How We Treat Fibromyalgia Pain
What Is Fibromyalgia Syndrome (FMS)?
Fibromyalgia (FMS) is a condition of sore muscles and increased sensitivity to pain. The ‘official’ definition requires that at least 11 of 18 designated tender point sites be especially sensitive to pressure induced pain. Other conditions must be excluded as the primary cause of pain, for example, osteoarthritis, disc disease, Lyme disease, and low thyroid.
With severe Fibromyalgia (FMS), many people develop symptoms in addition to general pain. These include cognitive or concentration difficulties, chronic fatigue, joint aches, poor sleep, or headache. Secondary depression and/or anxiety affect many, but not all. People with moderate to severe Chronic Fatigue Syndrome (CFS) often develop a similar range of symptoms.
Many people with severe Fibromyalgia qualify for the diagnosis of both Fibromyalgia Syndrome (FMS) and also Chronic Fatigue Syndrome (CFS).
Fibromyalgia Doctors: Even a few years ago many physicians believed that Fibromyalgia Syndrome (FMS) was mainly a disguised form of psychological distress or depression. While a few hold-outs remain, most physicians and official groups such as the American College of Rheumatology now agree that Fibromyalgia Syndrome (FMS) is both real and mainly physical.
For Fibromyalgia the central problem appears to be not just in the muscles, but within the pain signaling pathways of the brain and the spinal cord. There is an amplification of pain signals so that persons with Fibromyalgia experience pain at much lower levels of stimulation than do healthy people. This has been proved by sophisticated imaging techniques such as functional MRI. In Fibromyalgia patients a modest stimulus causes the brain’s pain centers to “light up”. This proves that persons with Fibromyalgia are telling the truth about the pain that they feel, and that this pain is physical and real. Think of pain pathways as a radio receiver. In Fibromyalgia, the knob controlling volume is always turned way up. The technical name scientists give this is neural sensitization.
Dr. Podell Is Among the Nation’s Leading Fibromyalgia Doctors
Our New Jersey Fibromyalgia Clinic has worked with more than 1000 persons who have mild, moderate and severe Fibromyalgia Syndrome (FMS) and/or Chronic Fatigue Syndrome (CFS).
Richard Podell M.D., Medical Director has lectured on Fibromyalgia Syndrome to professional and consumer support groups. He has written for magazines and professional journals, including Fibromyalgia Network and the Journal of Musculoskeletal Pain. A clinical professor at Robert Wood Johnson Medical School, Dr. Podell headed one of 10 research teams for a Food and Drug Administration approved study of Ampligen, an experimental treatment for people with Chronic Fatigue Syndrome, many of whom also had Fibromyalgia.
Dr. Podell is a member of the International Myopain Society, the main professional organization of Fibromyalgia physicians and scientists. He is a member of the American Association for Chronic Fatigue Syndrome, the American College of Physicians, the American Academy of Family Physicians and the New Jersey State Medical Society.
Dr. Podell has participated in workshops on Fibromyalgia at the National Institutes of Health and the most recent scientific meeting of the International Myopain Society held in Toledo, Spain. The New Jersey Chronic Fatigue Syndrome Association awarded Dr. Podell their Achievement Award. Dr. Podell is co-author of a text for physicians on the diagnosis and treatment of Chronic Fatigue Syndrome. This text also focused on Fibromyalgia. Dr. Podell serves has served as a medical expert on severe Fibromyalgia Syndrome and on Fibromyalgia disability.
Our Fibromyalgia Treatment Philosophy: We seek to combine the best of standard drug therapies with holistic support for the body’s natural healing systems. Drug treatments for Fibromyalgia can be very useful, but they often provide only partial relief. Therefore, we also seek to identify, understand and improve the body’s natural healing systems. We call this “integrative medicine”, combining the best of standard mainstream medicine and holistic or complementary alternative medicine.
Confirming a Severe Fibromyalgia Syndrome Diagnosis is Crucial
Dozens of common ailments can cause muscle pain and fatigue. Therefore, a main focus of our 2 hour long new patient visit is to be sure that we consider potential alternative and/or additional causes for your symptoms. That’s why we ask you to complete our very detailed case history questionnaire so we can review it before you come.
Standard Fibromyalgia Medicines
Just a few years ago, only one drug, Elavil (amitryptiline), had double blind studies showing benefit as Fibromyalgia treatment. Today we also have three FDA approved drugs: Cymbalta, Savella and Lyrica. These medicines work well for most patients IF side-effects don’t cause problems. Unfortunately, increased sensitivity to medicine side-effects is often part of the generally increased neurotransmitter sensitization that’s at the core of fibromyalgia. So, while many patients benefit greatly from these standard drugs, others do not. Hence the need to seek innovative treatments that go beyond the “standard”.
Dr. Podell’s Use of Innovative Medicines for Fibromyalgia Treatment
Part I: Innovative Prescription Medicines. These Fibromyalgia Treatments don’t work for everyone, but may help a significant number of patients.
Xyrem (sodium oxybate) a natural product, is standardly used to treat a form of narcolepsy. But, it has three double blind studies showing benefit for fibromyalgia. For a few patients improvement is dramatic. Sadly, Xyrem side effects often (but not always) prevent its effective use.
Zanaflex tizanidine is used to treat muscle spasm for persons with multiple sclerosis. Zanaflex helps pain in a proportion of fibromyalgia patients. At lower doses it can be a useful non-habit forming sleeping pill.
Baclofen is also used for muscle spasm in multiple sclerosis. Some fibromyalgia patients improve using Baclofen. It can also be used as an aide for sleep.
Lidoderm (lidocaine) patches: I find that about half my patients benefit from lidoderm patches. Lidocaine (xlyocaine) is the commonly used dental anesthetic. Worn as a patch over local areas for up to 12 hours, it turns off pain receptors just under the skin.
Flexeril. (cyclobenzaprine), a muscle relaxant, helps a fair proportion of persons with fibromyalgia. It’s also a decent non-habit forming sleeping pill.
Mirapex (pramipexole) is used to treat Parkinson’s Disease and also Restless Legs Syndrome. Mirapex increases the neurotransmitter, Dopamine. One double blind study shows benefit for fibromyalgia.
Klonopin (clonazepam): Like others in the Valium (diazepam) family Klonopin can relax muscles and help sleep. However, there is potential for addiction and abuse.
Namenda memantine is one of the best available treatments for Alzheimer’s Disease. Namenda blocks “NMDA receptors”. These are involved in important pain pathways. Namenda helps several kinds of pain, but has not been formally tested for fibromyalgia. In its favor, side effects are relatively uncommon.
Zofran (odansetron) is an anti-nausea medicine. It reduces pain for many Fibromyalgia patients. But, Zofran is highly constipating. A few, but only a few patients are able to tolerate it long term.
Part II: Natural Products for Fibromyalgia Treatment. These natural products have important roles in supporting the body’s natural healing systems. Most have double blind studies supporting their use for conditions other than fibromyalgia but have not been well-tested for fibromyalgia itself.
Magnesium helps energy metabolism, muscle relaxation and resistance to psychological stress. We measure red blood cell magnesium levels and find that many of our patients have less than optimal levels.
Acetyl Carnitine and its cousin Carnitine (Carnitor) are crucial for mitochondrial energy metabolism. One double blind study shows benefit for fibromyalgia. Others show benefit for fatigue and mental focus among “healthy” elderly persons. We often measure carnitine levels as part of our metabolic evaluation.
Lipoic Acid (thioctic acid) may help restore function of nerve tissue, For example, multiple studies support its use for nerve damage due to diabetes.
Natural Thyroid and Fibromyalgia: There is good double blind study evidence that adding thyroid can improve mood even among persons whose thyroid blood tests are perfectly “normal”. Anecdotally, some report benefit specifically for fibromyalgia. For further information please see our discussion below: Fibromyalgia and Low Thyroid Symptoms.
Coenzyme Q 10 is an important antioxidant and is critical for mitochondrial energy metabolism. Coenzyme Q has been shown to be useful for congestive heart failure. We often measure coenzyme Q levels.
Vitamin D should be measured. If vitamin D levels are low for some (but not all) patients supplementing vitamin D can improve fibromyalgia pain.
SAMe has at least ten double blind studies supporting its use for depression. It plays a positive role in brain biochemistry, liver support, osteoarthritis and other functions. One large non-double blind study and anecdotal support supports its use for Fibromyalgia. We lack double blind studies for using SAMe for Fibromyalgia, but we have received encouraging anecdotal reports.
Riboflavin or vitamin B2 acts to improve energy metabolism. Riboflavin, at high doses, has double blind studies and is now acknowledged to be an effective “preventive medicine” for migraine headache. Riboflavin blood levels can be measured.
Benfotiamine is a fat soluble form of Thiamine or Vitamin B1. Thiamine controls the entry point to the Krebs cycle, the cell’s major energy producing pathway. Thiamine blood levels can be measured.
Curcumin is a component of the Indian food herb turmeric. Curcumin, is an effective anti-inflammatory agent. But, its clinical effectiveness may require higher doses than are usually taken.
Gluten is a protein component of wheat, oats, barley and rye. A small percent of persons who are chronically ill or also “sensitive” or “allergic” to wheat gluten. This can be evaluated by testing the blood for antibodies against gluten.
Guaifenesin is a safe, mucus thinning agent found in Humibid, Entex and other medicines for respiratory infections. Dr. R. Paul St. Amand claims wonderful results using Guiafenesin to treat FMS. (What Your Doctor May Not Tell You About Fibromyalgia, Warner Books, 1999.) Our NJ, NY and PA Fibromyalgia patients have usually not reported benefit; but we remain open-minded.
Specialized Laboratory Tests can be used to look for Metabolic Imbalance include red blood cell fatty acid levels to measure whether pro-inflammatory omega 6 fatty acid levels are too high or anti-inflammatory omega 3 fatty acid levels are too low. We can also measure the blood or urine levels of amino acids and/or organic acids.
Being ill with Fibromyalgia creates both physical and psychological complications that tend to reduce natural Fibromyalgia healing. Most of these vicious cycles can be interrupted and reversed. Accomplishing this is a critical strategy for treatment. Please read our essay Eight Vicious Cycles that Block Fibromyalgia Healing.
Fibromyalgia Diet Treatments
People who have severe Fibromyalgia Syndrome (FMS) may do better if they completely avoid both MSG (monosodium glutamate) and also NutraSweet (aspartame), the artificial sweetener. Both glutamate (in MSG) and the amino acid, aspartic acid (in aspartame) stimulate pain augmenting receptors within the spinal cord. These are called NMDA receptors. Some individuals with Fibromyalgia improve very much on a Fibromyalgia diet that avoids MSG and aspartame.
In addition to these restrictions, we find that many people with chronic illness tend to do better with sensible diet therapy. Aim for five plus servings daily of multi-colored fruits and vegetables. (Nutrition science defines one ‘serving’ as ½ cup.) Eat modest–sized meals without excess fats, sugars or simple carbohydrates. Perhaps, easier said than done, but many patients have reported benefit from just a few weeks on this “Fibromyalgia diet”.
Occasionally, people with Fibromyalgia improve with the elimination of foods to which they are personally sensitive, for example, wheat/gluten, milk, yeast, and sugar.
Additional Fibromyalgia Treatments to Strengthen Natural Healing Systems
Cognitive Behavioral Therapy or CBT is a specialized set of skills that benefits almost all persons who suffer from any chronic illness—especially Fibromyalgia. It emphasizes practical coping skills, not deep psychotherapy. You can master the basics in just a few sessions. CBT teaches individuals to “reframe” situations to highlight the positive. Chronic illness tends to foster negative thinking. This harms the body physically, including the immune system. Feeling Good (and various successor books) by David Burns, M.D. is a helpful CBT workbook. We offer referrals to top CBT teachers.
Stress management/relaxation skills are also very useful. Most patients we see have fallen into a pattern of mal-adaptive breathing called “hyperventilation”. Often overlooked, low level hyperventilation can cause fibro-fog, increased pain, light-headed feelings and a host of other symptoms that in turn can worsen Fibromyalgia. It is relatively easy to learn to re-pattern your breathing. Other relaxation skills such as meditation also can help. We favor a technique called HeartMath which allows you to summon up and retain feelings of appreciation.
Exercise Reconditioning is also important. Too little exercise leads to muscle deconditioning and worse Fibromyalgia. Over-doing exercise can flare up your symptoms. The key is the Goldilocks Principle—not too much, not too little. Do just the right amount that’s appropriate for you. We help you find this your Goldilocks level.
Biomechanical (body work) therapies can help Fibromyalgia- but only if done by a professional who understands the Fibromyalgia patient’s special vulnerabilities. Done too vigorously, these therapies can make you worse. Effective therapeutic massage and physical therapy techniques for FMS muscle pain go by several names: Structural Integration, Janet Travell, M.D.-style Manual Trigger Point Therapy, Myofascial Release and Deep Connective Tissue Therapy.
We have been very pleased with the work of Carol Cote, P.T. and her associates in Morristown and Hackettstown, NJ. (tel: 973-538-8877) Please also see our listing of New Jersey, New York and Pennsylvania Fibromyalgia physical therapists who have special training in Fibromyalgia (and migraine) treatment techniques.
Hidden Infections, a Fibromyalgia Controversy
One school of thought speculates that many Fibromyalgia patients have unrecognized infections with atypical bacteria or viruses, including mycoplasma, chlamydia, Lyme disease and HHV-6. Although no treatment studies have been done for patients with fibromyalgia, several encouraging studies have been done for patients with chronic fatigue syndrome. Many of these CFS patients also have fibromyalgia. Unfortunately, none of the CFS studies were large or well-designed enough to put skepticism to rest. We continue to follow this research closely.
Fibromyalgia and Low Thyroid Symptoms
Does hypothyroidism cause Fibromyalgia? Dr. Robert Lowe has proposed that a hypothyroid or low metabolism state is a major cause of Fibromyalgia. Dr. Lowe believes that low thyroid can be a real problem even when standard thyroid hormone tests are normal. Dr. Lowe recommends that we consider treating Fibromyalgia with the T3 form of thyroid hormone, using natural Armour thyroid or synthetic T3 thyroid hormone, Cytomel.
Dr. Lowe’s website especially focuses on Fibromyalgia and its relation to low thyroid. It’s also a stimulating read with regard to a broad range of thyroid related health problems.
The most eloquent and informative up-to-date source of information about natural thyroid treatments is at Mary Shoman’s websites. Please visit her site about.com:thyroid disease. See Thyroid, Hypothyroid and Fibromyalgia for our discussion of thyroid problems.
See Fibromyalgia Disability: Medical Evidence That Supports The New Neural Sensitization Paradigm
Links to Useful Fibromyalgia Websites
See our discussion of how to be your own Fibromyalgia disability medical expert witness
See Fibromyalgia social security and disability
Fibromyalgia Network: One of the best information sources for patients. Combines up to date coverage of scientific and clinical research in language that patients can understand and appreciate.
Dr. Devin Starlyanyl's Fibromyalgia Site: Dr. Starlyanyl, a physician, has Fibromyalgia herself and has written a best-selling book for patients. Her website is one of the largest and best.
Fibromyalgia Treatment: Tips on the benefits of trigger point therapy, moist heat and gentle stretching from a former FMS sufferer.
ProHealthNetwork.com provides much information about Fibromyalgia and Chronic Fatigue Syndrome, while also selling nutritional supplements. Contact information is 2040 Alameda Padre Serra, Ste.101, Santa Barbara, CA, 93103, tel: 805-564-3064 ext. 236.