Carl Hendel, M.D.


What is Fibromyalgia?

I don't know that anyone truly knows! Through out the ages, people have had pain and sleep disturbances. There is currently a confusing alphabet soup of pain syndromes, and there are technical differences and slightly different approaches to therapy. Chronic Fatigue Syndrome (CFS), Fibromyalgia Syndrome (FMS) Myalgic Encephalomyelitis(ME), Myofascial Pain Syndrome (MPS) all have as a common denominator.......pain. And, in these syndromes, the approach to pain described in these pages can be helpful.

Medical science studies and classifies human pain and suffering. In order to have a diagnosis of fibromyalgia, you must fit a clinical picture, including widespread pain and tenderness, described as "aching all over", fatigue, exhaustion after minimal effort, and a sleep disturbance. Fibromyalgia affects about 2-4% of the population, and is more commonly diagnosed in women.

The sleep problem is often described as difficulty in getting restful sleep. Sometimes there is difficulty falling asleep, or staying asleep. Some people report that they sleep, but don't feel rested in the morning. Often, the nature of the sleep disturbance can be clarified by sleep laboratory studies. It seems that the delta wave (deep sleep pattern) has alpha wave (waking pattern) intrusions. Since much of our restorative processes (including the neurotransmittors) happens during normal deep sleep, this disrupted pattern may contribute to many of the abnormal chemical findings in fibromyalgia. Many of the symptoms found in fibromylagia can also be seen in normal volunteers subjected to sleep deprivation.

Other common features of fibromyalgia include intestinal troubles (Irritable Bowel Syndrome), anxiety and other mood disturbances, headaches, allergies, and Raynaud's phenomenon (intermittent cold white hands).

We do not know exactly what fibromyalgia is, but we are learning quickly. It is presently felt that FMS is NOT degenerative, progressive or inflammatory. It is considered to be a chronic pain/chronic stress syndrome by some.

This syndrome has been part of human history for a very long time. It was designated as an entity by Balfour in 1816. Since that time, FMS has been misunderstood and some in the past have assumed it to be solely a psychiatric condition. It it clear now that this is not the case. However, we do know that stress, both physical and emotional, are aggravating forces. If we hold a "flight or fight" state of mind, we do suffer the physiologic consequences of "holding" in our tissues, causing stagnation, pain, and tender/trigger points.

Scientific investigation has found some neurochemical markers in this syndrome. There is altered pain sensitivity, referred to as perceptual amplification or "allodynia," meaning that the same amount of pain stimulus that is minimally uncomfortable in a non-FMS person is very painful in FMS. The reports of more substance P in the spinal fluid of patients with fibromyalgia (part of the pain mechanism) is probably related to the loss of appropriate pain regulation in the central nervous system. There may be cascade of consequences as the abnormal pain chemistry influences other hormones, the stress response, and more. Lower levels of growth hormone and somatomedin C (part of the growth hormone mechanism), cortisol, and serotonin may all be part of this cascade. Other researchers are examining the role of the limbic system in the brain, and there is ongoing research examining the immune system response seen in FMS.

Many pharmacolgic interventions have been utilized for management, including trazadone, opiates, flexeril, xanax, elavil, soma, and others. These agents may have side effects, and may or may not significantly alter the clinical picture. Fibromyalgia pain most often does not respond to anti-inflammatory drugs.

How do we evaluate fibromyalgia pain?

Pain is a subjective, personal experience. We can ask about the intensity of the pain. Patients will report a pain level, with zero being no pain and 10 being extreme pain. But pain threshholds can be affected by many factors.

We can press on the painful spot. How much does the patient recoil? That may be affected by the nature of the exam, including the skill of the examiner and the emotional state of the patient. The diagnosis of fibromyalgia includes documenting significant tenderness in 11 of 18 possible locations in the body. The examiner is to press with 4 kg. of force. Most examiners don't have a clue what that means! I know, from my experience, that I can induce a pain response with very little force by insensitive connection to my patient. If I have connected, I can go quite deep into tissues with significant "force" and not elicit pain. None-the-less, its not difficult to determine if a person has generalized, predictably located tender points.


What can be done?

Many patients experience a sense of hopelessness and frustration. Often the doctors are frustrated also, not being able to help. It is at these times that we need to cultivate our own inner resources. This work is difficult and a person must be motivated. Often the inner work that is undertaken can be painful and difficult, and does not promise to cure the ailment. But life is a path, not a destination, and personal and spiritual growth often happens when we are challenged by pain and suffering. I can't remember who said it, but there is some wisdom in the saying "pain and suffering is inevitable, misery is optional."

There are many healing practices that offer some relief. Some require a help from a healer and teacher, but much of the work belongs clearly to the patient. Acupuncture, Interactive Imagerysm, and Manual Medicine (such as myofascial release and counterstrain techniques) often are helpful. Some form of spiritual practice with meditation is very important.

Some people have found diet to make a difference, but don't agree on what one should eat. Some have found that avoidance of potatoes, tomatoes and bell peppers has been helpful. Others encourage lots of fresh fruits and vegetables, especially oranges. Some believe vegetarian is best. I am not an expert in dietary areas, but would be curious about what Ayurvedic medicine might have to say about an individual's best dietary plan. Overall, dietary common sense applies, with avoidance of hypoglycemia, and a balance of complex carbohydrates, protein, and fats (the most appropriate percents of each is still the big question!). I also suggest adequate water intake, about eight 8 ounce glasses, daily

Exercise matters. Inappropriate exercise, however, can be detrimental. Although aerobic exercise is acceptable and recommended by some, over-exercise is definitely to be avoided. As always, "use mind and not force." Even stretching must only be taken to its "growing edge", not forcing anything. At the point just relax! Yoga, when taught in a gentle way by an experienced teacher can be wonderful. Water exercise is great. My personal recommendation, for reasons to be described, is Tai Chi (TaiJi Quan).

There is some evidence that increasing magnesium intake is helpful, since, in some pain syndromes (including fibromyalgia) there may be low magnesium levels. About 400 mg is appropriate (assuming you have healthy kidneys and liver). It may cause a little diarrhea in some people.

Guaifenesin, an over-the-counter cough medicine, has been acclaimed as a major breakthough for fibromyalgia, but I am not convinced. It is not without its problems, and good scientific evidence is still lacking. Proponents say that it clears phosphates and oxalates from the body and has changed their lives. The "detox" symptoms can be very unpleasant, and I do not recommend this as a first choice for treatment at this time. I would advise caution and more research before proceeding with this option.

Not everyone gets cured. As a matter of fact, "none of us get out of life alive", although that is a one-dimensional view. Learning to live with pain, learning to modify it and its impact on our lives is a challenge. Many people do well in maintaining a high quality life experience, and learn much along the path.

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