Professional Documents
Culture Documents
Treatment of
Fibromyalgia
Carolyn McMakin, MA, DC
FSM 2012
Fibromyalgia
Fibromyalgia is a full body pain
condition diagnosed by the
presence of chronic non-
non-
restorative sleep, fatigue, pain in
all four body quadrants and the
presence of 11/ 81 tender points
as measured by algometer
Current research describes it as
a neuroendocrine immune
condition
1
Fibromyalgia
Fibromyalgia patients have altered central
pain processing
Circulation in the thalamus is altered from
normal
Causing thalamus to do pain amplification
rather then its normal role of pain
suppression
Fibromyalgia patients have altered central
endocrine responses.
Fibromyalgia
Diagnostic Features
Widespread aching in all four quadrants
Eleven of eighteen tender points
Tender to less than 4 lbs./in2
Chronic sleep disturbance
waking every 90 - 120 minutes
Fatigue
Minimum of 3 months duration
2
Associated Conditions
Sleep Disturbance Raynaud’
Raynaud’s
Headache Migraine
Anxiety Mitral Valve
Dysmenorrhea prolapse
SICCA (dry eye) Prior depression
Irritable bowel Morning stiffness
syndrome Fatigue
Urinary urgency Myofascial pain
3
Algometer
Essential TESTING
CBC – normal
Chem screen – normal
Sed Rate - normal
Thyroid panel –
T3, T4,TSH - normal
4
Optional Testing
Serum food and mold allergy testing
IgG, IgE
5
DDX: Chronic Fatigue
Chronic fatigue – Epstein Barr connection
Cognitive problems
Non-
Non-exudative pharyngitis
DDX: Depression
Different serotonin and HPA axis profiles
Sleep disturbance differs-
differs- am awakening
Cognitive dysfunction is different
FMS responds to smaller doses of anti-
anti-
depressants
Depression prevalence similar to other
chronic pain conditions
Rule out major depression
6
DDX: Hypothyroidism
Early hypothyroidism shows diffuse
myalgia and fatigue
Abnormal lab values
Body temperature low
Constipation
Dry skin
Brittle hair
7
DDX:
Inflammatory Muscle Disease
Muscle weakness
8
DDX: Parkinson’s
Causes stiffness but not usually painful
Tremor
Loss of spontaneous movements
Sleep disturbance common in elderly
Myofascial pain due to arthritis may
confuse the picture
DDX:
Polymyalgia Rheumatica
Pain and stiffness in shoulders and pelvis
No weakness
Treatment: steroids
9
DDX: Rheumatoid Arthritis
Lupus
Systemic Sclerosis
Normal in FMS
DDX:
Silicone Breast Implant Reaction
Painful joints
10
DDX: Tendinitis
History of overuse
DDX: Candida
11
FMS is a distinct syndrome
Not secondary to:
Blood Disease
Cancer
Infection
Hormonal disturbances
Drug reactions
Allergies
Onset
55% Gradual adult onset
12
Prevalence of FMS
3-6 million in U.S.
5.7 to 9% - General clinics
3.7 to 20% - Rheumatology clinics
Age range 14-
14-68
1% incidence below age 60
4% above 60
92-
92-100% Caucasian
73-
73-88% Female
Course of FMS
13
Features of Fibromyalgia
Reduced serotonin levels
Abnormal serotonin metabolism
DHEA and urinary free cortisol
decreased
Serum cortisol slightly increased
Delta sleep interference
– alpha wave intrudes
14
Reduced levels of:
Neurotransmitters
Epinephrine, norepinephrine
Serotonin
Dopamine
15
Features of FMS
Altered mitochondrial phosphorylation
Decreased intramuscular ATP and
phosphocreatinine
Compromised microcirculation
Ultrasound decreases microcirculation
No consistent EMG changes
Alcohol increases symptoms
Conversion of Tryptophane to kyneurinine
Elevated substance P
3 to 6 times normal
Features of FMS
Reduced growth hormone
Secondary to sleep disturbance or ?
Worsened by fatigue, emotional stress
Associated with sleep apnea in men
Symptom overlap between FMS and
Chronic Fatigue Syndrome
13.3 times greater incidence with
cervical injures than with lower
extremity injuries
16
Features of FMS
Female predominance
Estrogen dependent shift in tryptophane
metabolism
Genetic predisposition
Enzyme substrate requirements
Food allergies
Amino acid transport proteins in gut
Liver pathway function
Incidence of
Conditions Related to FMS
General FMS
Multiple Chemical sensitivities 5% 25%
IBS 10% 40%
Headaches 5% 50%
Mitral valve prolapse 15% 75%
Restless leg syndrome 2% 30%
Dysmenorrhea 15% 50%
Endometriosis 2% 15%
Interstitial Cystitis <.5% 25%
Irritable bladder <.5% 15%
17
CNS Disorder
Biogenic amines reduced
18
CNS Disorder
depression
19
Neuroendocrine Disorder
20
21
Hormonal Perturbations in Fibromyalgia Syndrome
Annals New York Academy of Sciences, Neeck & Reidel
22
Hormonal Perturbations in Fibromyalgia Syndrome
Annals New York Academy of Sciences, Neeck & Reidel
Injections of CRH, TRH, GHRH, LHRH
Reduces deiodination of T4 to T3
The more stressful the situation the
lower the serum free T3 levels
Elevated glucocorticoid levels decrease
response of TSH to TRH
23
Neeck & Riedel
24
Hormonal Perturbations in Fibromyalgia Syndrome
Annals New York Academy of Sciences, Neeck & Reidel
Injections of CRH, TRH, GHRH, LHRH
Down-
Down-regulation of ACTH receptors
25
Burkhardt, Clark, Bennett, J. of Rheum. 1993
CRH Stimulation test
26
CRH inhibits LHRH directly
Reduces gonadal hormones
GHRH effect on GH
27
Hormonal Perturbations in Fibromyalgia Syndrome
Annals New York Academy of Sciences, Neeck & Reidel
Injections of CRH, TRH, GHRH, LHRH
Parathyroid Hormone, Calcitonin, and Calcium
Paresthesias
28
Hormonal Perturbations in Fibromyalgia Syndrome
Annals New York Academy of Sciences, Neeck & Reidel
Injections of CRH, TRH, GHRH, LHRH
Conclusions
Chronic pain drives and sustains the
hyperactivity of CRH neurons
CRH alters set point of other hormonal axes
CRH increases somatostatin which
Inhibits GH and TSH in pituitary
CRH inhibits LHRH directly
Reduces gonadal hormones
29
Evidence that Abnormalities of Central Neurohormonal
Systems are key to Understanding
Fibromyalgia and Chronic Fatigue Syndrome
Leslie Crofford, MD, Mark Demitrack, MD, 1996
Increased 24-
24-hour urinary cortisol excretion in patients with PTSD and
major depression, but not in patients with fibromyalgia.
Maes M, et al Acta Psychiatr Scand 1998:98 328-
328-335
30
Fibromyalgia and Cortisol
Increased urinary excretion
31
Reduced Hypothalamic-
Hypothalamic-Pituitary and Sympathoadrenal Responses to
Hypoglycemia in Women with Fibromyalgia Syndrome
Adler, G et al., American Journal of Medicine, May 1999
32
Hyposecretion of adrenal androgens and the relation of serum
adrenal steroids, serotonin and IgF1 to clinical features in women
women
with fibromyalgia. P.H. Dessein, et al, Pain 83, 1999
DHEA reduced in FM
Serum Testosterone reduced in FM
Correlation: DHEA and pain
Correlation: T and physical functioning
IGF-
IGF-1 and serotonin did not correlate with FIQ
Growth hormone
Serotonin production
33
Therapeutic Strategies from Dessein
34
Prescription Therapeutics
Amitryptoline - Elavil
SSRI’
SSRI’s - Paxil and Trazadone
Clomipramine
35
Guaifenesin: St.Amand, UCLA
Cytomel – T3
Lowe, John DC, Journal of Myofascial Therapy, Vol1, July 1994
Improvement in Euthyroid Fibromyalgia Patients treated with T3
36
Appropriate Pain Management
37
Non-Prescription
Therapeutics
38
Detoxification: 4 R program
5 - Hydroxy - Tryptophane
Puttini, PS, Fibromyalgia syndrome and 5HTP,
Journal of International Medical Research, April 1992.
39
5 - Hydroxy - Tryptophane
Nicolodi, M. “Fibromyalgia and Migraine”
Migraine”,
Adv Exp Med Biology 1996
Serotonin Metabolism
40
Serotonin Facts
41
Tryptophane Facts
Tryptophane Metabolism
Absorbed tryptophane
90% protein synthesis
9% niacin production
1 to 10% converted to 5-
5-HTP and serotonin
42
Tryptophane Conversion
Converts tryptophane to
Kynurenine
Picolinic acid
Niacin
Electro-acupuncture: 2 studies
43
Aerobic exercise: inconclusive
Niacin
250 mg/day
Increases circulation
Spares 5-
5-HTP ?
44
Hypnosis
Haanen,” Controlled trial of hypnotherapy in treatment of refractory
Haanen,”
fibromyalgia”
fibromyalgia”, Journal of Rheumatology, Jan 1991
45
Imagery, Progressive Muscle Relaxation
Walco, Ilowite, Journal of Rheumatology Jan, 1991
Reduced pain
Improved functioning
46
Doctors Recommend
Education
Gentle stretching
Massage
Visualization, meditation, relaxation
Warm water exercise
Support system
Avoid
Repetitive exercises
Swimming in cool water
Immobility
Sustained yoga postures
Chill
Steroids
Emotional distress
47
Disability Cases
48
It is easier if you recognize
49
Treatment Options
FSM and Functional medicine create a
viewpoint and treatment options
Eliminate pain as a stressor
Diet, nutrition and exercise
Energy production / Oxidative stress
Liver and cellular detoxification processes
GI Imbalance
Immune and Inflammatory Imbalance
Hormonal and Neurotransmitter Imbalance
Structural Imbalances
Mind and Spirit
Fibromyalgia
50
The most important thing you need
to know about Fibromyalgia is that
it is curable.
51
“Cure” means it goes away and
doesn’t come back except for an
occasional episode that would be
considered normal in the general
population.
Cautions
Never make promises.
There is no such thing as a sure thing.
Cautious optimism is always safe.
Hopeful skepticism is reasonable.
“Can’
Can’t hurt, might help.”
help.”
Use outcome measures to
track ADL’
ADL’s and ROM
52
Progression of Symptoms
Pain generalizes in one to three months
Characteristic of de-
de-afferentation injuries
Characteristic of central sensitization
Progression of Symptoms
Alterations in digestive function
Decrease in stomach acid and enzymes → reflux and food rotting →
IBS
Change in GI Ph leads to changes in bacterial flora → IBS
“Candida”
Candida”
53
Progression of Symptoms
Alterations in endocrine function
CRF decreases ↓ FSH, ↓ LH → reduces progesterone
Estrogen dominance, fatigue and PMS like symptoms
CRF reduces↓
reduces↓ GHRH → reduces growth hormone centrally
Growth hormone mediates amino acid transport for muscle repair
GH also impaired due to sleep disturbance – stage four missing
CRF reduces ↓ TSH → prevents TSH from rising even though patient
is functionally hypothyroid because
Cortisol reduces ↓T4 /T3 conversion
54
Typical Symptoms
Resistant to narcotics
Aching, burning, tingling, stabbing
Characteristic affective response
Neurologic Examination
55
Patient Selection
54 consecutive patients
Mean age 44 years
Met ACR criteria for Fibromyalgia
History of cervical spine trauma
MVA-
MVA- 36
Falls – 4
Lifting – 5
Post surgery – 2
Using a pick in hard soil - 1
56
IL-1 normal= 0-
0-25pg/ml
392.8
400
P=.004 150
100
50
21.4
0
10:50 11:20 11:30 12N 12:35
Step-
Step-wise linear
regression on time
points
P=0.0001
TNF-alpha normal=0-
normal=0-25pg/ml
299.1
300
250
Reduced from average 200
100
P=0.002, t-test 50
20.6
0
10:50 11:20 11:35 12N 12:35
57
IL-6 normal=0-
normal=0-25pg/ml
250
204.3
200
Reduced from average
150
239 ± 23 to 76 ± 38 pg/ml 100
P=0.008, t-test 50
15.6
0
10:50 11:20 11:35 12N 12:35
Substance P normal=0-
normal=0-30pg/ml
132.6
140
120
80
180 ± 31 to 54 ± 28 pg/ml 60
40
P=0.0001, t-test 20
10.5
0
10:50 11:20 11:35 12N 12:35
58
Calcitonin Gene Related Peptide-CGRP
normal = 0-
0-20 pg/ml
#4 CGRP = 22.4 20
970/ series 0
10:50 11:20 11:35 12N 12:35
#5 CGRP = 8.6
P=0.003, t-test 20
10
5.2
0
10:50 11:20 11:35 12N 12:35
59
Cortisol normal 5-
5-25 ug/ml
ug/ml
169.9
Increased from average 180
160
140
14.7 ± 1.8 to 105.3 ± 28.2 pg/ml 120
100
P=0.03, t-test 80
60
40
20
15.5
Not a stress response 0
10:50 11:20 11:35 12N 12:35
Reducing
450 Pain- Reproducible Interleukin-6
Interleukin-1
Results 350
400
300
350
250
300
250 200
200 150
150
100
100
50
50
pg/ml
pg/ml
1 2 3 4 5 1 2 3 1 2 3 1 2 3 4 5 1 2 3 1 2 3
1ST VISIT 2ND VISIT 3RD VISIT 1ST VISIT 2ND VISIT 3RD VISIT
450 10
TNF-alpha VAS Pain Score
400 9
350 8
7
300
6
250
5
200
4
150
3
100
2
50 1
pg/ml VAS
1 2 3 4 5 1 2 3 1 2 3 1 2 3 4 5 1 2 3 1 2 3
1ST VISIT 2ND VISIT 3RD VISIT 1ST VISIT 2ND VISIT 3RD VISIT
60
Control Patient
Diagnosed with Fibromyalgia
8/18 tender points
Normal patellar reflexes
Normal sensation
Lacked neuroendocrine profile
Myofascial Trigger Points
Neck
Low back
61
Lumbar Myofascial Pain
23 Cases Published - JBMT, 2004
Results
VAS before treatment 7.3 ± 1.2 (range 5-5-10/10)
P <0.0001
90 minutes first treatment
40 minutes subsequent treatments
All CTF patients experienced relief
Control patient did not respond to study protocol
Pain was reduced with myofascial trigger point
treatment protocol
62
Results
Five patients did not tolerate treatment
Headache, mid scapular pain
Cord compression/stenosis probable cause
58% (31/53) experienced resolution of fibromyalgia
symptoms
Improved tender point sensitivity
Improved sleep quality
One patient relapsed
13 / 53 discontinued treatment
Discontinued patients 3.5 treatments (1-
(1-9)
Had identical drop in pain to recovered group
Improving patients 4.4 treatments (3-
(3-7)
Recovered patients 8 treatments (2-
(2-17)
Clinical Presentation
Typical History
History of cervical trauma
MVA
Surgery
Fall
Lifting, moving household
Using a pick or shovel
Starts in the neck and shoulders
Generalizes after one to three months
Symptoms persist
63
Imaging
MRI shows a bulge or contained
herniation
64
The Cord and Central Pain
“Central pain can arise not only
from pathologic lesions in the thalamus
but also from lesions placed anywhere
along the nociceptive pathway
from the spinal cord and brain stem
to the thalamus.”
thalamus.”
Kandel and Schwartz; Textbook of Neurophysiology
65
Cervical Trauma Fibromyalgia
and Central Pain Model
CTF Patients describe central pain
Aching, burning, sharp, shooting. stabbing
Other types of Fibromyalgia:pain is different
Affective quality of the pain is characteristic
Unresponsive to narcotics
Unresponsive to other treatments
Trigger point injections, Epidurals, Surgery, Medication,
Microcurrent for myofascial pain
Progression of Symptoms
Pain generalizes in one to three months
Characteristic of deafferentation injuries
66
Treating Cervical Fibromyalgia
First patient success February 1999
Desperation
67
Typical CTF Treatment
Twenty treatments between 12/8 and 3/15
Microcurrent CTF protocol in the office
Home unit daily for pain relief at home
Massage at each visit
Manipulation as needed
Physical therapy to stabilize the spine
One epidural, several facet injections
Supplements
68
Cases
25 patients in 1999, 230 total since then
All patients have had pain reduction from
6-9/10 range to 0-
0-2/10 range in 60 minutes
Chronicity: 2 days to 50 years
Pain reduction begins immediately
Pain relief lasts for 5 to 48 hours
Repeat treatment 1-
1-2/week
Microcurrent and functional medicine follow-
follow-up
Resonance for
Cervical Trauma Fibromyalgia
Start with 40, 50 / 10 +/-
+/- for 1-
1- 2 minutes
POLARIZE positive +
40 / 10 - Inflammation in the Cord
284 / 10 - Chronic inflammation / cord
Auto Care: P / C
AutoCarePlus,
AutoCarePlus, HomeCare P/ CTF/ P
69
APPLICATION
Wrap red lead glove in a hot wet hand towel
Wrap the towel around the neck
70
Normal Course
Pain will begin to go down in ~10 minutes
Recedes from the feet up, arms go last
Have the patient put hands on abdomen
May need 40, 284 / 396 +→ +→ neck to hands
Takes 30 – 60 minutes to go to 0- 0-2/10
Once pain is 0-0-2/10 sit the patient up and
finish the protocol
STENOSIS CAUTION
If the patient has cervical cord stenosis or cord
compression this protocol can cause an
increase in midscapular pain and a headache
within minutes
STOP TREATING IMMEDIATELY.
IMMEDIATELY.
Starting treatment with the current alternating
40, 50/10 for about 1 minute each before you
polarize minimizes the potential for this problem.
No known way to predict who will have it
One patient needed to be treated sitting up to prevent
May be able to use the polarized protocols after
using this indirect approach.
71
If Response is Slow
Narcotics, anesthetics or even natural endorphins
can sometimes block response to treatment
19 / 10, 45
“Remove anesthesia”
anesthesia” from the cord and nervous
system
43, 46 / 10, 45
“Remove opiates”
opiates” from cord and nervous system
72
Treating CTF – Cord Fibrosis
91, 13, 3 / 10 + →
Repeat the process. Each time the patient moves to the edge of pain -
The range should increase – the edge of pain should move
Finish with the patient standing and flexing forward if this is tolerated
Treat for adhesions in the cord until forward flexion is comfortable
73
Getting Results to Last
81 / 10 Secretions / Cord
Run 1-
1-2 minutes
Use only when the pain is down to 1-
1-2/10
If pain is still present substance P is one of the
secretions increased and pain can go up.
Makes pain reduction more lasting
74
Address The Central Component
40 / 89, 90, 84, 94
Polarized neck to feet
970 / 89, 90, 94, 84?
Sympathetic Reaction
Cortisol
If patient becomes 180
160
120
Endorphins
100
Agitated 140
120 80
100
60
Irritated 80
60
40
Pre Tx
Post Tx
40 20
Anxious 20 0
0 5/11 5/14 5/17
10:50 11:20 11:35 12N 12:35
Shivers
May 2000
16
14
12
language 10
8
6
4
They don’
don’t always tell you 2
0
10:50 11:20 11:35 12N 12:35
75
Reactions
Bladder irritability
Increased frequency, urgency, discomfort
Nerves to the bladder get irritated when you run 40/10
Run 40, 284, 91/396, 37
Spine to Abdomen +→
+→
Increased arm pain
Nerves to the arm become irritated - ↑ Pain
Run 40, 284, 91, 13 / 396 +→
Neck to arm
Headache
Treat 40 / 89, 288, 396
Treat myofascial TrP’
TrP’s
Takes 30 – 60 minutes to go to 0-
0-2/10
Need 40 / 89,
89, 94, 90, 84 + to reduce central amplification
May need 94, 19, 43, 46 / 10 + >> if response is slow
Then go back to 40/10 + >>
Auto CarePlus:
CarePlus: P/CTF
76
Resonance For True Central Pain
Central pain is caused by damage in the brain
to pain processing centers (thalamus)
Stroke
Head injuries
Diffuse axonal injuries
40 / 89 + →
Neck to feet
284 / 89 + →
321 / 10 + → neck to feet used in 1999
Every patient responding to 321/10 has later
progressed to 284, 40 / 89
94, 321, 20, 40, 284, 81, 49 / 89
Use 40 / 89 if the patient develops a headache 5
to 10 minutes into the 40/10 protocol
40 / 90, 89, 84, 94 as needed
77
Recovery from Cervical Trauma Fibro
Get the pain down to a 4/10 at most times
FSM in office
Home Care or Auto Care unit
Deal with central up-
up-regulation
Deal with orthopedic issues
Myofascial pain
Facets
Discs
Deconditioning
Restore adrenals
FSM
Supplements
Restore GI function – FSM, Supplements
Restore neuroendocrine function
5-HTP, Theanine,
Theanine, PhosSerine
Medication management and withdrawal
78
Treatment Program
Getting pain to 0-
0-1/10 is the start of recovery
Still must address
Sleep
Adrenal status
GI repair
Orthopedic issues
Home Care
Cervical Trauma Fibromyalgia – Polarized
Cervical Trauma Fibromyalgia – Alt
Nerve Pain – Polarized
Discogenic Pain – Acute
Discogenic Pain – Chronic
Facet Generated Pain – Acute
Facet Generated Pain – Chronic
Ligament – Tendon - Bursa Pain
Myofascial Pain – Trigger Points
Adrenal Support
Quiet Adrenals
GI Support
Constipation
Insulin Resistance
Emotional Relax and Balance
Sleep
79
Sleep
As pain goes down sleep tends to improve
Use home unit before bed
Treat with concussion protocol 1/week
Sleep protocol
Supplements: GABA, 5-5-HTP, Valerian, Kava
Kava,
Kava, Magnesium, Somnolin
Quiet the adrenals, increase calming neurotransmitter
precursors
Gradually transition off of meds as possible
Adrenal Rehab
Use FSM adrenal protocols in morning
Use nutritional support
Herbs
Vitamin B5, C
80
GI Repair
The stress of the pain causes GI dysfunction
leaky gut, dysbiosis, maldigestion
FSM protocols 1/week for leaky gut, IBS
Nutritional supplements
Glutamine, Arabinoglycans, fiber, bacteria
Digestive enzymes
Orthopedic Issues
Once the fibro is gone – 4-6 weeks
The patient still has orthopedic complaints
Facet syndrome
Disc bulges
Ligament instability
Myofascial pain
81
Treat for Specific Orthopedic Issue
Facet Syndrome
FSM for facets
40, 284 / 59, 39, 783, 480, 157
91 / 783, 480, 191, 396, 142
82
Treat for Specific Orthopedic Issue
Ligament Instability
Usually Cervical
Contributes to both facet and disc problem
FSM for ligament instability
124, 40, 284, 81, 49 /100, 191,142
Stabilization Exercises
VERY small movements
Supplements
83
Emotional Psychological Issues
Always present
High percentage of patients have been abused or
molested as children
Pain becomes part of self definition
Who are they now that they are out of pain?
How do they have power in their lives if they don’
don’t
have pain, fibromyalgia?
Reframe
Condition has brought them gifts – opportunity to get rid
of the pain and keep the gifts
You can always get the pain down – emotional
issues most likely to prevent full recovery.
Try for a maintenance program
Let them get as well as they can tolerate for now.
84
I didn’t say it was easy or simple
I said it was possible
85
Prolonged Stress
Prolonged Stress leads to adrenal upregulation,
upregulation,
eventual adrenal exhaustion, GI dysfunction,
alterations in neurochemistry and the immune
system
“Why Zebras don’
don’t get ulcers”
ulcers”, Robert Zapolsky,
Zapolsky, MD
Stress Response
Prolonged severe stress causes
predictable sympathetic responses:
Increased heart rate, vasoconstriction
Decreased digestive function
Thinning of the gut wall – IgG food allergies
Decreased liver detoxification function
Altered microcirculation
Adrenal upregulation, Adrenal exhaustion
86
Prolonged Stress
FSM
40, 284 / 71, 562, 89, 94, 273, 315
294, 321, 9, 284, 81, 49 / 71 OR
294, 321, 9, 40, 284, 49 / 71
294, 321, 9, 40, 284, 81, 49 / 47
40 / 45, 89, 94
94, 321, 9, 40, 81, 49 / 116
SLEEP!!!!!!
Supplements
Adrenal support / or adrenal quieting
GI Repair
Neuro Endocrine Repair
87
Case : DF
Presented 11/2/98
DF : History
Lots of stress
Ran her own business
Heroin addict for 3 years at age 17
Bankruptcy, lost her home, 7 years ago
Daughter left home age 18, abused, divorced
Surgeries–
Surgeries–
4 abortions in 25 years
Burst appendix
Tonsils
Auto accident 2 years ago, concussion
Fell on her sacrum 8 years ago after an
abortion
88
DF : Symptoms
DF : Physical examination
Cervical ROM
Flex: 48/60, Ext: 40/50
LR: 50/70, RR: 85/70
LLF: 18/40, RLF: 40/40
Reflexes +2/4 x 5
Sensation appropriate C2 to S1
Active MFTP
Psoas, Rectus abdominus, Lumbar Psp
Scalenes, Cervical PSP, Levator, Traps
89
Stress Based Fibromyalgia
Treatment Protocol
Neuroendocrine rehab – 5-HTP, Magnesium
Allergy testing / avoidance
Adrenal support supplements
B-5, B-
B-6, Vitamin C, DHEA, Progesterone
Gut - Glutamine, diet, anti-
anti-oxidants
Liver – detox pathway support
Microcurrent to muscles – MFTP treatment
Microcurrent to gut, adrenals, liver
Restores diurnal rhythm more quickly
90
Microcurrent Adrenal Treatment
Cortisol Changes
30 minute Treatment 2.5
WB #1 - 48 yr old
2
Pre 1.1
Post 1.8 1.5
Pre Tx
WB #2 1
Post Tx
Pre 0.9
0.5
Post 1.2
AH - 29 yr old 0
WB WB AH
Pre 1.4 #1 #2
Post 2.1
91
DF Outcome
11/2/98 - 16/18 tender points
11/23/98 - 7/18 tender points (6 tx)
11/23/ 98 - 3/18 after Scalenes treated
27 treatments 11/98 to 11/99
4 treatments 11/99 to 11/00
Still deals with
Cervical and lumbar disc degeneration
Emotional issues, divorce, employment
Mold allergies
Menopause
92
Treating IgG Food Allergies
85% of immune system is in GI tract
Leaky Gut leads to food allergies IgG, IgE
IgG – delayed hypersensitivity – fatigue, pain
IgE – immediate – hives, itching, wheezing, pain
93
Treatment Protocol
Allergy Connection
94
Toxicity Fibromyalgia
Organic chemicals, pesticides are lipid soluble
Become incorporated into nerve membranes
Change firing characteristics
Create Pain
Pain creates the stress that leads to the
neuroendocrine changes → Fibro
95
Toxicity Based Fibromyalgia
History – You have to ask!
One time or chronic exposure
Employment
Chemical production, storing, shipping
Sick building
Paint, plastics, organic solvents, hydrocarbons
Home
Farm, orchard, neighborhood
Pesticide use
Drug exposure
96
Fibromyalgia History Challenges
Since they don’
don’t know what is important
they don’
don’t know what to tell you and
what to leave out
The patient can have more than one
condition.
Emotional factors and brain fog
complicate everything.
97
Toxicity based Fibromyalgia
History Questions
Have you ever worked on or near a farm or an orchard ?
Case: KS
First seen 4-
4-2-99
98
KS: Symptoms
KS: History
Constant tooth abscesses
Multiple root canals
Antibiotics for years for teeth
No flu shots
No travel
No MVA, no cervical trauma
Raised on poultry farm - DDT exposure
Dad died 1989 (stressful for her )
99
KS: Medications
Synthroid
Prozac – 2+ years
Not much help
KS Medical History
1966 Mononucleosis – hospital 1 week
1966 Hepatitis – hospital 1 week
1970 Normal childbirth
1975, 1978 C sections
Appendectomy- 5th month of pregnancy
1977 Appendectomy-
1985 Gallbladder removed
100
101
KS : Physical Exam
Reflexes and sensation – WNL
Fibromyalgia tender points 8/18
Pain meds
Palpation – Multiple MFTP
No Lumbar Examination
Cervical ROM:
F 60/60, E 44/50
LR 50/70, RR 45/70
102
103
KS Treatment
Supplements –Use any professional products
Spectrient, MCS, BioProtect, Lipoic Acid, 5-
5-HTP
EPA / DHA
Microcurrent
Liver and adrenals for two weeks
Muscle treatment done very carefully
7/28/99 Home Micro unit for leg/arm pain
No Massages
Manipulation as needed
Physical therapy to recondition
KS setbacks
Used an acid to remove wart on foot 6/99
Body pain went up to 4-
4-5/10
Fell on the side walk – Right leg pain 7/99
MRI L4-
L4-5 disc bulge
Reducing Ultram was difficult
Increased activity – especially lifting 5/00
Disc bulges in neck caused increased arm pain
from lifting grandchild
104
Toxicity Based Fibromyalgia
Treatment Protocol
Liver detoxification pathway support
Alpha Lipoic acid – 200 mg twice a day
Water – 2 quarts per day
Microcurrent – phase II pathways
Reduce or eliminate exposure
Improvement in four weeks
Resolution in four to six months
105
KS Outcome
9/8/99 Tender Points 0/18
Pain level reduced to 0-
0- 4 range by 8/99
Orthopedic pain flares occasionally
Right leg – L4-
L4-5 disc
Arm and neck C4-
C4-5 disc
Sleeps well
Off all medication except Synthroid
Oswestry Progression
3/17/99 – Pain everywhere A, B, S – 8 years
Neck 48% Low Back 64%
4/23/99 - Activity increased 25%
Neck 0%, Low Back 20%
6/14/99 – Activity increased 60%
Neck 10%, Low back 8%
12/1/99 – Activity 100%
Neck 8% Low Back 2%
106
Immune System-Viral Fibro
Patients report getting flu like illness and
never feeling well since then
Sometimes occurs after immunizations
FSM
45, 55, 40, 94, 321, 9, 49 / 116, 114
Concussion protocol, 42/00, 48/00 likely
Supplements
Anti-
Anti-oxidants, Vitamin C, Perilla
107
Treating
Hormone Imbalance Fibro
Salivary or blood Hormone testing
Rx Natural Progesterone
Cream, pills – Prometrium, compounded
Not Provera
Even after hysterectomy
FSM
Myofascial Pain
Concussion Protocol, 42/00, 55/00, 43/00?
Supplements
Fibroplex, GI, Adrenal, Neuroendocrine repair
108
UNDERSTANDING VESTIBULAR INJURIES
Vestibular input is so important to the brain that
the body has three systems of vestibular input –
the ears, the eyes and the mechanical receptors
in the lower extremity joints.
All of the input needs to correlate or this very
primitive part of the brain has problems.
When your ears are “broken”
broken” from a vestibular
injury your brain learns to ignore the ears and
depend on the eyes and mechanical receptors
for information about its location in space.
Vestibular Structures
The semicircular canals are
enclosed in the endolymphatic sac.
Normally it is a closed system
When the sac is torn, it is open to
air pressure, leaks fluid
Feeling of fullness in ear
Changes in air pressure change
vestibular input
Rainy days
Elevators
Altitude – mountains
Eighth nerve
Traction injury
Compression damage
Changes hearing and vestibular
function
109
Symptoms from Vestibular Injuries
When you are dependent on your eyes for
balance you have problems when you need your
eyes to process visual information.
Vestibular injury patients have difficulty with
Visually complex places
Shopping mall, Grocery store
Warehouse shopping – Costco, Sam’
Sam’s
Moving visual information
Moving traffic
Computer work
Reading
Symptoms may include anxiety, discomfort,
fatigue, dizziness, disequilibrium or nausea.
Panic attacks
The patient will often have been diagnosed as
having “panic attacks”
attacks”.
Ask, “Exactly when and where do you
have panic attacks?”
attacks?”.
If the attacks only occur in these visually
complex situations, or during sleep a
vestibular injury may be involved.
110
Symptoms from Vestibular Injuries
If the “panic attacks”
attacks” occur at night during sleep
a vestibular injury is almost certainly involved.
During sleep you are deprived of visual and
mechanical clues.
When you roll over in your sleep your brain has
only the ears for vestibular information.
If one ear gives the brain conflicting position
information the brain notifies the sympathetic
nervous system that “We are falling through
space – HELP!”
HELP!” and you wake up with pounding
heart and sweaty palms or a “panic attack”
attack”.
111
Vestibular History Questions
Do you ever feel dizzy or disoriented or have a
sense of disequilibrium?
Do you have difficulty with balance or
coordination?
Do you get anxious or uncomfortable in the mall,
warehouse shopping, or busy crowded places?
Do you wake up frequently during the night?
Do you have “panic attacks”
attacks” during the night or
while driving?
Do you have difficulty with memory or
sequencing?
112
Vestibular History Questions
Do sounds and noises seem louder than
they used to?
Do sounds and noises bother you more
than they used to?
Do you have trouble concentrating when
there is noise or motion around you?
113
Vestibular Diagnosis
Endolymphatic Hydrops
Endolymphatic Fistula
Inner ear Concussion
Centrally mediated vestibular problem
Need testing, expert referral to confirm diagnosis
Platform testing
ECOG
Vestibular testing lab
Most large metropolitan hospitals
Find the expert by asking the lab for doctors who
order tests and are good with patients
114
Treating Vestibular “Fibro”
Meclizine may be helpful
Hydrops =>
Low salt, small meals diet
Diuretic
Meclizine less effective but might help
Vestibular Rehabilitation exercises
FSM
Concussion Protocol, adrenals, GI repair
Supplements
GI Repair
Anti Oxidants, Adrenal Support
115
Treating Sleep Apnea “Fibro”
Diagnosis – sleep study
This is a life threatening condition
CPAP
Surgery may be effective – not proven
FSM
Pharynx, Larynx tissues ? Not much mileage
Concussion (42/00?)
Supplements
Adrenal support, GI, Neuroendocrine repair
Genetic Fibro
Fibro seems to run in some families
Most female family members get it by age
25
Genes regulate
Food allergies
Serotonin production
Liver detox pathway function
116
Genetic Based Fibromyalgia
Hypothesis
Enzyme systems have different
characteristics or requirements
serotonin, liver detox pathways
Transport systems have different
characteristics or requirements
Some food allergies are genetic
Gluten
Supplements
Depending on system that is the problem
117
It’s easy to walk on water once
you know where the rocks are.
I t is t he
he physician ’s job
t o hold t he vision on of t he
he
pat ient as
as healed
unt i l t he pat ient can see
see it . C
McMakin
118