Although chronic fatigue syndrome (CFS) has been defined as a separate syndrome to fibromyalgia (FM),
up to 70% of patients with fibromyalgia are also diagnosed with CFS and 35-70% of patients with CFS have also been diagnosed with fibromyalgia.
Thus studies of patients with CFS may have clinical relevance to fibromyalgia.
What Is Fibromyalgia?
Fibromyalgia is a condition that causes widespread pain and extreme tiredness. Like chronic fatigue syndrome it can be argued that it is a ‘diagnosis of exclusion’, meaning conventional tests have come back negative and you meet the criteria (a list of symptoms) for the condition. This, in my eyes, is incredibly frustrating as it doesn’t;t help us understand what might be at the root of the condition.
Fortunately our understanding of fibromyalgia is improving and we have several functional tests that may help us understand how we can support someone with the condition. This blog will summarise some of this research, and highlight the relevant tests available for each of these factors.
Fibromyalgia Symptoms
Symptoms vary significantly and can often fluctuate but include:
- Chronic pain
- Issues with sleep
- Fatigue
- Headaches
- Brain fog
- Irritable bowel syndrome: bloating, constipation, diarrhoea, and abdominal pain
What Causes Fibromyalgia?
There is no one definitive cause of fibromyalgia, but we do know there are numerous things that may contribute to it. I discuss these below, and also highlight the appropriate tests that can be considered.
How To Test For Fibromyalgia?
Every patient with chronic widespread pain requires at the first medical evaluation a complete history, and some laboratory tests to screen for metabolic or inflammatory causes of chronic widespread pain. These include:
- A complete blood count.
- C-reactive protein.
- Cserum calcium.
- Creatine phosphokinase.
- Thyroid stimulating hormone.
- Vitamin D
Small Intestine Bacterial Overgrowth (SIBO)
Investigators found small intestine bacterial overgrowth in 100% of 42 patients with Fibromyalgia.
SIBO stands for small intestine bacterial overgrowth and is thought to be the most common cause of irritable bowel syndrome. It is tested for via a breath test.
Interestingly not only is SIBO found in a high percentage of those with fibromyalgia but studies have shown that the degree of somatic pain in fibromyalgia correlated significantly with the hydrogen level seen on the breath test – i.e the worse the bacterial overgrowth the more pain was experienced.
In a well known study run by Dr. Pimemtel 100% of fibromyalgia participants were found to have SIBO.
Recommended Test: SIBO Breath Test
Leaky Gut
Leaky gut has also been detected in patients with Fibromyalgia (source) – which isn’t surpassing since we know approximately 50% of people with small intestinal bacterial overgrowth have leaky gut.
Increased leaky gut likely has pathogenetic relevance because it leads to the exposure of bacterial metabolites to immune cells which result in inflammation.
In the study, forty patients with primary fibromyalgia were enrolled and investigated for leaky gut. In the fibromyalgia group, 13 patients had raised gastroduodenal permeability and 15 patients had raised small intestinal permeability, but only one volunteer had increased gastroduodenal permeability.
The leaky gut values were significantly increased in the patient groups.
Recommended Test: Healthpath Gut Health Test.
The Gut Microbiome
Imbalances in the gut microbiome have also been detected in those with fibromyalgia. The below quote comes from a paper published in 2019 in the journal pain
Targeted serum metabolite analysis verified differences in the serum levels of butyrate and propionate in fibromyalgia patients.
Butyrate is produced by certain bacteria in the large intestine, such as Faecalibacterium, and has a key role to play within maintaining a healthy gut lining. It is literally the food for our colonocytes – cells that line the colon.
Recommended Test: Healthpath Gut Health Test
H. Pylori
Studies exploring the relationship between H. pylori and fibromyalgia are conflicting.
In one study the researchers found no differences in regards to any of the clinical features evaluated, whereas in another study the authors described significant associations between H. pylori IgG-positive patients and disease markers, including: post-exertion pain, morning stiffness, confusion, mood, tension headache, sleep disturbance, dyscognition, changes in appetite and fatigue.
One research group reported a significant reduction in pain following H. pylori eradication. (source)
Recommended Test: Healthpath Gut Health Test
Mitochondrial Dysfunction
Increased ROS (unstable molecules that cause cellular dysfunction) in Fibromyalgia, resulting in impaired mitochondrial function and reduced ATP in muscle and neural cells, might lead to chronic widespread pain. Therefore, antioxidants and mitochondrial support could offer a solution for the chronic pain in these patients.
In another study the authors concluded that there results lead to the hypothesis that:
inflammation could be a mitochondrial dysfunction-dependent event
Recommended Test: An organic acid test which will evaluate nutrient status, mitochondrial function, gut health and more.
Thyroid Hormones
We found a high prevalence of autoimmune thyroid disease among 207 patients with clinically defined fibromyalgia, with TRAb being especially prominent among these patients.
Three studies have found thyroid autoantibodies to be in greater percentages in subjects with Fibro compared with controls, in spite of normal thyroid hormone levels.
Recommended Test: Comprehensive thyroid blood test.
Cortisol
A significant difference in the night time serum cortisol level was observed among the patients and control groups. It could be concluded that there is an abnormality in circadian secretion of cortisol in those with fibromyalgia.
Emotional trauma has been associated with fibromyalgia and may lead to the reactivation of previously controlled infections
Recommended Test: Cortisol 24 hour saliva test.
Infections
Viral infections associated with fibromyalgia have included hepatitis C, hepatitis B, human immunodeficiency virus (HIV) and human T cell lymphotropic virus type I.
Mycoplasmal infections have been identified in 52 – 70% of CFS patients compared with 5 to 10% of healthy subjects in North America and Europe (Belgium).
Recommended Test: Comprehesnive viral profile.
Environmental Toxins
While there is no published evidence on this element I know from personal experience that both exposure to mould in a water damaged property, and, exposure to heavy metals from amalgam fillings can both contribute to fibromyalgia. These can often be easily ruled in or out via some basic questioning. For example have you knowingly been exposed to any mould? Have you lived in a visible damp property? Have there been any historical water leaks? Do you feel better when you spend some time outside of your property? Do you have any amalgam fillings?….and so on.
Neurotransmitters
Autoantibodies to serotonin were identified in 74% of 50 patients with fibromyalgia compared with 6% of 32 healthy controls. Notably, serotonin levels were normal in 90% of the fibromyalgia patients indicating serotonin receptor involvement.
Also, serum brain-derived neurotrophic factors (BDNF) were found at higher levels in fibromyalgia patients while BDNF methylation accounted for the regulation of protein expression. These data suggest that altered BDNF levels might represent a key mechanism explaining FM pathophysiology.
Inflammation
Emerging evidence has suggested inflammation, particularly neuroinflammation, as a potential contributor underlying the aetiology of fibromyalgia.
As well as neuroinflammation (inflammation in the nervous system) the literature is beginning to point to increased systemic levels of pro-inflammatory cytokines such as IL-6 and IL-8 in patients with fibromyalgia. A multi-center imaging study has also reported results suggestive of microglial activation related to the presence of fibromyalgia.
Indeed, many of the above factors can contribute to chronic systemic inflammation. And this has indeed been seen in those with fibromyalgia:
Normal-weight patients showed higher levels of C-reactive protein (CRP) indicating systemic inflammation is present.
Neurological Health
There is converging data in favour of a dysregulation of pain processing in the central nervous system of fibromyalgia patients, particularly associated with an increase in cerebral glutamate levels. Furthermore, there is evidence to support an association between increased glutamate levels and an increase in symptoms (Pyke et al., 2016).
Treatment
Treatment really does need to be tailored to the individual. A key concept in Functional Medicine is ‘treat the individual, not the disease’. So we can’t really discuss treatment of fibromyalgia with any level of depth. However there are some more generalised things that I would like to highlight that have been shown in the research to be effective.
Mindfulness
Meditation awareness training may be a suitable treatment for adults with fibro and appears to ameliorate symptoms and pain perception by reducing attachment to self (Gordon et al., 2017).
Amazingly music listening in daily life improved perceived control over pain in female patients (Linnemann, 2015)
Nutrition
Ultimately nutrition recommendations are going to vary depending on what we feel is the underlying cause(s). For example if SIBO is detected a FODMAP diet trial may recommended. However there is a little research on nutrition in fibromyalgia:
This study indicated that antioxidant protection from bioactive compounds present in fruit and vegetables could have an adjuvant role in fibromyalgia treatment (Costa de Miranda et al., 2017)
A paper published in 2020 that explored nutritional interventions in the management of Fibromyalgia stated that numerous interventions have been shown o helpful in reducing symptoms: “the administration of olive oil, the replacement diet with ancient grains, low-calorie diets, the low FODMAPs diet, the gluten-free diet, the monosodium glutamate and aspartame-free diet, vegetarian diets as well as the Mediterranean diet all appear to be effective in reducing the FM symptoms.” (source)
Supplements
In a systematic review published in 2020 the researchers found that supplementation with Chlorella green algae, coenzyme Q10, acetyl-l-carnitine or a combination of vitamin C and E significantly improved measures of pain (source). Other considerations include:
Vitamin D: Vitamin D replacement treatment in patients with nonspecific chronic widespread pain has provided improvements in musculoskeletal symptoms, level of depression and quality of life of patients. Patients with chronic widespread pain should be investigated for vitamin D deficiency.
B Vitamins: Dose-response relationship and long-lasting effects of vitamin B12/folic acid support a true positive response in the studied group of patients with ME/fibromyalgia
Hyperbaric oxygen therapy: Emerging evidence suggests that environmental interventions, such as exposure to hyperbaric oxygen therapy (HBOT), can relieve pain and improve the quality of life in patients with FM (source).
Medical cannabis: A systematic review on treatment options for fibromyalgia concluded that the studies reviewed suggest that medical cannabis is a safe and effective treatment for fibromyalgia pain. It is worth highlighting that the authors go on to say that there are several limitations that need further investigation and these include dosage, length of treatment, and adverse effects (source). Watch my interview with The Cantourage Clinic:
Breathwork: A study exploring breathing practices for fibromyalgia concluded that breathing exercises produced benefits on pain thresholds tolerance on tender points located in the upper half of the body, some of which predicted improvements in the impact of fibromyalgia in the functional capacity to perform daily life, pain, and fatigue. These results provide further support of an idea that breathing exercises are a real and effective intervention to consider in women with FM.
Exercise: A systematic review with meta-analysis concluded that, among patients with fibromyalgia, physical exercise-based therapy (including circuit-based exercises or exercise movement techniques) is effective at reducing pain, the impact of the disease and anxiety as well as increasing quality of life. The most effective dose of physical exercise-based therapy for reducing pain was 21-40 sessions, 3 sessions/week and 61-90 min per session. The effect of PEBT on pain reduction was maintained up to 12 weeks. (source)
Conclusion
I can conclude quite simply with this quote:
Investigation of potential triggers of chronic immune activation needs to include sources of underlying infection, unresolved physical or emotional trauma, toxins and food sensitivities.
In my experience there is often a combination of things that have accumulated over the years and culminated in a diagnosis in Fibromyalgia. As a result a program to recover from Fibromyalgia needs to be staggered with treatment layered in a sequential method.
Resources
Check out this book on Fibromyalgia, and the books I recommend in my library, such as Mindfulness For Health.
References
- Breeding et al., (2012) Integrative model of chronically activated immune-hormonal pathways important in the generation of Fibro, click here.
- Hauser et al., (2017) Management of fibro: practical guides from recent evidence-based guidelines, click here.
- Pyke et al., (2016) Measuring Glutamate Levels in the Brains of fibro Patients and a Potential Role for Glutamate in the Pathophysiology of Fibromyalgia Symptoms: A Systematic Review, click here.
- Nishioka et al., (2016) High prevalence of anti-TSH receptor antibody in fibro syndrome, click here.
- Van Gordon et al., (2017) Meditation awareness training for the treatment of fibro syndrome: A randomized controlled trial, click here.
- Costa de Miranda et al., (2017) Polyphenol-Rich Foods Alleviate Pain and Ameliorate Quality of Life in fibro Women, click here.
- Yilmaz et al., (2016) Efficacy of vitamin D replacement therapy on patients with chronic nonspecific widespread musculoskeletal pain with vitamin D deficiency, click here.
- Reginald et al., (2015) Response to vitamin B12 and folic acid in myalgic encephalomyelitis and fibro, click here.
- Gobble et al., (2008) Altered intestinal permeability in patients with primary fibromyalgia and in patients with complex regional pain syndrome, click here.
- Linnemann et al., (2015) The effects of music listening on pain and stress in the daily life of patients with fibro syndrome: click here.
- Rush et al., (2016) Nitric Oxide, Inflammation, Lipid Profile, and Cortisol in Normal- and Overweight Women With fibro, click here.
- Fatima et al., (2013) Circadian rhythm of serum cortisol in female patients with fibro syndrome, click here.
- Meeus et al., (2013) The role of mitochondrial dysfunctions due to oxidative and nitrosative stress in the chronic pain or chronic fatigue syndromes and fibro patients: peripheral and central mechanisms as therapeutic targets? click here.
- Cordero et al., (2013) Is inflammation a mitochondrial dysfunction-dependent event in fibro? click here.
- Gut microbiome: pertinence in fibro: click here
