Archive for the ‘Fibromyalgia’ Category

Fibromyalgia Wholistic Care

Posted: December 11, 2013 in Fibromyalgia

Fibromyalgia (FM) is a very challenging condition to both diagnose and treat since there are different clinical signs and symptoms that make each patient with FM unique. Therefore, we usually make the diagnosis by excluding other possibilities. To make matters even more challenging, there are “primary” and “secondary” types of FM, or those who develop FM for no know reason (primary) vs. those whose FM arises from a known condition (secondary). Because of these challenges, there is no single treatment program to apply to all struggling FM patients. Rather, studies often suggest that a multidisciplinary “team” of health care providers be utilized in the management of patients with FM. It is recommended that EACH FM patient have their needs be uniquely treated. This month, we will look a “multimodal” approach to treating FM that incorporates a “team” approach.

For those less familiar with FM, many patients with this condition have symptoms that include fatigue, “all over” body pain, sleep problems, mood symptoms, and chronic pain. They may also have conditions including irritable bowel syndrome, palpitations, thyroid dysfunction, adrenal dysfunction, gastroenterological symptoms, chronic headaches, and MANY others. Dealing with these and other FM symptoms can have a tremendous negative impact on one’s quality of life and activities of daily living.

So as previously stated, the treatment of FM requires a comprehensive approach where the patient’s individual symptoms are targeted, as there is no “cookie cutter / one size fits all” management approach. Effective management approaches include chiropractic, allopathic, acupuncture, soft tissue therapy, sleep hygiene counseling, nutritional counseling, mind-body therapy, and dietary counciling including nutritional supplementation that target specific deficiencies determined by lab/blood tests and/or are based on the clinical history.

Treatment is centered on the human body’s deficiencies with the most important being the removal of any and all “trigger(s)” that causes inflammation in the body. Use of an anti-inflammatory herb such as ginger, turmeric, boswellia, (and others) can help until the causes are identified. A gluten-free diet is often very successful in reducing the autoimmune reaction that occurs with gluten sensitivity, which is estimated to be as high as 80% of the general population. This is NOT to be confused with gluten intolerance or celiac disease (they affect 7-10% of the general population). Once inflammation is controlled, weaning away of the anti-inflammatory supplements can be done successfully.

The hormonal levels of the body must also be in balance, especially the thyroid, adrenal, and sex hormone levels. Lab tests should include a complete thyroid panel (TSH, T3, T4, T7/free thyroxin), a salivary cortisol test (for adrenal function), and sex hormone levels (DHEA, pregnenolone, progesterone, estradiol, and, free and total testosterone). Assess and eliminate food sensitivities/allergies (gluten and dairy are most common). Nutritional supplementation should include vitamins (a multiple, omega 3 fatty acids, Vitamin D3, and Co-enzyme Q-10; minerals (calcium, potassium, magnesium), amino acids and sometimes others (case dependant)). These keep our organs functioning well, like a finely tuned machine! Care must also be taken not to over-dose as well, so let us guide you in this process – consider chiropractic your “coach” in this team-based approach!

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Fibromyalgia and Nutrition

Posted: November 1, 2013 in Fibromyalgia

Fibromyalgia (FM) is truly a challenging condition to manage, as anyone with this condition will attest to! In the past, we’ve discussed many management strategies, including dietary suggestions. Although much of the nutritional information available about FM management is not supported by a lot of “scientific study,” the National Institute of Health through the NCCAM (National Center for Complementary and Alternative Medicine — formed by Congress to evaluate and appraise alternative treatments) provides information on dietary recommendations and supplements. They also provide dietary guidelines and define the benefits and effectiveness for FM patients and us doctors to follow. This month, we will dive deeper into nutritional considerations as this can REALLY make a huge difference for the FM patient!

Since fatigue, sleep quality, and muscle pain are three VERY common FM complaints, the FM patient can track their response to different dietary approaches as they add, modify, or delete various foods and/or supplements from their diet. We recommend “grading” these three symptoms daily on a 0-10 scale (0=good and 10=bad) as this can REALLY help the FM sufferer keep track of various changes that are made in the diet and is extremely useful for future reference.

FOODS: Since many FM sufferers have “sensitivities” to certain foods (reported to be as high as 42% of all FM patients), eliminating these foods makes GREAT sense.

First, it is REALLY IMPORTANT that you KEEP A FOOD JOURNAL for future reference (using the 0-10 scale) as it is impossible to remember all the reactions or responses to various foods even a day or two later, but especially a week or month later! Some common food offenders include MSG (commonly found in Chinese food – simply ask for the MSG to be NOT included when you place your order), certain preservatives, eggs, gluten (grains like wheat, oats, barley and rye), dairy, as well as other common allergens (such as chocolate, nuts, shellfish, and others). Common symptoms may include headaches, indigestion (irritable bowel syndrome), fatigue, and sleep interruptions. When using an “elimination diet,” it is important to make sure you’re getting the essential nutrients in your diet, in which supplementation can help.

Secondly, make it easier to eat in a healthful way! Have fruits and vegetables cut up and ready to eat so when you’re hungry, you can QUICKLY satisfy that urge. Lean meats or proteins are also VERY important! Remember, a well balanced diet gives you the “ammo” needed to fight fatigue, hurt less, help you sleep more deeply, and give you energy. By doing so, you will be able to stay more active and productive. Accept the fact that unless you pre-prepare the foods, you will instinctively reach for pre-packaged, no prep time, “fast food” options that most likely have poor nutritional content. Look for healthy foods that do not require a lot of preparation such as buying pre-washed, pre-cut vegetables. Some deli sections have pre-prepared foods like beet salad or quinoa that can be purchased in small quantities to add variety to your diet.

Third, plan for WHEN you eat. It is well known that eating small meals frequently during the day helps increase energy levels, such as at 9-10am and 2-3pm, especially if you’re feeling tired. Make sure the word “SMALL” is understood or else you’ll gain weight and not be hungry for the next meal! ALSO, DON’T SKIP BREAKFAST, AND DON’T EAT LATE AT NIGHT!!! Our metabolic rate (which regulates how efficiently we digest and breakdown our food) is highest in the morning and slowest at night. Try to include some protein and whole grains with your breakfast such as a boiled egg and oatmeal as this keeps the blood sugar from spiking and provides energy that lasts longer. Next month, we will look at supplementation including vitamins, minerals, and herbs that GREATLY help as well.

Confirming the diagnosis of fibromyalgia (FM) is challenging, as there are no blood tests to verify accuracy of the diagnosis like so many other disorders. However, blood tests are needed when FM is suspected to “rule in/out” something else that may be mimicking FM symptoms. Also, FM is often associated with other disorders that are diagnosed by blood testing, so it is still necessary to have that blood test. So what is the CURRENT recommendation for diagnosing FM?

The AmericanCollege of Rheumatology (ACR) developed criteria for diagnosing FM in 1990 and has updated it since then. The original 1990 criteria included the following: 1) A history of widespread (whole body) pain for three months or more; and 2) The presence of pain at 11 or more of 18 tender points which are spread out over the body. The main criticism regarding this approach has come from the poor accuracy and/or improper methods of testing the 18 tender points. As a result, this examination portion of the two main criteria has been either skipped, performed wrong, or mis-interpreted. This left the diagnosis of FM to be made based on symptoms alone. Also, since 1990, other KEY symptoms of FM have been identified that had previously been ignored including fatigue, mental fog (“cognitive symptoms”), and the extent of the body pain complaints (“somatic symptoms”).

As a result, it has been reported that the original 1990 approach was too strict and inaccurate because too many patients with FM were missed – 25% to be exact – by using this method. In 2010, the diagnostic approach was modified by using two different questionnaires: 1) The “Widespread Pain Index” or (WPI), which measures the number of painful body regions; and 2) the development of a “Symptom Severity” scale (SS). The MOST IMPORTANT FM diagnostic variables included the WPI score and scores of “cognitive symptoms,” which includes the “brain fog” common with FM, unrefreshed sleep, fatigue, and the  number of “somatic symptoms” (other complaints). The Symptom Severity scale (SS) incorporates these four categories and is scored by adding the totals from each category.  By using both the WPI and the SS, they correctly classified 88.1% of FM cases out of a group of 829 previously diagnosed FM patients and non-FM controls!

What’s important is that this NEW approach does NOT rely on the “old” physical exam requirement of finding at least 11 of 18 tender points. Because FM patients traditionally present with highly variable symptoms, removing the challenge of determining the diagnosis by physical examination is very important! Plus, now we can TRACK the outcomes of the FM patient to determine treatment success both during and after care. Since the 2010 approach has been released, it has been published in multiple languages and is starting to be used in primary care clinics. Recently, in July 2013, a study reported that the Modified ACR 2010 questionnaire is highly sensitive and specific for diagnosing FM, and its future use in primary care was encouraged. What is most exciting about this is that a referral to a rheumatologist may not be needed since this tool can be easily administered by primary care physicians, which include chiropractors!

In past health updates, we have discussed the need for a “team” of health care providers to best manage the FM patient. This multidisciplinary approach offers the FM patient multi-dimensional treatment strategies that encompass manual therapies, physical therapies, nutritional strategies, pharmacology, exercise, and stress management, cognitive management, and behavioral management. Now, with the release of the Modified ACR 2010 criteria, we can diagnose FM more accurately, track progress of the patient, and make timely modifications to the treatment plan when progress is not occurring. This is a “win-win” for the patient, providers/health care team, and the insurer!

Fibromyalgia and Sleep Interference

Posted: September 16, 2013 in Fibromyalgia

Fibromyalgia (FM) affects the entire body, which makes the diagnosis challenging! A VERY common issue with patients struggling with FM includes problems related to sleep. This goes beyond the number of hours one “tries to sleep” but rather the quality of sleep and feeling “restored” in the morning. That is, quality is more important than quantity! Let’s look further.

1. Common sleep problems: Insomnia, or difficulty falling asleep as well as frequent awakenings to the point of recalling being awake during the night is common with FM. Even more common are instances of waking up during the night but being unable to remember it in the morning. This interrupts “deep sleep” and poses an even more important issue. Common sleep disorders associated with FM include restless leg syndrome and sleep apnea. The goal of sleep is to feel restored when waking in the morning. Sleep deprivation can also be caused by pain, depression, and anxiety, all of which are associated with FM.

2. Restless Legs Syndrome (RLS): RLS is considered a neurologic disorder that usually occurs at night and at times during the day when the body is inactive. It is characterized by an overwhelming urge to move the legs when they are at rest.

3. Sleep Strategies: Developing better sleep “hygiene” is important in the management of FM. This can reduce pain, fatigue, the “fibro fog” and in turn, reduce anxiety and depression. Here are some effective ways to accomplish a better sleep pattern:

a) Though this sounds counterintuitive, sleep ONLY as much as needed to feel refreshed. Excessively long periods of time in bed relates to fragmented and shallow sleep.
b) Keep a diary to log how much you sleep each night, when you went to bed and woke up in the morning, when and what you last ate/drank prior to bedtime and any other “triggers” you can think of that may have interrupted your sleep. Follow the “best” pattern!
c) Try to go to bed at night and wake up in the morning at consistent times, once you determine the “best” pattern. This will strengthen your circadian rhythms and facilitate sleep quality.
d) Practice relaxation techniques such as gentle massage, deep breathing, and relaxation recordings to enhance restorative sleep. Soak in a hot bath or shower prior to going to bed.
e) Exercise regularly to enhance sleep quality.
f) Sound machines can help those accustomed to noise, as loud noises can disturb sleep, even if it’s not remembered in the mornings. Keep the room dark and/or use a sleep mask.
g) Avoid long daytime naps, as they can interfere with nighttime sleep.
h) Keep the bedroom temperature cool, as too much heat is sleep disturbing.
i) If you are hungry at night, a light carbohydrate rich snack may help you sleep.
j) Avoid nicotine, alcohol, or caffeine in the evenings as they interfere with sleep.

4. Medication and nutritional aids: First, try herbs like valerian root, hops, ginger, turmeric, boswellia, amino acids like melatonin, 5-HTP, tryptophan, magnesium, and/or Kava as NONE of these are habit forming. We can help you with this decision! If the herbal/nutritional approaches are not satisfying, we can refer you for a medical consult for prescription options.

Fibromyalgia (FM) is a condition with a polarized audience comprised of those who believe it’s real and those who don’t. This interesting political-like conflict is, in a large part, centered around the topic we discussed last month concerning the causes of FM. This month’s article will focus specifically on the immune system and its relationship to FM.

“EXTRA, EXTRA, READ ALL ABOUT IT! New research published on 12-17-12 in BMC Clinical Pathology describes cytokine abnormalities were found in FM patients when compared to healthy controls.” OK! But what does that mean?

Very simply, this study reports that immune dysfunction is part of the cause of FM. The most exciting part is that this study identified a BLOOD TEST (finally!) that, “…demonstrates value as a FM diagnostic tool.” Looking at this closer, the researchers used multiple methods to examine cytokine (proteins that help regulate our immune response) blood levels in FM patients. They found the FM group had, “…considerably lower cytokine concentration than the control group, which implies that cell-mediated immunity is impaired in fibromyalgia.” This study’s findings of an immune response abnormality strays from previous study findings which largely pointed to the central nervous system (CNS – brain & spinal cord) as the origin of the FM syndrome. This makes some sense as the study of immunology (in this case, “neuroimmunology” – the combination of neurology and immunology) has only been around for about 10 years, and as such, may hold some important answers as more evidence is uncovered to further support this potential “paradigm shift” in considering the primary cause of FM. The authors offer further excitement as this focus could lead to a better understanding of the cause of other neurological conditions such as multiple sclerosis (MS)! They go on by describing how body temperature, behavior, sleep, and mood can all be negatively affected by “pro-inflammatory cytokines” (PIC) which are released by certain types of activated white blood cells during infection. PIC have been found in the CNS in patients with brain injury, during viral and bacterial infections, and in other neurodegenerative processes (like MS)!

To further support this advance in understanding, the National Institutes of Health (NIH) reported, “…Despite the brain’s status as an immune privileged site, an extensive bi-directional communication takes place between the nervous and the immune system in both health and disease.” They describe multiple signaling pathways that exist between the brain and the immune system that function normally throughout our lifetime. When immune, physiological, and psychological “stressors” occur, cytokines and other immune molecules stimulate interactions within the endocrine (our hormone) system, nervous system and immune system. To prove this, brain cytokine levels go up following stress exposure and similarly go down when treatments are applied that alleviate stress. They list other conditions such as stroke, Parkinson’s, Alzheimer’s disease, MS, pain, and AIDS-associated dementia as being similarly affected as well. They also report that cytokines and other neuro-chemicals play a role in our neuro-development throughout our lifespan, help regulate brain development early in life and brain function throughout life, and how this all changes in the aging brain. There are also interactions of these immune chemicals that result in gender differences on brain function and behavior.

Needless to say, it will be very interesting to watch for additional developments along this line of research as it pertains to the FM patient and future treatment recommendations! Also, immune stimulation by chiropractic adjustments has been postulated as a benefit and this too may be better understood using this new research approach!

Fibromyalgia (FM) is a condition that is characterized by widespread pain, fatigue and an increased pain response. Symptoms can include tingling of the skin, muscle spasms, weakness in the arms and legs, nerve pain, muscle twitching, bowel disturbances, chronic sleep disturbances, and more. So, what can cause such a widespread, whole body condition? Though the “cause” of FM is unknown, several hypotheses have emerged. Here is what we know:

1. The brains of FM patients: Structural and functional differences have been identified in the brains of FM vs. healthy individuals. What is unclear is whether these identifiable brain changes cause the FM symptoms or are the result of an unknown cause. Some experts have reported that the abnormal brain findings may be the result of childhood stress, or prolonged, severe stress at any time in life. An area commonly affected is called the hippocampus, which plays a crucial role in maintaining cognitive functions, sleep regulation, and pain perception.
2. Lower pain threshold: Due to an increased reactivity of pain-sensitive nerve cells in the spinal cord and brain (called “central sensitization), FM patients feel pain sooner and worse than non-FM subjects.
3. Genetic predisposition: It has been reported that FM is often found in multiple family members. This genetic propensity also includes other conditions that often co-exist in FM patients such as chronic fatigue syndrome, irritable bowel syndrome (IBS), and depression.
4. Stress & lifestyle: Stress by itself may be an important cause of FM. It is not uncommon to develop FM after suffering from post-traumatic stress disorder. An association between physical and sexual abuse both in childhood and adulthood has also been identified. Poor lifestyle issues including smoking, obesity, and lack of physical activity increase the risk of developing FM.
5. Dopamine dysfunction: Dopamine is a chemical needed for neurotransmission and plays a role in pain perception. It is also connected to the development of restless leg syndrome (RLS), which is a frequent complaint of FM patients. Medications found effective for RLS such as pramipexole (also used for the treatment of Parkinson’s disease) can be helpful for some FM patients.
6. Abnormal serotonin metabolism: Another neurotransmitter, serotonin, regulates sleep patterns, mood, concentration, and pain and can be involved in causing FM. Decreases in other neurotransmitters (especially norepinephrine), when combined with serotonin depletion, can especially cause FM (more so in women than men). Hence, medications like duloxetine (Cympalta) originally used to treat depression and painful diabetic neuropathy, have been found to help FM patients, especially women.
7. Deficient growth hormone (GH) secretion: Abnormal levels of GH have been found in FM patients, but studies report mixed results when treating FM with GH.
8. Psychological factors: Strong evidence supports the association of FM and depression. Similarities include neuroendocrine abnormalities, psychological characteristics, physical symptoms and similar treatment benefits using the same approach (medication, counciling, etc.).
9. Physical Trauma: Trauma can increase the risk of FM. One report found a direct association with neck trauma and increased risk of developing FM.
10. Small bowel bacterial overgrowth: This can contribute to FM and may explain the association with IBS. The autoimmune response to the presence of bacteria resulting in FM symptoms has been hypothesized in these cases.

CONCLUSION: As previously stated, it is clear that a “team” of providers is needed to effectively treat FM. We’d be honored to be part of your team!

If you, a friend or family member requires care for FM, we sincerely appreciate the trust and confidence shown by choosing our services!

Fibromyalgia (FM) has quite a history! There is evidence that dates as far back as Hippocrates in ancient Greece, when he described a mysterious condition affecting the muscles which portrays FM quite accurately!

FM is a complex condition that includes fatigue and chronic muscle, tendon, and ligament pain that is wide-spread (NOT contained to one small region). Generalized pain and fatigue are the hallmarks of FM, which can range from mild to severe disability. However, there are many misconceptions about FM.

How much do you THINK you know about FM? Try the self-test below. For each statement, decide if the statement is true or false. The answers can be found below…
1. FM shortens one’s life span.
2. A patient may see several doctors before finding someone willing to help them.
3. FM can affect children, though it is most common in adults ages 20-55.
4. To properly diagnose FM, you must have at least 11 of 18 tender points.
5. With FM, you should not exercise if your body hurts.
6. A multi-discipline treatment approach usually works best (chiropractic, primary care, massage therapy, and others).
7. If you have FM, you were probably born with it.
8. Women usually develop FM more often than males.
9. The presence of pain associated FM signifies muscle deterioration.
10. It is easy to confuse FM with other diseases.

FM is present in 2-4% of the population and affects everyone differently, so each case is best managed by an individualized form of treatment. In other words, one treatment approach for every FM patient is NOT the proper approach. For some, fatigue is the primary issue, while for others, it’s the sleep disturbance, irritable bowel syndrome. or bladder problems that require the most attention. There is frequently a co-existing psychological condition that may include depression, anxiety, and/or a stress-related condition, such as post-traumatic stress disorder. In reference to the 10 statements above, FM does NOT shorten one’s life span, but it does affect quality of life. The primary goal of treatment is to help the FM patient gain control of their condition. It truly can take multple visits to different doctors before finding one that’s willing to work with you and coordinate care with other “team” providers to give you the best quality care. FM can affect children, though it’s rare – it’s primarily the 20-55 year old age group with a 9:1 ratio favoring the female population. The “old” 11 of 18 tender point diagnostic requirement has been replaced by “widespread, generalized pain,” NOT limited to specific points. Exercise is one of the BEST self-management strategies and should be encouraged. Though a genetic component has been identified, FM is NOT something you are “born with.” The pain associated with FM is NOT indicative of muscle deterioration. FM is often confused with other diseases and the diagnosis is made by eliminating the other more easily diagnosable disorders. Chiropractic is a VERY important part of the management team in the care of the FM patient.

Answers: 1. False; 2. True; 3. True; 4. False; 5. False; 6. True; 7. False; 8. True; 9. False; 10. True.