Fibromyalgia

By Al Robert Franco, MD

Mrs. Pain-Hurts' husband came home early from work to learn from his wife what the doctor had said about her condition. To his chagrin, he found her crying.

"He said there's nothing wrong with me," she said. "My lab tests and x-rays are normal, and he implied it's all in my head. He even suggested that I take a vacation or buy an entertaining book and try to relax."

Since she hadn't used the "C" word, her husband felt relieved. But Mrs. Pain-Hurts went on in frustration, "How can that be? I feel aches and pains all over and can't stand to be touched, I'm very tired but can't sleep at night, and I'm so depressed I can't think straight."

I've heard similar stories frequently - the frustration of patients who have generalized pains that become worse over time, all the harder to bear when relatives, friends, and even doctors question if the problem is real.

A complex illness, fibromyalgia is poorly understood by the public and even, still, by some members of the medical community. But awareness and knowledge are improving rapidly. In the future, reactions like the one Mrs. Pain-Hurts met from her doctor will be less frequent.

Fibromyalgia afflicts approximately 3 to 5 million Americans, but statistics are still far from reliable. It is reported worldwide, affecting predominantly women (75% or more), mostly aged 20 to 60. It is the most common rheumatic cause of chronic diffuse pain. American College of Rheumatology diagnostic criteria include widespread pain associated with at least 11 of 18 tender trigger points on physical examination.

Fibromyalgia produces generalized pains in areas above and below the waist as well as the right and left side of the body. The pain may be present for months or years and is frequently described as constant in duration and ranging from moderate to very severe. The physical findings show tenderness in the typical distribution as shown on Diagram A.

Equally important are those symptoms associated with the pain. These include restless, unrefreshing sleep, low energy, frequent headaches, and cognitive dysfunction (poor short-term memory, and difficulty thinking and finding the right words). Additionally, patients complain of irritable bowel and irritable bladder syndromes, menstrual irregularities, premenstrual-syndrome-like symptoms, cold sensitivity and Raynaud's phenomenon. Some experience burning and tingling of muscle groups, restless legs, and atypical fleeting pains.

These can lead to functional disability, poor physical fitness, work disability, psychological distress, and decreased quality of life, including relationship problems. Because fibromyalgia is so complex and its consequences so far-reaching, patients require individualized multidisciplinary treatment programs geared to their personal needs, socially, psychologically, and physically.

In order to understand the treatment of fibromyalgia, we need first to examine some of its features. Patients who experience sleep problems often lack periods of deep (REM stage) sleep and as a result cannot produce enough of the specialized hormone required to protect and mend their body tissues. A deficiency of growth hormone might worsen the pains generated by the micro trauma of muscles throughout daily activities. As well, the lack of restorative sleep logically produces fatigue.

Interestingly enough, the muscle biopsies of the tender points of patients with fibromyalgia have been found to be deficient in high-energy phosphate. When phosphates (ATP and ADP) produced by the mitochondria (intracellular energy factories) are low and therefore the energy in the muscle tissue is deficient. This easily leads to muscle fatigue and eventually to pain.

In my clinical practice at the Arthritis Center of Riverside in Southern California, I have seen the beneficial effect of the oral administration of malic acid and magnesium, which improves the efficiency of energy production from carbohydrates. Nutrients such as coenzyme Q10, Lipoic Acid also improve the function of mitochondriae, enhancing energy production. To promote more REM stage sleep, tricyclic anti-depressants in low doses can be effective as well as 5 hydroxy-triptofan (5HTP) or small doses of melatonin. Other useful prescription drugs include some hypnotics, but care should be taken to avoid a dependency problem.

Stretch exercises can be helpful to avoid fibromyalgia's pain. Also helpful are appropriate physical and hot pool therapy, massage therapy, micro current nerve stimulation, and acupuncture. Oral, non-steroidal anti-inflammatory drugs (NSAID'S) and local tender point injections with low dose, short acting corticosteroids and local anesthetics can be very helpful at times.

Although NSAID'S can be helpful, one should be cautious since they also can worsen the symptoms of irritable bowel syndrome (IBS); the parasympathetic nervous system mediates the IBS causing diarrhea alternating with constipation. I find that at least half of the patients with fibromyalgia benefit from the administration of live cultures of Lactobacillus acidophilus and Bifidobacterium. These friendly bacteria replenish and promote the natural microbial intestinal balance, improving the patients' symptoms of IBS usually within a month.

There are many anti-depressants that are effective for patients with fibromyalgia. However, treating the depression associated with this illness often requires more, and I find it useful to refer patients to a psychologist or a psychiatrist to explore other underlying causes.

If I had interviewed and examined Mrs. Pain-Hurts, I would have discussed the treatment options with her and explained the metabolic problems associated with fibromyalgia summarized here. There is an endocrine imbalance caused by a hypothalamic pituitary adrenal (HPA) axis dysfunction. The hypothalamus, located in the brain, sends signals to the pituitary gland. This so-called master gland sends signals to other glands including the adrenal glands and gonads.

The HPA axis dysfunction causes an abnormal increase or decrease of various hormones. It produces a decrease in the production of growth hormone, which repairs tissues. A decrease in thyroid stimulating hormone (TSH) and thyroxin (T4) can also occur, promoting hypothyroidism, a state in which all cellular functions are slowed down. Hypothyroidism and fibromyalgia can have many overlapping features, such as weight gain, poor memory, and muscle fatigue. Additionally, we also find low estrogen levels in females with fibromyalgia producing, at times, menopause-like symptoms.

The HPA axis dysfunction also causes the increased production of adrenocorticotropic hormone (ACTH), which, in turn, stimulates the adrenal glands to produce more cortisol. Increased production of cortisol causes carbohydrate abnormalities including truncal obesity and diabetes. Furthermore, excess cortisol production induces osteoporosis and immunosuppression.

We at the Arthritis Center of Riverside as well as others have found that a great number of patients who have fibromyalgia show evidence of mycoplasma infection. These small, cell-wall-deficient organisms hide inside the cells of the host, and our studies have shown they can be innocent bystanders in 10% to 15% of the normal population. However, I believe that the relative immunosuppression of patients with fibromyalgia, due to increased cortisol production, makes them prone to recurrent and chronic infections from those mycoplasma. They can cause joint pains, which I find often in patients who have chronic and well-entrenched fibromyalgia. Therefore, treatment with antibiotics that are effective against mycoplasma is important and should be integral to the therapy of patients with this illness. For more on mycoplasma and other infections that can trigger or be cofactors of rheumatic diseases go to www.thearthritiscenter.com.

Fibromyalgia is a complex illness that is seen relatively frequently in the practice of rheumatology. Even so, the disease has received widespread recognition only recently, including being named as a disabling disease by the state of California. There are many aspects to this illness that lead to intense suffering and frustration of patients as well as potential disability. A multidisciplinary treatment approach that includes pain control, sleep control, physical therapy, massage therapy, acupuncture, and expert psychological/psychiatric evaluation and treatment should be recommended. The possibility of underlying mycoplasma infection should be explored and, if present, it should be treated appropriately.

Patients with fibromyalgia need to have hope, which, in my opinion, improves the treatment outcome. The treatment briefly outlined here, which is based on a better understanding of this disease, offers just such healing hope.


References:

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