Identifying (and Pulling) the Trigger on Fibromyalgia

Overview

Widespread pain for at least 3 months without identifiable cause1?  It’s a nightmare 2-8% of the worldwide population can attest to1.  This is the new diagnostic criteria for Fibromyalgia, a disease of central pain sensitization with a  central nervous system  processing disturbance2 that has had its share of difficulty among clinicians to diagnose as it can coexist and coincide with various other autoimmune diseases or diseases of chronic infection.1  It is also characterized as a constellation of symptoms rather than an ability to identify and label as a concrete diagnosis,3 which leaves sufferers frustrated as they await an explanation.  Fibromyalgia is often accompanied by symptoms of fatigue, memory and sleep problems3,IBS, headache and mood disorders4 further adding to the difficulty as this does not narrow down the multitude of diseases with similar symptoms.

MRIs show that the areas in the brain that are involved in pain processing, namely: prefrontal cortex, the anterior cingulate, the amygdala, hippocampus and others differ in Fibromyalgia in comparison to healthy controls.1  This means that how people perceive pain may be different, and may even include a genetic variant that perceives pain at higher levels.1  The neurotransmitters glutamate and GABA seem to be involved, which invariably affects other neurotransmitter levels, but when an intervention to reduce pain appears, these areas of connectivity normalize.2

Interestingly, thorough history taking identifies that frequently the manifestation of the disease can be linked back to a central stressful trigger event like an accident, a trauma, a flu or illness, overwork, or emotional episode.3 This brings with it an intriguing speculation on how the stress response can quite literally change the brain and alter the physiology of the body to manifest as physical symptoms including chronic unexplainable pain.1

Autonomic dysfunction is certainly present in those with fibromyalgia.5 The autonomic nervous system houses both the sympathetic and parasympathetic nervous systems, the sympathetic being known as the “fight or flight” system, the increase of which is correlated with pain intensity and symptoms worsening with stress.6  This seems back up the theory of a single stressful triggering event prior to the onset of symptoms.

Luckily, effective non-pharmacological therapies are available.3

Therapeutic Foods

While no specific diet has been shown to be effective in those with Fibromyalgia, cofactors like CVD, diabetes, obesity, celiac disease food sensitivities, and autoimmune diseases4 that often coexist with  the syndrome and make symptoms worse, contributing to lower quality of life.4  For this reason, it is reasonable and respectfully recognized that weight control, elimination diets and anti-inflammatory diets are potential effective tools for the Fibromyalgia patient.4

These diets eliminate potential triggers like dairy, sugar, wheat, MSG and/or aspartame, included due to their influence on the central nervous system.4  These largely whole foods and plant based diets work to avoid processed foods and trans fats, increasing consumption of foods rich in Omega 3 fatty acids and antioxidants, an important consideration as chronic pain and inflammation can be related to increased oxidative stress.1

Interestingly one study showed that when participating in a 4 week diet removing glutamate excitotoxins MSG and aspartame, 84% of participants reported a greater than 30% of symptoms resolved.7,8

Supplements to Consider

More studies need to be done as, so far, there are low results of efficacy in particular supplements or natural medicines for Fibromyalgia.1  Some small studies however have shown a particular interest in the potential for 3 homeopathics:  Rhus Toxicodendron, Arnica montana, and Bryonia alba in the reduction of symptoms.1

In addition, low vitamin D appears to be linked to the pain of fibromyalgia, though evidence is largely unclear.9  Throughout the new studies collected into one review in 2015, the conclusion was still questionable as to whether or not vitamin D effectively addressed the issue of chronic pain.9  However, in relation to other symptoms and challenges associated with Fibromyalgia, vitamin D supplementation is not unreasonable.1  Vitamin D in the form of cholecalciferol can be taken year round, adjusting the dose according to season.  Dose can be determined through blood labs.  Those with primary hyperparathyroidism or granulomatous disease are contraindicated due to the increased risk of hypercalcemia.1

Largely due to the nature of Omega 3 fatty acids’ anti-inflammatory properties, can it be a supplement of consideration.  While there are no known effective statistics in the treatment of fibromyalgia at this time, omega 3 fatty acids are known to have a mild pain modulating effect, and may even help with mood and depression.1 The recommended dose is 2000 to 4000mg once daily.  This should be used with caution in those receiving anticoagulant therapy, and should be discontinued 2 weeks prior to elective surgical procedures as Omega 3s inhibit platelet function and clotting factors.1

Conclusion

While fibromyalgia can be a challenge in diagnosing, the good news is that there are effective non pharmaceutical options for relief.  While nutrition is assistive in reducing inflammatory processes, seemingly the best and most effective treatments are those that involve relaxation, meditation, exercise and bodywork.  A team approach where multiple providers can coordinate is a best case scenario.

References:

1. Rakel D. Integrative Medicine. In: Integrative Medicine. 4th ed. Elsevier; 2018:320-333.

2. Harris RE, Clauw DJ, Scott DJ, McLean SA, Gracely RH, Zubieta JK. Decreased central μ-opioid receptor availability in fibromyalgia. J Neurosci. 2007;27(37):10000-10006. doi:10.1523/JNEUROSCI.2849-07.2007

3. Clauw DJ. Fibromyalgia: a clinical review. JAMA. 2014;311(15):1547-1555. doi:10.1001/JAMA.2014.3266

4. Rossi A, Lollo A, Guzzo M. Fibromyalgia and Nutrition: What News? Clin Exp Rheumatol. 33(1 Suppl 88: S117-125). https://pubmed.ncbi.nlm.nih.gov/25786053/

5. Bradley LA. Pathophysiology of Fibromyalgia. Am J Med. 2009;122(12 SUPPL.). doi:10.1016/j.amjmed.2009.09.008

6. Zamuner A, Barbic F, Dipaola F. Relationship Between Sympathetic Activity and Pain Intensity in Fibromylagia. Clin Exp Rheumatol. 2015;33(1 Suppl 88: S53-S57). https://pubmed.ncbi.nlm.nih.gov/25786044/

7. Smith JD, Terpening CM, Schmidt SOF, Gums JG. Relief of fibromyalgia symptoms following discontinuation of dietary excitotoxins. Ann Pharmacother. 2001;35(6):702-706. doi:10.1345/aph.10254

8. Holton K, Taren D, Thomson C, Bennett R, Jones K. The Effect of Dietary Glutamate on Fibromyalgia and Irritable Bowel Syndrome. Clin Exp Rheumatol. 2012;30(6 Suppl 74: 10-17). https://pubmed.ncbi.nlm.nih.gov/22766026/

9. Straube S, Derry S, Straube C, Moore RA. Vitamin D for the treatment of chronic painful conditions in adults. Cochrane database Syst Rev. 2015;2015(5). doi:10.1002/14651858.CD007771.PUB3