Fibromyalgia Solutions

Fibromyalgia Solutions
by David Edelberg, M.D.Fibromyalgia, a chronic condition afflicting approximately ten million people, mainly women, has been an elusive and controversial diagnosis for years. Only recently are doctors understanding something about this condition, which, though not dangerous in any way, can really interfere with a person抯 sense of well-being, often more so than “serious” illnesses like heart disease, diabetes, or high blood pressure. Fibromyalgia, which simply means “pain in the muscles,” frequently goes undiagnosed for years. The severity of symptoms may range from the fairly innocuous “I carry all my stress in my neck,” to daily unrelenting diffuse muscle pain often combined with a sense of overwhelming fatigue.

Last month article discussed some of the newer concepts about fibromyalgia, that the condition is not so much a specific disease with positive blood tests, or changes in the body observable by x-ray or under a microscope, but rather a series of certain physical alterations the body can undergo in response to chronic stress. The source of stress can be highly variable, ranging from the relatively rare situation of physical trauma (the whiplash pain that just never goes away) to infectious (“It was the flu from Hell. I never recovered”) to the most frequent setting, an emotional one (“It began after what I remember was the worst year of my life”). With fibromyalgia, the well known adrenal gland “fight or flight” response of the body, which was designed to be turned off once the sudden emergency had passed, seems to remain in the “on” position, with complex body responses to stress spinning slowly but relentlessly out of control.

I believe the reason conventional medicine fares so poorly with fibromyalgia is that (unlike alternative medicine), the hurried primary care physician or rheumatologist does not establish a relationship with the patient and has little time to explore significant biographical issues. With fibromyalgia, these issues can go back for decades. Although the diagnosis itself is fairly easy, conventional medicine抯 focus on “disease” rather than “person” will automatically miss the unique biography of each individual patient. A well-meaning physician will get absolutely nowhere with “Well, you have the right number of trigger points. Here抯 a prescription for Prozac. Also, you抳e got to exercise.” Although Prozac and exercise both have their place, standardizing therapies to a “one size fits all” mentality is futile in a condition like fibromyalgia in which the complexity of the patient plays such an important part.

As the very first step in therapy, every single fibromyalgia patient needs at least one in-depth session to explore when and how things changed, and, be given the opportunity to verbalize how to set things right again. This certainly does not mean initiating lengthy psychotherapy…really, many women “get it” at the end of the first visit. But this self-understanding, this “listening to the message from the body” is so vital to making any progress with fibromyalgia that I have seen many patients improve by simply taking the information gathered from their initial visit, and allowing themselves a few days alone. The place is irrelevant, just somewhere off to a “room of one抯 own” for some cogitation and life re-examination. I must add, however, that I have observed numerous patients fortunate enough to be able to take a week off after their initial visit and head to a retreat center or a spa. With a healthful diet, meditation, and regular massage, the symptom response is so dramatic that they need no further convincing about the necessity of stress reduction and life changes.

Pain Control
The predominant symptom of fibromyalgia is, of course, pain. To make any progress, breaking the vicious cycle of pain, poor sleep, fatigue, worse pain, becomes of paramount importance. As most patients soon discover, standard over-the-counter painkillers like aspirin, Tylenol, and Advil are only marginally effective.

By the time I see most patients, they have learned how to get a few days of relief from a massage or a visit to a chiropractor or naprapath and then simply include regular treatment in their monthly budget.

Here is where the combination of conventional and alternative medicine (the combination is now called “integrative medicine”) comes in handy. For although regular bodywork is very soothing, adding some prescription medications will enhance the effect. These have to be used carefully. For unclear reasons, fibromyalgia patients are exquisitely sensitive to side effects. Cutting tablets into quarters, or emptying out half the contents of a capsule is an almost routine necessity if you suffer from fibromyalgia.

Frequently helpful are Flexeril (cyclobenzaprine), Skelaxin, and antidepressants, like Elavil and Prozac. The last two are prescribed for their pain effect, not for depression. Very severe muscle pain sometimes requires a codeine derivative called oxycodone (Vicodin).

Selected nutritional supplements are very important in the treatment of fibromyalgia as well. Many published studies attest to the effectiveness of combinations of magnesium and malic acid, L-carnitine, and coenzyme Q-10, along with a high potency multivitamin/antioxidant combination.

Rather dramatic relief of pain can be obtained in minutes by an office procedure called “trigger point injections.” Each of the painful tender points is injected through a very fine needle with a few drops (0.5 ml.) of a 50:50 mixture of lidocaine (a cousin to the dentist抯 novocaine) and an herbal extract called Sarapin. Interestingly, both these medicines are in the Physician抯 Desk Reference and the procedure is reimbursed by most health insurance companies, so it can抰 truly be called “alternative medicine.” However, because the combination is not “officially” approved for fibromyalgia, many conventional physicians are unwilling to use this wonderful treatment.

After the injections, the patient is usually quite surprised about the immediate relief. Unfortunately the effect is not permanent; the full effect lasts only a few days. However, for the majority of patients, when the medicine does wear off, the pain doesn抰 return to its original level of severity. And with subsequent injections, in some areas (especially neck and shoulders) the pain actually seems to disappear.

As a physician now working in a center of integrative medicine, I cannot imagine how my conventional colleagues work without alternative practitioners. Specific for fibromyalgia, I usually recommend trigger point myotherapy. Although a good massage therapist can provide real relief, when the therapist has acquired the additional training of deep tissue massage and trigger point therapy, the patient can feel a real difference. Most naprapaths and chiropractors do some deep tissue work but are unavailable for a sixty-minute session. Patients who have access to acupuncture will find that traditional Chinese medicine can be very helpful.

Sleep
Most patients with fibromyalgia soon discover the importance of a good night抯 sleep in relation to the degree of pain they feel the following day. Unable to find a comfortable position in bed and waking up frequently to change positions, patients begin the day utterly unrefreshed by the night spent in bed.

Since the importance of deep restful sleep cannot be overstated, I may start with something over-the-counter, like valerian or melatonin, but if that is not strong enough, I quickly move to a prescription medication. For many, the muscle relaxant Flexeril provides deep safe sleep free from morning hangover while also unlocking and relaxing the poor achy muscles. Another prescription medication, Ambien, is a gem because it works in 30 minutes and is metabolized out of the body in four hours so that the patient awakens free from the lethargy associated with sleeping pills (including melatonin!).

I am often asked if Ambien is addicting. The answer is that the FDA classifies Ambien as potentially habit forming but not addicting. Used for a limited period of time, that is, until the pain ­ lack of sleep cycle is broken, Ambien is a very useful drug.

Fatigue
The treatment of the fatigue aspects of fibromyalgia are fraught with controversy among physicians themselves. One very vocal group of “quackbusters” has gone on record asking that state medical boards nationwide actually pull the medical licenses of any physician who diagnoses chronic fatigue syndrome, treats candida, or uses low-dose hormone replacement therapy without “positive” blood tests. If you think you misread that sentence, read it again.

However, a small, but growing number of physicians believe that beyond the sleep issue, the fatigue aspect of fibromyalgia is due to an exhaustion of what is termed the hypothalamic-pituitary-adrenal (HPA) pathway. This is an interconnected system from the brain to the body. It抯 the pathway through which fear sets your heart racing, tenses your muscles, and puts the lump in your throat. It抯 a pathway that seems to get burned out by chronic physical and/or emotional stress.

Damage to this system could produce fatigue and a variety of seemingly unrelated health problems. For example, low adrenal gland function causes tiredness, low blood pressure, difficulty standing for a long time, poor concentration (“fibro-fog”), and is measurable by low blood or saliva levels of hormones cortisol and DHEA. Since the pituitary gland controls both the adrenal and the thyroid (or “energy level”) gland, low thyroid symptoms include fatigue, dry skin, cold intolerance, more brain fog and inability to lose weight despite careful eating. The blood level of thyroid hormone may be in the normal or low-normal range, but basal body temperatures (a long accepted measurement of reduced thyroid function) are quite low.

Probably through the effect on the adrenal gland, fibromyalgia sufferers are susceptible to certain infections: a flaring up of once dormant candida (yeast), intestinal parasites, or Epstein-Barr virus. These infections are not the cause of fibromyalgia, but rather the result of a compromised HPA axis. They may well be responsible for such seemingly unrelated symptoms as irritable bowel syndrome, recurrent vaginitis, or a sense of the flu.

Lastly, the effect of the pituitary gland on the sex glands produces such problems as lack of libido or severe premenstrual syndrome.

Treatment of the conditions associated with HPA abnormalities is highly individualized. Very few patients have all areas afflicted simultaneously. Placing everyone on thyroid replacement, or treating everyone for candida or parasites is an expensive waste of time. Fairly simple blood and stool tests (fortunately usually insurance reimbursable) quickly determine those areas that need to be addressed. Medications may include: thyroid hormone, adrenal hormones (cortisol, DHEA, fludrocortisone), progesterone for women and testosterone for men, anti-parasiticals (Yodoxin) or anticandida agents (Sporonox, Diflucan, Lamisil).

Results
It would be wonderful to be able to say that everyone under this program gets cured from their fibromyalgia and returns to their once-normal life. Physicians who work with large numbers of fibromyalgia patients pretty much agree on the following: virtually everyone experiences some degree of improvement. However, patients who have had fibromyalgia the longest time, say over ten years, are the most difficult to treat.

Truly, patients committed to a personal project of “wellness” have the greatest chance of success. This usually includes some biographical self-exploration, showing up for their appointments, gently exercising when advised to do so, eating a healthful diet, and taking both their supplements and prescriptions. In other words, patients who become members of their own health-care team, pro-active, challenging, questioning, and participating, do the very best.

These are the patients who, at some future office visit for some unrelated condition will pause and say, “Do you remember when I had that fibromyalgia?”

David Edelberg, M.D., practices integrative medicine at WholeHealth Chicago.

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