Over the past few decades, the incidence of chronic fatigue syndrome (CFS) and fibromyalgia (FMS) has exploded and is now present in approximately 12 to 24 million Americans! In 1987, the American Medical Association recognized fibromyalgia as a distinct syndrome (Starlanyl & Copeland 1996), American College of Rheumatology definition of fibromyalgia syndrome.
Definition
The definition of fibromyalgia syndrome (FMS) as stated by the American College of Rheumatology (ACR 1990) is as follows:
1. A history of widespread pain for at least 3 months. Pain is considered widespread when all of the following are present: pain in the left side of the body, the right side of the body, below the waist, and above the waist.
2. In addition, there should be axial pain (cervical spine or anterior chest or thoracic spine, or low back).
3. Pain (with the patient reporting ‘pain’ and not just ‘tenderness’) in 11 of 18 tender point sites on digital pressure involving 4 K of pressure. The sites are all bilateral and are situated:
• at the sub occipital muscle insertions (close to where rectus capitis posterior minor inserts)
• at the anterior aspects of the inter-transverse spaces between C5 and C7
• at the midpoint of the upper border of upper trapezius muscle
• at the origins of supraspinatus muscle above the scapular spines
• at the second costochondral junctions, on the upper surface, just lateral to the junctions
• 2 cm distal to the lateral epicondyles of the elbows
• in the upper outer quadrants of the buttocks in the anterior fold of gluteus medius
• posterior to the prominence of the greater trochanter (piriformis insertion)
• on the medial aspect of the knees, on the fatty pad, proximal to the joint line.
4. Predominantly chronic pain syndromes (upper extremity pain, cervical pain, thoracic pain, lumbar pain, lower extremity pain, and headache) are found more in the fibromyalgia group and experienced the most difficulties.
Pathogenesis (proposed)
The central sensitization is the most established pathophysiological mechanism of FM. It is associated with hyperalgesia and allodynia, which are commonly experienced in patients with FM. In fact, patients with FM seem to be more sensitive to multiple different stimuli, including heat, cold, and electrical stimulation. There is an increase in activation of neurons with low-intensity painful stimulation when compared to the control group. It is supposed to have a deficiency in the descending inhibitory pathway within the central nervous system (CNS) and an increased amount of neurotransmitters associated with nociception such as substance P, excitatory amino acids (e.g., glutamine, glycine, arginine, glutamic acid), and nerve growth factor (NGF). And decreased amount of anti-nociceptive neurotransmitters such as the biogenic amines (e.g., serotonin, norepinephrine, dopamine).
It is said there is polymorphism in the catechol-O-methyltransferase (COMT) enzyme, which breaks down catecholamine such as dopamine and norepinephrine as well as the endorphins. Evaluation for FM It includes pain assessment by way of a proper history and physical examination, laboratory evaluation to rule out other causes of pain if indicated, and any other evaluations.
• Fatigue: One of the most common associated symptoms of FM is fatigue. Approximately 80% of patients with FM also fall under the criteria for chronic fatigue syndrome, which include: fatigue for greater or equal to 6 months, sore throat, joint pain, muscle pain, and unrefreshing sleep.
• Lack of Sleep: Most patients with FM complains of nonrestorative sleep (NRS). NRS leads to impairment in daytime functioning.
• Affective Disorder: Chronic pain may lead to an increased incidence of affective distress. FM is most commonly associated with anxiety and depression. Approximately 13-71% of FM patients have associated anxiety. Depression may be seen in 20-80% of FM patients.
• Stiffness: Patients diagnosed with FM often complain of morning stiffness. This can be very debilitating and may last from 45 min to 4 hrs. The concentric muscle contraction and passive stretch can improve stiffness. Cognitive Dysfunction Most patients with FM complain of short-term memory loss, difficulty with multitasking, and poor concentration.
Lab tests
No specific laboratory finding is correlated with FM. Initial laboratory evaluation should consist of:
1. Complete blood count (CBC)
2. ESR.
3. Cyclic citrullinated peptide test
4. Rheumatoid factor
5. Thyroid function tests
6. Anti-nuclear antibody
7. Celiac serology
8. Vitamin D
Treatment modalities
A way to help these people is by optimizing energy production and eliminating the things that are draining body’s fuel tank. this is the SHINE protocol, which stands for the five main treatment areas:
1. Sleep: On average, most people do best with eight hours of sleep a night. For those with CFS/FMS, because your sleep center is not working, you need aggressive treatment to be sure that you can get at least eight hours of deep sleep each night.
2. Hormonal support: This includes treatment with bioidentical hormones for thyroid, adrenal, and ovarian/testicular support—even if your blood tests (which are very unreliable) are normal.
3. Infections: If sinusitis or irritable bowel syndrome are present, candida needs to be treated. In those with CFS/FMS, because your immune system is working poorly, there are many infections present that need to be treated.
4. Nutritional support: Make nutritional support easy without taking handfuls of supplements throughout the day by taking the Energy Revitalization System vitamin powder and D-ribose powder.
5. Exercise as able to condition: For some people with CFS/FMS, this may mean walking just a few hundred feet a day.
Why is sleep so important?
Beyond giving energy, sleep has a number of critical functions. For example, sleep:
1. is when tissue repair occurs, which is why poor sleep causes pain.
2. is also critical for proper growth hormone production. Growth hormone has also been called the “fountain of youth hormone” and is associated with looking young as well as increasing muscle and decreasing fat.
3. has been shown to be critical for immune function.
4. is important for weight regulation because appetite-suppressing hormones such as leptin are produced during sleep.
Studies have shown that poor sleep was associated with an average six-pound weight gain. In a study of 68,183 women, followed over sixteen years, those sleeping five or fewer hours per night had a 32 percent increased risk of gaining thirty-three pounds relative to those who slept seven hours per night.
Diet
The diet recommended for the treatment of fibromyalgia comprises of 40 percent carbohydrate, 30 percent protein and 30 percent unsaturated fat. These essential nutrients provide bodies with vital energy and, as our bodies are in a constant state of regeneration, serve as fundamental building materials. eat a moderately high amount of fiber. junk or fast food is not recommended for people with fibromyalgia – or for healthy people for that matter. Individuals can survive on junk food for a while because it is comprised mainly of carbohydrates and fat, which have a high energy value. The body needs a regular input of enzymes to function at optimum levels. These enzymes are crucial to good digestion and many of them are provided by fresh raw food. Enzymes speed up the chemical reactions within bodies and are essential to good health. The reduced activity levels common in people with fibromyalgia can lead to the early onset of osteoporosis. This is particularly likely among postmenopausal women. However, soya foods are believed to contain plant estrogens – oestrogen being one of the hormones that are in short supply during and after menopause as mentioned earlier. These have the effect of preventing bone density loss and reducing hot flushes, irritability, aching joints and depression – all of which are symptoms of the menopause.
Fat-containing foods are crucial to health as they slow the absorption of carbohydrates into the bloodstream, thus limiting the production of insulin, which is essential for controlling blood sugar levels. Saturated fats come mainly from animal sources and are generally solid at room temperature. Unsaturated fats are often called ‘polyunsaturated’ or ‘monounsaturated’ fats. These types of fats are derived mainly from vegetables, nuts, and seeds. usually liquid at room temperature. Examples of unsaturated fats are olive, rapeseed, safflower, and sunflower oils. While saturated fats are believed to be implicated in the development of heart disease, unsaturated fats actually have a protective effect. These omega 3 and omega 6 fatty acids are obtained from vegetable oils, seeds In fibromyalgia, the recommended daily fat intake is 30 percent, i.e. just over 28 grams (1 oz). This equates to only 320 calories. Eating the necessary unsaturated fat will ensure reduced calorie intake and greater energy provision. Foods containing fiber include fruits, vegetables, nuts, seeds, beans, peas, lentils, whole meal bread and cereals. Fibromyalgia healing diet contains fiber, and the above-mentioned are all highly nutritious foods, providing fiber, starch, and many essential vitamins and minerals.
Medications
Medications can help reduce the pain of fibromyalgia and improve sleep. Common choices include:
• Pain relievers: Over-the-counter pain relievers such as acetaminophen, ibuprofen, or naproxen sodium may be helpful. Opioid medications are not recommended, because they can lead to significant side effects and dependence and will worsen the pain over time.
• Antidepressants: Duloxetine may help ease the pain and fatigue associated with fibromyalgia. Your doctor may prescribe amitriptyline or the muscle relaxant cyclobenzaprine to help promote sleep.
• Anti-seizure drugs: Medications designed to treat epilepsy are often useful in reducing certain types of pain. Gabapentin is sometimes helpful in reducing fibromyalgia symptoms, while pregabalin was the first drug approved by the Food and Drug Administration to treat fibromyalgia.
Therapies
A variety of different therapies can help reduce the effect that fibromyalgia has on your body and your life. Examples include:
• Physical therapy: A physical therapist can teach you exercises that will improve your strength, flexibility and stamina. Water-based exercises might be particularly helpful.
• Occupational therapy: An occupational therapist can help you make adjustments to your work area or the way you perform certain tasks that will cause less stress on your body.
• Counseling: Talking with a counselor can help strengthen your belief in your abilities and teach you strategies for dealing with stressful situations.
By Dr. Niraj Shrestha
MS, Consultant Orthopedic Surgeon
Phect Hospital, Kirtipur