Fibromyalgia
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Fibromyalgia basically means that you have pain (algia) of fibrous tissues (fibro) and muscles (myo). However, in order to get this label, you must not have another known condition that causes the same symptoms. There is a recent (May, 2019) piece of exciting research in relation to what appears to be a large segment of fibromyalgia patients and a potential connection with insulin resistance. This leads in turn to some exciting new options to consider for treatment:
"Original Research: Open access published 6 May, 2019
“Is insulin resistance the cause of fibromyalgia? A preliminary report”. Miguel A. Pappolla, Laxmaiah Manchikanti, Clark R. Andersen, Nigel H. Greig, Fawad Ahmed, Xiang Fang, Michael A. Seffinger, Andrea M. Trescot.
PLOS ONE doi:10.1371/journal.pone.0216079
Abstract
Is insulin resistance the cause of fibromyalgia? A preliminary report
Fibromyalgia (FM) is one of the most frequent generalized pain disorders with poorly understood neurobiological mechanisms. This condition accounts for an enormous proportion of healthcare costs. Despite extensive research, the etiology of FM is unknown and thus, there is no disease-modifying therapy available for this condition. We show that most (if not all) patients with FM belong to a distinct population that can be segregated from a control group by their glycated hemoglobin A1c (HbA1c) levels, a surrogate marker of insulin resistance (IR). This was demonstrated by analyzing the data after introducing an age stratification correction into a linear regression model. This strategy showed highly significant differences between FM patients and control subjects (p < 0.0001 and p = 0.0002, for two separate control populations, respectively). A subgroup of patients meeting criteria for pre-diabetes or diabetes (patients with HbA1c values of 5.7% or greater) who had undergone treatment with metformin showed dramatic improvements of their widespread myofascial pain, as shown by their scores using a pre and post-treatment numerical pain rating scale (NPRS) for evaluation. Although preliminary, these findings suggest a pathogenetic relationship between FM and IR, which may lead to a radical paradigm shift in the management of this disorder."
Conditions that can cause symptoms similar to Fibromyalgia Syndrome (FMS) include hypothyroidism, moderate or severe adrenal insufficiency including full-blown Addison's Disease, sleep apnoea, polymyalgia rheumatica, lupus (SLE) and burnout (including Nervous Breakdown).
FMS and Chronic Fatigue Syndrome overlap, as most patients with FMS also have significant fatigue. If muscle pain is the dominant symptom then the label of FMS is the better fit. If exhaustion is the main symptom then CFS would be a better fit. Both conditions are diagnoses of exclusion, which means that the doctor needs to rule out other possible causes before concluding that you have CFS or fibromyalgia. Widespread muscle tenderness would be expected if a diagnosis of fibromyalgia is being considered. A formal tender-point count using the classic 18 standardised tender points (Ref. 1) is not included in the current fibromyalgia diagnostic criteria published by the American College of Rheumatology (ACR) in 2010 (Ref. 2). Despite this, the finding of widespread muscle tenderness is helpful in reaching a diagnosis of fibromyalgia.
Fibromyalgia should be differentiated from genetic and other well characterised 'myopathies' – diseases of muscle tissue. For more information, click here.
Rheumatologists are a group of specialist doctors who have taken on fibromyalgia as one of the disorders that they deal with. They are generally good at diagnosing it. Medications may be prescribed to alleviate the symptoms. These include nortryptiline, amitryptiline, Lyrica and Cymbalta. I cannot ever remember a rheumatologist prescribing opioid medications to a patient that I have dealt with. Opioids are a family of medications that are in the morphine family. They include codeine and many other medications with a variety of trade names and generic names. As far as I am concerned, it is a disaster for a patient with fibromyalgia to be given regular opioids unless they are not expected to live very long due to some terminal illness. Fibromyalgia is not a terminal illness. In my experience opioids only give partial relief from the muscle pain and they quickly lose their effectiveness such that a higher dose is needed to achieve the same effect. Doctors become resistant to prescribing these higher doses and so the patient ends up in the same pain as they were to begin with and with the additional burden of the opioid medication and all of its side effects. Getting off opioids is usually a nightmare for patients with fibromyalgia as it normally causes an increase in pain due to aggravating the tissue sensitisation. This increase in pain can sometimes be relieved by other measures but can be quite resistant and persistent. It requires careful medical supervision and lots of support. If you are not sure if you are on an opioid, ask your pharmacist or doctor, or check it out yourself online. Make sure you check carefully. I have had patients get quite shocked when I have told them that a certain medication they have been prescribed is actually a morphine derivative. Anti-inflammatory medications such as ibuprofen and diclofenac may be used by patients with fibromyalgia or prescribed by their doctors. However, these medications are not good to take long term as they increase the risk of various ailments including high blood pressure and kidney impairment.
In my experience, similarly to CFS, some possible causes of fibromyalgia my have been missed due to not being very well known or characterised or because they were not checked out quite enough. These possible causes include: Sick Buildings, Long term Infections, Poisoning, Mental/social/spiritual stress, Nutritional and gut problems, Hormonal problems and Sleep disturbances. Insulin resistance looks like a major player too (see above research). However, with fibromyalgia there is often an accident or injury involved with the start of the illness. This, in combination with a pre-existing problem (one of the seven above areas or some other unknown issue) may have caused the sensitisation of the tissues and nerves. This sensitisation results in the characteristic painful fibrous connective tissue and muscles of fibromyalgia. The medications used to treat the condition are designed to reduce this sensitisation. Treatment should aim to identify the causes and treat them while at the same time providing low-risk alleviation of symptoms.
On the subject of gut and nutritional issues, I have known of two patients whose symptoms were predominantly (but not completely) due to nightshade sensitivity. When they stopped consumption of nightshades they improved markedly. I have also read of an English GP who cured themselves of fibromyalgia by reducing their oxalate intake. I am in the process of further investigating these two areas and research done on them. In relation to oxalates, one theory is that antibiotics wipe out a gut bacteria called Oxalobacter which breaks down oxalates. If this bug goes then you may end up absorbing more oxalates than normal, especially in the case of a 'leaky gut' (which antibiotics might cause). It appears that some people get worse before getting better on a low oxalate diet due to the body releasing stored oxalates.
More natural pain-relieving methods that may help include far infra-red saunas, ginger, turmeric, warm baths with epsom salts, special types of magnesium (e.g. magnesium malate) and some other herbs like Boswellia and Willow Bark. However, I am not aware of any clinical trials assessing the effectiveness of these possible natural remedies. A relatively low-risk medication called low-dose naltrexone is also sometimes helpful. Low dose naltrexone has been studied (Ref. 3).
"Original Research: Open access published 6 May, 2019
“Is insulin resistance the cause of fibromyalgia? A preliminary report”. Miguel A. Pappolla, Laxmaiah Manchikanti, Clark R. Andersen, Nigel H. Greig, Fawad Ahmed, Xiang Fang, Michael A. Seffinger, Andrea M. Trescot.
PLOS ONE doi:10.1371/journal.pone.0216079
Abstract
Is insulin resistance the cause of fibromyalgia? A preliminary report
Fibromyalgia (FM) is one of the most frequent generalized pain disorders with poorly understood neurobiological mechanisms. This condition accounts for an enormous proportion of healthcare costs. Despite extensive research, the etiology of FM is unknown and thus, there is no disease-modifying therapy available for this condition. We show that most (if not all) patients with FM belong to a distinct population that can be segregated from a control group by their glycated hemoglobin A1c (HbA1c) levels, a surrogate marker of insulin resistance (IR). This was demonstrated by analyzing the data after introducing an age stratification correction into a linear regression model. This strategy showed highly significant differences between FM patients and control subjects (p < 0.0001 and p = 0.0002, for two separate control populations, respectively). A subgroup of patients meeting criteria for pre-diabetes or diabetes (patients with HbA1c values of 5.7% or greater) who had undergone treatment with metformin showed dramatic improvements of their widespread myofascial pain, as shown by their scores using a pre and post-treatment numerical pain rating scale (NPRS) for evaluation. Although preliminary, these findings suggest a pathogenetic relationship between FM and IR, which may lead to a radical paradigm shift in the management of this disorder."
Conditions that can cause symptoms similar to Fibromyalgia Syndrome (FMS) include hypothyroidism, moderate or severe adrenal insufficiency including full-blown Addison's Disease, sleep apnoea, polymyalgia rheumatica, lupus (SLE) and burnout (including Nervous Breakdown).
FMS and Chronic Fatigue Syndrome overlap, as most patients with FMS also have significant fatigue. If muscle pain is the dominant symptom then the label of FMS is the better fit. If exhaustion is the main symptom then CFS would be a better fit. Both conditions are diagnoses of exclusion, which means that the doctor needs to rule out other possible causes before concluding that you have CFS or fibromyalgia. Widespread muscle tenderness would be expected if a diagnosis of fibromyalgia is being considered. A formal tender-point count using the classic 18 standardised tender points (Ref. 1) is not included in the current fibromyalgia diagnostic criteria published by the American College of Rheumatology (ACR) in 2010 (Ref. 2). Despite this, the finding of widespread muscle tenderness is helpful in reaching a diagnosis of fibromyalgia.
Fibromyalgia should be differentiated from genetic and other well characterised 'myopathies' – diseases of muscle tissue. For more information, click here.
Rheumatologists are a group of specialist doctors who have taken on fibromyalgia as one of the disorders that they deal with. They are generally good at diagnosing it. Medications may be prescribed to alleviate the symptoms. These include nortryptiline, amitryptiline, Lyrica and Cymbalta. I cannot ever remember a rheumatologist prescribing opioid medications to a patient that I have dealt with. Opioids are a family of medications that are in the morphine family. They include codeine and many other medications with a variety of trade names and generic names. As far as I am concerned, it is a disaster for a patient with fibromyalgia to be given regular opioids unless they are not expected to live very long due to some terminal illness. Fibromyalgia is not a terminal illness. In my experience opioids only give partial relief from the muscle pain and they quickly lose their effectiveness such that a higher dose is needed to achieve the same effect. Doctors become resistant to prescribing these higher doses and so the patient ends up in the same pain as they were to begin with and with the additional burden of the opioid medication and all of its side effects. Getting off opioids is usually a nightmare for patients with fibromyalgia as it normally causes an increase in pain due to aggravating the tissue sensitisation. This increase in pain can sometimes be relieved by other measures but can be quite resistant and persistent. It requires careful medical supervision and lots of support. If you are not sure if you are on an opioid, ask your pharmacist or doctor, or check it out yourself online. Make sure you check carefully. I have had patients get quite shocked when I have told them that a certain medication they have been prescribed is actually a morphine derivative. Anti-inflammatory medications such as ibuprofen and diclofenac may be used by patients with fibromyalgia or prescribed by their doctors. However, these medications are not good to take long term as they increase the risk of various ailments including high blood pressure and kidney impairment.
In my experience, similarly to CFS, some possible causes of fibromyalgia my have been missed due to not being very well known or characterised or because they were not checked out quite enough. These possible causes include: Sick Buildings, Long term Infections, Poisoning, Mental/social/spiritual stress, Nutritional and gut problems, Hormonal problems and Sleep disturbances. Insulin resistance looks like a major player too (see above research). However, with fibromyalgia there is often an accident or injury involved with the start of the illness. This, in combination with a pre-existing problem (one of the seven above areas or some other unknown issue) may have caused the sensitisation of the tissues and nerves. This sensitisation results in the characteristic painful fibrous connective tissue and muscles of fibromyalgia. The medications used to treat the condition are designed to reduce this sensitisation. Treatment should aim to identify the causes and treat them while at the same time providing low-risk alleviation of symptoms.
On the subject of gut and nutritional issues, I have known of two patients whose symptoms were predominantly (but not completely) due to nightshade sensitivity. When they stopped consumption of nightshades they improved markedly. I have also read of an English GP who cured themselves of fibromyalgia by reducing their oxalate intake. I am in the process of further investigating these two areas and research done on them. In relation to oxalates, one theory is that antibiotics wipe out a gut bacteria called Oxalobacter which breaks down oxalates. If this bug goes then you may end up absorbing more oxalates than normal, especially in the case of a 'leaky gut' (which antibiotics might cause). It appears that some people get worse before getting better on a low oxalate diet due to the body releasing stored oxalates.
More natural pain-relieving methods that may help include far infra-red saunas, ginger, turmeric, warm baths with epsom salts, special types of magnesium (e.g. magnesium malate) and some other herbs like Boswellia and Willow Bark. However, I am not aware of any clinical trials assessing the effectiveness of these possible natural remedies. A relatively low-risk medication called low-dose naltrexone is also sometimes helpful. Low dose naltrexone has been studied (Ref. 3).
References
- Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990;33:160–72.
- Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res 2010;62:600–10.
- Younger J, et al., Low-dose naltrexone for the treatment of fibromyalgia: findings of a small, randomized, double-blind, placebo-controlled, counterbalanced, crossover trial assessing daily pain levels. Arthritis Rheum. 2013 Feb;65(2):529-38.
Images and content © D. Bird 2017