Fibromyalgia

By Alon Marcus

 

According to a consensus document on fibromyalgia (FM)—the Copen­hagen Declaration (Jacobsen, Samsoe, Lund, 1993)—FM is a painful, non‑articular condition predominantly involving muscles, and is the commonest cause of chronic widespread musculoskeletal pain. It was only by 1987 that FM was rec­ognized by the American Medical Association (AMA) as a distinct condition that is responsible for significant disability. Many however, still do not believe FM to be a distinct condi­tion and consider it a “garbage  diagnosis” for many separate disorders, including “just being” a verity of a chronic affective (somatization) disorder. FM is a chronic disorder and relatively unchanging. In FM the pain often is bilateral, variable and generalized (involving all four quadrants). The pain cannot be explained by peripheral mechanisms only and neural plasticity with CNS sensitization and reduced pain threshold playing a major role.

The patients often complain of fatigue, poor quality of sleep, morning stiffness and increased perception of effort. Muscular pain increases during repetitive muscular activity and usually eases on cessation. FM is frequently associated with other medical conditions such as; irritable bowel syn­drome, dysmenorrhea, headaches, subjective sensation of joint swelling (Baldry 1985), depression, generalized anxiety, mitral valve prolapse, restless leg syndrome, chronic fatigue syndrome, and myofascial pain syndrome (Goldenberg 1999 and Pellegrino 1996).

Common symptoms are: generalized pain which may be dull, deep, achy or at times sharp, throb­bing, shooting-especially if associated with other patholo­gies. There is often increased morning symptoms of stiffness, fatigue, and pain (which often are associated with Dampness, Cold, and Qi-Blood stagnation in TCM). Other symptoms such as dizziness and/or light-headedness, “spaceyness”/cognitive difficulties (“brain fog”) which can be due to orthostatic hypotension and/or hypovolemia (and often due to Phlegm or Blood deficiency in TCM), photo­phobia, stress intolerance, depression, sleep disturbances (early morning awakening which is seen in depression as well), digestive symptoms of bloating; gas cramping diarrhea and/or constipation, palpitations, easy sweating or night sweats, blared vision, urinary symptoms, respiratory symptoms, and allergic symptoms.

Dellenbach et al (2001) have suggested that many patients with chronic pelvic pain are suffering from what they call pelvic-fibromyalgia. Pelvic pain is a frequent and difficult problem because despite the quality and diversity of diag­nostic procedures no relevant etiology will be found in 30 to 40% of all cases. It has been proposed that in many cases the dominant pain is not visceral but parietal. In many of these patients the pelvic envelope is actually more painful than the pelvic content. In these cases one can evoke the diagno­sis of pelvic fibromyalgia and this is quite similar to classic FM. This form of pain actually is the somatization of a past and difficult issue which will be very slowly and progres­sively revealed in the realm of a multidisciplinary and simul­taneous physical and psychological approaches. In the majority of cases these women have a history of physical, moral or sexual trauma inflicted by family members or a third party. Taking in account the physical dimension of body pain at the same time as psychotherapy will consider­ably enhance the efficiency of treatment. In the experience of this study authors 70% of all women will be “cured” using this approach.

FM caused by trauma or another precipitating event such as serious illness (often infectious) tends to be more severe and have a worse prognosis than idiopathic FM (Romano 2000). FM is seen in 2-3.3% of north American population and is most prevalent in females between the ages of 40-64. Basal autonomic states of FM patients is characterized by increased sympathetic and decreased parasympathetic tone with associated increased resting heart rate, reduced heart rate variability, deranged response to orthostatic stress and a high incidence of Raynaud’s syndrome (Donaldson et al 2001).

The prognosis of FM is much less favorable than myofascial syndrome and patients often respond only temporarily to treatment. Reeves (1994) however, reported that prolotherapy was suc­cessful in resolving symptoms in more than 75% of his patients with “severe fibromyalgia.” OM and other natural approaches, preferably in concert, can be very helpful. Cures however are few.

Mechanisms of FM

Animal studies (Mense 1990), have shown that activity in central nociceptive neurons, receiving input mainly from muscles, are under more central inhibitory control than cen­tral nociceptive neurons receiving inputs from skin. This central inhibition may explain why treatment to the CNS with antidepressants often is helpful in FM patients. Further­more, a review article presented by Henriksson at the Second World Congress on MPS and FM states that there are, at present, a fairly large number of studies that indicate that FM patients have either a disturbance of pain modulation or a disturbed function of other regulatory systems.

He further cites studies that implicate serotonin metabolism and defi­ciency, an increased substance P in CSF, lower levels of cor­tisol, epinephrine and norepinephrine following exercise in patients than in controls, enhanced pituitary release of ACTH, low metenkephaline levels and lower levels of serum IGF-1. Finally, he cites a few reports of immunological dis­turbances in FM, for example, a defect in the interleukin‑2 pathway. Recently, information from PAT scans has shown a dysfunctions in thalamic activity. Compared to healthy individuals, FM patients have significantly lower resting-states levels of regional cerebral blood flow in the thalamus and caudate nucleus (Mountz et al 1995, Kwiatek et al 1997). Other theories include: central neurotransitter imbal­ances, thyroid hormone resistance, stress-related physiologi­cal changes, psychopathology, psychosocial factors, and disturbance of alpha intusion of sleep (Donaldson et al ibid).

Some authors suggest that FM is a somatization syndrome due to depression. Recent research suggests otherwise (Stiles and Landro 1995). Their data showed that a cognitive dys­function—reflecting a presumed compromise of the right hemisphere—which is present in major depression, is not found in primary FM. They concluded that this finding would suggest that primary FM and depression are different conditions. Croft et al (1994) have noted that the presence of many tender points is found also with depression, chronic fatigue, anxiety disorders, and other somatic symptoms including pain, are associated with the above as well. Other symptoms that are in common with depression include poor sleep, fatigue, morning stiffness, poor concentration and poor immediate recall (Donaldson et al ibid).

Differential Diagnosis

Several conditions can mimic fibromyalgia. Some examples include (Jacobsen, Samsoe and Lund 1993):

• Hypothyroidism.
• Widespread malignancy.
• Polymyalgia rheumatica.
• Osteomalacia.
• Generalized osteoarthritis.
• Early Parkinson’s disease.
• Initial stage of various connective tissue diseases.

Diagnostic Criteria

The American College of Rheumatology criteria for the clas­sification of fibromyalgia are;

• History of widespread pain, extending into the sides of the body and pain above and below the waist.
• Axial skeletal pain must be present. Low back pain is considered lower segment pain.
• Pain must also be present in 11 of 18 tender sites on digital palpation of an approximate force of 4kg. These are:
• At the suboccipital muscle insertions
• Anterior aspects of the intertransverse spaces of C5‑C7.
• Midpoint of the upper border of the trapezius.
• Origins of supraspinous above the scapula.
• Upper lateral aspects of the second costochondral junction.
• 2 cm distal to the lateral epicondyle.
• The upper outer quadrants of the buttocks in the anterior fold of the gluteal muscle.
• The posterior aspect of the trochanteric prominence of the greater trochanter.
• Medial fat pad proximal to the joint line of the knee.

The diagnostic criteria suggested by (Yunus et al. 1981; Moldofsky et al. 1975) are:

• Widespread aching of more than 3 months duration.
• Cutaneous and subcutaneous sensitivity as demonstrated by skin roll.
• Morning fatigue stiffness with disturbed sleep.
• Absence of laboratory evidence of inflammation or mus­cle damage.
• Bilateral tender points in at least 6 areas.

Fibromyalgia & OM

Because fibromyalgia presents with a variety of symptoms and fatigue is a common complaint, the disorder often falls within OM internal medical and Painful Obstruction classifi­cations. Stress, poor sleep quality, poor diet, insufficient rest, unresolved emotions (depression/anxiety/fear), or trauma can influence Organ functions, deplete True-Qi, Blood and flu­ids all of which may result in stagnation of Qi and Blood, formation of Dampness and Phlegm and symptoms and signs of FM. Blood loss may injure the Liver and Qi which then may fail to nourish the sinews. The muscles may tighten and loose their strength. FM with deficiency of Blood is more commonly seen in females—as blood is lost with menses. Stasis may be seen in chronic diseases and traumas.

Although not necessarily an externally contacted dis­order, many FM patients present with a history of infectious disease, injury, and/or severe medical condition—in which pathogenic factors often play a major role. FM may be best described by six OM clinical presentations.

• Retention of pathogenic factors.
• Latent pathogenic factors.
• Pathogenic factors between the Interior and Exterior (Shao Yang).
• Part of Organic and/or other internal disorder with/without externally contracted pathogenic factors. General stress depleting the True-Qi resulting in pathogenic factors and Organic disorders with Liver, Spleen and Heart involvement being the most common.
• Trauma injuring True-Qi and Blood.
• Hemorrhage.

FM begins often following an infectious, or other medical disease, which can lead to retained pathogenic factors. It may also result from trauma, blood loss, chronic stress or chronic diseases. Stress, trauma and retained pathogenic factors result in obstruction and often also, secondary unstable Yang (Yin-Fire, Empty-Heat, Wind etc.) which can mani­fests as facilitated sympathetic nervous system and may depress the parasympathetics.

Autonomic nervous dysfunc­tion (and unstable Yang) often manifests with increased pulse rate that tends to be variable (frequent changes in; rate strength and quality with little stimulation— which is associ­ated with weakness in OM often), or wiry pulse (often with Shao Yang syndrome), decreased circulation with trophic edema and increased red skin responses on various areas (i.e., the skin remains red when scraped or needle inserted, due to poor circulation from excessive sympathetic activity), increased fascial tissue sensitivity demonstrated by pinching or rolling the skin, tender muscles, nodulations in muscles, hypochondriac tension (felt in abdominal [Hara] evaluation), thoracic inlet/outlet tension (felt at and around the SCM muscles) and reactions at the Kidney/Chong chan­nels often. The organs/Organs can become congested and dysfunctional.

The main pathogenic factor seen clinically is Dampness, often with underlying deficiency. Transformative Heat and Yin Fire/unstable Yang are common complicating factors. The severity of the muscle aches is often related to the level of pathogenic Dampness or Phlegm. With time Blood stasis and more severe and fixed pain can develop. Risk factors for Dampness and Phlegm are:

• Improper treatment.

A common clinical iatrogenicity is due to excessive use tonifing methods in patient with pathogenic factors. This is said to result in further penetration of pathogenic fac­tors and increased symptoms of deficiency, stagnation and Heat. The proper treatment often is to eliminate pathogens which then result in recovery of the patients’ True-Qi.

Excessive or improper use of cold medicines/antibiotics is said to be capable of damaging the Spleen/Stomach and may result in Dampness and Phlegm, or drive Wind-Cold pathogenic factors internally, which become hidden. With hidden-Heat the patient becomes ill later when another infection or life stresses increase. Latent-Heat disorder is said to be more com­mon in a patient with deficient constitution (especially Yin).

Excessive or improper use of hot and spicy medicines are said to thicken, and consume fluids that may transform into Phlegm/mucus and lodge internally or within the joints and mus­cles. This may result in pain and obstruction. Hot and spicy medicines are said also to be capable of injuring Yin resulting in deficient Yin empty-Heat and difficulties with sleep.

Excessive use of Qi moving medicines are said to be capable of injuring Qi resulting in stagnation due to lack of move­ment from Qi weakness. Qi stagnation then may result in local transformative-Heat and inflammatory signs. Deficient Qi may result in eventual weakness of Blood. The sinews may tighten and patient’s sleep affected with increased dreams.

Excessive use of Blood moving medicines are said to be capable of injuring both the Qi and Blood again resulting in obstruction due to lack of vitality.

• Fever/Heat/Fire

Fever, Heat, and stagnation may damage the fluids, which congeal and thicken and do not flow. Excessive Coldness from Exterior, or Interior, causes are said to be able to congeal the fluids as well.

This common clinical presentation may result in the development of “Trigger Points” (Ashi-Kori-tight bends) in muscles that generally feel soft soggy and nodular with low general tone. Both Dampness and Yin deficiency may develop. Blood stasis is a secondary complication seen frequently. When Blood stasis is significant the patient may develop abdominal reactions at the left lower quadrant, visible darkened blood vessels, skin discoloration (especially lips), choppy or slippery/wiry pulse, and a hard area or point (fibrous tis­sue) within the muscular taught bend (Kori), often at the motor points (usually at midpoint of muscle), and fixed pain that is worse at night or by inactivity. If Phlegm and Blood stasis combine and stagnate the patient may develop bony swelling, spurs and/or inflamed and hard bursae. Insertional tendinitis may develop as well.

Deficient Yin patients may show a tight (vessel) or quick thready-wiry pulse. A pounding pulse can be seen in both deficient and excess conditions with pathogenic factors. A significantly weak patient may present with a pounding pulse, which may be slow or fast. The vessel wall tends to be tight in excessive conditions and softer in deficient patients (at least in Yang deficiency and Dampness). As the patient strength is increased the underlying (Organ) pulse may show. The tongue often shows signs of Damp­ness/Phlegm. Signs of Blood stasis may/not be seen.

• Spleen/pancreas and Liver

Pathogenic factors may damage the Spleen/pancreas disturbing the transforming and transporting functions of the Spleen. These patients may have digestive symptoms and may be sensitive to foods. They often feel bloated and have epigastric or lower abdominal discomfort and gas. The area around the umbilicus and between CV9-12 may  be tight and sensitive. A pulse around the umbilical region may be visible or palpable. The degree of Dampness or Phlegm is seen often on the tongue coat (but not always).

Another similar presentation may be seen in patients with prior weakness of Spleen/pancreas and a tendency to develop or retain Dampness. This condition is often secondary to poor dietary habits and or excessive stress. Signs are similar to above except that the patient has a long history of weak diges­tion and/or fatigue. Or may, at times, just report fatigue/sleepiness after eating and mild bloating. The tongue coat may be normal but tongue body is often swollen and pale. The right middle pulse tends to be soft or weak.

Spleen/pancreas weakness is said also to result in deficiency of Blood, which then may weaken the Liver (“fail to lubricate”) and may result in Liver Qi stagnation/congestion. The Liver then may fail to nourish the sinews; muscles/sinews develop tension and weakness. Liver Qi stagnation may result in variable and poorly localized pains, and leave the patient susceptible to emotional stress and aggravation.  Because Qi (or Phlegm/Dampness) stagnation is said to slow circulation, Blood stasis and or transformative Heat may develop. When Qi stagnation becomes severe and rebels swelling (usually not substantial or changing) may develop. Heat may congeal fluids, which become Phlegm. When Phlegm and Blood join, muscles may become fibrotic and loose flexibility; possibly permanently. With Qi stagnation the patient’s symptoms may frequently change.

Liver stagnation is a common condition found/seen in patients. Liver-wood stagnation is an excessive condition and may result in over-regulation of Spleen-earth (via five phase theory). This disharmony is anther risk factor of Spleen/pancreas failing to transform and transport which may result in Dampness.

• Lungs

Pathogenic factors can disturb the Lung’s descending function, which normally direct Fluids to the Kidneys (often after respiratory infections) and result in dryness, edema, and Qi dysfunction; as the Lungs are said to control Qi which is the motive force behind fluids and Blood. Failure of the Lungs to control Qi and vessels may lead to pulling of Blood, or fluids in lower body, seen as varicose veins or edema.

These patients more commonly show signs of upper edema (Phlegm) (under eyes, face and sinuses), and tenderness/induration at Lu-1 (pecks), GB-21 (traps), and UB-13 (upper back) areas. They may/or not have other respiratory symptoms. The tongue coat may show signs of Dampness/Phlegm and may also show dryness at the root.

• Kidney Yin, Yang, Essence or True-Qi deficiency.

The Kidneys are the source of Yin and Yang and can influence most of the bodily systems that may lead to FM. It is Kidney Yang that is the origin of Spleen Yang, which is the impetus within the Spleen in charge of transformation and transportation. The Kidneys are the root of Qi, and healthy functional breathing requires the Kidneys to except and root Qi. The Fire/force of the Heart, and Triple Warmer come from the Kidneys and therefor both Blood and fluid circulation are ultimately dependent of healthy Kidney function.

The fluids that travel with Defensive-Qi (via Triple Warmer) at the Cuo Li (the space between the skin and muscles/membrains/interstice) are rooted in Ming-man (Kidney Yang) both of which depend of the Kidneys for motility and warmth. The creation of Blood is also ultimately dependent of healthy marrow and Kidneys because the Kidneys warm the Spleen/pancreas, motivate moisten and nourish Liver, root the Lungs, and warm the Heart all of which are needed to form Blood. The Kidneys are said to be incharge of fluids, therefor, Dampness and other fluid dysfunctions can result from Kidney disorders.

Patients with Kidney (Essence or True Qi) weakness may have a long history of poor health (constitutional or from chronic illness) and general physical weakness (especially poor physical and mental endurance). The lower abdomen may be soft at the surface, and tense deeply with excessive pulsations felt. Kidney points at, or just below, the umbilicus may be tight and tender. The patient’s complexion may be dull, and especially in women the area around the mouth and eyes may be green and dark. Tenderness and tightness/indurations may be felt espe­cially at UB-52 (quadratus lumborum), CV4-6, K-7 and K-3. Phlegm develops due to a lack of vitality and may be “Unseen Phlegm” i.e. lacking many of the usual signs of Phlegm such as greasy, slimy tongue coat, especially in Kidney Yin deficient patients. The pulse at the proximal positions may reflect weakness.

Latent Pathogenic Factors are said to be seen most com­monly in deficient patients that do not have a clear history of onset of infectious disease. Insufficiency of the patient’s True Qi, Kidney Qi, Yin and Essence is said to result in pathogenic factors entering the Interior, without the develop­ment of superficial symptoms, (due to lack of battle between the anti-pathogenic Qi and pathogens) or with only mild symptoms.

Later, symptoms of Heat, irritability, digestive disturbances, fatigue and possibly muscle pain may develop. Yin deficient patients may tend to develop a com­plex syndrome with symptoms of Heat, Cold and Dampness. Yang deficient patients may tend to develop a Cold syn­drome with Dampness, local Fire however can be seen. In FM patients, if treatments that usually work in latent-Heat prove effective, the patients may or may not show the clas­sic syndrome of latent or retained pathogenic factors (e.g., infection, irritability, digestive symptoms signs etc.). Signs may be felt in the tissue texture of muscles as well as joint end-feels. They usually include “Rheumatic” type changes.

Pathogenic factors may be retained in the Shao Yang level (between the Exterior and Interior), especially in stressed patients. The patient is said to be temporarily deficient (from stress) and therefore unable to dispel the external pathogenic factors. The pathogenic factors are often weak as well. The main manifestation is alternating or combined symptoms of Heat and Cold. FM patients with Shao Yang syndrome may not show the classic (Shan Han Lun) syndrome but may more often present with both Internal and External symptoms, and have a rela­tively strong muscular physic. They complain often of temperature disregulation, saying that “since they have been sick” their internal temperature is not right—some time they feel exces­sively cold or hot.

Clinical experience (of the author) sug­gests this condition is more common in male patients. Secondary Yin deficiency, Liver Qi stagnation and Blood stasis may be complicating factors. The soft tissues, muscles and joints of these patients have a tighter feel com­pared with the more deficient patient. The patient usually appears to be physically strong. The subcostal and possibly epigastric and right lateral abdomen areas may be tight, sensi­tive and may show tight bends and indurations. The pulse may be wiry.

Treatment

FM is notoriously unresponsive to standard treat­ment. The standard of care (in US) continues to be treatment with antidepressant medication, despite much research showing that in most instances depression is a result, rather than a cause of the condition (Block 1993, Duna and Wilke 1993)—the effectiveness of which has much to do with improvement in sleep from these medicines, and lower doses of these drugs are usually used than for depression. Treatment may include physical medicine procedures such as: acupuncture, manual therapies (especially muscle energy, functional, counter-strain and cranial techniques), ultrasound, and heat. Internal therapies such as: herbal, nutritional and if needed pharmaceutical. Psychotherapy (cognitive), biofeedback and other relaxation exercise and EEG biofeedback may be helpful. The patient’s sleep quality must be improved; as altered sleep patterns are probably the most important clinical facet of FM. Patients should try to sleep at least 8 hours per day. FM patients must participate in mild weight-bearing exercises, which usually decrease their muscle pain. However, they should not over exercise and should conserve their energy. One-day rest between exercise sessions may be prudent.

Osteopathic approaches have been shown to be helpful in treating patients diagnosed with FM. Stotz and Kappler (1992) treated patients using a variety of osteopathic approaches. Goldenberg (1993) measured the effects of osteopathic manipulative therapy on the intensity of pain reported from tender points in 18 patients who met all the criteria for FM. Each patient had six treatments. Over a one year period 12 of the patients responded well, and their ten­der points became less sensitive (14% reduction verses a 34% increase in the six patients who did not respond). Activ­ities of daily living were significantly improved and general pain symptoms decreased. Rubin et al (1990) studied 19 patients with all the criteria of FM. The patients were treated once a week for 4 weeks using osteopathic therapies. 84.2% of patients had improved sleep, 94.7% reported less pain and most patients had fewer tender points on palpation at end of treatment.

Acupuncture has been shown to be helpful in FM. Sprott, Franke, Kluge, and Hein (1998) performed acupuncture ther­apy in FM patients and established a combination of meth­ods to objectify pain measurement before and after therapy. Acupuncture treatment of patients with FM was associated with decreased pain levels and fewer positive tender points as measured by VAS and dolorimetry. They also showed a decreased serotonin concentration in platelets and an increase of serotonin and substance P levels in serum after treatment. These results suggested that acupuncture therapy is associated with changes in the concentrations of pain-modulating substances in serum.

Sprott, Jeschonneck, Grohmann, Hein (2000) have shown that besides normalization of clinical parameters, acupuncture results in improvement in microcirculation above “tender points.”

Montakab (1999) has shown acupuncture to be helpful for insomnia (not in FM patients however). Forty patients with primary difficulties in either falling asleep or remaining asleep were diagnosed according to TCM and assigned to specific diagnostic subgroups and treated individually by a practitioner in his private practice. The patients were ran­domized into two groups, one receiving true acupuncture; the other needled at non-acupuncture points for 3-5 sessions at weekly intervals. The outcome of the therapy was assessed in several ways; first by an objective measurement of the sleep quality, and second by polysomnography in a specialized sleep laboratory, performed once before and once after termination of the series of treatments. Additional qualitative results were obtained from several question­naires. The objective measurement showed a statistically significant effect only in the patients who received the true acupuncture.

Zborovskii and Babaeva (1996) showed that 9.6% of 1240 patients making complaints of osteomuscular pains had clinical signs of primary fibromyalgia (PFM). They sug­gested therapies that combined the use of dimexide with NSAIDs and sessions of acupuncture that promotes the nor­malization of dysfunctions.

Evaluation of the effects of a standardized acupuncture treatment in primary Raynaud’s syndrome showed a signifi­cant decrease in the frequency of attacks from 1.4 day-1 to 0.6 day-1, P < 0.01 (control 1.6 to 1.2, P = 0.08). The overall reduction of attacks was 63% (control 27%, P = 0.03). The mean duration of the capillary flowstop reaction decreased from 71 to 24 s (week 1 vs. week 12, P = 0.001) and 38 s (week 1 vs. week 23, P = 0.02) respectively (Appiah, Hiller, Caspary, Alexander, Creutzig 1997). Both insomnia and Raynaud’s are very common in FM patients.

In general however, a review study by Sim and Adams  (1999) stated that there is little empirical evidence for the effectiveness of physical and other non-pharmacological approaches to the management of FM. And although a num­ber of studies have been conducted into such approaches, many of these are uncontrolled, and relatively few random­ized controlled trials of appropriate size and methodological rigor have been carried out. They reviewed evidence pre­sented under the headings of: exercise, EMG biofeedback training, electrotherapy and acupuncture, patient education and self-management programs, multimodal treatment approaches, and other interventions. They concluded that it is hard to reach firm conclusions from the literature, owing to the variety of interventions that have been evaluated and the varying methodological quality of the studies concerned. Nonetheless, in terms of specific interventions, exercise ther­apy has received a moderate degree of support from the liter­ature, and has been subjected to more randomized studies than any other intervention.

It is this author’s experience that no one style of medicine or technique is effective in the majority of FM patients (except perhaps exercise). An integrated approach is superior to any single intervention.

Acupuncture

Acupuncture is best utilized to address the patient’s physical presentation (with palpation based techniques). Pulses are balanced by four-needle technique or other channel thera­pies; abdominal presentations such as subcostal tension are addressed with techniques utilizing the Chong, Yin Wei, Liver and Pericardium channels. Since the pathogenesis and obstruction manifest mostly in the muscular tissues (even with internal Organic syndrome), trigger/Kori-Ashi release of affected, and related areas are achieved with gentle tech­niques that result in mild muscle twitches.

The Sinew channels on the affected areas are sedated (trigger release) and the paired Main channel may be tonified. Moxa can be used on areas with poor muscle and skin tone (may be found within the same muscle that has indurated triggers) and to vitalize deficient channels. Blood stasis is treated mainly via Chong, Liver channels, UB-17, LI-11, Sp-10 and 21. Dampness via the Spleen/pancreas, Lung and Kidney channels. Microsystems (ear, wrist/ankle etc.) can be used at the same time for further symptomatic relief. As distortion of body image (sensation of swelling w/out swelling, sensation of shrinking w/out shrinking) and difficulty describing symptoms are common in FM patients, Sp-4, Lu-7, UB-11, St-37, and 39 may be used often. Sp-21 may be used for “total body” pain.
Acupuncture is also helpful in treating the patient mood and sleep, which are extremely important to address. Poor sleep is probably the most important perpetuating factor seen in these patients. H-7, P-6, Amnien, Yinteng, Du-20 and ear-wrist and Shenman points may be used.

Manual Therapy

In all FM patients the thoracic inlet/outlet must be carefully evaluated by assessing soft tissue tension and length, respira­tory functions and proper joint play. Treatment can begin with trigger release, but if function of any of the above struc­tures does not improve, other techniques such as muscle energy, indirect/functional, and cranial techniques should be incorporated. For example, it is common for the first rib to subluxate due to scalene muscle tension (due to stress) together with a sudden sidebending of the neck. The rib lodges above the transverse process of the first thoracic ver­tebra. Subluxation results in poor rib cage function. Release of scalene muscle tension, on its own, will not restore the rib to its proper location. One must use manual therapy to restore rib cage function.

Also, good diaphragm and abdominal muscle tone are important in maintaining the abdominal viscera in proper position, and for proper venous drainage via the diaphrag­matic pump. Poor rib cage function and/or somatic dysfunc­tions can result in disturbances of circulation, poor muscle tone, and disturbances of organ functions. Innervation to many organs and trunk musculature is provided via the tho­racic segments.

It has been suggested (Chiatow 2001) that poor “drooped posture” can result in diaphragm and abdominal muscle relaxation which cease to support abdominal organs. The disturbances of circulation resulting from a “low diaphragm and ptosis” may give rise to chronic passive con­gestion in one or all of the organs of the abdomen and pelvis. Furthermore, the drag of these “congested organs” on their nerve supply, as well as the pressure on the sympathetic gan­glia and plexuses, probably causes many irregularities in their function, varying from partial paralysis to overstimula­tion. Proper rib cage and spinal functions are therefore extremely important as they controls respiration, lymphatic and blood circulation, nervous and organ functions all of which are necessary for FM patients to recover. Good man­ual functional evaluation is therefor suggested regardless of treatment style used.

TCM Herbs

As noted above FM caused by trauma or another precipitat­ing event such as serious illness tends to be more severe and have a worse prognosis than idiopathic FM. The information below mainly reflects this author’s experience and is based by enlarge on patients within this category. It is the author’s experience that FM patients are often sensitive and do not tolerate strong, spicy, hot or cold formulas. They tend to develop side-effects (even with so called individually appropriate formulas) and are often non-compliant. A mild approach to herbal formula design may be preferable. The most difficult aspect is to decide between elimination of pathogenic factors, tonification and/or harmonization. Although following traditional theory one usually eliminates pathogenic factors before tonifying, this is not always the best clinical approach in FM patients.

In patients with acute pathogenic factors, ether internal (or hidden-latent) or external, a mildly clearing formula may be used first (in hidden-latent Heat with small to moderate dose of San Zhi Zi). However, if after 10 days the patients still suffer from symptoms of the acute episode, a neutral tonification for­mula in small dose can be incorporated. Some patients, especially if they contract Exterior syndromes often, do better with an harmonizing or combined Exterior releasing and tonification. Even in these patients however, one must carefully analyze the patient condition and most often use only small amounts of tonic herbs. The following are treatment strategies based on common clinical presentation seen by the author. These formulas are based on disease diagnosis (biomedical FM) and modified for symptoms and TCM pattern discriminations.

To improve sleep and general physical condition, and eliminate pathogenic factors for FM patients:

A modification of Suan Zao Ren Tang can be used often.
The following for­mula may be analyzed as gently regulating the Liver (clear­ing Heat, nurturing Blood and ensuring free flow), strengthening Spleen/pancreas without being worm or spicy, regulating Qi and Blood flow (again gently), gently leading pathogenic factors to the surface and helping to settle the spirit:

Suan Zao Ren 12g
Fu Ling 12g
Chuan Xiong 6g
Su Ye 3g
Yi Yi Ren 15g
Ban Xia 6g
Yan Hu Suo 9g
Bi Xie 12g
Bai He 9g
Dan Shen 9g
Zhen Zhu Mu 15g
Zhi Mu 2g
Gan Cao 3g

Modifications:

– For Yin and/or Kidney deficiency add: Wu Wei Zi 6g, Tu Si Zi 9g, Shan Yao 15g, Tai Zi Shen 6g.
– For Liver Yin deficiency add: Ju Hua 9g, Tu Si Zi 9g, Gao Qi Zi 9g.
– For Liver Qi stagnation add: Ju Hua 9g, Ji Gu Cao 3g, Yu Jin 6g, Ma Ya 20g.
– For Spleen and Qi deficiency add: Shan Yao 9g, Ren Shen 6g.
– For unstable Yang harassing the Heart add: Ru Gui 5g, Huang Lian 3g.
– For poor appetite add: Ji Nei Jin 9g.
– For digestive symptoms with Dampness and blotting add: Da Fu Pi 6g, Pei Lan 6g.
– For Damp-Heat add: Huang Lian 3g.
– For Cold pain add: Yan Hu Suo 12g, Wei Ling Xian 6g, Gan Jiang 5g, Gui Zhi 3g.
– For Blood stasis or history of trauma add: Chuan Niu Xi 9g, Wu Ling Zi 6g, Dan Shen 12g, Ge Gen 9g.
– For severe fatigue after exercise add: Gan Cao 6g (one hour prior to exercise), Gao Qi Zi 12g, Tu Si Zi 12g, Sang Shen 15g, Salt 0.25g.
– For weak immune system with frequent colds or respiratory allergies add: Huang Qi 9g, Ren Shen 3g, Bai Zhu 3g, Fang Feng 6g, Wu Wei Zi 3g, Sha Shen 4g.
– If with Phlegm-Heat add: Huang Qin 6g, Huang lin 3g.
– For excessive sweating due to Qi/Yin deficiency add: Ma Huang Gen 9g, Mu Li 15g.
– For upper edema add: Sang Bai Pi 12g, Zhu Ling 9g, Gui Zhi 3g, Bai Zhu 3.
– For headaches add: Gou Teng 9g, Tian Ma 6g, Chuan Xiang, 9g.
– For chronic more severe insomnia add: Ban Xia 20g (note high dose), Zhu Ru 9g,  Xia Gu Cao 6g, Zhi Shi 3g, Long Gu 20g.
– For severe psychiatric symptoms add: Liao Diao Zhu 6g, Shi Chang Pu 2g.
– For muscle cramps (especially calf) and restless legs add: Bai Shao 12g; Gui Zhi 4g, Gan Cao 4g, Mu Gua 9g, Tao Ren 6g, Long Gu 15g.
– For fibrotic muscles and sinews add: Tao Ren 6g, Chuan Niu Xi 9g , Zhi Bei Mu 12g, Mu Li 20g, Wei Ling Xian 6g.
– For severe tension spasms and pain add: Bai Hua She 5g, Wu Gong 3g, Quan Xie 3g.

For patients with generalized muscle pain, mild articular signs but no significant difficulty with sleep and energy use:

Bi Xie 12g
Wei Ling Xian 6g
Yi Yi Ren 20g
Tu Si Zi 12g
Chuan Niu Xi 9g
Yin Hu Suo 9g
Ze Lan 6g
Chuan Shan Jia 6g
Zhen Zhu Mu 15g
Ma Ya 20g

Modifications:

– For muscle cramps and tightness add: Bai Shao 12g; Gui Zhi 4g, Gan Cao 4g, Mu Gua 9g
– For upper body symptoms add: Ge Gen 6g, Jiang Huang 9g Gui Zhi 6g (for Cold), Sang Zhi (for Heat)
– For lower body symptoms add: Huai Niu Xi 12g, Fang Ji 6g, Sang Ji Sheng 12g

For external Wind attack or retained pathogenic factors use:

Ju Hua 6g
Ge Hua 6g
Su Ye 3g
Su Gen 4g
Fu Ling 12g
Mai Ya 15g
Yin Chen Ho 3g
Gou Teng 6g
Gan Cao 1g.

Modifications:

– For Heat add: Bai Wei 2g, Lian Qiao 9g
– For symptoms of infection add: Pu Gong Ying, 12g, Yu Xing Cao 12g, Chuan Xin Lian 3g.
– For high fever add: Shi Gao 20g, Lu Gen  12g.
– For Wind-Cold add: Fang Feng 9g.
– For Damp-Heat-Phlegm add: Huang Qi 3g, Bi Xie 12g, Yin Chen Hao 12g, Chuan Bei Mu 9g, Huang Qin 6g.
– For Damp-Cold add: Bi Xie 12g, Cang Zhu 3g, Sheng Jiang 6g .
– For sinus symptoms add: Cang Er Zi 15g, Chan Tui 9g
– If also forehead headache add: Bai Zhi 5g.
– For severe pain add: Chuan Xiong 6g, Yan Hu Suo 9g, Ge Gen 9g, Wei Ling Xian 9g, Wu Ling Zi 6g, Bai Zhi 3g.
– For digestive symptoms: Ma Ya 15g, Da Fu Pi 6g, Pei Lan 6g.
– If with symptoms of Stomach Heat add: Zhu Ru 9g, Lu Gen  12g.
– For Shao Yang symptoms: Chi Hu 4g, Huang Qin 6g, Ren Shen 3g.
– or hoarseness, scratchy or sore throat add: Jie Geng 9g, Gan Cao 3g, Pang Da Hai 5g.
– For severe sore throat add: Ma Bo 1.5g, Ban Lan Gen 9g.
– For ear pain add: Huang Qi 9g, Chi Hu 3g, Long Dan Cao 6g.
– For strong Interior Heat and irritability add: San Zhi Zi 6g.
– For Constipation add: Da Huang 4g.

Nutritional and other Natural Therapies

A good healthy diet is important in FM. The patient should avoid any simple carbohydrates and sugars. Assessment for food allergies should be done using an elimination diet or blood tests. Assessment for hormonal levels is helpful as some patients benefit from DHEA and/or growth hormone supplementation. Some patient show excessive toxicity and should be evaluated for pesticide, formaldehyde, solvents and heavy metal toxicity.

Bacterial overgrowth in the small intestine was evaluated in 815 individuals using the lactulose hydrogen breath test, 152 individuals had the diagnosis of FM, of whom 29 who had concurrent inflammatory bowel disease were excluded. Out of the 123 subjects with FM syn­drome, 96, or 78%, tested positive for small intestinal bacte­rial overgrowth as diagnosed by the lactulose hydrogen breath test. Of those treated with antibiotics 57% reported global improvement in their symptoms. The data suggested that bowel symptoms in FM may be caused by small intestinal bacterial overgrowth.

There have been associations made between fibromyalgia symptoms and Chlamydia species as well as Borrelia burg­dorferi. In animal models, small intestinal bacterial over­growth can result in bacterial translocation to mesenteric lymph nodes and can produce systemic effects. These sys­temic effects are believed to be mediated by endotoxins from Gram-negative bacteria. These endotoxin effects may explain the soft tissue hyperalgesia that is seen in fibromyal­gia syndrome since injections of the endotoxin into lab ani­mals results in similar hyperalgesia. The authors conclude that the intestinal symptoms of FM patients may be related to small intestinal bacterial overgrowth, and treat­ment of small intestinal bacterial overgrowth can result in overall improvement in intestinal symptoms (Pimentel, Chow, Hallegua, Wallace, and Lin 2001).

Many patients with FM seem to be deficient in magne­sium and calcium. Dr. Hans Neiper popularized the use of magnesium aspartate. Another researcher by the name of Guy Abrahams, had studies magnesium maleate in a controlled trial in patients with FM. He found that the magnesium passes well into the cells and the mitochon­dria. The extrapolation of the effect to other aliphatic frac­tions, such as aspartate, glycinate and citrate (which is the cheapest) is by implication and has not been confirmed, so far. Myer’s cocktail (intravenous) is used with an emphasis on magnesium and calcium, as tolerated, remembering that high concentrations of magnesium tend to give a flush and may precipitate hypotension. The success rate is about 50%, which is superior to that achieved in conventional medicine. Women who receive this preparation sometimes have a pleasant vaginal warmth. The addition of oral lithium can offer a synergistic benefit (Dorman personal communica­tion). A malic acid-magnesium supplement can be helpful. Since oral absorption of magnesium is not optimal a magne­sium oil can be used topically.

A good multi-vitamin/mineral supplementation can be helpful. Methyl-sulfonyl-methane (MSM), capsaicin, devil’s claw, glucosamine, curcumin and baswellia have been reported to be helpful. In patients with gasrointestinal symp­toms the use deglycyrrhizinated licorice, bismuth salts, Ore­gon grape extract, L-glutamine, and probiotics are often helpful. For depression 5-HTP, SAMe, and St. John’s wort are used. For sleep and anxiety disorders kava, chamomile, valerian, GABA, L-theonine and Garum armoricum (Stabi­lium) or pharmaceutical medications can be used.

The author has been able to treat many patients with FM, using all the above suggested treatments successfully even after many have failed before.

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Many thanks to Alon Marcus for permission to reprint his article in the Jade e-news.  Dr. Marcus teaches courses on complementary orthopedics and is currently in private practice in Oakland, California.  www.integrativehealthmedicine.com

Alon Marcus received his licensed acupuncturist degree from American College of Traditional Chinese Medicine in San Francisco, California in 1984, and his Doctor of Oriental Medicine in Los Angeles , California in 1986. He also trained in Japan and China where he served his internship at Traditional Chinese Medicine Municipal Hospital in Guangzho.  Dr. Marcus has published numerous articles in both Eastern and Western medical journals, and the books Acute Abdominal Syndromes Their Diagnosis & Treatment According to Combined Chinese-Western Medicine (Blue Poppy Press, 1991) and Musculoskeletal Disorders: Healing Methods from Chinese Medicine, Orthopaedic Medicine, and Osteopathy (North Atlantic Books, 1998).