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Treating and Beating Fibromyalgia and Chronic Fatigue Syndrome Dr. Rodger Murphree What Is FMS? Fibromyalgia (FMS) is an illness characterized by diffuse muscle pain, poor sleep, and unrelenting fatigue. Leading FMS researchers estimate that between 2% and 4% of the general population suffer from the syndrome. Ninety percent of those diagnosed with FMS are women. www.TheFibroDoctor.com Defining FMS In 1990 The American College of Rheumatology first proposed the current criteria for defining FMS. The diagnosis requires that all three of the major criteria and four or more of the minor criteria be present: Major Criteria: 1. 2. 3. Generalized aches or stiffness of at least three anatomical sites for at least three months Six or more typical, reproducible tender points Exclusion of other disorders that can cause similar symptoms Minor Criteria: 1. 2. 3. 4. 5. 6. 7. 8. Generalized fatigue Chronic headache Sleep disturbance Neurological and psychological complaints Numbing or tingling sensations Irritable bowel syndrome Variation of symptoms in relation to activity, stress, and weather changes Depression www.TheFibroDoctor.com Other Symptoms Other symptoms associated with FMS include: 1. Cognitive disorders- including "fibro fog,” memory lapses, difficulty concentrating, and poor memory. 2. Depression. 3. Irritable Bowel Syndrome - swinging back and forth from diarrhea to constipation. 4. Chemical sensitivities- odors, cosmetics, detergents, dyes, and additives. 5. Allergies. 6. Chronic infections – sinusitis, UTI’s, URI’s, sore throat, and lymph nodes. 7. Headaches - including TMJ and neck pain. 8. Disequilibrium- dizziness and balance problems may also be present when standing. www.TheFibroDoctor.com Mentally ill? www.TheFibroDoctor.com Traditional Medicine Alone Often Fails: From the American College of Rheumatology website on the tricyclic medication Amitriptyline (Elavil) Four controlled trials have evaluated the efficacy of Amitriptyline in fibromyalgia… the longest-term trial showed no benefit when compared with placebo. Furthermore, the overall degree of benefit appears to be relatively small in relevant outcomes such as improvement in pain, fatigue, and sleep. www.TheFibroDoctor.com “Anti-inflammatory agents should be generally avoided” Furthermore, use of antianxiety medications (Klonopin, Xanax, etc), Benzodiazepines, corticosteroids, and nonsteroidal anti-inflammatory agents have been shown to be ineffective and should be generally avoided. www.TheFibroDoctor.com “Drug therapies are ineffective over 15 year span” Drug therapies are ineffective over 15 year span, and our best therapies Amitriptyline (Elavil) and Cyclobenzaprine (Flexeril), could not be distinguished from placebo after 3 months of therapy. Long term, follow-up observations indicated that clinical findings for patients with FMS did not change appreciably after 15 years. www.TheFibroDoctor.com Believed to be causes of FMS and CFS • • • • • • • Trauma Emotional/physical/mental stress Yeast overgrowth Chemical sensitivity Allergies Liver dysfunction Leaky gut syndrome • Low thyroid function • Nutritional deficiencies • Deficient serotonin • Adrenal dysfunction • Chronic viral/bacterial infections • Endocrine disorders • Autonomic disorders www.TheFibroDoctor.com I Believe Stress and Chronic HPA Dysfunction Cause Fibromyalgia Several studies have emonstrated how chronic stress undermines the normal hypothalamic-pituitary-adrenal axis (HPAAxis) Stress is the underlying catalyst for the onset of HPA axis (HPA) Dysfunction. www.TheFibroDoctor.com Fibromyalgia Patients Have Have Stressed out Their HPA-axis The Fibromyalgia Network Reports 62% of Patients Say Emotional or physical Stress Preceded Their Symptoms www.TheFibroDoctor.com Self Regulating Chart Sex Hormones Thyroid Hormone Digestion Blood Pressure Immune System Brain Chemicals Hypothalamus Self-Regulating Robot Monitors, Coordinates, and runs most systems of the body Stress-Coping Abilities Respiratory System Pain Inflammation Adrenal Hormones Sleep/Wake Cycle The Hypothalamus Regulates These Functions 1. Blood pressure 2. Digestion 3. Skin temperature 4. Circadian rhythms (sleep/wake cycle) 5. Hunger 6. Sex drive 7. Body temperature 8. Balance and coordination 9. Heart rate 10. Blood volume 11. Sweating 12. Blood vessel constriction 13. Adrenal hormones 14. Thyroid hormones 15. Metabolism www.TheFibroDoctor.com A Vicious Cycle • • • • Chronic stress disrupts HPA homeostasis/allodynia Chronic pain disrupts sleep/wake cycle This causes poor sleep Poor sleep - fatigue, increased sensitivity to pain, increased inflammation, suppressed immune function, and lowers metabolism. • Chronic poor sleep further depletes serotonin- IBS, more pain, low moods, and Fibro fog www.TheFibroDoctor.com Restoring Normal Autonomic/Hypothalamus Function Is key to beating FMS and CFS 1. Restoring/Boosting the essential neurotransmitters serotonin and norepinephrine. 2. Restoring hormonal imbalances, especially melatonin, cortisol, DHEA, and thyroid. Estrogen, progesterone and testosterone may also be low. www.TheFibroDoctor.com Poor Sleep Leads to: 1. An increase in substance P, leading to an increase of pain. 2. A decrease in growth hormone production, leading to poor repair of damaged muscle fibers. 3. Altered thyroid function 4. A decrease In energy production, leading to greater fatigue.” Research also shows that sleep deprivation markedly increased inflammatory cytokines (pain causing chemicals)—by a whopping 40%. Presented at the Endocrine Society in San Francisco, by Vgontzas in June 2002 www.TheFibroDoctor.com Poor sleep has been linked to various health problems including depression, fatigue, CFS, FMS, and headaches. www.TheFibroDoctor.com Substance P & Serotonin Substance P is a chemical known as a neurotransmitter. Substance P increases and enhances pain receptors. Substance P is normally kept in check by the neurotransmitter serotonin. Unfortunately, FMS patients have little if any serotonin to spare. www.TheFibroDoctor.com Sleep Medications that do Promote Restorative Sleep 9 9 9 9 9 Ambien Elavil Flexeril Trazadone Lunesta These medications do promote deep restorative sleep. However, they have potential side effects and usually start to lose their effectiveness over time. One of the potential side effects of Ambien is flu-like symptoms, achy muscles, fatigue and “brain fog.” www.TheFibroDoctor.com Potential Side-Effects of… Trazadone Flexeril Elavil Lunesta Fatigue Depression Fibro Fog Anxiety Drowsiness Fatigue Weight-gain Dizziness Tics Hang over Hang over Fatigue Parkinson like Fibro Fog Fatigue Hang over Stroke Upset Stomach symptoms Muscle stiffness Hallucinations Fibro Fog www.TheFibroDoctor.com Other Sleep Medications Benzodiazepines Xanax, Restoril, Ativan, Valium, Tranxene, Klonopin These medications don’t promote deep restorative sleep and are associated with numerous side effects. Such as: Depression, Fatigue, Fibro Fog, Dependence, Tardive Dyskinesia, Insomnia. These medications block the sleep inducing hormone, melatonin. www.TheFibroDoctor.com Benzodiazepines are addictive (within 2 weeks) and can cause a host of unwanted side effects. Poor sleep, seizures, mania, depression, suicide, ringing in the ears, amnesia, dizziness, anxiety, disorientation, low blood pressure... www.TheFibroDoctor.com Nausea, fluid retention, tremors, sexual dysfunction (decreased desire and performance), weakness, somnolence (prolonged drowsiness or a trance-like condition that may continue for a number of days), and headaches. www.TheFibroDoctor.com Forty percent of those age 60 or older who take tranquilizers, will experience tardive dyskinesia For many, these tremors are permanent. These drugs deplete CoQ10 and melatonin levels. www.TheFibroDoctor.com CoQ10 Deficiency A CoQ10 Deficiency can lead to Depression Fibro Fog/Confusion As well as muscle weakness and pain www.TheFibroDoctor.com Stress Stress is Responsible for 80-90% of all Illnesses and Poor Health. Chronic Stress is the Catalyst for Poor Health www.TheFibroDoctor.com Stress-Coping Savings Account Serotonin Dopamine Cortisol DHEA Human Growth Hormone Norepinephrine GABA Vitamins Minerals Antioxidants Serotonin We Are all born with a Stress-Coping savings account WITHDRAWALS Traffic James Poor Sleep Pollution Long Work Hours Unhappy at Job Mental Problems Money Problems Every moment of the day, we are making withdrawals from our Stress-Coping Savings Account www.TheFibroDoctor.com Stress Coping Account Is Your Account Bankrupt? If you make more withdrawals than deposits you bankrupt your account www.TheFibroDoctor.com Stress-Coping Savings Account X X X X XX X X X X XX X X X XX X XX X Serotonin We make deposits into our stress-coping savings account by going into deep sleep Deep Restorative Sleep Delta Wave Deposits Deep Restorative Sleep Is The Key to Rebuilding Our Stress-Coping Savings Account Stress-Coping Savings Account S S S S S S S S SS SS S S S S S SSS S Serotonin SEROTONIN DEEP SLEEP Deposits SEROTONIN • Less Pain - Blocks Substance Associated with Increasing Pain (substance P) Hormone - Boosts Mood • Happy Reduces anxiety • Increases Mental Clarity • Restores Normal Bowel Function - IBS The Importance of Serotonin Serotonin is a neurotransmitter or brain chemical. It helps regulate sleep, digestion, pain, mood, and mental clarity. Normal serotonin levels help: 1. Raise the pain threshold (have less pain). 2. You to fall asleep and stay asleep through the night. 3. Regulate moods. “It’s the happy hormone.” 4. Reduce anxiety. 5. Reduce sugar cravings and over-eating. 6. Increase a person’s mental abilities. 7. Regulate normal gut motility (transportation of foodstuff) and irritable bowel syndrome (IBS). www.TheFibroDoctor.com Serotonin Receptors You have more serotonin receptors in your intestinal tract than you do in your brain. Low serotonin interferes with proper intestinal function. Symptoms associated with IBS, diarrhea, and constipation, usually disappear within 1-2 weeks once serotonin levels are normalized. Goldberg et al. Modification of visceral sensitivity and pain in irritable bowel syndrome by 5HT3 antagonism (odansetm). Digestion 1996. Nov-Dec; 57(6): 478–83. www.TheFibroDoctor.com SSRI and SSNRI Medications Individuals with FMS are often prescribed a selective serotonin re-uptake inhibitor (SSRI) or selective serotonin and norepinephrine re-uptake inhibitor (SSNRI). Lexapro Cymbalta Celexa Paxil Prozac www.TheFibroDoctor.com Zoloft Effexor Antidepressant Drugs Have Potential and Common Side effects... www.TheFibroDoctor.com anxiety, depression, headache, muscle pain, chest pain, nervousness, sleeplessness, drowsiness, weakness, changes in sex drive, tremors, dry mouth, irritated stomach, loss of appetite, dizziness... www.TheFibroDoctor.com Nausea, rash, itching, weight gain, diarrhea, impotence, hair loss, dry skin, chest pain, bronchitis, abnormal heart beat, twitching, anemia, low blood sugar, and low thyroid. • Deplete melatonin levels. • Tricyclic antidepressants deplete CoQ10. www.TheFibroDoctor.com Selective Serotonin Re-uptake Inhibitor (SSRI) Medications: In almost half of the studies show that up to 70% of those taking SSRI antidepressant medications do just as well by taking a placebo or sugar pill. www.TheFibroDoctor.com Individuals on SSRI drugs increased their Hamilton Rating Scale 2 points compared to those on placebo. www.TheFibroDoctor.com Sleep disturbances, either insomnia or somnolence, have been reported in about 25% of patients taking serotonin reuptake inhibitors. THIS OFTEN LEADS TO MORE DRUGS TO TREAT THE ANTIDPRESSANT SIDE EFFECTS. www.TheFibroDoctor.com Down-Regulation The Longer You’re on SSRI Meds, The more likely you are to deplete your serotonin receptors. www.TheFibroDoctor.com SSRI’s Prozac Celexa Zoloft Paxil Lexapro SSRI’s are like gasoline additives that help you get more “milage” from the serotonin being released into the brain. S SS SS N S S S SN S N SS S N Normal Brain www.TheFibroDoctor.com S S S S S N N Gasoline Additive When your brain is running on “FUMES” … a gasoline additive won’t help Most individuals with Mood Disorders don’t have any Serotonin or Norepinephrine to re-uptake! S SS SS N S S N S S S N SS S N Normal Brain S S N Fibro Brain www.TheFibroDoctor.com 5HTP SEROTONIN 5HTP 5-Hydroxy Tryptophan + Vitamins B6, B3 and Magnesium = SEROTONIN www.TheFibroDoctor.com 5HTP increases your natural sleep hormone melatonin by 200% This in turn promotes deep restorative sleep www.TheFibroDoctor.com Stress Stress Coping Glands Most of my patients have not only bankrupted their stress coping savings account but have also exhausted their stress coping glands, the adrenal glands. www.TheFibroDoctor.com Stress General Adaptation Syndrome The general adaptation syndrome (GAS) is divided into 3 phases. • Fight or Flight • Resistance Reaction • Adrenal Exhaustion www.TheFibroDoctor.com The General Adaptation Syndrome Divided into 3 phases Fight or Flight The first phase is known as the "fight or flight response.” This response is an alarm reaction. The fight or flight response encourages the body to go on red alert and be ready for physical and mental activity. The heart beats faster to provide blood to the muscles and brain. The breath rate increases to supply extra oxygen to the muscles, heart and brain. Digestion and other functions not essential for maintaining the alarm reaction are halted. www.TheFibroDoctor.com Stress Stress and Nutritional Deficiencies Low Thyroid Function Stress, depression, anxiety and fatigue are all associated with low thyroid function. Thyroid hormones help regulate concentration, mental clarity, moods, and proper brain chemistry. T3 therapy is more effective in reducing the symptoms associated with depression than SSRI antidepressants. www.TheFibroDoctor.com Adrenal Burn Out The majority of patients I see for chronic illnesses, including FMS and CFS , are suffering from adrenal exhaustion. They have literally burned their stress monitoring organ out. Between years of poor sleep, unrelenting fatigue, chronic pain, excessive stimulants, poor diet, and relying on a plethora of prescription medications, the adrenal glands and the hormones they release have been used up. www.TheFibroDoctor.com Corticosteroids Cortisol is secreted by the adrenal glands that rest above each kidney. The adrenal gland is divided into the outer cortex and the smaller inner medulla. The cortex produces cortisol and dehydroepiandrosterone (DHEA). Cortisol helps increase cellular energy, mental clarity, immune function, and acts as a potent anti-inflammatory. DHEA helps increase mental clarity, well-being, stress coping abilities, immune function, and libido. Cortisol and DHEA help a person have more resistance to stress.Individuals with FMS have been shown to have a deficiency of cortisol. Brain Behav. Immun. 2004 Jul; 18(4):314-25. www.TheFibroDoctor.com Adrenal Cortical Glandular Extracts Those taking over-the-counter adrenal cortical glandular supplements usually repair their adrenal glands within 6 months. www.TheFibroDoctor.com Medical Myth Vitamin and Mineral Supplements Aren’t Helpful for Treating Disease www.TheFibroDoctor.com The Importance of Vitamins and Minerals In a cross-sectional study of 150 consecutive patients referred to a clinic in Minnesota for the evaluation of persistent, nonspecific musculoskeletal pain, 93% had serum levels indicative of vitamin-D deficiency. www.TheFibroDoctor.com Vitamin and Mineral Supplements B-vitamins play a crucial role in the production of neurotransmitters. A deficiency in any of the B-vitamins will increase the risk of mood disorders. www.TheFibroDoctor.com Vitamin and Mineral Supplements The standard American diet (even if you eat fruits and vegetables every day) is overloaded with toxic artificial chemicals. Modern processing methods remove 25-75% of the original nutrients. A U.S. Food and Drug Administration study, which analyzed over 234 foods over 2 years, found the average American diet to have less than 80% of the RDA of one or more of the following; calcium, magnesium, iron, zinc, copper, and manganese. www.TheFibroDoctor.com S- Adenosyl-methionine (SAMe) SAMe IS one of the best natural antidepressants available. SAMe helps boost serotonin and epinephrine levels. Combining SAMe with prescription antidepressants reduces the failure rate by 43%. There are over 100 peer-reviewed studies showing that SAMe is a safe and effective antidepressant. www.TheFibroDoctor.com Essential Fatty Acid Imbalances Research shows that low blood levels of omega 3 essential fatty acids are associated with depression. Restoring proper omega 6 to omega 3 ratio’s is important in optimizing neurotransmitter function. www.TheFibroDoctor.com Studies show that Folic acid is more effective than standard prescription antidepressants. 92% of those treated with folic acid made a full recovery, while only 70% of the control group (those taking antidepressants) made a full recovery. Studies that combining folic acid with a SSRI (Prozac) was more effective than taking the prescription drug alone. www.TheFibroDoctor.com Vitamin and Mineral Supplements Other studies have demonstrated magnesium deficiency in well over 50% of the population. A magnesium deficiency can contribute to arteriolosclerosis, fatigue, tight muscles, leg cramps, insomnia, constipation, cardiac arrhythmia, and heart disease. www.TheFibroDoctor.com Loss of Optimal Health Dr. Janet Travell, White House physician for Presidents John F. Kennedy and Lyndon B. Johnson, and Professor Emeritus of Internal Medicine at George Washington University co-wrote Myofascial Pain and Dysfunction The Trigger Point Manual, which is acknowledged as the authoritative work on muscle pain. In one chapter alone, Dr. Travell and co-author, Dr. David Simons, referenced 317 studies showing that problems such as hormonal, vitamin, and mineral deficiencies can contribute to muscle pain and soreness. www.TheFibroDoctor.com Fatigue and Immune Function *In a Scottish trial, patients with chronic fatigue syndrome were given EFA supplements with great success. Placebo controlled trials were held for 70 patients with persistent CFS giving them linolenic acid (flax seed oil) and eicosapentaenoic acid (fish oil). After 6 months, 84% of the patients in the group receiving EFA supplements, and only 22% of those in the placebo group rated themselves as better or much better. www.TheFibroDoctor.com Fatigue and Immune Function *In another successful study, 63 adults with CFS were enrolled in a double blind placebo controlled study with essential fatty acid therapy. The patient’s were ill for an average of 1-3 years after a viral infection. They all suffered from severe fatigue, myalgia (muscle pain), and a variety of psychological symptoms. After one month, 74% of the patients taking EFA supplements, and 23% of those on placebo, assessed themselves as improved. www.TheFibroDoctor.com Digestive Disorders A majority of patients suffering from FMS will also have one or more digestive disorders. Bloating, gas, indigestion, IBS, spastic colon, reflux, malabsorption, etc. Chaitow, L. “Fibromyalgia Workshop News 2000. www.TheFibroDoctor.com Abnormal Thyroid Function The symptoms of FMS and CFS are consistent with those associated with low thyroid function; low body temperature, cold hands and feet, tingling in the extremities, fatigue, and depressed mental acuity. Recent studies show that over 43% of individuals with FMS have low thyroid function. It's estimated that those with FMS are 10 to 250,000 times more likely to suffer from thyroid dysfunction. (Lowe, et al., 1997, pp. 31-58). www.TheFibroDoctor.com Thyroid Blood Tests May Not Be Accurate Dr. Broda Barnes was the first to show that a low basal body temperature was associated with low thyroid. His first study was published in 1942 and appeared in The Journal of the American Medical Association. This study tracked 1,000 college students and showed that monitoring body temperature for thyroid function was a valid, if not superior, approach to other thyroid tests. (Barnes, 1976). www.TheFibroDoctor.com