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Fibromyalgia:
Evidence-based Nutrition
and Lifestyle Management

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Fibromyalgia is classified as a rheumatic disorder that affects between three and six million North Americans. It is most commonly seen in women of childbearing years, but children, the elderly and men can also develop this disorder. The diagnosis of fibromyalgia requires that the patient must experience widespread pain in all four quadrants of the body for at least three months duration, in combination with tenderness at 11 or more of the 18 specific 'tenderpoint' sites. Ninety percent of fibromyalgia patients have jaw and facial tenderness that can produce temperomandibular joint dysfunction syndrome (TMJDS), and 50% of all fibromyalgia patients report sensitivities to odours, noise, bright lights, medication and various foods. Other commonly noted symptoms include disturbed sleep patterns, fatigue, morning stiffness, depression, recurrent headaches, tender lymph nodes, bowel or bladder disturbances, sensitivity to heat or cold, anxiety, gastrointestinal disturbances, dizziness, occasional tachycardia and environmental allergies. Co-morbidity issues such as irritable bowel syndrome, Raynaud's disease and TMJDS are also frequently encountered in these patients.

Possible Causes

Fibromyalgia is thought to be triggered by infections, physical trauma and/or other illnesses such as lupus or rheumatoid arthritis and leaky gut syndrome. (1) In regards to leaky gut syndrome, epidemiological studies have shown that patients with functional gastrointestinal disorders such as irritable bowel syndrome frequently overlap with fibromyalgia. Fibromyalgia occurs in up to 60% of patients with functional bowel disorders, and 50% of patients experience functional dyspepsia, and 70% have irritable bowel syndrome. These digestive disorders can cause a leaky gut, which permits partially digested food matter and other foreign compounds to leak from the gut into the bloodstream, triggering immune inflammatory reactions. This, in turn, can produce a wide range of undesirable systemic effects on the body, including the aggravation of fibromyalgia, according to some authorities. (2) There is also a close relationship between fibromyalgia and chronic fatigue syndrome. (3)

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Treatments

Conventional treatment for fibromyalgia involves a combination of medications, as well as a low-impact exercise program to improve fitness, stretching techniques to ease muscle tension and cognitive therapy to reduce the impact of stress. As patients with fibromyalgia have been shown to have low serotonin levels, which may account for a tendency towards depression, tricyclic antidepressants drugs such as amitriptyline and serotonin re-uptake inhibitors, such as fluoxetine are commonly prescribed as a means to elevate mood and improve sleep disturbances. Oral analgesics, such as aspirin, ibuprofen and acetaminophen, are sometimes prescribed to reduce pain. (1)

NUTRITION AND LIFESTYLE MANAGEMENT OF FIBROMYALGIA

A number of dietary modifications and nutritional supplements have been shown to be effective in the complementary management of fibromyalgia. In a controlled study, women with fibromyalgia were put on a vegetarian diet consisting of only raw foods - primarily fruits, vegetables, nuts, seeds, legumes and cereals ( e.g. rolled oats). The diet included some fermented foods, including a fermented yogurt-food made from oats, a fermented beverage made from berries, and several types of fermented vegetables, particularly cabbage. During the three-month trial, women following the therapeutic diet experienced a significant reduction in body weight, pain, morning stiffness, use of painkillers, depression, and the number of sore fibromyalgia points, compared with those who continued to follow their regular diet. This may hint at the idea that prostaglandin synthesis may be a contributing factor in fibromyalgia as a high animal fat diet encourages the production of prostaglandin series-2, which is known to promote swelling and pain in arthritis patients. (4) As noted previously, low-impact endurance exercise (two 25-minute exercise classes plus two educational sessions per week) has resulted in immediate and sustained improvement in walking distance, fatigue, and well-being in a group of fibromyalgia patients. (5) A 35-minute exercise program in a warm pool once a week for six months, coupled with counselling sessions, also led to improvements in endurance, pain reduction, distress, depression and anxiety in another clinical trial involving fibromyalgia sufferers. (6)

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5-HTP

With respect to nutritional supplementation, several studies (preliminary and double-blind trials) have shown that 5-hydroxy-tryptophan (5-HTP) may be effective at reducing many fibromyalgia symptoms (depression, anxiety, insomnia and body pains), when taken at a dosage of 100 mg. three times per day for 30 days. 5-HTP is a natural constituent of the graffonia simplicifolia seed (an African seed), and is the immediate precursor to the synthesis of serotonin in the brain. Studies demonstrate that 5-HTP crosses the blood-brain barrier and is an available substrate for conversion to serotonin, which elevates mood, modulates pain and other physiological outcomes. Note that if a patient is already taking a medication to enhance their brain levels of serotonin and/or other neurotransmitters (antidepressant drugs) it is contraindicated to recommend concurrent supplementation with 5-HTP (as well as melatonin and St. John's Wort) as this could result in serotonin syndrome, which can be life-threatening. (7,8,9,10,11)

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SAMe

S-adenosylmethionine (SAMe) has also shown success in these cases. Due to its participation as a methyl donor in many biochemical reactions, it functions to help reduce inflammation and pain, and reduce depression by acting as a coenzyme in the natural synthesis of serotonin and other neurotransmitters. A six-week double-blind study showed that patients receiving 800 mg of (SAMe) per day reported improvements in pain, fatigue, morning stiffness and mood, compared with the placebo group. (12) Another smaller double-blind trial also illustrated similar outcomes, prompting researchers to state, "SAMe seems to be an effective and safe therapy in the management of primary fibromyalgia". (13) Note that in the body, SAMe is made naturally from the conversion of homocysteine to methionine, once homocysteine picks up a methyl group from Vitamin B12 (Vitamin B12 originally obtained this methyl group from folic acid). Methionine then picks up adenosine from ATP (adenosine triphosphate) to become SAMe. However, supplementation with SAMe appears to be beneficial in fibromyalgia patients, as well as in some cases of arthritis. In Europe it is used to battle depression and anxiety disorders.

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Melantonin

One study reported that patients with fibromyalgia had nighttime melatonin levels that were 31% lower than the control group, which may contribute to impaired sleep, fatigue and altered pain perception. (14) In one therapeutic trial, patients were given 3 mg of melatonin each day before bedtime. After one month, patients receiving the melatonin reported improvement in sleep, tender point count, and severity of pain at selected sites. (15)

Other Supplements

Many patients with fibromyalgia also report significant reduction in pain using a combination of magnesium (300-600 mg per day) and malic acid (1200-1400 mg per day). The mechanism of action in this case is yet unknown, but may involve reduced muscle tension. (16,17)

In patients that have concurrent functional intestinal disturbances, it may be useful to include a full spectrum digestive enzyme product. This would help prevent leakage into the bloodstream of partially digested food matter (especially tripeptides and dipeptides), which can trigger immune inflammatory reactions. (1)

A B-50 complex may also be considered to help boost energy, and it is interesting to note that some studies have found low vitamin B1 (thiamine) levels and reduced activity of some thiamine-dependent enzymes among people with fibromyalgia. (18,19)

Alternative practitioners should also be aware of the natural anti-inflammatory effects of herbal agents such as curcumin, boswellia, white willow extract and ginger, as supplements that combine these agents together can be helpful in a variety of inflammatory conditions, and help reduce the patient's need for non-steroidal anti-inflammatory drugs (NSAIDs) which frequently cause gastrointestinal irritation, erosion, ulceration and bleeding, as well as liver and kidney toxicity. (1)

With respect to other therapeutic interventions, several open trials have demonstrated that chiropractic treatment (involving joint manipulation, stretching, soft tissue massage and lifestyle counseling) was able to reduce pain, feeling of fatigue, and improve sleep, in a high percentage of patients with fibromyalgia. Overall, 50-60% of patients reported significant improvement in these parameters. (20,21,22)

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Electroacupuncture

The use of electroacupuncture has also shown promising results for these patients. In one study of patients receiving electroacupuncture for their symptoms, 46% reported that this intervention provided them with the best relief of symptoms compared to all other therapies they had tried, and 64% reported using less pain medication than prior to treatment with electroacupuncture. (23) Other trials using electroacupuncture have demonstrated improvement in the symptoms of fibromyalgia as well. (24,25)

Conclusion

In summary, a number of complementary and alternative therapies, as well as nutritional supplements and lifestyle modifications, have been shown to be effective in managing a broad number of symptoms in patients suffering from fibromyalgia. Based upon the current research status, alternative practitioners should consider using the most appropriate of these interventions to help patients who are afflicted with this very bothersome, complex disorder. Most practitioners agree that fibromyalgia is a very difficult problem to treat and, thus, practitioners should embrace any interventions that have been shown to be useful and safe in the management of these cases.

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REFERENCES:

1. Intramedicine Inc. 2000-2003. www.content.intramedicine.com
2. Chang L. The association of functional gastrointestinal disorders and fibromyalgia. Eur J Surg Suppl 1998;583:32-6
3. Goldenberg DL. Fibromyalgia and chronic fatigue syndrome: are they the same? J Musculoskel Med 1990;7:19
4. Kaartinen K, Lammi K, Hypen M, et al. Vegan diet alleviates fibromyalgia symptoms. Scan J Rheumatol 2000;29:308-13
5. Gowans SE, deHueck A, Voss S, Richardson M.A randomized, controlled trial of exercise and education for individuals with fibromyalgia. Arthritis Care Res 1999;12:120-8
6. Mannerkorpi K, Nyberg B, Ahlmen M, Ekdahl C. Pool exercise combined with an education program for patients with fibromyalgia syndrome. A prospective, randomized study. J Rheumatol 2000;27:2473-81
7. Fava M, Rosenbaum JF, MacLaughlin R, et al. Neuroendocrine effects of S-adenosyl-L-methionine, a novel putative antidepressant. J Psychiatr Res 1990;24:177-84
8. Bell KM, Potkin SG, Carreon D, Plon L. S-adenosylmethionine blood levels in major depression: changes with drug treatments. Acta Neurol Scan 1994; 154(suppl);15-8
10. Puttini PS, Caruso I. Primary fibromyalgia syndrome and 5-hydroxy-L-tryptophan: a 90-day open study. J Int Med Res 1992;20:182-9
11. Moldofsky H, Warsh JJ. Plasma tryptophan and musculoskeletal pain in non-articular rheumatism ("fibrositis syndrome") Pain 1978;5:65-71
12. Jacobsen S et al. Oral S-adenosylmethionine in primary fibromyalgia. Double-blind clinical evaluation. Scand J Rheumatol 1991;20(4):294-302
13. Ravoni A et al. Evaluation of S-adenosylmethionine in primary fibromyalgia. A double-blind crossover study. Am J Med Nov 1987;83(5A):107-10
14. Wikner J et al. Fibromyalgia-a syndrome associated with decreased nocturnal melatonin secretion. Clin Endocrinol (Oxf). Aug 1998;49(2):179-83
15. Citera G, et al. The effect of melatonin in patients with fibromyalgia: a pilot study. Clin Rheumatol 2000;19(1):9-13
16. Russell IJ et al. Treatment of fibromyalgia syndrome with Super Malic: a randomized, double-blind, placebo controlled, crossover pilot study. J Rheumatol May 1995;22(5):953-8
17. Abraham GE, Flechas JD. Management of fibromyalgia: Rationale for the use of magnesium and malic acid. J Nutr Med 1992;3:49-59
18. Eisinger J, Zakarian H, Plantamura A, et al. Studies of transketolase in chronic pain. J Adv Med 1992;5:105-13
19. Eisinger J, Bagneres D, Arroyo P, et al. Effects of magnesium, high energy phosphates, piracetam, and thiamin on erythrocyte transketolase. Magnesium Res 1994;7(1):59-61
20. Wolfe F.The clinical syndrome of fibrositis. Am J Med 1986;81(Supp 3A):7-14
21. Blunt KL, Moez HR, Rajwani MH< Guerriero Rc. The effectiveness of chiropractic management of fibromyalgia patients: a pilot study. J Manipulative Physiol Ther 2000;23:225-30
22. Hains G, Hains F. Combined ischemic compression and spinal manipulation in the treatment of fibromyalgia; a preliminary estimate of dose and efficacy. J Manipulative Physiol Ther 2000;23:225-30
23. Waylonis GW. Long-term follow-up on patients with fibrositis treated with acupuncture. Ohio State Med J 1977;73:288-302
24. Deluze C, Bosia L, Zirbs A, et al. Electroacupuncture in fibromyalgia: results of a controlled trial BMJ 1992;305(6864):1249-52
25. Berman BM, Ezzo J, Hadhazy V, Swyers JP. Is acupuncture effective in the treatment of fibromyalgia? J Fam Pract 1999;48:213-8

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ACKNOWLEDGEMENT

The above is from a submission by Dr. James Meschino. He prefaced this article by saying that from his "..own experience [he] knows how difficult it can be to get lasting results with [fibromyalgia] patients." ..."there is good evidence to support chiropractic care and electroacupuncture from several clinical trials. As well, nutrition and supplementation should be incorporated into the management of these conditions to address some of the biochemical aspects of this condition. in general, I would give these patients a high potency multi-vitamin and mineral that is antioxidant enriched and contains a B-50 complex. In addition, I would include an essential oils product to encourage the production of anti-inflammatory prostaglandins as well as a product that could naturally reduce inflammation in a direct fashion by blocking the production of prostaglandin series - 2 (curcumin, boswellia, white willow extract, ginger). The research suggests that S-adenosylmethionine should be considered and this is a supplement that I believe should be included for these patients. Note that raising serotonin or melatonin levels directly through the use of 5-HTP, St. John's Wort or melatonin supplementation is useful, but contraindicated for patients already taking anti-depressants."


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