Fibromyalgia: Put the Pain in Its Place

While some fibromyalgia patients respond favorably to regular chiropractic care, others experience minimal relief.¹ Unfortunately, many of these patients must rely on pharmacological management to relieve their constant pain. The most common medications prescribed for fibromyalgia are anti-epileptic drugs like Lyrica, serotonin-norepinephrine reuptake inhibitors like Cymbalta, and newcomer Savella. All of these medications have high risk of side effects and cannot be stopped abruptly without a proper weaning schedule. Cymbalta withdrawal symptoms may be so severe in certain patients that the FDA issued notice, citing withdrawal as its own diagnosis: Cymbalta discontinuation syndrome.²

A Drug Effectiveness Review Project (DERP) meta-analysis indicated low-strength evidence of these drugs' effectiveness for managing overall fibromyalgia symptoms.³ Furthermore, the National Pain Foundation's large-scale 2014 survey of 1,339 fibromyalgia patients revealed that more than 60 percent of patients reported no improvements at all with these FDA-approved medications.⁴

Even more surprising, results from this survey showed 43 percent of fibromyalgia sufferers felt their physician was not knowledgeable about the disorder, and over a third felt their physician did not take their fibromyalgia seriously.

The Chiropractic Opportunity

Chiropractors are poised with the correct tools to effectively manage fibromyalgia patients. Do we take these patients' condition seriously? Knowledge and understanding of this common condition are essential for better results for these patients.

However, manipulation and myofascial strategies alone may be inadequate. To get the results these patients deserve, we must evaluate the literature and use all diagnostic and therapeutic tools at our disposal. Most important of all is instilling hope in the patient that their illness is in fact treatable.

It is all too common that patients receive a diagnosis of fibromyalgia without a thorough assessment. Some patients wait as long as five years to be diagnosed with fibromyalgia by exclusion. Yet, many times fibromyalgia symptoms can imitate other treatable conditions such as nutrient deficiency, celiac disease, non-celiac gluten sensitivity, or dysbiosis. These imitators are less frequently measured in allopathic medicine. Before reaching for manual methods to treat these patients, the chiropractor must first perform a careful reassessment and rule out these other potential, treatable conditions.

Screen for Nutrient Deficiency: Low Levels of Vitamin B₁₂

Vitamin B₁₂ deficiency frequently masquerades as fibromyalgia. The neuropathic-type pain experienced by these patients may be due to B₁₂ deficiency. This deficiency is common in vegetarians, those with poor digestion or those with inadequate stomach acid due to chronic proton-pump inhibitor (PPI) use.

Vitamin B₁₂ deficiency is frequently overlooked by many general practitioners and rheumatologists. This is partly due to the fact that serum B₁₂ level is a notoriously unreliable marker. Urinary or serum methylmalonic acid (MMA) is a far better indirect assessment of functional B₁₂ status and should be used to rule out deficiency.⁵

Screen for Celiac and Non-Celiac Gluten Sensitivity

It is now widely accepted that sensitivity to gluten is a spectrum disorder, far more prevalent than previously believed. Studies suggest that gluten sensitivity is common in fibromyalgia patients, yet many go undiagnosed;⁶ and that only half of gluten-sensitive patients have the HLA-DQ2 or HLA-DQ8 genotype, further complicating proper diagnosis.⁷

Part of the reason for this is that traditional gluten allergy testing looks for sensitivity to the peptide gliadin exclusively. Few clinicians are aware that there are at least 50 toxic epitopes in gluten, each capable of exerting cytotoxic, immunomodulating, and tight-junction activities.⁸ Better testing is now available that can provide an accurate diagnosis before villus damage occurs. However, the best and most affordable diagnostic tool is a gluten elimination diet for 30 days or more. A recent 2014 study suggested that gluten removal may not only improve symptoms, but also could result in complete fibromyalgia remission.⁷

Screen for Small Intestine Bowel Overgrowth (SIBO)

Some have suggested that the underlying cause of fibromyalgia is small intestine bowel overgrowth (SIBO). The presence of SIBO in fibromyalgia is far more prevalent than that seen in irritable bowel patients.⁹ With unwanted bacterial species in the small intestine, systemic inflammation is promoted, which disrupts tight-junction integrity. The "leakiness" of the mucosal lining allows for food antigens and lipopolysaccharide (LPS) from gram-negative bacteria to translocate into circulation.

From here, the immune system is triggered, releasing pro-inflammatory cytokines that can worsen the ongoing feeling of malaise. Additionally, LPS may cross the blood-brain barrier and lead to the "fibro fog" and memory problems common in these patients.¹⁰

The gold standard test for diagnosing SIBO is the lactulose-mannose challenge. Patients drink a sugar solution and breath measures for hydrogen and methane are taken over the course of several hours. Proper management of SIBO requires dietary changes as well as supportive supplements. Patients should eliminate sugar and refined carbohydrates from the diet to inhibit continued growth of the small-intestine bacteria. Additionally, herbal anti-microbials can be used such as oregano, golden seal, berberine, or wormwood.

To repair the inflamed intestinal mucosa and improve tight-junction integrity, nutraceutical support may include glutamine, zinc carnosine, deglycyrrhizinated licorice, and N-acetly L-cysteine. Repopulating the gut with beneficial species through ingestion of fermented foods and probiotic species will also be beneficial to prevent relapse due to overgrowth.

Provide Sleep Support

Unrefreshing sleep is a hallmark characteristic of fibromyalgia. In fact, the widespread pain experienced may be due to the fact that these patients do not enter deep delta wave sleep, during which growth hormone is released to promote tissue healing.¹¹

Advising the patient on sleep hygiene and offering supportive supplements may improve energy levels and reduce pain. Studies suggest melatonin, glycine, theanine and magnesium may aid in sleep onset and deeper sleep.¹² Additionally, traditional herbs such as hops, chamomile, passion flower and valerian are effective. These herbs are frequently part of supplement formulas, providing a synergistic effect.

A thorough, integrative approach to treatment will ensure the best results for fibromyalgia patients. Thus far, medication management has been grossly inadequate at providing relief. Many of these patients are improperly diagnosed, told there is no cure, or have spent years and countless dollars to get a diagnosis. Once diagnosed, they are told to cope with symptoms and learn to live with their condition. This unfortunate scenario promotes patient passivity and depression.

Because fibromyalgia patients flock to chiropractors for symptomatic relief, it is our duty to provide complete care, often beyond simple manual therapies, in order to empower the patient to achieve true health.

References

1. Schneider M, Vernon H, Ko G, Lawson G, Perera J. Chiropractic management of fibromyalgia syndrome: a systematic review of the literature. J Manipulative Physiol Ther, 2009;32(1):25-40.
2. Cymbalta (Duloxetine): Discontinuation Syndrome Issues of Scope, Severity, Duration & Management. Food and Drug Administration, June 9, 2009.
3. Drug Effectiveness Review Project, April 2011. By Beth Smith, DO, Kim Peterson, MS, Rochelle Fu, PhD, Marian McDonagh, PharmD, and Sujata Thakurta, MPA:HA. Portland (OR): Oregon Health & Science University.
4. FDAReg Watch. "Marijuana Rated Significantly More Effective in Treating Fibromyalgia Symptoms than FDA-Approved Drugs, Global Survey Finds." Press release, April 21, 2014.
5. Brown DL, Oh RC. Vitamin B₁₂ deficiency. Am Fam Physician, 2003;67(5):979-986.
6. Rodrigo L, Blanco I, Bobes J, de Serres FJ. Remarkable prevalence of coeliac disease in patients with irritable bowel syndrome plus fibromyalgia in comparison with those with isolated irritable bowel syndrome: a case-finding study. Arthritis Res Ther, 2013;15(6):R201.
7. Isasi C, et al. Fibromyalgia and non-celiac gluten sensitivity: a description with remission of fibromyalgia. Rheumatol Int, 2014 (e-pub ahead of print).
8. Fasano A. Zonulin and its regulation of intestinal barrier function: the biological door to inflammation, autoimmunity, and cancer. Physiol Rev, 2011;91(1):151-75.
9. Pimentel M, Wallace D, Hallegua D, Chow E, Kong Y, Park S, Lin HC. A link between irritable bowel syndrome and fibromyalgia may be related to findings on lactulose breath testing. Ann Rheum Dis, 2004;63(4):450-2.
10. Vasquez A. Fibromyalgia in a Nutshell: A Safe and Effective Functional Medicine Strategy. Portland, OR; Integrative and Biological Research and Consulting, LLC; 2012.
11. Bennett RM. Adult growth hormone deficiency in patients with fibromyalgia. Curr Rheumatol Rep, 2002;(4):306-12.
12. Bannai M, Kawai N, Ono K, Nakahara K, Murakami N. The effects of glycine on subjective daytime performance in partially sleep-restricted healthy volunteers. Front Neurol, 2012;3:61.