Dr. George B. Isaac MD - Rheumatology

Dr. George B. Isaac MD - Learn about this mysterious ailment, the signs, and symptoms, the latest theory on the cause, and some treatment options in this article. An in-depth look at diet and supplementation that may benefit fibromyalgia see the article "Nutritional Strategies For Fibromyalgia."

Complicated Syndrome

Fibromyalgia (FM) literally means pain in the fibrous connective tissue that surrounds joints, typically the muscle and the tendon that attaches the muscle to the bone. It isn't a disease, but rather a syndrome, which is a collection of signs and symptoms that occur together. It is a form of soft tissue rheumatism. The American College of Rheumatology defines FM as widespread pain present for at least three months in combination with tenderness at 11 or more of 18 specific tender point sites. FM used to be called fibrositis, but that erroneous definition meant an inflammatory condition was present, and that is not the case. Because of the difficulty in diagnosing FM and the similarities that FM has to other diseases, many people are not properly diagnosed, or the diagnosis takes much time and effort. Since FM affects 2% of the United States population, with a breakdown of 3.4% in women and 0.5% in men, this is not a rare syndrome.

Signs and Symptoms

FM patients usually report that they "hurt all over" and describe their pain as stabbing, aching, or nagging. They also describe feelings of stiffness, especially upon waking up. Pain with palpation is found in 11 of 18 specific points that have been identified around the body. FM patients can suffer from fatigue, sleep disturbances, headaches, abdominal pain, bloating, constipation, diarrhea, bladder urgency, and frequency, and skin sensitivity. FM seems to occur in a vicious circle. The lack of sleep leads to sore muscles and fatigue, which leads to less participation in physical activity, which results in depression and further deconditioned muscles, which leads to more pain, which leads to less sleep.

The Central Nervous System Theory

Many researchers now believe that the central nervous system (CNS) plays a large role in the development of this syndrome. The central nervous system is composed of the spinal cord and brain. What investigators think is that an event, either emotionally or physically traumatic, leads to hyperactivity in the CNS. This hyperactivity leads to sleep disturbances, like the increased number of awakenings found in FM patients. The hyperactivity also affects the ratio of excitatory to inhibitory neurotransmitters. Neurotransmitters are chemical messengers that communicate between nerves. In FM, there appear to be larger concentrations of excitatory neurotransmitters (like Substance P) and lower concentrations of inhibitory neurotransmitters (like serotonin). This irregular ratio causes pain amplification in FM patients. FM patients' pain perception is normal, but their sensitivity to pain is increased and their tolerance of pain is decreased. The CNS hyperactivity can then lead to problems involving all bodily systems, which explains the seemingly unrelated symptoms of FM. There is even reason to believe that FM may have a genetic component.

FM Management

A combination of medication, cognitive behavior therapy, relaxation techniques, exercise, and education is recommended as a treatment for FM. Medications that help promote sleep and relaxation have been used, but studies have met with mixed results. Nonsteroidal anti-inflammatory drugs (NSAIDs) aren't more effective than placebos and corticosteroid injections make FM symptoms are worse. Trigger point injections using a local anesthetic can be helpful, but only have temporary effects, and the authors of one study that showed symptom improvement still recommended other forms of treatment. Only one high-quality study suggests that real acupuncture is more effective than sham acupuncture. Cognitive behavior therapy, which involves learning effective coping strategies, and stress-reduction programs were proven to be successful in the long term treatment of FM.

Exercise programs that emphasize cardiovascular fitness seem to be the tool for breaking the circle of pain. FM patients are deconditioned from avoiding exercise. This can lead to further pain from shortened and tight muscles. Many doctors recommend a balanced program of flexibility, gentle strengthening, and aerobic conditioning. Exercise should be thought of as health training, not sports training. The intensity and duration should begin slowly, but become a part of the FM patient's lifestyle. Pool exercises are a good place to start with a gradual progression to land exercises. Physical therapists can help design exercise and stretching programs. The Arthritis Foundation recommends also learning progressive muscle relaxation techniques in addition to exercise and stretching.

The Good News

FM is not a life-threatening disease, nor is it physically deforming. Symptoms do not usually get worse and maybe lessened with appropriate interventions. Although researchers are still working on a complete explanation for the syndrome, progress is advancing rapidly. Without a definitive treatment for every FM patient, an individualized approach and experimentation with different methods should be utilized. In a study of FM patients who still had symptoms after ten years of onset, 66% of patients reported that their symptoms were a little or a lot better, 55% said they felt well or very well, and only 7% felt they were doing poorly.

Dr. George B. Isaac MD - Natural Approaches For Fibromyalgia

Dr. George B. Isaac MD - Fibromyalgia (FM) is a common, yet not well-understood a disorder that affects thousands of persons. The word fibromyalgia comes from the Latin term for fibrous tissue (fibro) and the Greek term for muscle (myo) and pain (algia). It is marked by widespread muscle pain, fatigue, and multiple tender points on specific areas of the body. The challenges with FM are that the symptoms are not clearly visible, and it cannot be diagnosed by a particular blood test or marker. As such, FM is still associated with stigma among both medical professionals and the public. For those with FM, not being understood can be just as painful as the symptoms of the disease.

Defining Fibromyalgia

The American College of Rheumatology (ACR) has established two criteria for the diagnosis of FM: a history of widespread pain lasting more than 3 months and the presence of 11 or more tender points out of 18 standard sites on the body (neck, shoulders, back, hips, and upper and lower extremities).

Theories - Causes

While there are various theories and contributing factors, the underlying cause(s) are not known. For many sufferers, there is an event or the experience that triggers the onset of the disease, such as an infection, emotional stress, trauma, injury or exposure to certain drugs or chemicals. According to a recent paper in the Annals of Internal Medicine, 33 percent of FM patients also suffer from multiple chemical sensitivity.

Dr. George B. Isaac MD -  FM seems to run in families. Researchers have identified one gene believed to be involved in the syndrome. A new 4-year study funded by the National Institutes of Health (NIH) will examine this further.

Those with rheumatoid arthritis and other autoimmune diseases, such as lupus, appear to be at greater risk for developing FM.

Individuals with FM have elevated levels of a chemical, called substance P that is involved in our sensation of pain signals. They also have lower levels of serotonin and norepinephrine - two very important chemical messengers in the brain that modulate pain as well as mood.

A recent study has demonstrated that an imbalance of oxidants and antioxidants may be at play in the development of FM. Researchers from  found significantly increased levels of the oxidant malondialdehyde and decreased levels of the antioxidant superoxide dismutase in patients with FM compared to controls.

Treatment for FM

A comprehensive program that includes counseling (emotional support), proper nutrition, exercise, stress management and the use of various supplements to reduce symptoms and improve well-being offers the greatest benefit for FM sufferers. In some cases, medication may be required to control pain, inflammation and insomnia, however, it is always best to try the non-drug approaches first.

Dr. George B. Isaac MD - The following nutritional supplements have been studied for their benefits in FM:

SAMe - short for S-adenosylmethionine, this nutrient is involved in many biochemical reactions in the body, including the production of neurotransmitters (serotonin), antioxidants, hormones, and the sulfur-containing compounds of the joint. Levels are depleted with age and in those with depression, liver disorders, and osteoarthritis. SAMe has been studied for FM and found to alleviate pain, fatigue, and stiffness and improve mood. SAMe is very safe and not associated with the unpleasant side effects seen with prescription antidepressants. The recommended dose is 800 mg of natural (Iso-Active) SAMe daily. It is best to choose a firm that is enteric-coated. Take on an empty stomach.

5-HTP - short for 5-hydroxytryptophan, this supplement helps to boost serotonin levels and alleviate depression symptoms. It may also be helpful in reducing tender points, anxiety and improving sleep quality. It is not good to combine this supplement with prescription antidepressants or other drugs that modify serotonin levels. The recommended dose is 100 mg three times daily.

Melatonin - this hormone is responsible for regulating our sleep cycles. Supplementing with melatonin may help to shorten the time needed to fall asleep, reduce night-time wakening and improve sleep quality. In one study 3 mg of melatonin at bedtime was found to reduce tender points and to improve sleep and other measures of disease severity.

Antioxidants - preliminary research has found that vitamin E supplements could be helpful in improving the symptoms of FM. Considering the new research on the oxidant-antioxidant imbalance seen in FM, it makes sense to consider supplementing with a good antioxidant. Most multivitamin formulas contain antioxidants like vitamins E and C. Some formulas also contain hot new antioxidant ingredients like pomegranate, blueberry and cranberry, which offers a range of health benefits.

Magnesium - one study found that a combination of magnesium (300-600 mg) and malic acid (1200-2400 mg) helped to reduce muscle pain in people with fibromyalgia.

Since stress is known to aggravate the symptoms of FM, it is important to find ways to cope effectively. Here are some tips to consider:

· Relaxation techniques, such as breathing exercises, meditation and yoga

· Regular exercise, such as walking, swimming, stretching and Pilates

· Healthful diet - lots of fresh fruits, vegetables, whole grains, lean protein, and essential fats

· Positive outlook - counseling and cognitive therapy can be very helpful

· Sleep - important for overall well being

· Minimize alcohol, caffeine, and consumption of fast food and processed food (which are full of dangerous chemicals and preservatives)

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