studying the effects of a vegetarian diet in RA patients noted significant improvement in symptoms including pain, morning stiffness, joint swelling and overall health. Moreover, the improvements lasted two years, indicating diet therapy could produce long-term effects. No improvement was seen among control subjects who continued to eat an omnivorous diet. [11,12]These studies provide a model for what might constitute a dietary approach to treating FMS.
The same team also studied the effects of allergy-provoking foods in RA patients. They eliminated foods most likely to cause allergic reactions including fish, meat, milk, oranges, peas, pineapple, shellfish, tomatoes, and wheat and corn flours. Patients on the elimination diet showed significant reduction in the number of tender points, which suggests RA patients may benefit by eliminating allergy-provoking foods. [13] This elimination diet approach is commonly used by physicians to modify FMS symptoms.
In addition to exercise and diet therapies, there are some supplements that may be helpful. Bear in mind that research is preliminary and efficacy is not proven.
French scientists found magnesium levels in red blood cells to be low in the FMS patients they examined. This low magnesium status was linked to abnormal thiamine metabolism. [14]Magnesium is essential for providing energy within muscle cells for normal contraction and relaxation. Researchers linked the low magnesium levels and abnormal thiamine metabolism to poor muscle metabolism.
Malic acid is a natural companion of magnesium and thiamine in the energy cycle. Some doctors, including Jorge Flechas, M.D., of Hendersonville, N.C., suggest malic acid for patients with FMS. Flechas says malic acid increases ATP synthesis (energy production). Flechas and colleagues studied the effects of magnesium and malic acid supplementation on 24 FMS subjects who were enrolled in a placebo-controlled four-week trial. Each patient received three tablets that contained 200 mg malic acid and 50 mg magnesium twice a day. At the end of the trial, no significant improvement was noted. However, during a follow-up six-month open trial with doubled doses (six tablets, twice daily), researchers noted significant reduction in pain and tenderness, plus improved psychological scores. [15]
Natural Options
Remind customers considering natural FMS treatments that not everyone responds the same to any one remedy. Therefore, a certain amount of trial and error may be required to find an optimal combination. Suggest that customers explore food elimination diets and supplements plans with a doctor who treats FMS with complimentary therapies. Recommending a multivitamin that contains B-vitamins, antioxidants, chelated minerals and extra magnesium is a good idea.
Fibromyalgia is a relatively new diagnosis. Our understanding of this painful condition is still sketchy and therefore so are the treatment choices. With the help of a supportive health care provider, customers may find relief in a range of complementary therapies.
Marcia Zimmerman, C.N., is founder and CEO of The Zimmerman Group Inc. in Alameda, Calif. She is author of The ADD Nutrition Solution--A Drug-Free 30-Day Plan (Henry Holt and Co., 1999).
Sidebars:
Dietary Influences on Pain
References
1.Saul D. Newer treatments for fibromyalgia pain. Internat J Integrat Med 1999 May/Jun;1(3):28-32.
2.Margolis S, Flynn J. Arthritis. Johns Hopkins White Papers, The Johns Hopkins Medical Institutions; Baltimore (Md.) 1999. p. 52-60.
3.Duna GF, et al. Diagnosis, etiology and therapy of fibromyalgia. Compr Ther 1993;19(2):60-3.
4.Kenner C. Fibromyalgia and chronic fatigue: the holistic perspective. Holistic Nurse Practitioner 1998;12(3):55-63.
5.Henriksson CM. Longterm effects of fibromyalgia on everyday life--a study of 56 patients. Scand J Rheumatol 1994;23(1):36-41.
6.Mason L, et al. Evaluation of a multimodal treatment program for fibromyalgia. J Behavioral Med 1998;21(2):163-78.
7.Moldofsky H. The neuroscience and endocrinology of fibromyalgia. National Institute of Arthritis and Musculoskeletal and Skin Diseases; NIH Workshop, 1996 July 16-17.
8.Caruso I, et al. Double-blind study of 5-hydroxy-L-tryptophan versus placebo in the treatment of primary fibromyalgia syndrome. J Internat Med Res 1990;18;201-9.
9.Puttini PS, Caruso I. Primary fibromyalgia syndrome and 5-hydroxy-L-tryptophan: a 90-day open study. J Internat Med Res 1992;20:182-9.
10.Crofford LJ. The neuroscience and endocrinology of fibromyalgia. National Institute of Arthritis and Musculoskeletal and Skin Diseases; NIH Workshop, Bethesda, Md., 1996 July 16-17.
11.Kjeldsen-Kragh J, et al. Vegetarian diet for patients with rheumatoid arthritis status: two years after introduction of the diet. Clin Rheumatol 1994;13(4):649.
12.Haugen MA, et al. Changes in plasma phospholipid fatty acids and their relationship to disease activity in rheumatoid arthritis patients treated with a vegetarian diet. Br J Nutr 1994;72(4):555-66.
13.Haugen MA. A pilot study of the effect of an elemental diet in the management of rheumatoid arthritis. Clin Exp Rheumatol 1994; 12(3):275-9.
14.Eisinger J, et al. Selenium and magnesium status in fibromyalgia. Magnesium Research 1994;7(3-4):285-8.
15.Russell IJ, et al. Treatment of fibromyalgia syndrome with super malic: a randomized, double-blind, placebo-controlled, crossover pilot study. J Rheumatol 1995;22(5):953-8
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