How We Treat Fibromyalgia Pain
To Treat Fibromyalgia Syndrome (FMS) and Relieve Fibromyalgia Pain We Must First Understand It’s Cause: Increased Sensitization of the Central Nervous System’s Pain Signaling Pathways
Fibromyalgia 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 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. Many people with severe Fibromyalgia qualify for the diagnosis of both Fibromyalgia and Chronic Fatigue Syndrome (CFS). Likewise, people with moderate to severe CFS often develop similar symptoms to a person with Fibromyalgia.
Fibromyalgia Doctors: Even a few years ago many physicians believed that 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 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. When we apply a mild stimulus to a person with Fibromyalgia, we can see the pain centers in the brain “light up” and become active. This proves that persons with FMS are telling the truth about the pain that they feel. 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. More information on neural sensitization and other related research can be found on Breakthrough Research for FMS and CFS.
Dr. Podell’s New Jersey Fibromyalgia Clinic has worked with more than 1,000 persons seeking relief from severe Fibromyalgia and Chronic Fatigue Syndrome. Their Fibromyalgia Treatment Philosophy: 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 must also 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.
In addition to his clinical practice, Dr. Podell has lectured on Fibromyalgia to many physician and patient groups. He was invited to present a half day seminar to the Association of Administrative Law Judges. These are the judges who help social security decide whether a person with Fibromyalgia and Chronic Fatigue Syndrome is medically disabled. He has also testified in court as a Fibromyalgia expert in New Jersey, New York and Pennsylvania.
The Center For Disease Control named Dr. Podell’s practice to be one of seven practices nationwide for an ongoing research program to help persons who suffer from Chronic Fatigue Syndrome and/or Fibromyalgia. As clinical professor at Robert Wood Johnson Medical School Dr Podell was proud to be named in October 2012 as one of New Jersey’s “Best TOP Doctors” by the Star-Ledger Inside Jersey Magazine.
To Relieve Fibromyalgia Pain, First Confirm the Diagnosis
Dozens of common and not-so-common ailments can mimic severe Fibromyalgia or complicate its course. So we must first be sure
- We have the correct diagnosis and
- We identify co-existing health problems that can make Fibromyalgia worse.
Just a few years ago, only one drug, Elavil (amitryptiline), had double blind studies showing benefit for Fibromyalgia pain relief. 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 sensitivity 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”.
Part I: Innovative Prescription Medicines
These Fibromyalgia therapies don’t work for everyone but may help a significant number:
Low Dose Naltrexone (LDN) at the usual 50 mg dose blocks the effects of narcotic pain medicines. Full dose Naltrexone tends to increase Fibromyalgia pain. But, we now have two double blind studies which show that at low doses of 1 to 4 mg, low dose naltrexone often helps reduce Fibromyalgia pain.
Zanaflex (tizanidine) is used to treat muscle spasm for persons with multiple sclerosis. Zanaflex helps pain in a proportion of Fibromyalgia patients. It can also 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 aid for sleep.
Lidoderm (lidocaine) patches: About half of Dr.Podell’s patients benefit from Lidoderm patches. Lidocaine (xylocaine) 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.
Xyrem (sodium oxybate) a natural product, is standardly used to treat a form of narcolepsy. Xyrem also 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.
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.
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: Innovative Natural Fibromyalgia Treatments
Melatonin is a natural hormone that helps induce sleep. Recent research suggests that melatonin taken before sleep for one to two months significantly reduces pain due to Fibromyalgia and also chronic pain from migraine.
Medical Marijuana was recently legalized in New Jersey. Fibromyalgia patients who have “intractable skeletal muscular spasticity” may qualify for the medical marijuana program.
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. Our clinic often measures carnitine levels as part of our metabolic evaluation.
Coenzyme Q 10, an important antioxidant, is also important for mitochondrial energy metabolism. Coenzyme Q has been shown to be useful for congestive heart failure. We often measure coenzyme Q levels.
Riboflavin or vitamin B2 can improve mitochondrial energy metabolism. Riboflavin blood levels can be measured with a simple lab test.
Lipoic Acid (thioctic acid) may help mitochondrial metabolism. Multiple studies support its use to treat nerve damage due to diabetes.
N-Acetyl Cysteine (NAC) helps the body build the important antioxidant glutathione. There are theoretical reasons to believe that NAC taken at high doses can reduce Fibromyalgia pain.
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 Fibromyalgia and Low Thyroid Symptoms.
Vitamin D should be measured and if levels are low, supplementing vitamin D may help relieve Fibromyalgia pain.
SAMe (S-adenosyl Methionine) has at least ten double blind studies supporting its use for depression. We lack double blind studies for Fibromyalgia, but we have received encouraging reports from our patients.
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. Dr. Podell prefers the Meriva brand of Curcumin because of its superior absorption.
Gluten is a protein component of wheat, oats, barley and rye. A small percent of persons who are chronically ill are also “sensitive” or “allergic” to wheat gluten. This can be evaluated by testing the blood for antibodies against gluten.
IgG food sensitivity blood tests are believed to provide useful clues by many alternative medicine physicians. This is different than the standard IgE antiboidy food allergy tests which are rarely useful for Fibromyalgia, migraine, and other pain related problems. For this reason, Dr. Podell offers IgG testing for selected patients.
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. 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 Imbalances. These tests 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. More information can be found on Eight Vicious Cycles that Block Fibromyalgia and Chronic Fatigue Healing
People who have severe 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. 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. Dr. Liz Lipski has published an excellent example of a diet that eliminates most foods with which people often have problems. This is strict but practical and contains shopping lists, food plans and recipes.
Cognitive Behavioral Therapy or CBT is a specialized set of skills that benefits almost all persons who suffer from any chronic illness. 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.
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.
These in turn worsen Fibromyalgia pain. 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.
We heartily recommend Edwina (Wendy) King, R.N., Ph.D, an excellent and compassionate psychiatric nurse practitioner. She has helped many of our patients master relaxation skills and also cognitive behavioral therapy.
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 muscle pain treatment techniques.
Does hypothyroidism cause Fibromyalgia? Dr. Robert Lowe has proposed that a hypothyroid or low metabolism state can increase vulnerability to Fibromyalgia. Dr. Lowe and others recommend that we consider treating Fibromyalgia with the T3 form of thyroid hormone, using natural Armour thyroid or synthetic T3 thyroid hormone, Cytomel.
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 Low Thyroid, Hypothyroidism, and Natural Hypothyroid Therapies for our discussion of thyroid problems.
Help Your Doctor Document Your Illness
It’s difficult to explain all your symptoms and limitations within the time limit of most medical visits especially if Fibromyalgia is severe. The FIQR can help your Fibromyalgia doctors and general physician better understand your illness.
- Breakthrough Research for Fibromyalgia (FMS) and Chronic Fatigue Syndrome (CFS)
- Fibromyalgia, social security, and disability
- Co-cure is run by and for patients and advocates with focus on FMS and CFS
- Dr. Devin Starlanyl's Fibromyalgia Site: Dr. Starlanyl is a physician who has Fibromyalgia and has written a best-selling book for patients. Her website is one of the largest and best.