My latest assignment for my Master’s in Holistic Nutrition was to write a paper about a disorder of the nervous system. I chose Fibromyalgia as it affects someone close to me and I wanted to find out the various therapeutic modalities and treatment options available.
If you’d like to nerd out with me, continue reading:
Fibromyalgia syndrome (FMS) is characterized by widespread, generalized pain of at least a 3-month duration, affecting an estimated 6-12 million Americans, 80% of whom are women (Kohlstadt, 2012, p. 637; Pizzorno & Murray, 2013, p. 1374; Rakel, 2018, p. 475). Patients with FMS typically experience pain at certain anatomical points on the body, along with extreme fatigue, joint stiffness, headaches, sleep disturbances, irritable bowel, cognitive dysfunction, anxiety, depression, and exercise intolerance, among other symptoms (Pizzorno & Murray, 2013, p. 1375). Although not considered an autoimmune disorder, FMS can coexist and imitate such conditions as Lyme disease, hypothyroidism, and hepatitis C (Rakel, 2018, p. 475). Once considered a result of serotonin deficiency, FMS is now thought to be a disorder of the central nervous system (CNS), specifically neuronal dysregulation (Gota, 2018; Kohlstadt, 2012, p. 637) and a dampening of hypothalamus–pituitary–adrenal reactivity (Gota, 2018).
There is a strong psychosomatic component to FMS. Symptoms seem to begin with a precipitating stress occurrence or trigger, such as an accident, illness, emotional stress, or trauma (Galvez-Sánchez, Duschek, & Reyes Del Paso, 2019; Rakel, 2018, p. 475). Patients may present with a sensitive personality temperament, inappropriate cortisol response to stress, heightened pain perception (hyperalgesia), and/or a concurrent mood disorder such as anxiety or depression (Bellato et al., 2012; Gota, 2018; Rakel, 2018, p. 475).
The etiology of FMS isn’t fully understood, though there may be genetic, hormonal, psychiatric, external stressor, neurotransmitter, immune system, and other contributing dysfunctions (Bellato et al., 2012). Obesity, reduced physical activity, hypothyroidism, adrenal dysfunction, irritable bowel syndrome, post-traumatic stress disorder (PTSD), and nonrestorative sleep all are recognized as possible underlying causes (Coppens et al., 2017; Kohlstadt, 2012, p. 642).
Diagnosis of FM can be challenging, as each patient presents with a unique combination of symptoms (Bellato et al., 2012). A thorough patient history including sleep quality, physical activity level, bowel habits, pain perception, fatigue level, menstruation, and cognitive function are key (Pizzorno & Murray, 2013). The ACR Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity, the Pain Distribution Body Form, the FibroQuest Symptoms Survey, and/or the Fibromyalgia Impact Questionnaire may be used to measure the patient’s pain, symptoms, and functional status (Pizzorno & Murray, 2013, p. 1381).
A physical examination finding abnormal tenderness at 11or more of 18 specific anatomic tender points indicates FMS (Pizzorno & Murray, 2013, p. 1375). The Widespread Pain Index and Symptom Severity Scale also help define the patient’s pain experience (Gota, 2018). A mental health screening, including Zung’s Self-Rating Depression Scale, may provide insight to depression, anxiety, trauma, and PTSD and provide opportunities for referral to mental health specialists (Coppens et al., 2017; Pizzorno & Murray, 2013, p. 1381).
Laboratory tests include a complete blood count, erythrocyte sedimentation rate, cyclic citrullinated peptide test, rheumatoid factor, antinuclear antibody, Celiac serology, and vitamin D levels, to rule out infection, autoimmune disorders, etc. (Fibromyalgia, 2020). In addition, a thyroid function test and thyroid antibodies test may be ordered to rule out concurrent hypothyroidism (Pizzorno & Murray, 2013, p. 1377). Adrenocorticotropic Hormone test (ACTH), salivary cortisol, Dehydroepiandrosterone Sulfate (DHEA-S), 24-hour urine cortisol, and urinary organic acids (OAT) testing help uncover other possible metabolic, toxic, and infectious contributors to FMS (Kohlstadt, 2012, p. 642). Finally, a colonoscopy and/or stool culture may be ordered to rule out other sources of gastrointestinal discomfort (Kohlstadt, 2012, p. 642).
Pain relievers, antidepressants, muscle relaxants, and anti-seizure drugs are prescribed most often for FMS. Over the counter non-steroidal anti-inflammatories (NSAIDs) such as ibuprofen (Advil, Motrin IB) and naproxen sodium (Aleve), are preferred to allay the discomforts associated with FMS (Fibromyalgia, 2020). Acetaminophen (Tylenol) is another widely-used option (Fibromyalgia, 2020). In addition, the analgesic, tramadol, is approved by the FDA specifically to treat pain in FMS (Bellato et al., 2012). Opioids are not recommended due to their significant side effects and dependence (Bellato et al. 2012; Fibromyalgia, 2020). In addition, they have not proven effective in long-term relief, possibly worsening the pain experience over time (Fibromyalgia, 2020).
Serotonin-norepinephrine reuptake inhibitors (SARIs) such as duloxetine (Cymbalta), milnacipran (Savella), and trazodone (Desyrel), as well as the tricyclic antidepressant/sedative (TCA) amitriptyline (Elavil), are commonly prescribed to help with anxiety and depression associated with FMS (Bilodeau, 2020; Fibromyalgia, 2020; Gota, 2018). Other medications such as the muscle relaxant cyclobenzaprine (Flexeril), the anticonvulsant pregabalin (Lyrica), gabapentin (Neurontin), and/or melatonin are also often prescribed to help with sleep (Bilodeau, 2020; Gota, 2018). Referral to support groups, counseling, and/or therapy may also be part of a traditional FMS treatment plan (National Fibromyalgia Association, 2020).
An integrative approach to FMS includes a focus on nutrition, movement, detoxification, mental health support, and sleep hygiene, minimizing long-term pharmaceutical use (Myers, 2020). Digestive issues including food intolerances, candida albicans overgrowth, small intestinal bacterial overgrowth (SIBO), leaky gut, irritable bowel syndrome (IBS), and gut dysbiosis are all addressed in a functional treatment plan (Kresser 2019; Myers, 2020). Healing the gut and restoring a healthy gut microbiome is the foundation for healing FMS (Kresser, 2019).
Removing inflammatory foods, ingredients, and medications such as gluten, sugar, industrial seed oils, dairy, MSG, aspartame, coffee, and when possible, antibiotics, and replacing them with an antiinflammatory diet rich in leafy greens (kale, salad greens, chard, arugula, etc.), cruciferous vegetables (broccoli, cauliflower, Brussels sprouts, etc.), omega-3 fats (salmon, sardines, anchovies, etc.), fermented foods (unsweetened, full-fat yogurt, sauerkraut, kombucha, etc.), fermented fibers (sweet potato, yams, etc.), and bone broth (Kresser, 2019; Rakel, 2018, p. 483) heals the gut and begins restoration of the microbiome. Integration of adaptogenic herbs into the diet such as turmeric, ashwagandha, schisandra, rhodiola, and ginseng aid in balancing the immune system and help to decrease inflammation (Myers, 2020). Finally, nutritional support of the thyroid may be encouraged with consumption of sea vegetables and dulse (Higdon & Drake, 2012, p. 153).
FMS patients often present with deficiencies in magnesium and vitamin D (Myers, 2020). A balance of calcium, magnesium, vitamin D, and vitamin K is crucial to support optimal uptake of all four nutrients (Mercola, 2018). Food sources of magnesium are oats, spinach, beans, nuts, seeds, blackstrap molasses, banana, and avocado (Higdon & Drake, 2012, p. 175; Mercola, 2018). Vitamin D sources are salmon, sardines, and mackerel (Higdon & Drake, 2012, p. 91). Balanced supplementation is an option when quality food sources aren’t available or tolerated (Higdon & Drake, 2012, p. 175; Mercola, 2018).
B12 deficiency is also common in FMS patients, and may be the result of age, poor digestion and/or absorption of nutrients, poor diet, or mutation of the MTHFR gene (Kohlstadt, 2012, p. 652; Myers, 2020). Genetic testing may be prescribed by an integrative practitioner. If a mutation is found, supplementation with methylfolate in addition to dietary means (salmon, beef, eggs, chicken, turkey, and nutritional yeast) helps optimize B12 levels (Higdon & Drake, 2012, p. 67-68; Procyk, 2018, p. 101). Healing the gut as mentioned earlier is key to B12 digestions and absorption (Myers, 2020).
Other supplements for FMS may include a high-quality multivitamin, iron, coenzyme Q10, acetyl-L-carnitine, D-ribose, S-adenosylmethionine, boswellia, N-acetyl choline, milk thistle, alpha lipoic acid, and/or St. John’s wort (Kohlsdadt, 2012, p. 652; Myers, 2020; Rakel, 2018, p. 479).
In addition to the laboratory tests mentioned above, functional medicine practitioners may also order an intestinal barrier function test to evaluate the mucosal lining of the intestines, and/or a comprehensive stool assessment to check for parasites and bacterial infections (Grisanti, 2015). Heavy metals testing with a pre- and post- DMPS urine challenge reveals heavy metal burden and indicates any need for chelation therapy (Myers, 2020). Celiac serology confirms sensitivity or allergy to gluten (Fibromyalgia, 2020).
Finally, positive lifestyle habits are encouraged in the integrative treatment of FMS. Exercise has been shown to ease the pain of FMS patients (Bellato et al., 2020; Mercola, 2010). Starting with just a few minutes a day working up to at least 30, a combination of weight-bearing, aerobic, and strength training activities bring the best benefit (Pizzorno & Murray, 2013, p. 1382; Rakel, 2018, p. 483). Sleep hygiene is addressed, optimizing the sleep environment, quality, and duration (Chetlin & Landis, 2020). Stress, anxiety, and/or depression are managed through psychotherapy, cognitive behavioral therapy, emotional freedom technique tapping (EFT), meditation, journaling, art, etc. (Michalsen et al., 2013; Rakel, 2018, p. 482). Lastly, various forms of fasting have been shown to help with inflammation and pain management (Michalsen et al., 2013).
References
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