Fibromyalgia and Chronic Pain Syndromes
Paul Reller, L.Ac.
Recent evidence, from John Hopkins Medical Center and others, shows that the exact cause of fibromyalgia still eludes us, but seems to be related to a number of factors, including viral illness, physical or emotional stress, myofascial pain syndromes, autonomic nervous dysfunction, serotonin imbalance, lack of deep sleep, sleep disorder, and low blood pressure. The syndrome, which now accounts for about 20 percent of all visits to rheumatologists and affects about 2 percent of Americans, especially women over age 40, may be different from one patient to the next, and involve a number of the above causes. Fibromyalgia is associated with other poorly defined syndromes, including Chronic Fatique Syndrome, Guillame Barre' Syndrome, and various autoimmune disorders, and an estimated one-third of fibromyalgia patients experience restless leg syndrome, a sleep movement disorder that is also associated with Rheumatoid Arthritis. The World Health Organization (WHO) now classifies such syndromes under the title Encephalomyopathy, meaning that they are a complex array of multi-system disorders affecting the brain stem (encephalo-) and muscles (myopathy) in a neuromuscular disease. You should read the article on this website titled Chronic Fatique to better understand the complex underlying pathology associated with these disorders. There is also sound evidence that a signficant percentage of patients diagnosed with fibromyalgia, a central nervous system disorder, instead have a peripheral nervous system disorder called small-fiber neuropathy.
The name fibromyalgia literally means pain (algia) in the muscles (myo) and fibrous soft tissue (fibro), such as the muscle tendon and the connective ligaments. Like arthritis, or joint (arthro) inflammation (itis), which now has over 44 classified types, fibromyalgia may refer to a variety of presentations of chronic developing myofascial pain syndromes, and include symptoms of neuropathy and depression. Neuropathy may include unpleasant sensations such as numbness and tingling, burning sensation, and a heavy or leaden feel to an area or the body. Often, other syndromes such as irritable bowel and restless leg syndromes accompany fibromyalgia. Any combination of the above factors may be important in your syndrome and needs to be addressed in the treatment protocol. Since fibromyalgia is a complex multi-system disease, affecting the central and peripheral nervous system, the hormonal, or endocrine system, and the immune system, symptom presentation may vary widely from patient to patient. Treatment protocol must be individualized, address all systems affected by the disease, and persistent.
In the September 10, 2012 issue of the esteemed medical journal Archives of Internal Medicine, the renowned health outcomes researcher Andrew Vickers of Memorial Sloan-Kettering in New York released his meta-review of current scientific research on acupuncture and the treatment of chronic pain. In this meta-review Dr. Vickers and colleagues limited research data to only the highest-quality human clinical trials to deflect the historic criticisms of acupuncture research. This review, from over 18,000 patients in 29 high-quality clinical trials, provided proof that acupuncture treatment for chronic pain significantly outperforms so-called sham or placebo acupuncture, and more importantly, outperforms standard treatment by even greater measures. Dr. Vickers was quoted as stating: “Our findings provide the most robust evidence to date that doctors are justified in making referrals to acupuncture for their patients with chronic pain. I hope that our findings help inform future clinical and policy decisions for acupuncture.”
Holistic medicine, especially Traditional Chinese Medicine, has long seen chronic pain syndromes as a potential problem involving multiple systems in the body, including the neurological, immune, and mind-body relationship. Modern medicine is finally adopting a holistic perspective as well. A growing interest in the field of neuroimmunopsychology has evolved due to the wealth of research that points to the interaction between chemical mediators in the nervous system, immune cytokines, and hormonal chemicals. Indeed, we now acknowledge that many hormones act as important neurotransmitters, many neurotransmitters, such as serotonin, act as hormones, and many immune mediators, or cytokines, stimulate both hormone and neurotransmitter receptors. A complex field of chemicals decides the role of these chemicals in the body and depends upon a balanced homeostasis of chemical reactions, a sort of quantum field of ever changing chemistry. Two approaches may be taken therapeutically to affect imbalances in this system. One, an allopathic approach where a synthesized version of one of these many chemicals may be introduced to affect a sequence of chemical events, and two, a natural and holistic approach, where restoration of the homeostatic balance programmed into the genetic code is achieved. In fibromyalgia, or fibromyalgic encephalomyopathy, research has uncovered a number of imbalances, and a number of presentations, with many patients also suffering from other disease mechanisms as well, especially sleep disorders, anxiety and depressive disorders, and autoimmune disorders. One complex decision is whether the fibromyalgic encephalomyopathy is primary or secondary to other disorders. In other words, do we try to resolve other health problems first, many of them subclinical and undiagnosed, or do we try to resolve the fibromyalgic encephalomyopathy first.
Researchers at the University of Michigan Medical Center, Mark A. Demitrack and Leslie J. Crofford, with funding by Lilly Research Center (Eli Lilly pharmaceuticals), discovered that the same underlying pathophysiology exists for both Fibromyalgia and Chronic Fatique Syndrome. Dysfunction in the hypothalamus-pituitary-adrenal axis, or main endocrine control in the body, with a moderate basal hypocorticolism, or cortisol deficiency within a diurnal cycle, was a common underlying feature of both of these diseases. Since standard medicine had considered both of these presentations as variants of Major Depression Syndrome, this research changed the course of thinking in standard medicine, as major depression usually involves a hypercortisol condition, or glucocorticoid excess. Restoration of cortisol balance may thus be very important in the treatment protocol with fibromyalgic encephalomyopathy. These researchers also noted that immunological pathologies that were frequently seen in fibromyalgia could be explained by the relationship between immune modulators and glucocorticoids. They stated: “Because glucocorticoids (cortisols) represent the most potent endogenous immunosuppressive compounds, it is also intriguing to propose that some of the reported immunologic disturbances in patients with fibromylagia or chronic fatique syndrome may also reflect the immune activation threat that might be expected to accompany a mild or relative glucocorticoid deficiency.” Chronic inflammatory states and autoimmune diseases thus could also be explained by the hypocorticolism and hypothalamic or adrenal deficiency syndromes.
We see from these important scientific studies that the pathology of Fibromyalgia, or fibromyalgic encephalomyopathy, probably has a central basis in pain perception and regulation, centered in the hypothalamus, amygdala and hippocampus (limbic system), but also a central basis in endocrine dysfunction and depressed or altered cortisol responses due to mild functional problems with the hypothalamus and adrenal regulation. Since cortisol is governed by a diurnal pattern, the question of hypo- or hypercorticolism may be a moot point in many cases, as there is often an excess of cortisol coupled with a deficiency within this diurnal, or day and night, cycle. The hypothalamus is thus a key command center in the brain that is tied to the pathology of fibromyalgia in a number of ways, and may be a key focus in treatment to restore homeostatic balance and function and resolve the pathology.
Distinguishing Fibromyalgia from Somatoform Pain Disorder
Somatoform Pain Disorder, or somatic pain syndrome, is now recognized as accounting for perhaps 20 percent of chronic pain syndromes, but has always been ignored in standard medicine, especially in recent decades when discouragement of cognitive and behavioral psychotherapy to promote increased pharmaceutical treatment became prevalent. Somatoform disorders produce real physical symptoms, but without apparent physical cause, and are a disorder of the central and peripheral nervous system, and the interactions between the endocrine, nervous and immunological systems. In other words, a Mind-Body pathology, where physical triggers can stimulate dysfunction in the cognitive, sensory and motor control centers in the brain, and psychological and emotional triggers can lead to physical dysfunctions as well. Patients are routinely told that their symptoms appear to be due to stress, or emotional stress, and a dismissing attitude by physicians, with the symptoms being “all in their head” or even faked (malingering), has been common. Often, Somatoform Pain Disorder is linked to other somatic syndromes, such as Body Dysmorphic Disorder (negative perception of physical features and distress over perceived defects in appearance), and Somatization Disorder (perception of multiple symptom complaints about gastrointestinal discomfort, sexual problems, neurological symptoms, and pain that has no objective physical cause). While standard guidelines point to the need to hear multiple chronic symptom complaints without apparent physical cause to diagnose these Somatoform Disorders, surveys of primary care physicians have noted that a great majority of these cases concern only one unexplained symptom that occurs for at least 6 months, not a combination of symptoms in presentation. With more of an emphasis on Mind-Body Medicine in recent years, something standard medicine has finally borrowed from Complementary Medicine, Somatoform Pain Disorder has been taken more seriously since about 2008. Still, it appears that just as Fibromyalgia and pain in Chronic Fatigue Syndrome was dismissed for many years, Somatoform Pain Disorder is also still largely dismissed in the clinic. Patients with these problems know that the pain is real, though, and the explanation that it is “all in their head” is taking on a more real definition with greater public understanding of Somatoform Disorders.
The Complementary Medical Science of Traditional Chinese Medicine (TCM) has historically taken the subject of Mind-Body Medicine very seriously, and treats this with a holistic view. The earliest preserved text in TCM, the Huang Di Nei Jing, or canon of corporeal medicine related to the patriarch Huang Di, stated in the first chapters that TCM physicians observed that emotional constraint was a root cause of most physical diseases, either causing symptoms directly or indirectly, or both. The belief in TCM was that physical disorder caused mental and emotional stress and dysfunction, and likewise, mental and emotional dysfunction caused physical disorder. These two realms, the Mind and the Body, could not be realistically separated, and treatment must always address both the balance of the mental/emotional health and function, and the physical health and function. Patterns of association between the organ systems and emotional expressions and controls were emphasized by early Chinese Daoist physicians, and continue to be in modern times as well. The recent emphasis in Mind-Body Medicine in standard medicine has perhaps been prompted by the public interest in Complementary Medicine and its success in treating health problems with this approach.
The occurrence of somatic symptoms that are left unexplained in standard care is the bane of most physicians, and with managed care and less time to explore fully the differential diagnosis in difficult cases, as well as the denial of care with common psychological therapies, such as Cognitive and Behavioral Therapies, the incidence of unexplained somatic symptoms has increased dramatically. The triad of chronic pain, poor sleep quality, and fatigue is very common clinically, and links Fibromyalgia, Chronic Fatigue Syndrome, and other pathologies, such as Irritable Bowel Syndrome, TMJ syndrome, interstitial cystitis and Pelvic Pain Syndrome, and syndromes of atypical chest and costal pain. The U.S. Centers for Disease Control and Prevention list the criteria for Chronic Fatigue Syndrome diagnosis as including chronic muscle and joint pain without swelling, headache patterns, chronic sore throat, malaise following exercise, unrefreshing sleep, and impaired short term memory or ability to concentrate. Prevalence of sleep-related movement disorders, such as bruxism and restless leg, and mild cases of obstructive sleep apnea are prevalent in fibromyalgia, and CAP (cyclic alternating pattern) events in sleep disorder, where studies show an instability of non-REM sleep periods and arousal sensitivity, have been noted as a potential objective marker of fibromyalgia. Obviously, there is a need to address an array of health problems in most patients with Fibromyalgia, Chronic Fatigue Syndrome, and Somatoform Pain Disorder. Integration of Complementary Medicine is the best way to achieve this therapeutic goal, and the Licensed Acupuncturist and herbalist is able to supply a comprehensive and holistic therapeutic approach.
Current pharmacological treatments for fibromyalgic encephalomyopathy treat just a small part of the pathology and long-term success with this limited treatment protocol is elusive
Many medical doctors that specialize in the integrated treatment of fibromyalgia in 2011 agree that research in the last decade has elucidated the key aspects of this complex neurological disorder, but that current pharmacological treatment is still in its infancy, and addresses only a limited part of the scope of the pathology. Groundbreaking study with functional MRI in 2002 showed that the modulation of pain signals in the central brain is dysfunctional in all patients with fibromyalgia, with an increased perception of peripheral pain and an amplified response to pain signals in the areas of the brain that process chronic pain (hyperalgesia). Both an imbalance between these centers of pain perception and association, the hypothalamus, amygdala and hippocampus, and the problems in the peripheral tissues and pain receptors, as well as the transmission and processing of pain signals in the spinal cord and brain stem, are involved in this complex chronic pain pathology. One of the medical doctors that specializes in this research and fibromyalgia treatment, Dr. Ginevra Liptan of Portland, Oregon, an authority on the disease at the Oregon Health Sciences Research Center, explains how doctors still avoid real treatment protocols and even diagnosis of fibromyalgia, and that a complete integrated protocol involves more than simple pharmacological therapy. For a short discussion of these subjects, click here to access an interview with Dr. Liptan: http://www.youtube.com/watch?v=QiWgTPHwo7E. Dr. Liptan advocates a comprehensive treatment protocol that utilizes specialized physiotherapies, treatment of sleep disorders, and an integration of various therapeutic specialties.
Dr. Liptan especially advocates myofascial massage therapies. European studies have shown that pain receptors in the connective tissues, or fascia, were more involved in triggering of pain signals in fibromyalgia, and that myofascial release was proven to provide long-term reduction of fibromyalgic pain. Current studies in Europe (cited below in additional information with links) show that alleviation of myofascial trigger points provides much pain relief in fibromyalgia and appears to act on the central nervous system and areas of the brain concerned with pain sensitization. Treatment of myofascial trigger points may incorporate a number of therapies. Manual trigger point release, active release therapy, neuromuscular reeducation, and trigger point needling all may be utilized in therapy by a skilled practitioner. Post-isometric relaxation, targeted stretch and exercise, and other therapeutic techniques may also be taught to the patient to practice daily. Many current studies, especially at Harvard, also show how traditional acupuncture is proven to beneficially modulate the brain activity in the key centers that process pain signals in fibromylagia, the hypothalamus, amygdala and hippocampus, which are proven to be the centers of pain perception and sensitization with fibromyalgic encephalomyopathy. These fMRI studies, combined with PET scans, laboratory analysis of blood and saliva, and other tests, clearly define the dramatic ways that acupuncture stimulation restores homeostatic mechanisms that balance the signals between these areas that process pain signals and associate emotional responses and memories with pain cognition (see the article entitlted Brain Function on this website). Integration of a comprehensive treatment protocol, with acupuncture, myofascial release, instruction in improved excercise, stretch and postural mechanic routines, and improvement in sleep function, are very important to the success of any fibromyalgia therapy, and a knowledgeable Licensed Acupuncturist and herbalist with a specialty in myofascial therapy, or TuiNa, can deliver these important therapies.
In perhaps a majority of cases, sleep disorders are present, and appear to have much to do with the dysfunctions in the central nervous system. Sleep apneas, nocturnal bruxism (grinding of the teeth), and restless leg syndrome are the three most prominent disorders associated with sleep dysfunction and peripheral motor and sensory problems. Often, these sleep disorders go unnoticed by the patient, but do effect the cycle of deep sleep stages and transitions. Almost all fibromyalgia patients, in some studies, show that these sleep cycles are disrupted. In recent years, much research has elucidated this pathology as well, and again, herbal and nutrient medicine, and acupuncture, have been shown to have a significant effect on sleep. Since these disorders are also complex, and involve an array of underlying problems, a holistic approach is needed to resolve them, and standard medicine still takes the attitude that we must be satified with managing symptoms rather than resolving the problems themselves. You may read more about some of these health problems in other articles on this website, particularly concerning sleep apnea and nocturnal bruxism. Resolution of these sleep disorders, and restoration of a normal homeostatic sleep cycle may be an important first step in resolving fibromyalgic encephalomyopathy once and for all.
Standard pharmacological therapies in fibromyalgia
Fibromyalgia, Encephalomyopathy, and the various associated neuromuscular disorders associated with fibromyalgia are difficult to diagnose, define, and treat, and standard medicine has routinely told patients with these disorders that there is nothing wrong with them, that fibromyalgia doesn't exist, that they must have a psychological disorder, and other frustrating answers to their pleas for help. Since standard tests often reveal no gross abnormalities, either in the lab tests or radiological exams, many medical doctors become skeptical of the patient presentation. Since the introduction of pharmaceutical protocols to treat fibromyalgia, the diagnosis of this disorder has soared. There are now many medications utilized in pharmacological treatment of fibromyalgia, and more the 75 percent of patients are reported to take 2 or more medications concurrently to treat the disease. A 12-month treatment study in 2013, called the REFLECTIONS Study, and sponsored by Eli Lilly and Company, found that the satisfaction level for treatment with this drug protocol was about 43 percent. The standard pharmaceutical treatment for fibromyalgia is an anticonvulsant drug that appears to mimic the neurotransmitter GABA, called Lyrica, or pregabalin, and is an offshoot of the drug Neurontin, or gabapentin. The exact mechanisms of physiological action of these anti-seizure medications continue to elude researchers, though, and sometimes alarming CNS effects do occur. These drugs bind to the calcium channels in the central nervous system and inhibit calcium influx into nerve terminals, decreasing the release of neurotransmitters such as glutamate, noradrenaline, and substance P, and may increase the GABA levels, in much the same way as benzodiazepines, barbituates and other antidepressants. Like antidepressants, this drug may block a symptom mechanism, but will not address the underlying complex dysfunction in the body. Side effects with chronic use are also an issue. Whether or not the patient decides to treat with Lyrica, or a multidrug regimen, it is still wise to address the underlying multi-system disease mechanisms and restore a healthy state.
A 2006 review of diagnosis and treatment of fibromyalgia by experts at Harvard Medical School, Massachusetts General Hospital, and McLean Hospital, which is associated with Harvard Medical School (McLean Annals of Behavioral Neurology 2006; 1:1-9: David T. Plante et al) noted: “Evidence for the efficacy of pharmacological interventions is mixed. A recent clinical review of treatments for fibromyalgia concluded that tricyclic antidepressants such as amitriptyline were effective for fibromylagia, as was cyclobenzaprine, which unfortunately has significant side effects limiting its clinical usefulness. Other agents often used clinically but which experimentally have only modest efficacy include selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SSNRIs) (Celexa). in fact, the response of fibromyalgia and other functional somatic syndromes to antidepressants has led some investigators to hypothesize that these disorders share a common physiologic abnormality with depression, and may be classified as “affective spectrum disorders”. Other agents such as pregabalin (Lyrica) and modanifil (Provigil) show promise in fibromyalgia treatment, but evidence supporting their clinical use is lacking, and prescribing practices may be influenced more by pharmaceutical lobbying than experimental data.” We see that even among conservative experts, there was concern that the sudden acknowledgement of fibromyalgia and chronic somatic pain disorders resulted in widespread prescription of medications with limited evidence of efficacy, and heavily promoted by advertising and marketing strategies rather than clinical effectiveness. The dropout rate in clinical drug trials for fibromyalgia patients has also been a factor that alarms researchers, with a 2012 meta-review by the Saarbrucken Clinic in Germany (Clinical Journal of Pain 2012 June;28(5):437-51) noting that the overall dropout rate due to adverse events in clinical trials of pharmaceuticals to treat fibromyalgia was 16.3 percent. While the nature of the disease is attributed, there are also serious concerns mounting about the adverse effects noted in all clinical trials of some of these drugs.
Many patients are alarmed at some of the common and not-so-common side effects of these medications used to treat fibromyalgia, with a significant percentage of patients discontinuing the drugs. Common side effects with short term use of gabapentin (Neurontin) involve somnolence, fatigue, headache, dizziness and ataxia (imbalance), as well as visual effects. Joint pain has occurred frequently in clinical trials, and various musculoskeletal pain complaints occur more frequently with chronic use, along with weight gain. These adverse effects impair the ability to drive or work, and were reported in more than 10 percent of the patients selected for the clinical trials by the manufacturer. A smaller percentage of patients experience more alarming Central Nervous System (CNS) effects, such as vertigo, anxiety, feelings of hostility, and hypekinesia (extreme restlessness, impulsiveness, shortened attention span, muscle spasm, uncontrolled movement and muscular firing). Reflexes are affected frequently, with both excess reflex and diminished reflexes. Episodes of paresthesia (numbness and tingling), paresis (weakness), dysesthesia (pins and needles sensation, heat sensations etc.), and dystonia (sustained or repetitive muscle contracture), as well as agitation and paranoia, euphoria, and psychosis are reported less frequently, but are alarming adverse effects often not associated with the drugs. Sudden withdrawal causes alarming adverse effects in about 2 percent of patients selected in clinical trials as well. The U.S. FDA has issued a 2009 warning that drug reaction with eosinophilia (excess of a type of white blood cell) and multiorgan hypersensitivity (DRESS) has been well documented in a number of cases, presenting with swollen lymph nodes, liver and kidney inflammation, and abnormal immune responses. The incidence of just 3 cases of eosinophilia myalgia syndrome, caused by an inexplicable bacterial contamination of L-tryptophan supplements in 1989 led to the banning of the amino acid supplement for about 15 years in the United States. Clinical trials also noted that concurrent use with Naproxen or Hydrocodone (Oxycontin) increased gabapentin absorption by 15 percent, and concurrent use with hydrocodone and the larger dose of 500 mg gabapentin decreased hydrocodone by 22 percent, potentiating problems with multidrug pain management over time.
A second common treatment for fibromyalgia involves another type of drug, antidepressant selective sertonin and norepinephrine reuptake inhibitors (SSNRIs). Many patients are prescribed Celexa (citalopram), one of these drugs that showed modest benefit in clinical trials conducted by the manufacturer. The pathway of benefit for these drugs is still unclear, and while the drug does alter the neurotransmitter serotinin pathway for a while, studies indicate that the body adapts by creating more reuptake receptors over time. The side effects of the drug are considerable with chronic use, and over time nervousness, restlessness, trouble concentrating, drowsiness, insomnia, weight changes, increased urination, indigestion, nausea, increased intestinal gas, loss of appetite, dry mouth, tinnitus, decreased libido, and difficulty having an orgasm, have all been reported by a significant percentage of users. A smaller percentage of patients report muscle stiffness, fasciculations, tremors, agitation, increased sweating, episodes of fast heart rate (tachycardia), and problems with balance of coordination. Each individual patient is not expected to experience all of these side effects, but the mechanisms responsible for these side effects are alarming for the thoughtful patient. There are warnings with these drugs as well, especially for patients under age 19, for the possibility that erratic behavior and suicidal thoughts may occur with chronic use. In addition, the problems with suddenly stopping these drugs has become a widespread concern in the medical community, as sudden stopping of the chemical block of neurotransmitter reuptake receptors has a strange effect on the central nervous system. The patients are now instructed to decrease dosage gradually if they choose to stop taking this drug. Again, even if the fibromyalgia patient decides to utilize this class of drugs to treat the disease, many disease mechanisms are not addressed or improved by use of the drug, and potential side effects may need to be addressed as well in the overall treatment approach. These roles, improving the physiological mechanisms that contribute to the disease, and dealing with unwanted side effects, are important roles in Integrative and Complementary Medicine. Many experts in this field now recommend that a complement of therapies, especially non-pharmacological therapies that reduce pain sensitivity, act to modulate pain centers in the brain, and help restore a sound sleep cycle, are utilized with these pharmacological interventions.
Because of the numerous side effects with SSRI medication over time, there is a poor consistency with use in the patient population, especially with fibromyalgia, due to the fact that symptoms may vary from one time period to another. The inconsistent dosage of an SSRI, though, itself presents problems with neurotransmitter balance and CNS health, as well as regulation of the digestive reactions and hormonal balances related to bone health. Newer SSRI medications are being developed that have fewer side effects, such as the hormonal loss of sexual drive and the autonomic difficulties with sexual function, but one problem is not overcome. Increasingly, patients with chronic pain are prescribed various other medications that also alter the serotonin metabolism, and concurrent use of these medications creates a serotonin excess, and more rarely, an acute serotonin syndrome that may be serious with physiological dysfunctions that at worst are life-threatening. The common use of Tramodol or other opioid receptor agonists for chronic pain increases the risk of serotonin excess considerably when prescribed with SSRI medications. Other medications also affect serotonin levels, including the migraine medications called triptans (e.g. Imitrex), cough medications with dextromethorphan, the pain medication Demerol, and antidepressant MAO inhibitors. Also, recreational drug use may alter the serotonin levels, and use of amphetamines, cocaine, ecstasy (MDMA), and the snorting of oxy with a psyche drug all may induce or increase the risk for serotonin excess or serotonin syndrome. Increasingly, patients are also prescribed amphetamine medications or other drugs that alter the serotonin metabolism for ADD or ADHD (attention deficit and hyperactivity disorder). Multidrug protocols in fibromyalgia are now common, and two of the most common drugs prescribed, SSRI medication and tricyclic antidepressants have long been contraindicated, with warnings of potential drug interactions since 1997. Awareness of these potential drug interactions is important to the patient that wishes to minimize risk and take the safest and most effective combination of therapies. Avoiding potentially problematic drug interactions may also be a reason to integrate acupuncture, herbal and nutrient medicine, and physiotherapies such as myofascial release and neuromuscualr reeducation into the complement of therapeutic protocols.
Integrating Complementary Medicine into the treatment protocols in standard medicine
Today, more and more medical doctors are utilizing Complementary Medicine and taking a holistic approach to fibromyalgia. Studies in Europe now show a much higher rate of success with the integration of Complementary Medicine in the treatment of chronic pain syndromes. To see evidence of this, click on this link: http://www.ncbi.nlm.nih.gov/pubmed/21563096. While this approach is more complicated than taking a single pill to block some of the symptoms, and is thus frustrating to the suffering patient, it does produce both a decrease in pain and a restoration of overall health, which is valuable in a number of ways, increasing quality of life and preventing other disease. This approach also recognizes that we must treat both the disease and the illness. This means that both the multi-systems dysfunction, or disease mechanism, and the patient's problems dealing with the disease, which we term the illness, must be addressed. The treatment must address the pain of uncertainty, confusion about the disease, and worry about the future, and must be individually tailored to each individual patient, promoting a pro-active approach to recovery. With fibromyalgia, if the patient does not take charge, and does not utlilize the various physicians to help themselves correct the multi-system dysfunctions, there will be a tendency to fall back into a depressed, inactive, and hopeless mental state that will only perpetuate the disease.
Both the National Institute of Health (NIH) and the World Health Organization (WHO) have recognized acupuncture as a proven effective medical treatment for fibromyalgia and myofascial pain syndromes. The Licensed Acupuncturist, who has a number of treatment modalities besides acupuncture in his scope of practice, may address these factors with a treatment protocol that includes soft tissue mobilization, myofascial release, herbal prescriptions, nutritional supplements, instructions in therapeutic activities and correction of postural mechanics, and advice in dietary changes and simple behavioral lifestyle routines. These treatment methods, combined with acupuncture, can correct serotonin imbalance, help to restore deep sleep cycles, stimulate a better immune response to deep viral infection and physical stress, improve circulation, release myofascial trigger points, relieve stiffness and hardening of soft tissues, restore balance to the autonomic nervous system (sympathetic and parasympathetic), and relieve emotional stress. Specific herbal chemicals and nutrient medicines can also achieve similar effects to the drug Lyrica, and a knowledgeable research-oriented Licensed Acupuncturist and hebalist can utilize this evidence-based medical approach to achieve neurological correction in a safer and more natural manner. The research into biological medicines is expanding rapidly due to the promise of these natural medicines.
The underlying systems that may present dysfunction in fibromyalgia, or neuromuscular encephalomyopathy, include disordered sleep, hormonal deficiencies not revealed on standard tests, nutritional deficiencies, hypothalamic pituitary dysfunction, chronic infections that are often latent and triggered by physiological and emotional stress, mitochondrial dysfunction or cellular energy disorder, gastrointestinal dysfunction, blood coagulation defects, neurotoxins, and environmental and heavy metal toxicity. While this is a long list of problems to address, success with fibromyalgia may only occur when the patient utilizes their physicians to assess and correct all of these various dysfunction where applicable. Since these various systems in the body affect each other, when only one system is corrected, the entire chain of dysfunction is not addressed. A number of articles on this website will help the patient understand and treat these various contributing problems. While the situation may be complicated, the approach of gaining understanding and taking a step-by-step patient proactive approach to your health will be effective over time, and yield considerable benefits in overall quality of life and prevention of other serious health threats as you age.
In 2010, many clinical trials have been completed that show that a low dosage of medical marijuana is proven to be very effective in treatment neuropathic pain, and the widespread acknowledgement of this fact is spurring a potential legalization of marijuana, along with the current allowance of medical cannabis use in many states (a poll in New York state now finds that 55% of registered Republican voters support a medical marijuana legalization). A 2008 clinical study at the University of California Davis campus proved efficacy, and a subsequent set of 5 double-blinded placebo human study at the Unviversity of California San Diego campus found that marijiuana was effective in reducing muscle spasm associated with multiple sclerosis, as well as various neurological pains associated with a number of common neurolgical injuries as well as illnesses. The outcomes of these trials, which were prohibited in the United States for decades following the famous LaGuardia Committee study by the New York Academy of Medicine and its positive findings in 1944, finds that a small dosage of marijuana is more effective than current pharmaceutical pain relievers for this type of pain. California mandated the study of medical marijuana at its universities following the legalization of medical use of cannabis to determine scientifically its acutal medical benefits. Many patients are finding out now that utilizing a small dosage allows one to function without pain, and without significant enebriation from the herb, and a ballot measure in the fall of 2010 is expected to bring legalization and regulation of this herb. The ability to function better and decrase chronic pain allows the patient to explore a number of healthy treatment protocols to finally address the underlying health problems as well.
The role of the central nervous system dysfunctions in fibromyalgia and chronic pain syndromes
A very large percentage of the U.S. population is afflicted with chronic pain syndromes, and while many of these may be diagnosed as fibromyalgia today, the majority of chronic pain syndromes are not understood by either patients or their physicians as a multifactorial neurological disease in and of itself. The underlying cause of the chronic pain may be resolved, and still the chronic pain persists. It is very difficult for the patient to understand how their tissue injury, or underlying disease, may be resolved and still the chronic pain persists and can often become severe and debilitating. Understanding of chronic pain allows the individual patient to take a more proactive approach to successful treatment protocol. Persisting within a system that poorly defines this disease mechanism leads to confusion, frustration and despair. Applying broad terms such as fibromyalgia to chronic pain often does not help to resolve the individual case, either, as once again, the primary doctor does not seek a thorough, patient-centered, individualized and multidisciplinary course of treatment to resolve the mechanisms of chronic pain.
Fibromyalgia is diagnosed with a process of ruling out other pathologies, since there are not definitive tests yet. This is called a diagnosis of exclusion. Not long ago, most doctors denied that fibromyalgia even existed, but after the promotion of drug therapies utilizing Lyrica, Neurontin, and Celexa to treat fibromyalgia, the diagnosis of fibromyalgia suddenly became common, often without a complete diagnostic workup. A disease needing a diagnosis of exclusion requires more diagnostic testing than a normal disease for which definitive tests exist, not less. Other diseases must be excluded, and this is a time-intensive and lengthy process, involving a number of tests in a sequential order, depending upon the individual presentation. Patients receiving an easy diagnosis of fibromyalgia should insist on a complete diagnostic workup so that other diseases are not overlooked as the patient is just prescribed one of the drugs above.
More and more experts are becoming alarmed that a large number of patients are not being diagnosed accurately when fibromyalgia is chosen as the diagnosis. For example, in 2013, experts at Harvard Medical School and Massachusetts General Hospital studied patients diagnosed with fibromyalgia and found that specific tests for an underdiagnosed disorder called small-fiber polyneuropathy (SFPN) were positive in 41 percent of patients randomly chosen with a diagnosis of fibromyalgia. These more rare disorders are not easily diagnosed, and the tests needed, such as skin biopsies, are rarely ordered. The study also found that a significant percentage of these patients had markers for immune dysfunction (autoimmune pathology) and hepatitis C, which would also explain their symptoms. The study authors emphasized that some of the patients diagnosed with fibromyalgia have been misdiagnosed in the system, leading to improper treatment strategies (see study link below in information resources). Small-fiber polyneuropathy is a disease primarily affecting the peripheral nervous system, not the central nervous system, and involves damage to the unmyelinated nerve fibers, categorized as C fibers, that exist in the skin, organs and peripheral nerve endings, and help control the autonomic functions. The symptoms usually involve variable sensory dysfunctions, including paresthesias, and the hallmark of chronic pain syndromes, a decrease in peripheral pain sensitivity that eventually leads to a heightened CNS response to pain. Disorders of the peripheral nervous system that are similar and underdiagnosed are grouped under the umbrella term of Charcot’s diseases or syndromes, acknowledging the work of the famed neurologist of the 19th century, Jean-Marie Charcot, hailed as the “founder of modern neurology”. Many diseases of the peripheral nervous system have his name attached, and most of these diseases are now inexplicably ignored. The most famous of these diseases, termed Charcot-Marie-Tooth Disease is considered a rare hereditary disorder, yet modern study has found that the genetic components to the disease are not that definitive, and many patients apparently have a milder form of the disease. The name itself tends to be dismissed, especially by patients, since it implies a disorder of the teeth, but the term Tooth refers to a famous British neurologist of the 19th century, Dr. Howard Henry Tooth. Obviously, the science of genetics has progressed exponentially since these early discoveries, yet the categorization of many of these Charcot diseases are not updated. The diagnosis of small-fiber polyneuropathy is still largely a diagnosis of exclusion as well, but as the Harvard study showed, newer tests and skin biopsies do provide more definitive diagnostic procedures.
Many patients with chronic pain are not given a clear diagnostic explanation for their pain and are led to believe that it is “all in their head”. This is more true than we would like to believe, but this does not mean that the pain is imagined. Research is showing a number of physiological mechanisms that contribute to the sensations of chronic inexplicable pain. For example, chronic pain may be increased in intensity by excitotoxicity related to excessive glutamate stimulation of NMDA receptors. NMDA (N-methyl-D-aspartate) is an amino acid derivative not normally produced in biological tissue, which mimics the neurotransmitter glutamate at receptors in the brain, and is called an excitotoxin. NMDA was first synthesized in the 1960s. NMDA only binds to and regulates the NMDA receptor, though, while glutamate is a neurotransmitter that has a wide array of effects on different types of receptors in the brain. We have adapted to NMDA in the environment by forming NMDA receptors that appear to be important in neural plasticity and memory function. The way that pain signals reach our brain, and their persistence, has much to do with the formation of NMDA receptors and our adaptation to chronic pain. Drugs that antagonize NMDA receptors are used as anesthetics (ketamine), recreational drugs (PCP), and pain relievers (methadone). A number of mineral ions modulate the NMDA receptors, including magnesium, potassium, calcium, and zinc. A type of lead, Pb2+, is found to antagonize the NMDA receptor. Overexcitation of NMDA receptors is associated with agitation, which is seen in alcohol withdrawal. A 2006 study at Stanford University found that the elusive mechanism of action of pregabalin (Lyrica) appears to depend on these NMDA glutamate receptors being activated, affecting glutamate receptors near these NMDA receptors, and reducing the activity in synaptic vesicles in neurons of key areas of the body, such as the hippocampus (Micheva et al; PMID: 16641316). While pregabalin may work by inhibiting synaptic function in brains with NMDA excitotoxicity, a restorative approach, eliminating this excitotoxicity and restoring GABA functions and glutamate homeostasis may be ultimately a better and healthier approach.
Pain signals travel along fast and slow nerve pathways, with acute pain signals generally exciting the fast, or less myelinated, axons, and chronic pain travelling along heavily myelinated C fibers that stimulate the frontal cortex and midbrain, creating an easy association to pain with memories and emotions. One way that this chronic pain is hyperexcited is through NMDA receptors in both the spinal cord and brain. Prolonged firing of these C fibers in chronic pain syndromes causes excess release of glutamate that stimulates NMDA receptors in the spinal cord and heightens pain. Excitotoxicity may play an important role in patients with hyperalgesia, or inexplicably higher levels of pain in chronic pain syndromes. Patients with chronic pain syndromes are thus also more at risk for excitotoxicity induced by food chemicals and environmental toxins. MSG (a glutamate compound) and numerous other excitotoxins created by the food industry to increase the desire to buy processed food products are now in almost all processed foods. Poor gastrointestinal health, sometimes characterized as “Leaky gut syndrome” may contribute much to the excitotoxicity of chronic pain disease by allowing excitotoxins directly into the bloodstream, rather than shunting them to the liver to be detoxified. We can see that a variety of factors may contribute to the individual chronic pain syndrome, and adopting a more natural and healthy diet may be important in the overall treatment protocol.
Excess stimulation of NMDA receptors in the brainstem and brain by glutamate, produced in excess due to the persistence of the chronic pain signal, may be the most important central mechanism to hyperalgesia, or inexplicably heightened pain, in chronic pain syndromes. This is called excitotoxicity (go to the web article entitled Brain Health on this website to learn more). Glutamate is the most abundant excitatory neurotransmitter in the nervous system, and is stored in vesicles at the nerve synapses. Glutamate is the carboxylated anion or salt of glutamic acid, a non-essential amino acid, meaning that our bodies can produce it, and we do not need an essential food source, like essential amino acids. In disease mechanisms of the brain, glutamate can accumulate outside neural cells, causing excess calcium ions to enter via NMDA receptors, leading to a type of neuronal damage that we call excitotoxicity. Excitotoxicity is not confined to chronic pain syndromes, though, but is a mechanism seen in a variety of brain disorders, including post-stroke debility, seizure activity, autism, Alzheimer’s disease, and amyotrophic lateral sclerosis. The glutamate excess seen with chronic pain and the ensuing excitotoxicity that creates the inexplicable pain persistence, is just one example of how glutamate excitotoxicity at NMDA receptors may create disease. When this occurs, we need to focus on more than the body part that hurts, and restore the brain function through a holistic healing protocol.
Standard Medicine is reassessing its approach to chronic pain and fibromyalgia
In 2011, the National Academy of Sciences, Institute of Medicines, issued a report on chronic pain entitled Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academy of Sciences is a private, nonprofit society of distinguished scholars engaged in research who has operated on a charter to advise the federal government since 1863. The Institute of Medicine was established as part of this academy in 1970 to examine public health policy and advise the federal government. Dr. Harvey V. Fineberg is the current president. The committee advising on the policies of chronic pain care includes eminent professors at Stanford University, the University of Michigan, University of Pennsylvania, University of Washington, Duke University, Yale University, UCSF, and other reknowned institutions of medicine. The summary of this committee stated: “Acute and chronic pain affects large numbers of Americans, with at least 116 million U.S. adults burdened by chronic pain alone. The annual national economic cost associated with chronic pain is estimated to be $560-635 billion. For many patients, treatment of pain is inadequate not just because of uncertain diagnoses and societal stigma, but also because of the shortcomings in the availability of effective treatments and inadequate patient and clinician knowledge about the best ways to manage pain. In the committee’s view, addressing the nation’s enormous burden of pain will require a cultural transformation in the way pain is understood, assessed, and treated.”
This committee describes chronic pain as a disease in itself, having a distinct pathology, causing changes through the nervous system that often worsen with time, and has significant psychological and cognitive correlates. The committee cited a need for a comprehensive and interdisciplinary approach to assessment and treatment. While the committee at this point failed to endorse specific integration of conservative therapies and holistic approaches, it did stress the need for clinicians to understand that chronic pain must be approached not merely by an endless search for an underlying cause and administration of pain medication, but by treating the chronic pain as a disease itself and prescribing comprehensive and individualized treatment to address the chronic pain pathology itself. The main criticism of the current approach is that pain management mainly takes place through the primary care and self-management of the disease, avoiding the use of specialty care. This inadequate treatment is driven by a mandate to avoid payment for the specialty care and interdisciplinary approach, but the committee on chronic pain at the Institutes of Health found that this payment denial of care is actually costing us dearly. By denying adequate treatment at an early stage, we create a perpetual pain syndrome that continues to cost not only the patient, but the society, government (who pays for most of the care an debility of chronic pain), the taxpayer, and even the insurer, who is stuck paying for endless doctor’s visits and expensive pain medications, as well as numerous other health problems that eventually occur due to the ill health in chronic pain syndromes.
By the time that a cause of pain becomes chronic, a time intensive and thorough treatment approach is needed, addressing not only tissue repair, but neuroimmunological health, sometimes hormonal health, and cognitive processes. The Licensed Acupuncturist that is skilled in soft tissue physiotherapies and nutrient and herbal medicine, and has a knowledge and awareness of the disease mechanisms in chronic pain syndromes is an ideal physician to integrate into the treatment team. Recent advances in research of the central mechanisms of chronic pain cognition in the hypothalamus, amygdala and other associated nuclei in the brain’s limbic system have led us to an understanding of how acupuncture stimulation may work in this treatment protocol. The promise of these various treatment modalities, deep tissue physiotherapy, acupuncture, electroacupuncture, herbal medicine and nutrient medicine, combined with a sensible patient education and cognitive approach, offers a solution to many of the problems of designing a therapeutic protocol that actually addresses the complexity of the disease of chronic pain.
The Treatment Plan and the diagnostic workup in Fibromyalgia
The treatment plan must include a step-by-step approach to these various interwoven health problems combined with changes in your own routine. This holistic and pro-active patient-centered approach is essential. Standard medicine has no cure, but a comprehensive package of care by the TCM physician, or Licensed Acupuncturist, sometimes integrated with medical doctors that also utilize holistic approaches to care, can have dramatic results. The various therapies of the TCM physician may act synergistically to insure better treatment outcome, combining acupuncture, herbal medicine, nutrient medicine, bioidentical hormone therapy, physiotherapy, and patient instruction to address the multi-system dysfunction. The individual patient will set goals and see progress achieved on any of the factors that make up their pattern. In a short time, after progress is made on a number to the causative factors, and a sequence of herbal formulas and nutritional supplement courses have been completed, the physiotherapies and needling stimulation will be able to reduce the pain and nervous dysfunction. Treatment of both the underlying causative mechanisms and the symptom manifestation will insure the best outcome.
There are no objective tests to confirm fibromyalgia other than the triggering of symptoms at a variety of myofascial trigger points (ACR guidelines). These American College of Rheumatology guidelines also state that chronic pain (occurring for at least 3 months) in all four body quadrants should be apparent. At one point, the medical community wanted to limit diagnosis by saying that only tenderness and triggering at specific points on the body could confirm a diagnosis. This has been proven untrue. Of course, a physician skilled in manual therapies and myofascial trigger point analysis is needed to confirm this testing of fibromyalgia trigger points and assess whether the triggering of pain is related to local tissue pathology or a central neuromuscular cause. Even though there are no specific tests beside trigger point assessment to confirm fibromyalgia diagnosis, there are an array of tests that are helpful to piece together the multi-system puzzle. Some tests will be performed strictly to rule out other diseases, and when these tests come back negative, other tests may be performed to achieve an accurate picture of the multi-system imbalance.
Because fibromyalgia is similar to various autoimmune disorders, such as rheumatoid arthritis, lupus and Sjogren's syndrome, as well as disorders such as Lyme disease and thyroid dysfunction, various lab tests should be conducted to check for markers such as rheumatoid factor and erythrocyte sedimentation rate (ESR), as well as thyroid and pituitary hormones, and other disease markers. A diagnosis of exclusion is used, where other diseases are tested for and ruled out. Autoimmune diseases often coexist with fibromyalgia, though. Negative results of various tests do not rule out the diagnosis of fibromyalgia, but do help guide the complex treatment plan. Active metabolite hormonal panels are highly recommended to aid diagnosis, especially to assess cortisol imbalances. These tests are simple to perform, do not require drawing of blood, and are relatively inexpensive and highly accurate. Patients may collect their own samples of saliva, blood spot, and even urine spot, that are analyzed with advanced scientific methods, providing a useful analysis of overall hormonal balance and thyroid function, key nutritional deficiencies, and metabolic disorders. Even if the disorder is subclinical, meaning that the tested values do not indicate a standard diagnosis of clinical disease, these tests reveal the relative imbalances and holistic dysfunction that need to be brought back into balance to correct the underlying disease mechanisms in fibromyalgia.
Integrating your therapy with guidance and advice from an open-minded rheumatologist that believes in a multi-factored integrative approach can be very helpful to your course of therapy. The Fibromyalgia and Fatique Center is one example of a comprehensive integrated approach taken by medical doctors with a specialty in rheumatology, neurology and endocrinology. Such clinical approaches are having great success and expanding rapidly in the United States, yet are still frowned upon by standard hospital groups. These more modern medical doctors are open-minded and utilize the objective scientific evidence in Complementary Medicine to treat with herbs, nutritional supplements, bioidentical hormones, and the most benign pharmaceutical approaches. These clinics actually encourage integrated health care with the Licensed Acupuncturist, and realize that in difficult multi-system diseases, persistence, time spent with the patient, and a team approach, is the most sensible and effective treatment strategy. Many approaches of Complementary Medicine and the holistic perspectives of Traditional Chinese Medicine are now considered the guiding philosophy rather than the enemy of standard medicine. Europe, Australia, and Brazil are countries that are integrating this approach rapidly into their standard health care systems because their medicine has a public health approach and is not dominated by the pharmaceutical and insurance corporate interests.
Current scientific study of fibromyalgia treatments in the United States
Herbal and nutritional supplements that have been studied and found effective for fibromyalgia include 5HTP from Griffonia seeds, SamE methionine, magnesium aspartate, chlorella and other algaes, anthocyanadins such as in mangosteen, pomegranate, and other herbs (e.g. gingko biloba). Pomegranate extract from the whole fruit, husk and seeds is recommended. A mind body behavioral approach, long used by Traditional Chinese Medicine, has also been found helpful in studies. A systematic review of sound randomized controlled studies scored on the CONSORT system found these supplements, as well as acupuncture and physiotherapy, to be sound, proven, and effective therapies for fibromyalgia (PubMed PMID:12849718). In addition, a variety of herbal formulas, bovine colostrums, proteolytic enzymes, vitamins, amino acids, and immune modulating and adaptogenic herbs may have very positive results, and are generally recognized by specialists as effective in clinical practice. Preliminary studies on a wide variety of natural therapeutics is thus underway due to the promise of these treatments, and new information on evidence-based approaches in Complementary Medicine and the treatment of fibromyalgia and related health problems is being published every month. Since fibromyalgia is a complex multi-system disease mechanism, the physician should utilize specific herbal and nutrient medicines to address each aspect of the disease, and tailor this individually to the patient. Evidence-based protocol helps guide this therapy immensely.
Of course, it is important to find a Licensed Acupuncturist that is skilled and knowledgeable to perform these therapies and direct this complex course of therapy. Acupuncture alone may be of benefit, but the wise patient will choose a more comprehensive approach to insure success. Published studies of acupuncture in the treatment of fibromyalgia, while recognized by many esteemed health organizations, such as the Mayo Clinic, have presented a variety of results. Some fibromyalgia patients have experienced mild aggravation of their symptoms from acupuncture treatment performed by an unskilled practitioner or M.D. with little training. Generally, though, studies have consistently shown improvement from any acupuncture treatment, and some double blind studies even found significant benefit from the sham acupuncture used in the study. Sham acupuncture in studies usually consists of needling points other than those typically chosen for fibromyalgia, pointing to the fact that general acupuncture therapy could exert significant benefit. Clinical trials of acupuncture limit needling techniques and require uniform point selection to achieve a uniform treatment study and consistency of data. This is different than the complex needling techniques and individualized point selection that the trained acupuncturist utilizes clinically to achieve the best results. You will be surprised by the results of a skilled and guided course of therapies as described above.
Hormonal imbalances relating to fibromyalgia
Recent research has uncovered a strong link between the serotonin system and the estradiol system in the brain in relation to chronic systemic pain sensation and modulation. While some studies have shown little obvious relationship to the changing menstrual cycle hormones and the elevated pain threshold, (slightly elevated progesterone levels during the mid-luteal phase, pre-menstrually, in normal subjects with fibromyalgia, pointing to increased need or excess production and fluctuating cortisol concentrations), other studies have shown a definite link to the levels of estradiol hormones and serotonin pain modulation. Most studies confirm a consistency of deficient central serotonin levels in fibromyalgia patients, which may create a need for increased hormonal regulation of pain at receptors that may be triggered both by serotonin and estradiol, or cortisol.
The most compelling hormonal link in fibromyalgia research resides in the deficiencies of the hypothalamus and adrenal systems, or the hypothalamus-pituitary-adrenal axis, which is a primary feedback system regulating hormonal balance. When physical and emotional stress creates dysfunction in the adrenal and hypothalamic systems, diurnal cortisol levels are affected, and growth factors become deficient, leading to insomnia, anxiety, depression, poor tissue maintenance, and hypothyroid states. Diminished hypothalamic function is linked to low levels of central serotonin, resulting in exagerrated levels of Substance P in the spinal cord, causing exaggerated sensations of pain. Adrenal stress may not only alter diurnal cortisol production, but may stimulate increased adrenalin, which we call by the name norepinephrine. Norepinephrine is another hormonal neurotransmitter that can stimulate receptors that modulate the pain perception and response. Any or all of these hormonal imbalances could contribute to the complex fibromylagia syndrome and perception of pain.
Myalgia after stopping hormone therapies
The deficiencies of normal hormone production account for a high incidence of systemic muscle pain after stopping hormone therapies of contraceptive or hormone replacement therapies. All fibromyalgia syndromes are not alike, but your syndrome may be related to this type of hormonal imbalance. In this case, a hormonal panel should be ordered, and subsequent analysis and restoration of physiological normal production of hormones achieved. This could be an important facet of treatment for a number of fibromyalgia patients. Keep in mind that synthetic pharmaceutical hormones do not restore hormone production, but actually replace natural hormones and inhibit natural hormonal production. A physician trained in bioidentical hormone therapy, nutrient medicine, herbal medicine, and acupuncture can help restore you to a functional state.
Vasomotor dysregulation, vasoconstriction and low-level ischemia
This has been shown to be the common thread in fibromyalgia patients. The exact cause, neurological, endocrine or immune is still being investigated. The most thorough course of treatment will address all the possibilities. The neurological cause would seem to be related to the autonomic nervous system. Standard allopathic medicine looks to an either/or approach and often misses the causes of systemic disorders when there is a complicated link between systems. A holistic approach would look to bring related systems back to normal function to correct the problem. It is known that estrogen hormones, neuropeptides and the immune modulator nitric oxide all affect the peripheral muscle vasodilation and are controlled by a neuro-hormonal axis. Homocysteine levels also are highly related to vasodilation disorder, with higher plasma levels consistently noted in vasomotor dysregulation. Homocysteine is an amino acid formed from cysteine and methionine, and an excess implies a metabolic imbalance related to deficiencies of Vitamins B6 (P5P), B12, B9 (folic acid or 5MTHhF) or betaine, or a stress of the glutathione metabolism. Studies have found a consistent increased concentration of homocysteine in the cerebrospinal fluid of patients with fibromyalgia (PMID:9310111). Folic (5MTHhF) + B6 (P5P) supplementation decreases homocysteine levels in most patients. B12 deficiency should be investigated also as a cause (B12 injections are the only sure way of supplementation, but use of sublingual supplements,especially liquid forms, Dang gui, and improved diet may help). Selenium (methylselenocysteine) + VitE may be useful to reduce oxidative stress and improve vasomotor dysregulation. SAMe is a methionine that may improve this imbalance as well. Green tea or green tea extracts (catechins) have also been proven useful to lower homocysteine levels.
Sulfur deficiencies in fibromyalgia
Sulfur is an abundant nutrient in the human body and integral to a number of nutrient compounds found beneficial in fibromyalgia treatment, including SamE, MSM, DMSO, glucosamine sulfate, methionine, cysteine, cystine, homocysteine, homocystine, and taurine. Sulfur deficiency and sulfur dysregulation are thus being explored. Sulfur containing foods include egg yolks, legumes, onions, garlic, turnips, nuts, kale, seaweeds, raspberries, radishes, watercress, and dark leafy greens in general, such as collards. Sulfur is also a key ingredient of collagen formation and the health of connective or fibrous tissues. Sulfur is an essential nutrient in relation to methionine and cysteine. Alpha lipoic acid may aid in the sulfur metabolisms. Imbalance of the liver and amino acid system may be related to nutrient deficiencies of sulfur containing nutrients. While modern medicine thinks these approaches are without merit, historical use of sulfur and sulfur containing chemicals is abundant in medical use, including the use of sulfur baths to treat musculoskeletal disorders. Recent studies have shown that the balneotherapy (high mineral concentrations of sulfur, selenium, silica and radium in hot water) at Dead Sea spas are proven effective for fibromyalgia therapy. Addition of herbal or essential oil infusions in the hot bath may have a similar result when combined with sea salts (pine needle oil, thyme, chamomile). Modern commercial food production has caused a number of depletions of common nutrients in our diets, and even when we think we are eating a healthy diet, we may be experiencing nutrient deficiencies. A visit to a quality mineral spa such as Wilbur Hotsprings may have benefit. One can drink this mineral water when the tubs are being filled in the morning at this spa.
Coagulation disorders and accumulation of fibrin proteins on blood vessel endothelium that inhibits normal oxygen and nutrients to the muscles and prevents clearing of chemicals that trigger pain
Prolonged or severe physical, emotional, or mental strain triggers the body to produce high levels of stress hormones, such as cortisol, and immune system mediators. In many patients with fibromylagia, perhaps related to epigenetic propensity, this hyperactivation of the immune system appears capable of triggering an abnormal cascade of coagulation proteins, resulting in excess protein fibrins depositing on small blood vessel linings. Any number of stresses, including injury, surgery, childbirth, viral illness, or emotional trauma, could trigger a hypecoagulation state. Some patients may produce excess clotting factor thrombin, some may produce lower levels of proteolytic enzymes that clear away excess fibrin proteins, and some may have chronic inflammatory states that create excess adherence of clotting fibrin to inflamed capillaries beds in muscles. Food allergies, intestinal dysbiosis, leaky gut syndrome, sluggish liver, chronic low-grade viral infections, yeast or fungi overgrowths, or accumulation of environmental toxins, could all trigger excess immune responses of the T-cell helpers type one (TH1) that lead to excess immune response of blood coagulation and fibrin accumulation. Fibrin accumulation and hardening of the small vessel walls could also be worsened with excess of advanced glycation endproducts (AGEs). Attention to overall health and contributing health factors may be important in the treatment protocol.
Areas of the body that are prone to the most strain and the most muscle contraction, limiting local blood flow, are likely areas of fibrin accumulation. Fibrin accumulation in large blood vessels may create thrombi, or blood clots, but in small vessels will create a stiff mesh that limits the amount of blood flow into the muscle tissues, and subsequently a deficiency in nutrient oxygen and other important tissue nutrients, such as calcium, magnesium, and the building blocks of ATP, the fuel for firing muscles. This leads to both a feeling of muscle fatique, and stimulation of pain receptors. Not only are nutrients inhibited to the muscles with fibrin accumulation, but molecules that may stimulate pain receptors may also not be cleared effectively by the diminished local blood flow. Both soft tissue mobilization and myofascial release, and the use of proteolytic enzymes, such as serratiopeptidase and nattokinase, will help to resolve this fibrin accumulation. Vitamin K (K1 and K2) may be deficient in the individual with excess fibrin accumulation and has been found to be protective of neurons subjected to methylmercury toxicity as well. Once the local vascular problems and nutrient dystrophy are corrected, the patient may benefit from a short course of super nutrient supplementation, such as D-ribose, which creates higher levels of ATP, as well as Vitamins B1 and B2. Unfortunately, if the underlying causes, and the mechanisms of abnormal pain sensitivity, are not also addressed, by neurohormonal restoration, this combination of tissue therapies may be limited and temporary. A comprehensive approach to the complex disease mechanisms is important.
Complexity of the approach to treatment as a discouragement
All fibromyalgia patients must unfortunately acquire extreme patience when undergoing therapy for this condition. Trial and error must be a part of the treatment protocol since there is no guaranteed approach in the world. Persistence is the key to success. This is very frustrating for both the patient and the physician, but a good communicative and trusting working relationship will result in excellent results. I recommend good dialogue and feedback rather than snap judgments of the therapeutic course. Keep in mind that in these difficult disorders that patient may not have an objective view and needs the intelligent therapist to provide this perspective. Avoid competitive thinking when discussing the therapies and keep an open mind. Avoid infusing the discussions with advice from other physicians that contradicts your physician’s approach. Keep in mind that no physician has demonstrated proven success with fibromyalgia so far, so there is no definitive authority on the subject.
By taking a comprehensive holistic approach I have had great success in treating most cases of fibromyalgia and other chronic pain syndromes, and I emphasize to patients that I hope our work together, and the work of many patients and Licensed Acupuncturists and herbalists, produces similar success in a field where there has been very poor success so far. There is never a guarantee of success in the treatment of any disorder with any treatment protocol, and difficult diseases are frustrating, but as in any endeavor in life, an intelligent and persistent approach will most likely guarantee eventual success. A healthy and hopeful stubbornness has its rewards.
Treatment Protocol for Fibromyalgia: a comprehensive array of therapies
Fibromyalgia is a difficult problem to treat. Currently, modern medicine uses an SSRI (selective serotonin reuptake inhibitor) called Celexa, or a benzodiazepine anxiety medication like Xanax. A new type of drug, Pregabalin, or Lyrica, is a type of anticonvulsant like Neurontin that has proven to have some efficacy. Lyrica acts by inhibiting the calcium entry into nerve terminals in the central nervous system (spine and brain). This reduces certain neurotransmitters (glutamate, noradrenaline and substance P) and thus decreases a percentage of the neural firing associated with fibromyalgia pain. There are a number of side effects with these drugs that can be decreased with concurrent Complementary Medicine, and long term use is problematic. Withdrawal from SSRIs and benzodiazepines have also become a common health problem successfully treated with Complementary Medicine. Problems with pharmaceutical treatments have prompted a strong interest in the treatments of Complementary and Integrative Medicine, even among the medical doctors, clinics and hospitals of standard medicine. Since fibromyalgia is a multi-system disease, these specific pharmaceutical protocols have limited overall benefit.
Whether choosing drugs to treat or not, there are a number of therapies that can be combined to both relieve the chronic symptoms of fibromyalgia as well as getting at the cause. Recent research into the facets of the central nervous system responsible for the pain response has led to better use of specific herbal chemicals to counter these pathways of pain. Inhibition of voltage-dependant calcium channels and substance P, and improved metabolism of the glutamate and norepinephrine systems by herbal chemicals has been documented. In addition, calming of the central nervous system and improved sleep patterns can be achieved with herbal formulas. Poor sleep patterns and poor control of mood and emotion are heavily linked to the fibromyalgia syndrome. To achieve the greatest success, the patient should think beyond just temporary symtom relief, and look to find a comprehensive package of care that addresses the various interrelated dysfunctional systems in the body.
Besides addressing the perception of pain in the central nervous system, a combination of soft tissue therapies and herbal/nutrient medicine can also clear the problems at the muscles themselves. As stated, hard fibrin accumulation in small blood vessels can be cleared with proteolytic enzymes and various specific herbs, such as Gingko biloba. Along with clearing of tissue accumulation and microcirculation, deficient nutrients can then be resupplied to establish better function. Acupuncture can aid the protocol, affecting both the local tissues and the central nervous system, and stimulating a hormonal cascade that has benefits long after the treatment. While direct myofascial problems are not a primary cause of pain in fibromyalgia, they are often a key contributor to the intensity of your pain and stress fatique. Soft tissue therapies and myofascial release often improve your overall condition and decrease the stress on your nervous system. Acupuncture has been endorsed by the WHO and NIH as a proven benefit in fibromyalgia since about 1996. This therapeutic stimulation acts both on the healthy function of the central nervous system as well as the local tissues and is a key part to a holistic approach to effective therapy.
Besides treatment directed focally at problems in the central nervous system and peripheral tissues, underlying dysfunctions may also need to be addressed. Restoration of adrenal and hypothalamic functions, hormonal balance, and the chronic causes of these dysfunctions, such as poor GI health, accumulations of neurotoxins such as heavy metals from the environment, chronic allergic and hyperimmune states, sleep disorders, and sluggish liver function, can all be addressed with a comprehensive protocol in Complementary Medicine. In addition, a number of mind-body therapeutics are now proving to be remarkably effective, including Qi Gong, Tai Chi, and Yoga. Qi Gong is the therapeutic protocol in Traditional Chinese Medicine that has been highly developed, and is integral to the practice, both in the physician practice, and with instruction to the patient. This therapeutic protocol, originally called Yang Sheng, or nurturing vitality, involves a wide array of techniques that focus better mind-body coordination. Tai chi (Tai ji), is a type of Qi Gong, originally developed for athletic training, that refined the complex practice to more simplified protocols. The TCM physician is able to both incorporate Qi Gong into the treatments, and if requested, teach the patient how to focus qi gong exercises that would be most beneficial at home.
To summarize, a variety of systems in the body are found to act synergistically to create the overall syndrome in fibromyalgia and chronic fatique. These include coagulation disorders and fibrin accumulation on small blood vessels, diminished T-helper cell type one (TH1) response in the immune system (perhaps related to chronic stealth viral infections), immune dysfunctions and allergic responses that trigger latent viral infections, neurotoxin accumulations from a variety of sources, such as fungi, mold, altered symbiotic bacteria, pesticides, and heavy metals, adrenal and hypothalamic strain and deficiencies, mitochondrial dysfunctions in neural cells, and gastrointestinal dysfunctions that add stress to the body. While this presents a complex health problem, the good news is that current scientific research supports a variety of effective therapeutic protocols in Complementary Medicine, and the patient can finally trust that this difficult health problems can be resolved.
A thorough treatment protocol will analyze each individual case and address any and all of the systems that may be dysfunctional in your body. The care can be integrated between medical doctors and other Complementary Medicine physicians, such as a knowledgeable Licensed Acupuncturist. The Licensed Acupuncturist may be able to provide the time intensive part of the therapy that is cost prohibitive to the M.D. The M.D., if open-minded to Complementary Medicine and new approaches, can more easily order various tests, as well as prescribe pharmaceutical medications if the patient desires this approach within the treatment plan.
Acupuncture has been recommended for treatment of fibromyalgia, a systemic syndrome that standard therapies have not been able to help, by the National Institute of Health, the World Health Organization, the Mayo Clinic, and numerous government health services around the world. Evidence has supported the use of acupuncture despite the problems of study design with a double blinded placebo controlled model for manual medicine, and despite the lack of funds to conduct large scale trials of this sort in the United States. To further explore the state of, and problems with, acupuncture research deemed acceptable by the medical industry in the United States, go to my articles on reseearch under For Practitioners. The following evidence is just a small portion of the scientific study supporting acupuncture in the treatment of fibromyalgia.
- A review of the studies of efficacy of pharmacological interventions in fibromyalgia, published in the journal Prescrire International in 2009, found that an array of pharmaceuticals has shown limited benefits and often alarming long-term side effects, with a high rate of noncompliance: http://www.ncbi.nlm.nih.gov/pubmed/19746561.org/
- Pharmacological treatment of fibromyalgia as recommended by the prestigious German S3 guidelines of the Association of the Scientific Medical Societies in 2012, suggests that only Amitriptyline (Elavil) is recommended for fibromyalgia, except in cases of comordid generalized anxiety and depressive disorder, where Duloxetine may be added to therapy. Amitriptyline is a tricyclic antidepressant that may increase serotonin and norepinephrine (adrenalin) bioavailability, and acts as an anticholinergic (inhibiting the neurotransmitter acetylcholine), where most of its side effects, such a weight gain, constipation, nervousness, loss of sexual drive, and muscle stiffness are derived. Duloxetine (Cymbalta) is an SNRI (selective serotonin and norepinephrine reuptake inhibitor) that was shown in a randomized controlled human clinical trial at the University of Cincinnati College of Medicine in 2004 to improve fibromyalgia symptoms for women, but not for men, and did not improve pain scores at the end of 12 weeks (PMID: 15457467). Generally, there is risk of combining a tricyclic antidepressant and an SNRI: http://www.ncbi.nlm.nih.gov/pubmed/22760463
- A 2012 update to the prestigious German 53 guidelines of the Association of the Scientific Medical Societies concerning Fibromyalgia Syndrome (FMS) noted that current scientific study did not identify distinct causative or pathophysiological factors that explained the fibromyalgia pathology, but that there was strong association with lifestyle factors of obesity and lack of physical activity, as well as smoking, physical and sexual abuse history either in childhood or adulthood, and rheumatic inflammatory diseases. The society concluded in 2012 that Fibromyalgia was a syndrome, not a disease, and that it most likely was the result of various pathological factors and mechanisms, and hence needed a more individualized and comprehensive approach in treatment: http://www.ncbi.nlm.nih.gov/pubmed/22760458
- Further review of pharmacological efficacy in the treatment of fibromyalgia at Sapienza University of Rome, Italy, concluded that various pharmacological treatments have been used with inconclusive results, that much off-label prescription not approved by the FDA is utilized, and that the best treatment should combine drug therapy with non-pharmacological therapy and patient education: http://www.ncbi.nlm.nih.gov/pubmed/21176430
- A 2013 study at Harvard Medical School and Massachusetts General Hospital randomly chose a set of patients diagnosed with fibromyalgia and found compelling evidence that a significant percentage tested positive for small-fiber polyneuropathy and hepatitis C, indicating that many patients may be either misdiagnosed with fibromyalgia now that prescription drugs are heavily advertised for treatment, or that diseases such as these are concurrent with fibromyalgia and not treated. The sentiment of an increasing number of experts is that the complex process of a diagnosis of exclusion, involving a systematic set of tests that are often not commonly used, is not being performed with fibromyalgia patients, with prescription of these drugs given without much of a diagnostic workup: http://www.ncbi.nlm.nih.gov/pubmed/23748113
- A study of myofascial trigger point therapy and fibromyalgia at the University of Chieti, Italy, Pathophysiology of Pain Laboratory, in 2011, found that treatment of myofascial trigger points produces significant pain relief in fibromyalgia by acting on the level of central nervous system sensitization, and that myofascial trigger point therapy should be systematically performed before any specific pharmacological treatment is started: http://www.ncbi.nlm.nih.gov/pubmed/21541831
- A study comparing myofascial release therapy to Swedish massage in the treatment of fibromyalgia, at the Frida Center for Fibromyalgia, Portland, Oregon, U.S.A found that myofascial release therapy resulted in significant and consistent pain reductions and significantly better measured outcomes over Swedish massage therapy: http://www.ncbi.nlm.nih.gov/pubmed/23768283
- A 2013 study at the University of Liverpool, Liverpool, United Kingdom, found that a neurodegeneration and loss of local grey matter in the brainstem, coupled with growth of grey matter in the primary somatosensory areas of the cortex, may explain the chronic progressive sensitivity to pressure pain in fibromyalgia. A more holistic treatment protocol to address these concerns is needed in the overall treatment, and Complementary Medicine provides a variety of aids to brain health with acupuncture, herbal and nutrient medicine: http://www.ncbi.nlm.nih.gov/pubmed/24179860
- The National Pain Foundation acknowledges the efficacy of Complementary Medicine, and specifically acupuncture and herbal medicine, and the recommendation by the World Health Organization that acupuncture be utilized for variety of pain disorders, supported by numerous scientific studies: http://www.nationalpainfoundation.org/
- The prestigious German S3 guidelines of the Association of the Scientific Medical Societies updated their fibromyalgia treatment guidelines concerning Complementary Medicine in 2011, with acupuncture considered effective, and meditative therapies such as qi gong, tai chi, and yoga strongly recommended, based on current evidence-based studies. This revision stated that mindfulness-based stress reduction, homeopathy, and nutritional supplements are no longer recommended, based on current large studies. An acupuncture protocol with herbal medicine, physiotherapies, and instruction in individualized Gi Gong therapy by a competent Licensed Acupuncturist and herbalist may be very effective for this difficult to treat pathology: http://www.ncbi.nlm.nih.gov/pubmed/22760464
- A 2010 meta-analysis of randomized human clinical trials assessing TCM treatments for fibromyalgia, using acupuncture, cupping, and Chinese herbal medicine, conducted by Beijing University in China, found that 25 such trials could be used, held to the highest standards. TCM therapies of acupuncture, cupping and herbal medicines appeared to be effective and compare well to conventional medications, with no significant adverse effects. No clinical trials were found to evaluate Tui na, the branch of direct physiotherapy in TCM: http://www.ncbi.nlm.nih.gov/pubmed/20423209
- A meta-review of scientific study of pain treatment with acupuncture was conducted in 2012 by the esteemed Sloan-Kettering Cancer Center in New York, U.S.A. and published in the Archives of Internal Medicine, perhaps finally dispelling the notion that acupuncture only produces a placebo effect and is not proven over so-called placebo acupuncture. This article in the New York Daily News interviews some of the researchers that now suggest that acupuncture for chronic pain treatment can no longer be dismissed, and who found that professional needle manipulation is proven to exert more profound effects than simple needle insertion : http://www.nydailynews.com/life-style/health/sloan-kettering-study-acupuncture-works-chronic-pain-article-1.1156095
- A summary of the large meta-review of clinical studies of acupuncture for chronic pain conducted by Dr. Andrew Vickers et al at Sloan-Kettering Cancer Center in 2012 is presented here, in Archives of Internal Medicine, now called JAMA Internal Medicine: http://archinte.jamanetwork.com/article.aspx?articleid=1357513
- A 2002 clinical trial at the University of Sao Paulo School of Medicine: Brazil has included Complementary Medicine into its healthcare system and this has produced significant reduction in total health expenditure: http://www.springerlink.com/content/c824l36kq6113152/
- A 2007 review of Complementary Medicine and evidence for the best protocol of combined therapies, including acupuncture; this physician combines these therapies in his practice to offer the best treatment protocol, time intensive, evidence-based and effective. Thomas Hardy-Pickering is an accomplished researcher and homeopathic medical doctor in Great Britain: http://cat.inist.fr/?aModele=afficheN&cpsidt=19003452
- The Mayo Clinic has completed small studies of its own that confirm the efficacy of acupuncture in the treatment protocol for fibromyalgia (2006): http://www.mayoclinic.org/news2006-rst/3495.html
- A 2002 National Institute of Health (NIH) review of acupuncture clinical trials and evidence in the United States: http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102276047.html
- An example of an integrative medical approach in standard medicine to fibromyalgia treatment is seen at this website, presented by the Illinois Multi-Med healthcare centers: http://www.illinoismultimed.com/specialties/fibromyalgia/fibro_hypercoagulate.html
- In 2008, the Huffington Post in 2008 reported on the success of numerous clinical trials at the University of California campuses on the efficacy of medical marijuana to reduce neuropathic pain, as is seen in fibromyalgia: http://www.huffingtonpost.com/2010/02/18/marijuana-provides-pain-r_n_466993.html
- The National Pain Foundation now gives a succinct explanation of how chemicals called cannabinoids, which are found in marijuana, and actually produced endogenously in the brain as well, exert profound beneficial effects on pain control, as well as beneficial effects on both the central nervous system and immune system: http://www.nationalpainfoundation.org/articles/112/marijuana-and-pain-management
- A study in 2011, at Kitasato University in Japan, found that Vitamin K produced significant neuroprotective effects for neurons subjected to mercury toxicity. Since these K chemicals also promote improved anticoagulant and fibrin clearance, and may be deficient in patients with poor GI health or flora and fauna imbalance in the intestines, these supplements may be applicabel in treatment of fibromyalgia: http://www.ncbi.nlm.nih.gov/pubmed/21488088
- A metanalysis of randomized clinical trials of Chinese herbal medicines and acupuncture in the treatment of fibromyalgia showed that only 25 of these types of research study with significant size were recorded by 2010, but that significant benefits were demonstrated with acpuncture and Chinese herbal medicine: http://www.ncbi.nlm.nih.gov/pubmed/20423209
- A 2010 study at Dalian Medical University in China found that standardized extracts of medicinal Gingko biloba were effective in protecting neurons against glutamate toxicity, a key factor in the excitotoxicity that explains chronic pain disease. The chemical makeup of such herbs as Gingko biloba may vary, depending on the conditions in which it grew, and obtaining the herbal extract from a reliable medical source is important: http://www.ncbi.nlm.nih.gov/pubmed/20349729
- A 2003 study at the Kyung Hee University in Seoul, South Korea, found that the Chinese herb Uncaria rhynchophylla (Gou teng - analagous to Cat’s claw, a South American uncaria) offers protection from NMDA excitotoxicity : http://www.ncbi.nlm.nih.gov/pubmed/12832857
- A 2004 study at the China Academy of Traditional Chinese Medicine in Beijing, China, found that the herb Gastrodia elata (Tian ma) exerts a neuroprotective role by affecting excitotoxicity, making this herb a potential aid to treating chronic pain as well as oxidative neurotoxicity and inflammation : http://www.ncbi.nlm.nih.gov/pubmed/15706859
- A 1995 study by the University of Illinois at Peoria, Illinois, U.S.A found that there was a much higher than normal incidence of restless leg syndrome in fibromyalgia and rheumatoid arthritis patients than in the normal patient population. While no clear causative relationship exists, health experts believe that a common underlying disease mechanism between a number of disorders, including irritable bowel syndromes (IBS), are related to a neuroendocrine, or neurohormonal imbalance : http://www.bmj.com/content/312/7042/1339
- A 2010 study, published in the Oct. 15, 2010 issue of the journal Journal of Clinical Sleep Medicine found that adults with fibromyalgia had a 10-fold higher incidence of restless leg syndrome than the normal population, and that 33 percent of patients diagnosed with fibromyalgia experienced restless leg syndrome. Experts believe that the disruption in restful sleep associated with this movement disorder may be part of the disease mechanism of fibromylagia : http://www.sciencedaily.com/releases/2010/10/101015091454.htm
- A 2013 randomized, double-blinded, and placebo-controlled human clinical study, from the University of Sao Paulo, Sao Paulo, Brazil, showed that the nutrient creatine improved muscle function in chronic fibromyalgia patients and may be a healthy and effective addition to the holistic treatment regimen for patients with easy fatigue. The supplement D-Ribose has also been studied in this regard and found beneficial: http://www.ncbi.nlm.nih.gov/pubmed/23554283
- A 2013 randomized and placebo-controlled human clinical study, from Yokohama city University, Yokohama, Japan, found that patients with juvenile fibromyalgia showed a significant deficiency of CoQ10 in circulation, and that supplementation improved fatigue, cholesterol metabolism, and helped with antioxidant status: http://www.ncbi.nlm.nih.gov/pubmed/23394493
The information on this website is not intended to be used as a specific medical advice or cure. Please consult with the practitioner or an appropriate physician, such as a licensed acupuncturist, naturopath, or medical doctor, to discuss the proper application of the information contained on this website.